IMAGE  EVALUATION 
TEST  TARGET  (MT-S) 


4p 

^5^  ...  K^.r 


:a 


% 


1.0    Si 


I.I 


1.25 


M    125 


iiiiiM 
1.4    11.6 


Photographic 

Sciences 
Corporation 


r*  '.'SST  MAIN  STREET 

V:i£nSTER,N.Y.  14580 

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CIHM/ICMH 

Microfiche 

Series. 


CIHM/ICMH 
Collection  de 
microfiches. 


Canadian  Institute  for  Historical  Microreproductions  /  Institut  Canadian  de  microreproductions  historiques 


Technical  and  Bibliographic  Notes/Notes  techniques  et  bibliographiques 


The  Institute  has  attempted  to  obtain  the  best 
original  cop/  available  for  filming.  Features  of  this 
copy  which  may  be  bibliographically  unique, 
which  may  alter  any  of  the  images  in  the 
reprof/uction,  or  which  may  significantly  change 
the  usudi  method  of  filming,  are  checked  below. 


D 


n 


D 
D 

D 
D 

n 


[^ 


D 


D 


Coloured  covers/ 
Couverture  de  couleur 

Covers  damaged/ 
Couverture  endommagee 

Covers  restored  and/or  laminated/ 
Couverture  restaurde  et/ou  pellicul6e 

Cover  title  missing/ 

Le  titre  de  couverture  manque 

Coloured  maps/ 

Cartes  g^ographiques  en  couleur 

Coloured  ink  (i.e.  other  than  blue  or  black)/ 
Encre  de  couleur  (i.e.  autre  que  bleue  ou  noire) 

Coloured  plates  and/or  illustrations/ 
Planches  et/ou  illustrations  en  couleur 

Bound  with  other  material/ 
Relie  avec  d'autres  documents 

Tight  binding  may  cause  shadows  or  distorticr, 
along  interior  margin/ 

La  reliure  serree  peut  causer  de  I'ombre  ou  de  la 
distortion  le  long  de  la  marge  intdrieure 

Blank  leaves  added  during  restoration  may 
appear  within  the  text.  Whenever  possible,  these 
have  been  omitted  from  filming/ 
II  se  peut  que  certaines  pages  blanches  ajout6es 
lors  dune  restauration  apparaissent  dans  le  texte, 
mais,  lorsque  cela  dtait  possible,  ces  pages  n'ont 
pas  6t6  film6es. 

Additional  comments:/ 
Commentaires  suppl6mentaires; 


L'Institut  a  microfilm^  le  meilleur  exemplaire 
qu'il  lui  a  dt6  possible  de  se  procurer.  Les  details 
de  cet  exemplaire  qui  sont  peut-dtre  uniques  du 
point  de  vue  bibliographique,  qui  peuvent  modifier 
une  image  reproduite,  ou  qui  peuvent  exiger  une 
modification  dans  la  mithode  normale  de  filmage 
sont  indiqu6s  ci-dessous. 


I      I    Coloured  pages/ 
r~^  Pages  damaged/ 


Pages  de  couleur 

Pages  damaged/ 
Pages  endommagdes 

Pages  restored  and/oi 

Pages  restaurdes  et/ou  pellicul6es 


The 
to  th 


I      I    Pages  restored  and/or  laminatsd/ 


0   Pages  discoloured,  stained  or  foxed/ 
Pages  ddcolordes,  tachetdes  ou  piqu^es 

□Pages  detached/ 
Pages  d^tach^es 

r~~|^Showthrough/ 
I— —I    Transparence 

□    Quality  of  print  varies/ 
Quality  in^gale  de  I'impression 

□    Includes  supplementary  material/ 
Comprend  du  materiel  supplementaire 

□    Only  edition  available/ 
Seule  Edition  disponible 


D 


Pages  wholly  or  partially  obscured  by  errata 
slips,  tissues,  etc.,  have  been  refilmed  to 
ensure  the  best  possible  image/ 
Les  pages  totalement  ou  partiellement 
obscurcies  par  un  feuillet  d'errata,  une  pelure, 
etc.,  ont  6t6  filmdes  ck  nouveau  de  facon  ck 
obtenir  la  meilleure  image  possible. 


The 
posi 

of  tr 

filmi 


Orig 
begi 
thai 
sion 
othe 
first 
sion, 
or  ill 


The 
shall 
TINL 
whic 

Map 
diffe 
entir 
begii 
right 
requi 
meth 


This  item  is  filmed  at  the  reduction  ratio  checked  below/ 

Ce  document  est  film6  au  taux  de  reduction  indiqud  ci-dessous. 

10X  14X  18X  22X 


26X 


30X 


/ 

12X 

16X 

20X 

24X 

28X 

32X 

The  copy  filmed  here  has  been  reproduced  thanks 
to  the  generosity  of: 

University  of  British  Columbia  Library 


L'exemplaire  filmd  fut  reproduit  grAce  A  la 
g6n6ro8it6  de: 

University  of  British  Columbia  Library 


The  images  appearing  here  are  the  best  quality 
possible  considering  the  condition  and  legibility 
of  the  original  copy  and  in  keeping  with  the 
filming  contract  specifications. 


Original  copies  in  printed  paper  covers  are  filmed 
beginning  with  the  front  cover  and  endirg  on 
the  last  page  with  a  printed  or  illustrated  impres- 
sion, or  the  back  cover  when  appropriate.  All 
other  original  copies  are  filmed  beginning  on  the 
first  page  with  a  printed  or  illustrated  impres- 
sion, and  ending  on  the  last  page  with  a  printed 
or  illustrated  impression. 


The  last  recorded  frame  on  each  microfiche 
shall  contain  the  symbol  — »>  (meaning  "CON- 
TINUED"), or  the  symbol  V  (meaning  "END"), 
whichever  applies. 

Maps,  plates,  charts,  etc.,  may  be  filmed  at 
different  reduction  ratios.  Those  too  large  to  be 
entirely  included  in  one  exposure  are  filmed 
beginning  in  the  upper  left  hand  corner,  left  to 
right  and  top  to  bottom,  as  many  frames  as 
required.  The  following  diagrams  illustrate  the 
method: 


Les  images  suiv^r^es  ont  6t6  reproduites  avec  le 
plus  grand  soin,  compte  tenu  de  la  condition  et 
de  la  nettet^  de  l'exemplaire  film6,  et  en 
conformity  avec  les  conditions  du  contrat  de 
filmage. 

Les  exemplaires  originaux  dont  la  couverture  an 
papier  est  imprimde  sont  filmis  en  commenpant 
par  le  premier  plat  et  en  terminant  soit  par  la 
dernidre  page  qui  comporte  une  empreinte 
d'impression  ou  d'illustration,  soit  par  le  second 
plat,  selon  le  cas.  Tous  les  autres  exemplaires 
originaux  sont  filmds  en  commenpant  par  la 
premidre  page  qui  comporte  une  empreinte 
d'impression  ou  d'illustration  et  en  terminant  par 
la  dernidre  page  qui  comporte  une  telle 
empreinte. 

Un  des  symboles  suivants  apparaitra  sur  la 
dernidre  image  de  chaque  microfiche,  selon  le 
cas:  le  symbole  — ♦►  signifie  "A  SUIVRE  ",  le 
symbole  V  signifie  'FIN". 

Les  cartes,  planches,  tableaux,  etc.,  peuvent  dtre 
filmds  d  des  taux  de  reduction  diff^rents. 
Lorsque  le  document  est  trop  grand  pour  dtre 
roproduit  en  un  seul  cliche,  il  est  film6  d  partir 
de  Tangle  supdrieur  gauche,  de  gauche  d  droite, 
et  de  haut  en  bas,  en  prenant  le  nombre 
d'images  ndcessaire.  Les  diagrammes  suivants 
illustrent  la  mdthode. 


1 

2 

3 

4 

5 

6 

/ 


THE  PRINCIPLES  AND 
PEACTICE  OF  MEDICINE 


I-KSIfiXED   mil   TIIK   l-SK   OF 
ra.VC.JTIONKUS   AN-,.   .STUDK.NTS   OF   MKI.ICN,, 


HY 


WILLIAM  OSLER,  M.  IX 


1-'>|! 


"-KKSSOU  of\,^c"h.  x"'^  rr'ninvr   '■'"•^"— ^-  '•  — 

I'I1VS1,,AXM.V-,:,„K,.-    TO    Tl  F  Mvo  '""■K'N-<    IMVKlislrv    ANI. 

^.K.,.v  PKOKK..O.  OF  .„F  .x.T;:;':,.Kr;  ^,^;;;;';l;^  r';7"-  "■^■■■'■'^•"- 

'1..>N>\1,\AMA,    l'llll.AI>Kr.lMllA 


SECOND  EDITION 


D. 


NEW    YORK 
APPLETOX     AND     COMPANY 
1895 


CoPYIlKiHT,  IBfl'-J,  1895, 
nv   I).   Al-ri.KTON   AND  (X^MFANY. 


^402:. 


TO 


THE  MEMORY  OF  MV  TEACHERS: 

WILLIAM   AirniUR  J(3HNS0Nr 

PRIEST   ,n-    THE    PARISH    OE    WESTO.V,    OXTiRIQ. 

JAMES  I50VKLL, 

OK   THE    TORONTO    S.  IIOOI,   OE    .MEDICINE, 

AND   OF    THE 

l-NIVERSITV   01.    TltlNITV    ,  OLLEOE,    TORONTO. 

HOHERT   PALMER  HOWARD 

BKAN   OK   THE    MEDICAL    FACCETV    AND    PROFESSOr'  OF    MEDICIXE 
M-^lilLL    CXIVERSITV,    MONTREAL.  ' 


PREFACE   TO   THE   SECOND    EDITION. 


I  iiAVK  to  thank  many  friends  for  corrections  and  sufrf^cstions, 
and  the  professidn  at  larijje  for  their  kind  reception  of  tlio  first 
e(htion. 

I  am  under  special  ol)]i<:;ations  to  I)r.  II.  M.  Thomas  and  to  Dr. 
W.  S.  Thavcr  for  mucli  vahiable  assistance ;  to  Professor  AVelch  and 
to  Dr.  Flexner  for  counsel  on  (juestions  of  patholotjy  and  bacteriology  ; 
and  to  ]\Iiss  13.  O.  Iluinpton  for  help  in  the  preimration  of  the  index. 

Several  sections  have  been  rewritten,  all  carefully  corrected,  and 
luM'c  and  there  many  fresh  details  have  been  added.  The  important 
additions  are  as  follows  : 

In  Section  I  the  article  on  Typhoid  Fever  has  been  thoroughly  re- 
vised to  date,  and  that  on  ^lalarial  Fever  in  large  part  rewritten.  The 
subject  of  Diphtheria  has  been  completely  recast,  and  extended  from 
eleven  to  twenty  pages.  The  article  on  Sopticivmia  and  Pya'inia  has 
tu'on  rearranged  and  largely  rewritten.  Short  descriptions  of  the 
I>iibonic  Plague  and  of  the  Foot  and  j\Iouth  Disease  have  been  added. 
New  matter  will  also  be  found  in  connection  with  Cholera,  Syphilis, 
Tuberculosis,  and  others  of  the  infectious  diseases.  In  this  section,  in 
describing  the  stage  of  incubation,  the  report  of  the  Clinical  Society 
of  London  has  been  adoi)ted. 

in  Section  IF  the  articles  on  (iout  and  Diabetes  have  been  ex- 
tended. A  description  of  Infantile  Scurvy  and  of  the  I  hemorrhagic 
Diseases  of  the  Xew-boru  has  been  added. 

In  Section  III  there  has  been  added  an  account  of  Eczema  of  the 
Tongue  and  of  Leukoplakia,  and  under  Chronic  Tonsillitis  will  be 
toiind  additioTial  details  regarding  the  injurious  clTi'cts  (jf  mouth- 
breathing.  The  ^Methods  of  Clinical  Examination  of  the  Stomach 
have  been  omitted,  since  they  more  correctly  belong  to,  and  are  more 
fully  given  in,  manuals  of  diagnosis.     The  subject  of  Appendicitis  has 


VI 


I'KEl'ACK  TO  THE  .SECOND   EDITION. 


been  coinpK'tcly  rewritten  and  iiiiicli  extended.  \  new  seetion  lias 
been  added  on  Alleetiuns  of  tlie  Mesentery,  and  under  Diseases  of 
tlie  Liver  a  <leserij)ti(in  of  liie  dislocations  and  det'orndties  of  the  orii'an. 
I'nder  Localized  reritonitis  a  new  wecttiun  will  lie  fonnil  on  the  Suh- 
phreidc  Variety. 

In  Seetions  I \'  and  V  many  minor  additions  and  corrections  have 
been  made.  In  writiiij;  on  Ant;ina  Pectoris,  it  was  a  pk'asnre  to  be 
able  to  jrive  the  credit  of  the  "intermittent  claudication"  theory  to 
that  distin<:;nished  old  (rlasirow  |ir(d'es>or,  Allan  I>urns. 

In  Si'ction  \'I  the  subjects  of  Ana'nua  and  Lenkienua  have  been 
revised  and  rearran<j:e(L  In  tin;  articles  (»n  Addison's  Disease  and  on 
K.\o])hthahiuc  (ioitre  and  Myxu'denm  will  be  found  references  to  the 


new  investi<;ati(in^ 


In  Section  \' II  a  brief  account  of  Ainiria  has  l»cen  added,  and  a 
number  of  minor  corrections  and  additions  have  been  made. 

In  Diseases  of  the  Xervous  System  a  new  introductory  section  has 
been  written,  with  new  diai^rams,  which  will  pntve  helpful  to  the  stn- 
(k'lit.  Most  of  the  important  points  winch  liavu  arisen  during  the  pa>t 
three  years  have  been  incorporated. 

In    Section    IX    the   article    on  ^luscular  Atrophies  has  lieen   re- 

nucd. 

In  Section  X  the  imj)ortant  studies  of  Gosio  and  of  Sanger  upon 
Arsenical  Poisoning  have  been  referred  to. 

In  the  section  on  Parasites  the  subject  of  Psorospcrmiasis  has  been 
recast,  a  short  account  of  the  Parasitic  Infusoria  has  been  added,  and  a 
number  of  nunor  corrections  have  been  made.  I  am  under  special 
indebtedness  to  Dr.  Stiles,  tlie  leading  authority  on  parasites  in  tins 
country,  for  a  careful  revision  of  the  nomenclature  in  acc(»rdance  with 
the  rules  of  the  International  Committee,  and  for  valuable  advice 
relating  to  tlie  subject.  I  could  not,  however,  yield  to  the  change  of 
name  from  Tr'n'Iiltui  to  Ti'JchlnclIa. 

And,  lastly,  I  have  added,  when  possible,  tlie  description  of  certain 
special  symptoms — as  Cheync-Stokes  breathing.  Trousseau's  ])hcnome- 
non,  and  Oliver's  tracheal  tugging — in  the  words  of  the  authors. 


1  Fbaxkun  St.  W,, 
July  1,  IS'Jo. 


C  O  N  T  K  N  T  S 


s::('Ti()x  I. 

^PKCIFIC  IXFKCTKM'S   DJ.^EASES. 


I.  Tvj.hoid  Fi.vcr 
II.  'lypliiis  Frver 

III.  I{«'l;i|i.siri^r  Kever 

IV.  Siiiall-jiox       .._'"' 

Variola  Vera 

l|il'llir.lTllilJ.'ic  .S||,„|l-i»,x    .  \  [ 

Varioloid    ,  _ 

V.  ^'•"•'•i>'iii(('oNv-,.ox)-VacoitinlioM" 
\  I.   \ancclla(Cliifkcni.(.x) 

VII.  .Seal Jet  Fever 
VIII.  Measles.         .."_■_■■• 
IV.   l{lll.ella  ({{ollielri).  ."  "  '  ■ 

■\'.  Kj.ideinie  I'arotiiis  (.Munips)" 

XI.     \VllOO|)i||^r.e„||^r|, 

MI.  Iiilliieiiza 
Mil.  J>erif,'ue  ... 
MV.  CerL'ljro-.spirial  Meningitis 

■\'^'.  nijilitlipria     . 
•\'V1.   Krysij.eias      . 

■VVII.  Septiea'miaand  JViemia 

Septiea'tnia         .         .        ^ 

Sc'ptieo-Fva'tiiia 
Win.  Cholera  Asiatiea    .         .         '        '         ' 
XI.V.  Vellow  Fi'Vfr  '         '        '        ' 

-\X.  The  Biiljonic;  J'la;,'iie 
X.VI.  Dysentery 

•\XII.  MalarialFever       ■        .        ]  ' 

Intermittent  Vawr    .         .  ' 

Continued  and  Ueniittonl  .Malarial  Feve 
Pernicious  Malarial  Fever 
.Mfdarial  Ca(,liexia      .        ,        "        ' 
Anthrax        .        . 
Hydrophobia 
Tetanus  .        .        _ 

Syphilis.        ,        . 
Acijuired    ... 
<'onf,'Pnital         .        .        _ 
Visceral 


XXIIl. 
X.VIV. 

XX  v. 
XXVI. 


I 

.      4.1 

.    "  47 

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144 
1').-) 

loa 

1«7 

170 
174 

177 
IW» 
1.S4 
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1!J1 


Vlll 


CO  NT  K  NTS. 


X.WII.  Tiilicrciilosis 

1.  (iciu'i'til  EtiiiloKy  ini'l  Mi'i'ii'l  Aimtdiny    , 

2.  Acute  Tulicrciilii.sis 

;i.  'I'uliorculo.sis  of  till'  Lyiii|ili-j;!iiii(ls  (Scnifiila) 


4. 

6. 

0. 

7. 

8. 

0. 
10. 
It. 


of  tlio  LmiK-^  (i'litliisis.  Coiimuiiii) 
of  the  Serous  Meiiihnines     , 
of  the  Aliiiu'iiliiry  Caiml 
of  tliij  Liver  .... 
of  tli(   llniiii  .■uiil  S|iiiml  Cord 
oi  ;iif  (leiiit()-uriimi\v  Sy>tem 
of  the  iMiiinmary  (ilaiiil 
of  the  Arteries 


12.  T'ro;,'iiosis  in  Tuberculosis  . 
1!}.  I'r<i|iliylaxis  in  Tiibcreulosis 
14.  Trealiiient  of  Tuberculosis 

XXVIII.  Leim.sy 

XXIX'.  (J landers 

XXX.  Aclinoinycosis 

XXXI.  Infectious  Diseases  of  I)oul>ir;il  Nature 

1.  Febricula  (Eplieinerul  l-Vv cr)     , 

2.  Weil's  Disease     .... 
8.  Milk-sickness      .        . 

4.  Malta  Fovof        .        ... 

5.  Mountain  Fever 

(>.  Miliary  Fever  vSweuting  Sickness) 
7.  Foot  and  Mouth  Di.seaso    . 


i(jn) 


PAnH 
2(« 
203 
217 
324 
22H 

2rj,') 

2(10 

2(i;j 
2<i;5 

•2M 
207 
207 
2(17 
20!) 
270 
277 
2H0 
2H2 
28") 
2^-) 
2S0 
287 
287 
288 
289 
2<J0 


SECTION    II. 
CONSTITUTIONAL   DISKASKS. 


I.  Rhc  ;matic  Fever        .        ... 
II.  Chronic  Rheuinatism         .... 

III.  Pseudo-rheumatic  A (Tect ions 

IV.  ^luscular  Klieumatisni       .... 
V.  Arthritis  Deformans  (Kheumatoid  Arthritis) 

VL  (iout 

VII.  Dialietes  Jlellitus 

VII L  Diabetes  Insipidus      .        .        .        .        . 

IX.  Rickets 

X.  Scurvy  (Scorbutus) 

-XL  I'ur|)urii 

XII.  Iliemoiihilia        .        .        .        .        . 


292 

aoo 
aoi 
ao:J 
305 
30!) 
320 
330 
332 
337 
343 
348 


SECTION  IIL 
DISEASE.-}   OF   THE    DIGESTIVE   SYSTEM. 


I.  Diseases  of  the  Mouth 

Stomjititis       .        .        .         . 
Aphthons  Stomatitis 
Ulcerative  Stomatitis     . 
Parasitic  Stomatitis  (Thrush) 
Gangrenous  Stomatitis  . 
Mercurial  Stomatitis 


351 
351 
351 
352 
353 
354 
355 


(•<)NTF':nts. 


ix 


II.  Discinos  of  the  Siilivnry  Olaiuls 

II  v|iiMM'('roti(iii        .... 

Xcrostoiiiiii 

iiilliitniiialiiin  of  llic  Salivary  (iliiiiils 
III.  Di-ca'ifs  (if  llic  IMiarynx    , 
('irciilali)fy  Distiirliariccs 
Acute  I'liaryimilis 
Clii'oiiio  I'liaryriifilis 
I'lctM'iilinii  (if  the  l'iiaryii.\     . 
Acute  liifectidiis  l*h!i'j;m(iii  of  I  lie  I'lia 
l{i'tr()-i>iiarynf;(>al  Ab.M'css 
Aii.<,'iiia  Ijiidiivici    .... 
I\'.    Diseases  of  the  Tonsils       . 

FollicMiar  or  Ijaciiiiar 'roiisljiitis  . 
Siipjuir.'tivc^  'roiisillilis  . 
("Iironic  Toiisillilis 
\'    Diseases  of  tlie  (l'',so|iliai,'iis 
Acute  (Ksoplui^'itis 
S|iasin  of  tile  (l%s(>|)liai!;us 
Stricture  of  the  (Ksopiuifrns*  . 
rancor  of  the  (Kso|ihaf,'us 
]{u|iture  of  the  (I'lsojihajjus  . 
Dilatations  and  I)iverli(nihi  . 
"V'i.  Diseases  of  tlie  Stomach    . 

Acute  (lastritis       .... 

I'lilcfjiuonous  (iaslrilis 

Toxic  (iastritis    .... 

I)il)htherilic  (iastritis 

Mycotic  (Jastrilis 
Chronic  Givstriti.s  (Chronic  Dyspe[)sii 
Neuroses  of  Stonnu^li 

(iastralf^ia 

Nervous  Dyspepsia 

Nervous  Vomit inj? 

Pcristalt'c  Unrest 

Rumination        .... 
Dilatation  of  Stomach  . 
Pe[)tic  Ulcer  ((Jastric  and  Duodemil) 
Cancer  of  Stonnich 
Ha'uiorrhage  from  the  Stomach    . 
\\\.  Diseases  of  tlie  Inlestines  , 

1.  Di.seases  of  the  Intestines  associated 

Catarrlial  Enteritis 
Diarrluea        .... 
Enteritis  in  Children 
Diphtheritic  or  Croupous  Enterit 
Plilegmonous  Enteritis. 
Mucous  Colitis 
Ulcerative  Enteritis 

2.  Appendicitis  (Tyi)hlitis  and  Perityi 
53.  Intestinal  Obstruction 

4.  Constipation  (Coslivencss) 


viix 


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;iH.-) 
;{H,-i 
yH<j 
;{K7 

;!SH 

;{»() 
;i!)4 

402 
411 
414 
414 
414 
414 
417 
421 
422 
422 
42;5 
42!» 

44;} 

451 


CONTENTS. 


i>,  Jlisc'cllaneous  AfTerlions,        .        , 
Dilatation  of  tlio  CoIdii 
AITcctidiis  of  lliu  Mi'sciitery 
VIII.  Diseases  of  the  Livi'i'        .•      . 

1.  .luiiiidico  (h'tci'iis)    .... 

2.  AfTcctioiis  of  tiio  IMooil-vesspls  of  the  L 
li.  Diseases  of  the  Hilo-pas.suges  . 

Catai'i'luil  .laiinilice 
Ciiolelilhiasis  ((iail-stoncs)  , 
Dtiier  Alleetioiis  of  tiiii  Hiie-ducts 

4.  Cirrhosis 

5,  Abscess  of  the  Liver 

().  New  (irowths  in  the  Liver 

7.  Fatty  Liver 

8.  Amyloid  J^iver         .... 

!».  Anomalies  in  Form  and  Position  of  the 
IX.  Diseases  of  the  Pancreas  . 

1.  Jla-morrhage 

2.  Acute  Pancreatitis  .... 
;>.  Clironie  Pancreatitis 

4.  Pancreatic  Cysts       .... 

T).  Cancer      ...... 

0.  Pancreatic  Calculi    .... 

X.  Diseases  of  the  IVritoineuin     . 
L  Acute  (icneral  Peritonitis 
2.  Peritonitis  in  Infants       ... 
;3.  Localized  Peritonitis 

4.  Chronic  Peritonitis. 

5.  New  Growths  in  the  Peritona-nm    . 
0,  Ascites  (Ilydro-iierilonieuni)   . 


ver 


Liver 


PAGR 

4r»4 
4r.4 
4r)4 
4',: 

4r)7 

4(!;{ 
4(i;{ 

4(15 
471 
474 
480 
485 
48!) 
4!)(> 
491 
4it2 
4i)2 
4!»8 
4i).j 
4!),') 
4!)(! 
4!)7 
4!)8 
4i)8 
502 
r)02 
505 
506 
507 


SECTION  IV. 

DISEASES   OF  THE   RESPIRATORY    SYSTEM. 

I.  Diseases  of  tlie  Nose        .... 

Acute  Coryza 

Chronic  Nasal  Catarrh 
Autumnal  Catarrh  (May  Fever)  . 

Epistaxis 

II.  Diseases  of  the  Larynx     .... 

1.  Acute  Catarrhal  Larynj^itis     . 

2.  Chronic  Ijarynjjilis  .... 
!).  (Ivlematous  Larynjjitis    . 

4.  Spasmodic  Laryngitis  (Laryngismus  Stridulus) 

5.  Tuberculous  Laryngitis  . 
G.  Syphilitic  Laryngitis       .         .        . 

III.  Diseases  of  the  IJronchi   .... 

1.  Acute  bronchitis     .... 

2.  Chronic  Pronchitis  .... 
!{.  Bronchiectasis ..... 

4.  Pronciiial  Asthma   .... 

5.  Fibrinous  Bronchitis 


513 
512 
513 
515 
510 
518 
518 
519 
519 
520 
521 
623 
524 
524 
526 
539 

5;]i 

585 


CONTENTS. 


XI 


IV.  Diseases  of  the  Lungs         .... 

1.  ("irouliitory  Disturlmiicos  in  the  Lungs 

2.  I'ncunioniii  .... 
;i.  Clironit'  luterstitiiil  I'neuiiKiniii  (Cirrhosis  of  1 

4.  Hronchn-pueuihonia  (Caiiilhiry  IJroneiiilis) 

5.  Enipliysuniii 

( 'oinpensiitDry  l-lniphysenia 
Ilyi»ertn)|)hi(^  Einpiiysenia 
Atropliic  Knipliysenia 
G.  (langrene  of  tlie  Lung 

7.  Abscess  of  the  Lung    . 

8.  I'lieunionokoniosis 
l(.  New  (trowtiis  in  the  Lungs 

\.  Diseases  of  tlie  Pleura 
1.  Acute  Pleurisy     . 

Fil)rinous  or  Piastie  Pkuirisy 
Sero-liliriiious  Pleurisy    . 
Purulent  Pleurisy  (Knipyenia 
Tuberculous  Pleurisy 
Other  Varieties  of  Pleurisy 

3.  rhronic  Pleurisy 
ii.  llytlrothorax        ... 

4.  Pneumothorax  (llydro-piunimothorax  and  I'yo 
Allections  of  the  Mcdiastiuuni  . 


ling) 


pneumothorax 


PAOE 

r,;t7 
rm 

rm; 

r,iH 

.ITH 

ru\) 

rM 
r>HA 
ma 

'MO 

rm 

rm 
rm 
rm 
r.!»7 

(!()() 
(iOO 

(;()8 

()()8 

oil 


SECTION   V. 
DISEASES  OF   THE  CIRCULATOUY   SYSTEM. 


I.  Diseases  of  the  Pericardium 

1.  Pericardii  is 

3.  Other  AITections  of  the  Pericardium 
ir.  Diseases  of  the  Heart  . 

1.  Enihiearditis 

Acute  Endocarditis . 
Chronic  Endocarditis 

2.  Chronic  Valvular  Disease    . 

Aortic  Incom|)etency 
Aortic  Stenosis 
Mitral  Incompetency 
jMitral'Steuiisis 
Tricuspid  \';dve  Disease  . 
Pulmoinu-y  X'alve  Disease 
(Combined  Valvular  Lesions 

3.  Hypertrophy  and  Dilatation 

Ilypeitrophy  of  the  Heart 
Dilatation  of  the  Heart    . 

4.  Affections  of  the  Myocardium 

Aneurism  of  the  Heart    . 
Rupture  of  the  Heart 
New  Growths  aiul  i'arasites 
Wounds  and  Forei'Mi  Bodies 


GIO 

(110 

037 
037 
037 
0:54 
0:57 
o:J7 
04;J 

04r) 

04!» 

(;■);{ 

m:\ 
m:i 

070 
075 

OH  I 
(iH3 
0M3 
08a 


Xll 


CONTENTS. 


0. 

III.  Disc 

1. 

2. 

;{. 


Xourosos  of  the  Heart         .... 

Piilpitiilion 

Arrliythiiiiii 

liapid  Heart  (Tachycardia)     . 

Slow  Heart  (Hradycardia) 

Atig'iia  Pectoris 

l'oii!,'eiiital  AflFectioHs  of  tlio  Heart    . 

ases  of  the  Artci'ies 

Degenerations 

Artcrio-selerosis  (Arterio-eapillary  Fibrosis) 
Aneurism 

Aneurism  of  the  Thoracic  Aorta    . 

Aneurism  of  tiie  Abdominal  Aorta 

Aneurism  of  the  Branches  of  tlie  Abdominal 

Artorio-venous  Anour'  m       .        . 

Congonital  Aneurism      .... 


Aorta 


PAOB 

684 
C84 
(iHo 
G87 
('.88 
CDO 
605 
6i)9 
6!)}) 
700 
TOO 
707 
710 
717 
718 
718 


SECTION   VI. 
DISEASES   OF   THE   BLOOD  AND   DUCTLESS   GLANDS. 

I.  Ana-mia 720 

Secondary  Ana^nia 720 

Primary  or  Essential  Ana>mia 723 

II.  Lcuka>mia 7-i'S 

III.  Ilodgkin's  Disi'ase 742 

I\^  Addison's  Disease 746 

V,  Diseases  of  the  Thyroid  Gland 7r)0 

Goitre 700 

Tumorsof  the  Thyroid 7r)0 

Exophthalmic  Goitre 7r)l 

Myxccdema 754 


SECTION   VII. 

DISEASES  OF  TIIE   KIDNEYS. 

I.  Anomalies  in  Form  and  Position 758 

Movable  Kidney 758 

II.  Circulatory  Disturbances 762 

III.  Anomalies  of  the  Urinary  Secretion .  703 

1.  Anuria 763 

2.  ILeniaturia 704 

3.  Ila'inoglobinuria 705 

4.  Albuminuria 767 

5.  Pyuria  (Pus  in  the  Urine)  771 

0.  (.'hyluria  (Non-j)arasitic) 772 

7.  Lithuria 772 

8.  Oxaluria 774 

».  Cystinuria 774 

10.  Phosphaturia 775 

11.  Indieanuria 770 

12.  iMelanuria 770 

13.  Olhor  Substances 777 


CONTENTS. 


Xlll 


IV. 

V, 
VI, 


VII 

\lll 
l.\ 

.\'I, 
\ll 

Mil, 


rrirmia 

Aciili'  Mright's  Disease     . 

Ciininic  Hriylil's  Disease. 
Chronic  Parenchymatous  Nei)hrilis 
Chronie  Interstitial  Nei)hrilis 

Amyloid  Disease       .... 

Pyelitis 

Hydronephrosis        .... 

Nephrolithiasis  (Renal  Caleiiliis) 

Tumors  of  the  Kidney 

Cystic  Disease  of  the  Kidney  . 

I'erinephric  Abscess 


I'A(!E 

778 
7H2 
7H7 
7H8 
7!l(l 
7<J8 
7!»!t 

m;\ 

K(K! 
811 
813 
814 


SECTION    VIII. 
DISEASES   OF  THE    NERVOUS   SYSTEM. 

1.  (ieneral  Introduction  . 
II.  Disea.'^es  of  the  Nerves 

1.  N(!uritis  (Intlaiumation  of  the  Nerve-fiWres 

2.  Neuromata 

3.  Diseases  of  the  Cranial  Nt^rves   . 

Olfactory  Nerve        .... 
Optic  Nerve  and  Tract     . 

Ijcsions  of  the  Retina  . 

Lesions  of  the  Optic  Nerve  . 

AlTeetions  of  the  Chiasnui  and  Tract 

AfTections  of  the  Tract  and  TcnU'es 
Motor  Nerves  of  the  Eyeball 
Fifth  Nerve      .        .    "    . 
Facial  Nerve     . 
Auditory  Nerve 
(riosso-pharynfjeal  Nerve 
Pneumogastric  Nerve 
Spinal  Acces^ory  Nerve   . 
llypf)glossal  Nerve  . 

4.  Diseases  of  the  Spinal  Nerves 

Cervical  Plexus 
Brachial  Plexus 
Lumbar  and  Sacral  Plexuses 
Sciatica     .... 
II.  Disoa.ses  of  the  Spimd  Cord 
1.  'J'opieal  I)iaj,?niisis 
3.  Adeetions  of  the  Meninjjes 
Diseases  of  the  Dura  Mater 
Diseases  of  the  Pia  ]\Iater 
Ibeinorrhaf^e  into  the  Spiiuil  Memltrane 

3.  Adeetions  of  the  Hlood-vesseb 

4.  Acute  AfTections  of  the  SpiiuU  Cord  . 

Acute  IMyelitis 

Myelitis  of  the  Anterior  lion 

Acute  ami  Subacute  Polio-myclili-in  Ailnli- 

Acute  Ascending  (Landry's)  Paralysis    . 


810 
8;{;} 

8;{;{ 
8:{!» 

840 
840 
841 
841 
844 

84r> 

845 

84H 
85!! 

mr, 

8.M) 

8(;;{ 

8(i.'{ 

H(;7 

870 
871 
871 

87;{ 

87(» 
877 
87!l 
87!» 
881 
881 
88;{ 

88r) 

88fi 
88!  I 
88!) 
8!>2 
H!)(i 
8!)0 


^mcwsvw^^^Kmm 


XIV 


CONTENTS. 


•f,') 


5,  riironie  AfTootions  of  llic  S|)inal  Conl 

Simstie  Piii'n[ili'giiV   .... 

Locomotor  Ataxin    .... 

Hereditary  Ataxia  (l-'rieilreich's  .\taxia) 

Syriiigo-iiiyelia         .... 

("oniprcssion  of  the  Spinal  Cord 

Lesions  of  t)ie  Cauda  K(|uina  and  Conns  Medullar 

Tumors  of  .Si)inHl  Cord  and  its  Memlirancs 

Progressive  (Spinal)  Muscular  Atrophy 
l{ull)ar  Paralysis  .... 

IV.    Diseases  of  tlie  Brain 

1.  'J'o|)ical  Diagnosis        .... 

','.  Aphasia        ...... 

;>.  Alfections  of  the  Meninges 

Diseases  of  the  Dura  Mater  (Pachymeniiigiti 

Diseases  of  the  Pia  JIater 
4.  AfFt'ctions  of  the  Blood-vessels   . 

Hypera'mia 

Ana'inia 

(Edema  of  the  Bniin 

Cerehral  llaMnorrhagc 

Embolism  and  Thrombosis  (Cereiiral  Softcni 

Aneurism  of  the  Cerebral  Artei'ies  . 

Endarteritis 

'J'hronibosi.s  of  the  Cerebral  Sii'.uses  and 

0.  lleini|ilegia  and  Diplegia  in  Children 

Hemiplegia       ..... 

S|)astie  Diplegia  (I5irlh  Palsies) 

Spastic  Paraplegia   .... 
(i.  Sclerosis  of  the  Brair^  .... 

Miliary  Sclerosis       .... 

Dilfuse  Sclerosis       .       '. 

Tuberous  Sclerosi ;   .... 

Insular  Sclerosis  i. Sclerose  en  Placpies) 
7.  Chronic  DilTuse  Meiingo-encephalitis 
H.  Tumors  of  the  Brain   .... 
i».  Inthunmation  of  tlK'  Brain  . 
10.  Chi'onic  Hydrocephalus 
V.  General  and  Functiona'  Diseases 

1.  Acute  Delirium  (Boll's  M.iriia)    . 
'2.  Paralysis  Agitans        .... 

Other  Forms  of  Tremor  . 
a.  Acute  Chorea  (Sydenham's  Chorea  ;  St.  ^' 
4.  Other  Alfections  d  -scribed  as  Chorea 

Chorea  Major;  Pandemic  Chorea   . 


Haiiit  ^ipasm  ;  '.'oiixulsive  Tic 

Sallatoric  Spasm 

Chronic  Chorea 

Rhythmic  Chorea     . 
T).  Infantile  Convulsions  (Eclampsia) 
(i.  Ejiilepsy 

Oiaiid  JIal        .... 


Vein 


tlis 


Dai; 


IS 


e) 


PAOE 

^H 

f<!»8 

"9 

,<!»« 

M 

0(»2 

m 

till 

M 

!)13 

M 

i)l4 

M 

i)l(i 

'1 

1)17 

J 

!)19 

■m 

i)22 

M 

!)24 

■1 

!)24 
027 

-a- 

1 

n;j2 

!);i2 

9;j;j 

i);}7 

«;]7 

9)38 

939 

940 

949 

900 

9o0 

Oofi 

9o8 

9.-)8 

9(11 

■■M 

9(i2 

S 

9G;} 

-^9 

9(54 

^B 

964 

Ih 

905 

m 

905 

WM 

900 

1^1^ 

9:0 

^M 

974 

^m 

977 

^B 

!)8() 

^H 

980 

jH 

982 

^B 

984 

H 

985 

w 

9!M> 

H 

99(i 

H 

990 

H 

997 

H 

998 

■ 

999 

B 

9!l!) 

1 

1003 

■ 

1004 

■       vir 

B      ^'^n. 

CONTENTS, 


PAfiE 

8i)W 

3!W 

003 

itli 

<,)13 

1)14 

i)10 

917 

!)19 

i«2 

!J!>4 

i)24 

!)37 
,  933 
,  9;i3 
.  9:5:5 
.  9:57 
.  9:57 
.  938 
.  939 
.  940 
.  949 
.  9o5 
.     9o6 

.   i)m 

.  958 

.  9.')8 

.  9(1 1 

.  963 

.  9G:5 

.  9(54 

.  964 

.   dCtn 

.  965 

.  960 

.  97(1 

.  974 

.  977 

.  980 

.  080 

.  082 

.  984 

,  985 

.  OOtt 

.  996 

.  996 

.  907 

.  098 

.  099 

.  909 

.  1003 

.  1004 


•^ 


Neuroses 


SIS 


Petit  Ma\     .... 
JiioksoiiiiiM  Kpilepsy  . 

7.  Mif,'rniiie         •        .        .        , 

8.  Neunilnia 

0.  Professional  Spasnis;  Oeeiinntion 

10.  Tetany 

11.  Hysteria.        •        .        .        .' 

Convulsive  Fonii 
Non-eonviilsive  Vurm 
13.  Neiirastjieni/i.         ... 

13.  The  TrHutiiati(!  Neuroses 

14.  Other  Forms  of  Fiinelional  Para 

Periodica!  I'arji lysis    . 
Astasia — Aliasia. 
VI.  Vaso-niotor  niid  Trophic  Disorders 
1.  Kaynaiul's  Disease. 
3.  An^n„.,„.„,.oiie.  (Fdeina 

3.  Facial  IliMui-atrophy     . 

4.  Acrome^^-alia  .        ."      , 

5.  Sclerodernia    .... 

Ainhuiu 


SECTION  IX. 
DI«!EA,SES  OF  THK   MUSCLES. 

I.  Myositis 

II.  Tiie  Mu.scular  Dystrophies 

Progressive  Neural  .Miiseuhir  Atrophy 
IIT.  Thomsen's  Disease:  Myotonia  Con-enita 
IV.  Paramyoclonus  3Iultiplcx 


SECTION  X. 


THE   INTO.nCATIONS;   SU 

I.  Alcoholism     .... 

1.  Acute  Alcoholisir  . 

2.  Chronic  Alcoholism 

3.  Delirium  'J'remens 

IT.  Jlorphia  IIal)it       .        .        .        ". 
HI.  Lead  Poison  in  <t 
IV.  Arsenical  Poisonin;L,' 
V.  Ptomaine  Poisoning' 
1.  Meat  Poisonim; 
3.  Poisoning  liy  Milk  Products. 
3.  Poisoninjr  by  Shell-fish  and  Fish 
VI.  Grain  Poi.sonins 
1.  Eri^otism 
3.  Lathyrism 
3.  Pclliigra. 
VII.  Suu-stroke      . 
VIII.  Obesity    .        .  •        •        . 


xV-STIlOKE;  OBESITY. 


XV 

PAGE 

1006 

1007 

1011 

1013 

1017 

1019 

1031 

1032 

1033 

1033 

1035 

1039 

1();S9 

1040 

1041 

1041 

1043 

1044 

1045 

1048 

1049 


1050 
1051 
1054 
1054 
1055 


1057 

1057 

1057 

1059 

1061 

1063 

1067 

1009 

1069 

1071 

1071 

1073 

1072 

1072 

1073 

1073 

1077 


XVI 


CONTENTS. 


si^X'TioN  xr. 

DISEASES  DUE   TO   ANIMAL  PARASITES. 


I.  Psorospormiasis 

1.  Internal  Psorospcrmiasis 

2.  ('iitancous  Psorosperiniasis 
II.  Parasitic  Infusoria 

III.  Distoiniasis     .... 

IV.  Disoasos  caused  by  Neinatocles 

1.  Aseariasis 

2.  Triehiniasis    . 

3.  Anchylostoiniasis  . 

4.  Filiariasis 

5.  Dracdiitiasis   . 

6.  Other  Nematodes  . 

Aeanlhocephala 
V.  Diseases  caused  by  ("ostodes. 

1.  Intestinal  Cestodes;  Tape- worms 

2.  Visceral  ('estodes   . 

Cysticercus  Cellulosai 
Echinococ'cus  Disease 
Multiloeular  Echinococcus 
VI.  Parasitic  Araeiinida 
VII.  Parasitic  Insects     . 
VIII,  Myiasis 


PAOB 

1080 
1080 
1081 
1083 
1083 
1083 
108;{ 
1085 
1090 
1091 

loas 

1094 
1095 
10!)fl 
1090 
1099 
1099 
1100 
1105 
1106 
1108 
1109 


'kOB 

nH 

OHO 

:|B 

1080 

^sB 

1081 

'9 

1083 

9 

1083 

.|H 

108!$ 

mm 

1083 

;|B 

1085 
1090 

m     ...u^ 

1091 

WL       "' 

1093 

9          '"' 

1094 

m        '^'- 

1095 

m         V 

1090 
1090 
1099 

1   nl: 

1099 

%      vin. 

1100 

m        '^• 

1105 

M        X. 

1106 
1108 
1109 

1      ^'' 

J|       XIII. 

■        XIV. 

H    '^^'' 

H 

H 

H     XVIII. 

■       XIX. 

^H.         FKIt'RG 

CHARTS  AND  ILLUSTRATIONS. 


Typhoid  Fever  with  Ileliipse        .... 

Ilhistnitiiis  the  Blood  Chiiiiges  in  Typhoid  Fever 

'I'vphoid  Fever — IlaMnorrluijio  from  the  l?ovveIs* 

Iliustratinjj  Influence  of  Hatlis  in  Typhoid  Fever 

IletiipsinK  I'Y'ver  (after  Murehisoii) 

Snmll-pox  (lifter  Striimpell). 

Ilii'Miorrliufjic  Small-pox      .... 

.Scarlet  Fever  (after  Strunipcll)    . 

Measles  (after  Striimpell)      .... 

iMalaria — Tertian  A<;ue         .... 

Illustrating  Heredity  in  Tuberculosis  . 

Chronic  Tuberculosis,  Two-hourly  Chart  for  Three  Days  . 

Blood   Chart,   illustrating   Rapid   Production  of  Ana^nda   in   Pu 

IFaMnorrhagiea 

Temperature,  Pulse,  and  Respiration  Chart  in  Pneumonia 
Blood  Chart,  illustrating  Aiupmia  in  Purpura  Ihemorrhagicja 

Blood  Chart,  illustrating  Chlorosis 

Blood  Chart,  illustrating  Pernicious  Amcmia 

Blood  Chart,  illustrating  LiudvaMina 

Case  of  Sun-stroke  treated  with  the  Ice-bath.     Recovery,    (Rectal 

peraturcs) 


PAOE 

14 
19 
33 

:i9 

49 

'ii 

57 

74 

83 

164,  165 

207 

344 


ri)ura 


Tern 


;546 


552 
731 
724 
7;i0 
739 

1075 


1.  Diagram  of  Motor  Path  (Van  Gehuchten) 817 

3.  Diagram  of  Motor  Path  from  Right  Brain  (Van  Gehuchten)     .        .        .818 

3.  Diagram  of  Cerebral  Localization 822 

4.  Diagram  of  Motor  and  Sensory  Representation  in  the  Internal  Capsule    .    833 

5.  Dingram  of  Motor  and  Sensory  Paths  in  ('rura 824 

6.  Diagi-am  of  Cross-section  of  Spinal  Cord 824 

7,  8.  Head's  Diagrams  of  Skin  Areas  corresponding  to  the  Different  Spinal 

Segments 826,  827 

9.  Diagram  of  Visual  Paths  (Vialet) 840 

10.  Liehtheim's  Schema 927 

11,  Diagram  of  Motor  Path  from  Right  Brain 945 


*  The  red  shows  the  two-hourly,  the  black  the  morning  and  evening  temperature. 


"Exporiccu  is  f,,l!m.i.,„s  and  j,<,lc,,no.>t  dinietUt." 
HiiTocKATKs:  Aphuri.vm,  I. 

"And  I  said  of  rnodi.'ine,  that,  this  is  nii  art  which 
Cons,do.,    the   ..on.,i,„tio„  of   the   patio  „i.s 

pnneiplos  of  action  and  reasons  in  cih  cli.' ' 

Plato  :  Guiy/cis, 


A  TEXT-BOOK    ON 
ITIE   PKACTICE   OK   MJ^:jJlCrNE. 


SEcriox  I. 


SPECIFIC   IIS^FECTIOUS   DISEASES. 


I.    TYPHOID    FEVER. 

Definition. — An  itifoetious  disoaso,  cliiiriiclorizod  unatomiciilly  by 
liypiTpliisia  iiiid  ulconitioii  of  the  lyin])li-fiilli(;k's  of  the  iiitcstiiics,  swcll- 
iiiil  of  tlio  niest'iitoric  ^liiiids  and  s|ilo('n,  and  parcncliyinatous  cliaiiircs 
ill  the  other  organs.  Tlie  bacillus  of  Kbcrth  is  constuntly  present  in  the 
lesions.  Clinically  the  disease  is  marked  by  fever,  a  rose-coloroil  eruption, 
(iiarrluea,  abdominal  tenderness,  tympanites,  and  enlargement  of  the 
spleen  ;  but  these  symptom.s  are  extremely  inconstant,  and  even  the  fever 
varies  in  its  characters. 

Historical  Note. — 'I'he  dates  1813  and  1850  include  the  modern 
discussion  of  the  subject.  I'rior  to  tlie  former  year  many  observers  hud 
iKited  clinical  dilTensnces  in  the  continued  fevers.  Iluxham  in  particular, 
in  his  renuirkable  Essay  on  Fevers,  had  "  taken  noti(;e  of  tlie  very  great 
(lilTerence  there  is  between  the  putrid  maliipidtit  and  the  slow  ncrniits 
fcri'r."  In  1813  I'ierre  Bretonneau,  of  Tours,  distinguished  "dotliieiien- 
terite"  as  a  sejiarate  disease  ;  and  Petit  and  Serres  described  eutero-mes- 
cnteric  fever.  Trousseau  and  Velpeau,  students  of  liretonnean,  were,  in 
IS-.M),  instrumental  in  making  his  views  known  to  Andral  and  others  in 
I'aris.  In  1829  Louis'  great  work  appeared,  in  wliich  the  luime  "  typhoid  " 
was  given  to  the  fever.  At  this  period  typiioid  fever  alone  prevailed  in 
Paris,  and  it  was  universally  believed  to  be  identical  with  the  continued 
iVver  of  (ireat  Britain,  where  in  reality  typhoid  and  typhus  coexisted  ;  and 
the  intestinal  lesion  was  regarded  as  an  accidental  occurrence  in  the  (bourse 
f  (irdinary  typhus.  Louis'  students  returning  to  their  homes  in  different 
iiiitr;es  had  opportunities  of  studyitig  the  ])revaleiit  fevers  in  the  thor- 
oiiy^li  and  ^'stematic  manner  of  their  master.  Among  these  were  certain 
young  American  physicians,  to  one  of  whom,  (ierhard,  of  I'hiiadelphia,  is 
duo  the  great  honor  of  having  first  clearly  laid  down  the  ditferences 
between  the  two  diseases,     llis  papers  in  the  American  Journal  of  the 


(I 

CO 


3 


SI'KCIFIC   lNKK("n0US   DlSEASKS. 


Mctliciil  Scionoos,  ls:{7,  •'  rndKuhtcdly  tlic  first  in  any  l;m,i,niii<ro  which 
^nvf  ii  full  1111(1  satisractdi'v  iiccoiiiit  of  the  ciiiiical  and  aiiatoinn'al  distini!- 
tions  wti  now  rcco^^nizc,  .No  student  should  fail  to  read  ihi'su  urticlos, 
anionj,'  tin-  most  classical  in  Anutrican  medical  literature. 

lionis'  influence  was  early  felt  in  ]{oston,  to  whicli,  in  is;?;},  James 
.Jackson,  .Jr.,  had  returned  from  J'aris.  In  this  year  he  demonstrated,  in 
his  father's  wards  at  the  Massachusetts  (Jeneral  Hospital,  the  identity  of 
the  ty[)hus  of  tins  country  with  the  ty[)hoid  of  Louis,  lie  had  already, 
in  l(S;}(i,  iKtticed  tho  intistinal  lesions  in  tho  common  fever  of  New  Eng- 
land. 'rhou<,di  cut  olT  at  the;  very  outset  of  his  career,  we  may  reasonahly 
attribute  to  his  inspiration  the  two  elaborate  memoirs  on  ty]»hoi(l  fever 
wliich,  ill  18;J8  and  lH;5!t,  were  issued  from  the  Massachusetts  (ieneral 
Hospital,  by  James  Jackson,  Sr.,  and  Kiiooh  Ilalc.  These,  with  (Jerliard's 
articles,  contributed  to  make  typlujid  fever,  as  distin^Miisiied  from  ty])lius, 
wididy  reco^'iiized  in  the  professi<jii  here;  long  befont  the  distinctions  were 
recognized  generally  in  Kurope.  Thus,  they  were  described  uiuler  diU'er- 
ent  headings  in  the  tirst  eilitioii  of  Martletl's  admirable  work  on  Fevers, 
l)ublished  in  1S4'3. 

The  recognition  in  I'aris  of  a  fever  distinct  from  typhoid,  without 
intestinal  lesions,  was  due  largely  to  the  inllucnce  of  the  able  ])a]>ers  of 
(ieorgc  C  Shattuck,  of  Hoston,  and  Alfred  Stille,  of  I'hiladelpliia,  which 
were  read  before  the  Societe  medicah^  d'Observation  in  18:58.  At  Louis' 
reijuest,  Shattuck  went  to  the  London  Fever  Hospital  to  study  the  disease 
in  Fngland,  where  ho  saw  the  two  distii;>;t  alTcctions,  and  brought  back  a 
report  which  was  very  convincing  to  the  members  of  the  society  (Medical 
Examiner,  IMiiladelphia,  1840). 

Stille  had  the  atlvantage  of  going  to  Paris  knowing  thoroughly  the 
clinical  features  of  typhus  fever,  for  he  had  been  (ierhard's  housc-j)hysician 
at  the  Philadelphia  llosj)ital  during  the  epidemic  of  18;i(i.  At  La  Pitie, 
with  Louis,  he  saw  (juitc  a  different  affection,  while  in  London,  Dublin, 
and  Naples  he  recognized  typhus  as  he  had  seen  it  in  i'hiladel])hia.  The 
results  of  his  observation  were  given  in  an  exhaustive  j)aper  which  ])re- 
sented  in  tabular  form  the  contrasts  and  distinctions,  clinical  and  ana- 
tomical, wliich  wo  now  recognize. 

In  (ireat  Pritain  the  non-identity  of  typhus  and  typhoid  was  clearly 
established  at  (Jlasgow,  where  from  1830  to  1838  A.  P.  Stewart  studied 
the  continued  fevers,  and  in  1840  published  the  results  of  his  observations. 
In  the  decade  which  followed  many  important  works  were  issued  and 
more  correct  views  gradually  prevailed  ;  but  it  was  not  until  the  jiublica- 
tion  of  Jenner's  observations  between  184'J  and  1851  tliat  the  question 
Avas  finally  settled  in  England. 

Etiology. — Tyi)h()id  fever  iirevails  especially  in  temperate  climates, 
in  which  it  constitutes  the  most  common  continued  fever.  Widely  dis- 
tributed throughout  all  parts  of  tlie  world,  it  probably  presents  every- 
where the  same  essential  characters. 


TYPIlOtn  FEVRR. 


wli  it'll 
listiiKv 
irticlcs, 

,  .hiiiu'S 
;iU'(l,  in 
iitity  ol" 
ili'ciidy, 
w  Kiig- 
soimbly 
id  fever 
(Iciu'val 
rrliiird's 
ty])liiis, 
)iis  were 
:r  dilTer- 
.  Fevers, 

without 
)ai'ers  of 
11,  w  hi  ell 
it  Tiouis' 
e  disease 
t  biick  a 
(Medieul 

rhly  tlie 
ihysiciau 
ia  IMtie, 

Dublin, 
a.     The 
1  it'll  jire- 
luid  ana- 
Is  clearly 
studied 

•vations. 
iied  and 

[luhlica- 

[ueslion 

[lirnates, 
llely  dis- 
Is  every- 


It  prevails  most  in  the  aiitiiiiiu  nmnths.  Of  1,8SiO  cases  admitted  to 
the  Mnntrcal  (iciieral  Hospital  in  twenty  years,  more  than  iifly  per  cent 
were  in  the  months  of  August,  Septeinher,  and  October.  (H"  l,:)Sl  cases 
treated  diiriiij^  twelve  years  at  the  'i'oronto  (ieiieral  Hospital,  |fll  oe- 
ciiirerl  in  these  months  ((Jraham).  It  has  been  well  ealletl  the  autumnal 
fever. 

It  has  been  observed  to  jirevail  most  in  hot  and  dry  seasons.  Accord- 
iie.'  t((  i'ettenknfer,  epidemics  are  most  I'onimon  when  the  <,'round-water  is 
jnu,  under  which  circumstaiices  the  spriiiixs  and  water-sources  drain  more 
tlinronj,'hly  contaminated  foci  and  are  more  likely  to  be  highly  char<fed 
wiili  poison.  It  may  be  also,  as  I?auni<^arteu  suggests,  thiit  in  dry  seasons 
tlie  poison  is  more  disseminated  in  the  dust. 

Males  and  females  an!  about  etpndly  liable  to  tlie  disease,  but  nudes 
with  typhoid  tire  nnidi  more  fre([iu'iitly  admitted  into  hos[)itals. 

Typhoid  fever  is  a  disetise  of  youth  iind  early  adult  lil'e.  The  greatest 
susceptibility  is  between  the  ages  of  lifteen  and  twenty-tive.  Of  t'ldO  of 
tlio  Montreal  cases  there  were  under  fifteen  years  of  age,  ;"»]  ;  hetween 
lil'tieii  and  twenty-live  years,  30S  ;  between  twenty-live  and  thirty-live  years, 
l."i:i;  hetween  thirty-five  and  forty-five  years,  415 ;  lietween  forty-five  and 
lil'ty-live  years,  C ;  uiid  over  fifty-five  years,  IJ.  Cases  are  rare  over  sixty. 
It,  is  not  very  infretpient  in  childhood,  but  infants  are  rarely  attaclu'd. 
.Mm'i'hisoii  has  seen  a  case  at  the  sixth  month.  Tln'  diseas(>  may  be  con- 
genital in  cases  in  which  the  mother  has  had  the  disease  late  in  pregnancy. 

As  in  other  fevers,  not  all  exposed  to  the  infection  take  the  disease, 
aiid  there  are  grades  of  susceptibility.  kSome  families  seem  nnu'e  disjxised 
to  infection  tluin  other.s. 

Ty[ihoid  fever  is  becoming  less  prevalent  in  the  hirge  cities  in  conse- 
qiieiice  of  improved  sanitation.  In  suburban  and  country  districts  it  is 
,'ili|i;ireiitly  on  the  increase. 

The  Specific  Germ.— The  researches  of  Eberth,  Koch,  fialTky,  and 
others  have  shown  thiit  there  is  a  special  micro-organism  roiistdiithi  asso- 
ciated with  ty[)lioid  fever.  It  is  a  rather  short,  thitdv,  motile  bacillus,  with 
roiiiHled  end.s,  in  one  of  which,  sometimes  in  both  (particularly  in  cul- 
tures), there  can  be  seen  a  glistening  round  body,  believed  to  be  a  spore; 
iiiit  these  polar  structures  are  jirobably  only  areas  of  dense  ])rotoplasm. 
It  grows  readily  on  various  nutritive  media,  and  can  now  be  differentiated 
fnmi  the  Ixirtrrinin  coU  roiiimintc,  with  whi(di,  and  with  certain  other 
hiieilli,  it  is  apt  to  be  confounded.  This  organism  fulfils  two  of  the  re- 
<|iiiremcnt3  of  Koch's  law — it  is  constantly  present,  and  it  grows  outside 
tile  liody  in  a  specific  manner.  The  third  requirement,  the  production 
of  the  disease  ex|)erimentally  by  the  cultures,  has  not  yet  been  met. 
Probably  tiie  animals  used  for  experimentation  are  not  susceptible  to 
typhoid  fever.  The  bacilli  or  their  toxins  inoculated  in  large  cpiantities 
into  the  blood  of  rabb'ts  are  jiathogeinc,  and  in  some  instances  ulcerative 
and  necrotic  lesions  in  the  intestine  may  be  produced.     But  similar  intes- 


SI'KCIKIC    INI'KCTIOUS   DISK  ASKS. 


tiiiiil  l(>si()ns  limy  l)i'  ••iiiiscd  l)y  oLIht  biicUfriii,  iiicliuliiij;  tlii'  /itir/rriuin  aili 
fDiiiiiiinir. 

(iilliiii's  iirc  killi'il  at  a  ti'Hi|>('riittiro  of  f50°  ('.  !t  is  not  probabli^  tliat 
the  ty|>lii)itl  l)acillii.s  produces  spores,  but  it  resists  dry iiiij  for  days.  Houil- 
loii  cidtiircs  arc  dcstroyctl  by  carbnlic  uml,  I  to  '40(),  and  by  corrosive  siil)- 
liiiiatc,  I  lo  ;.',.jU(). 

In  recent  ciisen  of  tyjjhoid  fever  tbc?  bacilli  are  found  in  ibe  lyinpboid 
tissues  of  \\h;  intestines,  in  tbo  niesent(!ric  <f|ands,  in  tbe  spleen,  in  tlic 
bone  marrow,  in  llic  liver,  and  in  tbe  bib*.  'I'bo  bacilli  occur  also  in  ir- 
re^ndar  clumps  in  tbe  coutenis  of  tbe  intestines  and  in  tbe  stools;  but  tbo 
studies  of  Sanarelli  and  of  W'atbelet,  witb  more  recent  nu-lbods  of  dilTcr- 
entiatinj,'  tbe  colon  bacillus,  bave  sbown  tbat  tbey  are  scanty  in  tbe  fa'ces, 
and  may  nut  be  present  in  tbe  stools  until  tbe  ter.tb  day  or  later.  Cul- 
tures from  tbe  ('(intents  of  tbe  small  intestine  in  fatal  cases  may  be  ne<;a- 
tive.  Tbe  bacilli  bave  been  found  in  tbe  blood  and  in  tbe  rose-colored 
spots.  In  tbe  urine  tbey  nuiy  be  present  in  nundn'rs,  and  tbey  bave  been 
found  in  tbe  sweat.  From  tbe  endocardial  vegi-tations,  from  mcninircal 
and  pleural  exudates,  and  from  fo(;i  of  su|»puration  in  various  parts,  ibe 
bacilli  liav((  also  been  isolated. 

Outside  Ibe  body  tbe  bacilli  retain  tlieir  vitality  for  weeks  in  water. 
Wbetber  an  increase  can  occur  is  not  yet  linally  .settled.  Holton  denies  it, 
but  tbe  general  opinion  seems  to  be  tbat  sucb  increase  nuiy  take  ])Iace  to 
some  extent.  Tbey  disappear  from  ordimiry  water  in  conipetilion  witb 
.sapropliytes  m  a  few  days,  in  nulk  tbey  undcr^fo  rapid  develojiment  wilb- 
out  cbanj:in<.^  tbe  appearance  of  tbe  milk.  Tbey  may  itu'rease  in  tbe  soil 
and  retain  tl cir  vitality  foi'  niontbs.  'i'bey  are  not  killed  by  freezing,  but, 
as  Pnulden  bas  sliown,  nuiy  live  in  ice  for  montbs.  in  many  epidemicts 
tbe  bacilli  bave  been  detccted-in  tl;i'  infected  water.  Tbe  detection  bow- 
ever  of  tlu^  typboid  bacillus  in  di  itdving-water  is  by  no  means  easy,  and 
the  question  in  iiulividual  cases  muf-t  be  settled  by  experts  wlio  have  bad 
special  experience  witb  this  germ.  Bolb  I'rudden  and  Ernst  liave  fouiul 
it  in  water-lilters. 

Tbe  direct  infection  by  dust  of  exposed  food-stulTs,  sucb  as  milk,  is 
very  ))robal)le.  Tlu^  bacilli  retain  tlieir  vitality  for  many  weeks ;  in  gar- 
den eartb  tweiity-(Mie  days,  in  tilter-sand  eigbty-two  days,  in  dust  of  tbo 
street  tbirty  days,  on  linen  sixty  to  seventy  days,  on  wood  tbirty-two  days 
(L'lTelmatin). 

Modes  of  Conveyance. — Oi)  ('onidi/foi/. — Tbe  possibility  of  tbe  direct 
transmission  tbrougb  tbe  air  from  one  person  to  anotber  must  be 
acknowledged.  Tbere  are  bouse  epidemics  in  wbicb  contamination  of 
tbo  water  or  food  could  be  almost  positively  exiduded.  The  nui>!es  and 
attendants  wlio  bave  to  d(  witb  tbo  stools  and  body-linen  of  tbo  pa- 
tients are  alone  liable  to  direct  infection.  During  the  })ast  six  years 
one  nurse,  one  orderly,  and  one  patient  contracted  the  disease  in  my 
wards. 


'i 


•J 


I 

i 
] 


i: 


TYIMIOin   FRVKIl. 


uiu  eoli 

h\e  tlmt 

Hoiiil- 

ivo  8ub- 

lupliniil 

1,  in  tlu.' 
^o  in  ir- 
hut.  liie 
)f  (iilTcr- 
i(j  la'ci'S, 
■r.  Ciil- 
bo  iicjia- 
.'-('olori'd 
avi:  hi'i'ti 
iciiiiijrciil 
liirts,  I  lie 

ill    WlltlT. 

(It'iiios  it, 
■  |»Ia(H'  to 
lion  with 
I'lit  willi- 
tlie  soil 
liT,  but, 

l(l(!Illi(^S 

11  liow- 
isy,  and 
ivi!  lia('. 
e  foiu'il 

milk,  is 
ill  iiar- 
st  of  the 
wo  days 

10  direct 
[iiust  be 
ation  of 
fses  and 
the  })ii- 
ix  years 
in  my 


(//)  fiifcrlian  iif  ii'iitrr  is  iiii<|iicsti(iiialily  the  most  eommon  tt"-"'  tf 
ciiiivi'vanct'.  Many  cpidcriiics  have  been  shown  to  oriirinatc  in  the  con- 
hiiiiiiialion  of  a  well  or  a  sprini,'.  A  very  slrikiiii:  one  occurred  at  I'lym- 
(Milli,  i'a.,  in  ISS,"»,  wliicli  was  investiKjitcd  l)y  Shakespeare.  'The  town, 
with  a  population  of  ei;^dit  thousand,  was  in  part  .supplied  with  driiik- 
iiiir-water  from  a  reservoir  fed  by  a  mountiiin  stream.  I)iirin<f  .laniiary, 
I'lliniarv,  i'lid  March,  in  a  eottafje  liy  the  side  of  ami  at  a  distance  of  from 
sixty  to  eifxhty  feet  from  this  streatn,  a  man  was  ill  with  typhoid  fever. 
Tlie  atti'iidaiits  were  in  the  habit  at  niirht  of  tlirowin;;  out  the  evaciia- 
liniis  on  till'  ^roimd  toward  the  stream.  DiiriiiL'' these  months  the  ;;roiind 
\\;i<  frozen  and  covereil  with  snow.  In  the  latter  pai't  of  March  ainl  early 
in  April  there  was  oonsiderable  rainfall  and  a  thaw,  in  which  a  lar<f(>  part 
(if  ilic  three  months'  ai-cnmnlafion  of  discliarires  was  washed  into  the 
hrnnk,  not  sixty  feet  distant.  At  the  very  time  of  this  thaw  the  [latieiit, 
had  niimeroiiH  and  eopions  discharu;es.  Alxnit  the  loth  of  A|)ril  eases  of 
tvplioid  fever  broke  out  in  the  town,  appearintr  fur  a  lime  at  the  rate  of 
liflv  a  ilay.  In  all  about  twelve  hundred  people  wen;  alTected.  An  ini- 
iiiciise  majoritvof  all  the  eases  were  in  the  part  of  the  town  which  received 
water  from  the  infected  reservoir. 

{<■)  hifi'riio)!  of  luxuL — Milh  may  be  the  source  of  infection.  One  of 
the  most  thoroiifjlily  studied  epidemics  due  to  this  cause  was  that  iiivesfi- 
iratod  by  Mallard  in  Islintrtoii.  'I'he  milk  may  be  eontaniinatecl  by  infected 
water  used  in  cleansin'r  the  cans.  In  fresh  milk  it  has  been  slntwn  thai 
the  L'erms  prow  rapidly. 

in  addition  to  the  milk,  the  j.r('riiis  may  be  conveyed  in  ice,  salads  of 
various  sorts,  (telery ;  and  the  food  maybe  readily  eontaminatc'd  by  the 
soiled  fnifrers  of  the  attendants,  or  of  the  patient  himself.  A  fly  which 
lias  alighted  on  the  soiled  linen  of  a  typhoid  patient  in  a  ward  may  sub- 
s('(iiiently  contiiminate  ilie  milk  or  other  food. 

Oyster.s  may  beeome  infeeted  dnriiii,''  the  process  of  fattoniiiLr  or  fresli- 
(■ninji;.  In  the  Middletown  epidemic,  rt'ported  by  If.  W.  ('onn,  the  chain 
of  circumstantial  evidence  seems  complete ;  atid  most  supirestive  sporadic 
eases  have  been  recorded  by  Sir  William  Broad  bent  and  others. 

('.  J.  Foote  has  made  an  intorestiiifj  hacteriolojjical  studv  of  the  sui)- 
jcct.  Oysters  taken  from  the  feedlng-rrronnds  in  rivers  contiiin  a  very 
imuOi  larffcr  number  of  micro-orpuiisni>  of  sdl  sorts  tlian  those  from  the 
.*ea.  lie  has  shown,  too,  tliat  Kberth's  bacillus  will  live  in  the  brackish 
water  in  wliicli  oyster's  are  fattened  even  wlien  frozen  ;  and  that  it  will  also 
live  in  the  oyster  itself,  and  for  a  lon<Ter  time  than  in  the  water  in  which 
the  oyster  grow.s.  Whether  multiplication  takes  place  in  the  oyster  is 
doiihtful. 

{(I)  Contamination  of  the  Soil. — Pettenkofer  liolds  that  tlu;  poison  is 
not  eliminated  in  a  condition  capable  (.f  comninnicatinir  the  disease  di- 
roctly,  but  that  it  must  first  undergo  changes  in  the  soil,  which  changes 
are  favored  by  the  ground-water. 


Q  SPECIFIC   INFECTIOUS  DISEASES. 

Filth,  bad  sewers,  or  cfosspools  cim  not  in  themselves  cause  typhoid 
fever,  but  they  furnish  the  conditions  suital)le  for  the  preserva^on  of  the 
bacillus,  and  possibly  for  its  j)ropa<jation. 

Once  in  tlie  intestinal  canal  the  germs  probably  do  not,  as  do  tlie  chol- 
era bacilli,  increase  in  the  contents,  but  ])enetrate  the  e})ithelial  lining  and 
reacli  the  lym])h()id  tissue,  u])()n  which  they  exert  their  si)eeitic  action, 
causing  a  cell  proliferation  greatly  in  excess  of  the  physiological  process. 
The  necrosis  may  be  regarded  as  the  result  of  the  maximum  intensity  of 
the  action  of  the  bacilli — an  action  not  coniined  to  the  lymjdiatic  appa- 
ratus of  the  intestinal  wall,  but  also  met  with  in  a  typical  manner  in  the 
enlarged  mesenteric  glands  and  in  the  liver  and  spleen. 

Froducfs  of  flic  (irowlh  of  the  BiiciUi. — Brieger  and  Fraenkel  have 
separated  from  bouillon  cultures  a  poison  belonging  to  the  group  of  tox- 
albumiiis,  and  to  this  typhotoxin,  as  it  has  been  called,  the  more  serious 
features  of  the  disease  are  ascribed.  Sanarelli  has  found  that  in  addition 
to  a  general  toxic  action  similar  to  other  poisons  of  its  class,  the  typho- 
toxin produces  in  animals  clumges  in  the  small  bowel,  particularly  in  the 
lynij)h  elements. 

Morbid  Anatomy. — The  statistical  details  under  this  heading  are 
based  upon  eighty  autopsies,  a  niajurity  of  which  were  performed  at  the 
Montreal  General  llosjjital,  and  upon  the  records  of  two  thousand  post- 
mortems at  the  ^lunich  Pathologicid  Institute.* 

Intestines. — A  catarrhal  condition  exists  throughout  the  small  and 
large  Ixiwel,  and  to  this  is  due,  in  all  i)robability,  the  diarrha-a  with  the 
thin  pea-soup-like  stools.  Associated  with  this  catarrh  there  is  some  epi- 
thelial desquamation. 

Specific  changes  occur  in  the  lymphoid  elements  of  the  bowel,  chiefly 
at  the  lower  end  of  the  ileum.  '  The  alterations  which  occur  are  most  con- 
veniently described  in  four  stages: 

1.  Ifi/prrplasid,  which  involves  the  glands  of  Peyer  in  the  jejunum  and 
ileum,  and  to  a  variable  extent  those  in  the  large  intestine.  The  follicles 
are  swollen,  grayish-white  in  color,  and  the  ])atches  may  project  to  a  dis- 
tance of  from  three  to  five  mm.  In  exceptional  cases  they  may  be  still 
more  ])rominent.  The  solitary  glands,  which  range  in  size  from  a  pin's 
head  to  a  large  pea,  are  usually  deeply  imbedded  in  the  submucosa,  but 
project  to  a  variable  extent.  Occasionally  they  are  very  prominent,  and 
may  be  almost  jjcdunculated.  Microsco])ical  examination  shows  at  the 
outset  a  condition  of  hyperivmia  of  the  follicles.  Later  there  is  a  great 
increase  and  accumulation  of  cells  of  the  lymph-tissue  which  may  even 
infiltrate  the  adjacent  mucosa  and  the  nniscularis ;  and  the  blood-vessels 
are  more  or  less  compressed,  which  gives  the  whitish,  ana?mic  ajipearitva 
to  the  follicles.  The  cells  have  all  the  characters  of  ordinary  lymph-coi  • 
pnscles.     Some  of  them  however  are  larger,  epithelioid,  and  contain  several 


*  Mlinchenor  inedicinische  Wochenschrift,  Nos.  3  and  4,  1891. 


TYPHOID  FEVER. 


liefly 

at  COU- 

1  and 

liek'S 
I  dis- 
3  siill 

pin's 
a,  bnt 
t,  and 
It  the 

sxreat 
/  even 
vessels 

ili-COl  ■ 

several 


iinoici.  Occasionally  colls  containing  rod  bloofl-corpnsclos  arc  seen.  This 
so-called  niedidlary  iiifiltration,  which  is  always  more  intense  toward  the 
lower  end  of  the  ilenni,  reaches  its  height  from  tiie  eighth  to  the  tenth 
(lav  and  then  undergoes  one  of  two  changes,  rcsaliifion  or  ucrrasis.  Di'ath 
verv  rarely  takes  place  at  this  stage.  Kesolution  is  accomplished  by  a  fatty 
and  granular  change  in  the  cells,  which  are  destroyed  and  absorbed.  A 
curious  coiulition  of  the  i)at(dies  is  ])roditced  at  this  stage,  in  which  they 
have  a  reticulated  ai)pearance,  the  phi q lies  a  surfiicc  rc/icti/('i'.  Tiie  swoll- 
en fdllick'S  in  the  patch  undergo  resolution  ami  shrink  more  rapidly  than 
the  surrounding  franu^work,  or  what  is  more  probable  the  follicles  aloiu' 
owing  to  the  intense  hyperplasia  become  necrotic  and  disintegrate,  leaving 
tlie  little  pits.  In  this  process  superficial  luemorrhages  may  result,  and 
small  ulcers  may  originate  by  the  fusion  of  these  superlicial  losses  of  sub- 
stance. 

'J'liere  is  nothing  distinctive  in  the  hyperplasia  of  the  lymjih-follicles 
in  typhoid  fever;  but  apart  from  this  disease  we  rarely  see  in  adults  a 
marked  aifection  of  these  glands  with  fever.  In  children  however  it  is 
not  uncommon  when  death  has  (>ccnrred  from  intestiiud  ail'ections,  and  it 
is  also  met  with  in  measles,  diiditheria,  and  scarlet  fever. 

'I  J\'errosi.s  and  iSloiiq/iuif/. — When  the  hyperplasia  of  the  lym])h-fol- 
licles  loaches  a  certain  grade  resolution  is  no  longer  iiossible.  'I'lie  blood- 
vessels become  clioked,  there  is  a  condition  of  aiueniic  necrosis,  and 
sloughs  form  which  must  be  separated  and  thrown  olT.  The  necroris  is 
probably  {]uo  in  great  part  to  the  direct  action  of  the  bacilli.  The  piocess 
may  be  superlicial,  aifecting  only  the  njiper  part  of  the  mucous  coat,  or  it 
may  extend  to  and  involve  the  subuuicosa.  The  "slough  "  may  sometimes 
lie  upon  the  Peyer's  patch,  scarcely  invohing  the  epithelium  (Mandiand). 
It  is  always  more  intense  toward  the  ileo-civcal  valve,  and  in  very  severe 
cases  the  greater  part  of  the  mucosa  of  the  last  foot  of  the  ileum  may  be 
converted  into  a  brownish-black  es(diar.  The  necrotic  area  in  tlie  solitary 
glands  forms  a  yellowish  cap  which  often  involves  only  the  most  promi- 
iiont  i'i>int  of  a  follicle.  The  extent  to  which  the  necrosis  reaches  is  very 
variable.  It  may  pass  deep  into  the  muscular  coat  reaching  to  or  even 
perfciratiug  the  peritonaMun. 

3.  f'/n  ntfion. — The  separation  of  the  necrotic  tissue — the  sloughing — 
is  gradually  elfected  from  the  edges  inward,  and  results  in  the  formation 
of  an  ulcer,  the  size  and  extent  of  which  are  directly  ])roportionate  to  the 
atnount  of  necrosis.  If  this  be  superficial,  the  entire  thickness  of  the 
unicosa  may  not  be  involved  and  the  loss  of  substance  may  bc^  small  and 
shallow.  More  commonly  the  slough  in  separating  exposes  the  submucosa 
ami  rnuscularis,  particularly  the  latter,  which  forms  the  floor  of  a  majority 
•  if  all  typhoid  lilcors.  It  is  not  common  for  an  entire  Peyer's  patch  to 
slough  away,  and  a  perfectly  ovoid  ulcer  ojiposite  to  tlio  mesentery  i.s 
rarely  seen.  Irregularly  oval  and  ronmlcd  foitns  are  most  common.  A 
large  patch  may  present  three  or  four  ulcers  divided  by  sei)ta  of  mucous 


8 


SPECIFIC   INFECTIOUS   DISEASES. 


inombrano.  The  tonnituil  six  or  eight  inches  of  tlie  mucous  membrane 
of  the  il(uim  may  form  a  large  ulcer,  in  which  are  here  and  there  islands 
of  mucosa.  The  edges  of  the  ulcer  are  usually  swollen,  soft,  sometimes 
congested,  and  often  undermined.  At  a  late  period  the  ulcers  near  the 
valve  may  have  very  irregular  sinuous  borders.  The  base  of  a  ty])hoid 
ulcer  is  snujoth  and  clean,  usually  formed  of  the  submucosa  or  of  Llie 
muscularis. 

Tlu'rc  may  be  large  ulcers  near  the  valve  and  swollen  liyperasmic 
patches  of  I'eycr  in  the  upper  jtiirt  of  the  ileum. 

4.  lI('nUn(j. — Tills  begins  with  the  development  of  a  thin  granulation 
tissue  which  covers  the  base  and  gives  to  it  a  soft,  shining  ajtpearance. 
The  mucosa  gradually  extends  from  the  edge,  and  a  new  growth  of  epi- 
thelium is  formed.  The  glandular  elements  are  reformed  ;  the  healed 
ulcer  is  somewhat  depressed  and  is  usually  pigmented.  Occasionally  an 
appearance  is  seen  as  if  an  ulcer  had  healed  in  one  phuie  and  was  extend- 
ing in  another.  In  death  during  relapse  healing  ulcers  may  be  seen  in 
some  patches  with  fresh  ulcers  in  others. 

We  may  say,  indeed,  that  healing  begins  with  the  separation  of  the 
sloughs,  as,  when  i'csolnti('n  is  im])ossible,  the  removal  of  the  necrosed 
part  is  tlu>  llrst  step  in  th  .^  j)rocess  of  repair.  l'racti(^ally,  in  fatiil  cases, 
we  seldom  meet  with  evidences  of  cicatrization,  as  the  majority  of  deaths 
occur  before  this  stage  is  reached. 

Large  Intestine. — 'i'he  ca-cum  and  colon  are  afTected  in  about  one 
third  of  the  cases.  Sometimes  the  solitary  glaiuls  are  greatly  eidarged. 
The  ulcers  are  usually  larger  in  the  ca'cuni  than  in  the  colon.  Perfora- 
tion of  the  ca'cum  is  rare.     'I'he  a])peiulix  nuiy  be  involved. 

Are  the  enteric  lesions  constant  and  specific  ?  In  an  immense  major- 
ity of  all  cases  the  intestinal  lymph-follicles  are  involved,  but  it  is  claimed 
that  excei)tioiiaIlv  the  disease  nuiv  exist  without  lesions  of  the  bowel. 
Several  instances  are  reported ;  but  Du  Cazel's  case  is  the  most  satisfac- 
tory. The  symj)toms  were  those  of  typhoid  fever,  and  at  the  autopsy 
the  spleen,  mesenteric  glaiuls,  and  kidneys  were  swollen  and  congested. 
There  was  no  lesion  of  the  intestine.  Typhoid  bacilli  were  isolated  by 
the  most  approved  receitt  methods. 

Perforation  of  the  Bowel. —  fn  one  hundred  and  fourteen  cases  of  the 
two  thousand  Munich  autopsies  (o'7  percent)  and  in  twenty-two  instances 
in  my  series,  the  intestine  was  perforated  and  death  caused  by  peritonitis. 
The  perforation  nuiy  occur  in  ulcers  from  which  the  sloughs  have  already 
sej)arated,  or  it  may  be  directly  due  to  the  extension  of  a  necrosis  through 
all  the  coats.  In  only  a  few  cases  is  the  perforation  at  the  bottom  of  a 
clean  thin-walled  ulcer.  In  one  instance  the  perfortition  occurred  two 
weeks  after  the  tem])erature  had  become  normal.  The  sloughs  ai-c,  as  a 
rule,  adherent  about  the  site  of  perforation,  which  in  a  majority  of  the  cases 
occur  in  small  deep  ulcers.  There  may  be  two  or  even  three  perforations. 
The  orifice  is  usually  within  the  last  foot  of  the  ileum.     In  only  one  of 


TVIMIOH)    FEVKR. 


9 


of  the 
stiincos 
tonitis, 
iilreiuly 
iroiigh 
n  of  a 
!(1  two 
c,  as  a 
c  cases 
ations. 
one  of 


iiiv  cases  was  it  distant  eiglitooii  iiiclics.  Fn  four  eases  of  my  series  tlie 
appeiulix  was  perforated  and  in  two  tlie  large  bowel,  rcritoiiitis  was 
])ro,«ei)t  in  every  instanee. 

II(t'iii(irr/i(t(/('  from  tlie  bowels  occnrred  in  ninety-nine  of  the  Mnnich 
ciisi'S.  The  bleeding  seems  to  residt  directly  fi'om  the  separation  i>\'  the 
sl(iiiij;hs.  I  was  not  able  in  any  instance  to  iind  the  bleeding  vessel,  in 
one  case  only  a  single  patch  had  slonghed,  and  a  linn  clot  was  adherent 
t(i  it.  The  bleeding  may  also  come  from  the  soft  swollen  edges  of  the 
]);itcli. 

The  nicscNfcrif  (jhtiuls  at  first  show  iidense  hyper;eniia  and  subse- 
quently become  greatly  swollen.  Spots  of  necrosis  are  common.  In  sev- 
eral of  my  cases  suppuration  had  occurred,  smd  in  one  a  large  al)seess  of 
the  mesentery  was  j)resi'nt.  The  bunch  <if  glands  in  the  mesentery,  at 
the  lower  end  of  the  ileum,  is  espt'cially  involved.  'J'he  retroperitoneal 
glands  are  also  swollen. 

The  spJi'on  is  invariably  enlarged  in  the  early  stages  of  the  disease.  In 
oidy  <»ne  of  my  eases  did  it  exceeil  20  ounces  ((JUU  grammes)  in  weight. 
The  tissue  is  soft,  even  dillluent.  Infarction  is  not  infrequent.  Rupture 
inav  occur  spontaneously  or  as  a  result  of  injury.  In  the  Muiuch  autop- 
sies there  were  five  instances  of  rupture  of  tin-  spleen,  one  of  which  re- 
sulted from  a  gangrenous  abscess. 

The  Uccr  shows  si<;iis  of  pareiudivnuitous  degeneration.  Kai'lv  in  the 
disease  it  is  hypera'mic,  and  in  a  majority  of  instances  it  is  swollen,  some- 
what ])ale,  on  section  turbid,  and  microscopically  the  cells  are  very  gniiui- 
lar  and  loaded  with  fat.  Nodular  areas  (microscopic)  occur  in  nuiny  cases, 
as  described  by  llandford.  Heed,  in  Welch's  laboratory,  could  not  deter- 
iiiiue  any  relation  between  the  groups  of  bacilli  and  these  areas.  Some  of 
tin'  nodules  are  lymplioid,  others  are  nt'crotic  (Aniyot).  In  twelve  of  the 
Munich  autopsies  liver  abscess  was  fouiul,  and  in  three,  acnite  yellow 
ati'opliy.  Diphtheritic  inilammation  of  the  gall-bladder  is  occasionally 
met  with.  This  may  lead  to  perforation  and  fatal  ))eritonitis.  The 
ty])hoid  bacilli  have  been  demonstrated  in  the  inflamed  organ  (C'hiai'i). 
I'yli'phleliitis  may  folhjw  abscess  of  tic  mesentery  or  perforation  of  the 
appendix. 

Kidneys.— Cloudy  swelling,  with  granular  degeneration  of  the  cidls  of 
the  C(»nvoluted  tul)ules,  less  commonly  an  ai-nte  nephritis,  nniy  be  presetit. 
liayer,  Wagner,  and  others  desci'ilx'd  tlu'  occurrence  of  nnmeror.s  srmill 
areas  infiltrated   with   round   cells,   which   may   have   tiie   appearance  of 


yinpliomata,  or  nniy  ])ass  on  to  softenmg  and  siip[)uration,  proilucing 


the 


sii-ealled   miUavy   (ihsci'sxrs.     It  is  usually  a  late  change.     Th(>  typhoid 
bacilli  alone  have  been  found  by 
also  be  found  in  the  lu'ine.     In  t( 
wards  Blumer  found  the  bacilli  in  two.     Diphtheritic  iidlamnuUion  of  the 

mv  cases,  in 


some  observers  in  these  areas.    1'hey  nuiy 
case^ 


l'S  o 


P.v 


iria  in  tvnhoid  fever 


m  mv 


pelvis  of  the  kidney  may  occur.     It  was  pi'c'cnt   in   thre(>  of 

one  of  which  tlie  tips  of  the  papilluj  were  also  allected.     Catarrh  of  the 


10 


sPKciFir  iXFErnuus  diseases. 


bladdor  is  not  uncommon.  Diplitlioritic  influniniation  of  it  may  also 
oociir.     Orchitis  is  occasionally  met  with. 

Respiratory  Organs. — riccratimi  of  the  larynx  occnr.s  in  a  certain 
nutnl/cr  (if  casi's  ;  in  the  Munich  scries  it  was  iu)tc(l  one  hundred  and  seven 
tinu'!!.  It  luay  come  on  at  the  same  time  as  the  ulceration  in  the  ileum, 
hut  the  bacilli  have  iu)t  yet,  I  iii'lieve,  been  found  in  tlui  ulcers.  They 
o(!Cur  in  the  posterior  wall,  at  the  insertion  of  the  cords,  at  the  base  of  the 
cj/iijloftis.  and  on  the  ary-epiglottidean  folds.  In  the  later  periods  catar- 
rhal and  diphtheritic  ulcers  may  be  ])reseut. 

(Kdeina  of  the  <rlotlis  was  present  in  twenty  of  the  Municdi  cases,  in 
eight  of  which  tracheotomy  was  p(>rformed.  Diphtheritis  of  the  pharynx 
and  larynx  is  not  very  uncommon.  It  occurred  in  a  most  extensive  form 
in  two  of  my  cases.  Lobar  pneumonia  may  be  found  early  in  the  disease 
(see  PxKi'.Mo-TVpirrs),  or  it  may  be  a  late  event.  Hypostatic  congestion 
and  the  condition  of  the  lung  spoken  of  as  splenization  are  very  common. 
Gangrene  of  the  lung  occurred  in  forty  ca.ses  in  the  Munich  series;  ab- 
scess of  the  lung  in  fourteen  ;  luemorrhagic  infarction  in  one  hundri'd  and 
twenty-)iine.  Pleurisy  is  not  ii  very  common  event.  Fibriiu)us  ])leurisy 
occurred  in  al)out  six  per  cent  of  the  Munich  cases,  and  empyema  in 
nearly  two  per  cent. 

Changes  in  the  Circulatory  System.— Endocarditis  is  rare.  I  have 
met  with  it  twice,  and  it  existed  in  eleven  only  of  the  ^lunich  autopsies, 
in  which  also  there  were  fourteen  cases  of  pericarditis.  Myocarditis  is  not 
very  iiifrc(jucnt.  Dewevrc,  in  a  series  of  forty-eight  cases,  found  in  six- 
teen granular  or  fatty  degeneration,  and  in  three  a  proliferating  endarter- 
itis in  the  small  vessels.  It  is  remarkable  that  even  in  cases  of  death  from 
heart-failure,  with  intense  fever,  the  cell-libres  may  present  little  or  no 
observable  change.  The  aiicrrcs  are  not  infrerpieutly  involved  in  typhoid 
fever.  Baric  distinguishes  an  acute  obliterating  arteritis  and  a  partial 
arteritis,  and  states  that  they  both  occin*  most  commonly  in  the  arteries  of 
the  lower  e.vLremities.  They  are  responsible,  no  doubt,  for  certain  of  the 
cases  of  blocking  of  the  arterial  trunks.  This  arteritis  mav  affect  the 
smaller  vessels,  particu  arly  those  of  the  heart.  In  the  veins,  thrombi  are 
not  infrequently  foui'  i,  particularly  in  the  femoral  veins,  aiul  more  rarely 
in  the  cerebral  veins  or  sinuses. 

Nervous  System. — There  are  very  few  coarse  changes  met  with.  Men- 
ingitis is  extremely  rare.  It  was  not  present  in  any  one  of  my  autopsies, 
and  occurred  in  only  eleven  of  the  two  thousand  Munich  cases.  The  exu- 
dation may  be  either  serous  or  purulent,  and  in  both  typhoid  bacilli  have 
l»een  demonstrated  (Pictine).  Thrombosis  of  the  cortical  veins  of  the 
pia  nuiter  caused  the  death,  on  the  eighth  day,  of  one  of  my  assistants. 
The  atiatomical  lesion  of  the  aphasia — seen  not  infrerpiently  in  children 
— is  not  known,  possibly  it  is  an  eiux'phalitis.  Parenchymatous  changes 
have  been  met  with  in  the  i)eripheral  nerves,  and  appear  to  be  not  very 
uncommon,  even  when  there  have  been  no  symptoms  of  neuritis. 


TYPHOID   FEVKR. 


11 


The  t'olini/iiri/  nni.'^rh's  sliow,  in  ('crtiiiii  instaiifcs,  llio  clKuiixos  (l(.'sf'ril)('(l 
livZriikcr,  wiiicli  occur  lu)\vcvcr  in  all  long-staiuliii,:,'  IVbrilu  alTccnioiis,  and 
an!  n(jt  j)cciiliai'  to  typhoid  fever.  The  nniscle  siibstanco  within  the  sar- 
idlniiina  uiuleri,n)es  either  a  j^ranular  deircnerition  or  a  hyaline  Iransfor- 
uiatiiin.  Tlie  abdominal  muscles,  the  adductors  of  the  thi;^dis,  and  the 
iiecliirals  are  most  commonly  involved.  llui)ture  of  a  rectus  abdominis 
has  been  found  ])ost-mortem.  JlaMimrrliage  may  occur.  Abscesseri  may 
(k'vcloi)  in  the  muscles  durin.iij  convalescence. 

Typhoid  Septicasinia. — 'I'iiei'c  arc  instances  of  the  g^encral  infection  of 
the  body  with  the  Kberth  bacilli.  The  hiuuan  blood-serum  as  a  rule 
lapidly  kills  the  typhoid  germ  ;  but  under  certain  conditions,  as  yet  un- 
known— cither  increased  virul(Mu;e  of  the  germ  or  dimiiushed  bactcri- 
(•i(hd  power  of  the  blood-serum — it  multiplies  in  all  the  organs  and  in  the 
blood,  constituting  a  veritable  septicaMuia.  Such  u  case  has  been  described 
recently  by  Flexncr  from  my  wards.*  'J'he  intestimd  lesions  were  slight, 
I'ntil  the  development  of  parotitis  the  symptoms  pointed  rather  to  cerebro- 
spinal meningitis.     The  temperature  was  low  and  irri'gular. 

Symptoms. — In  a  disease  so  complex  as  typhoid  fever  it  will  be  well 
llrst  to  give  a  general  descrii)tion,  and  then  to  study  nioi'e  fully  the  symp- 
toms, complications,  and  sequehc  according  to  the  individual  organs. 

General  Description. — The  period  of  incubation  lasts  from  "eight  to 
fouiteeu  days,  sometimes  twenty-three"  (Clinical  Society),  during  which 
then'  are  feelings  of  lassitude  ami  inaptitude  for  work.  The  onset  is  rarely 
abi'upt.  There  may  be  prodronuil  symptoms,  (jitlier  a  rigor,  which  is  rare, 
or  chilly  feelings,  headache,  nausea,  loss  of  a4i[)etite,  pains  in  the  back  and 
legs,  ami  nose-bleeding.  These  symptoms  increase  in  severity  and  the 
]i;iiient  at  last  takes  to  his  bed.  From  this  event,  in  a  nuijority  of  cases, 
the  deiiiute  onset  of  the  disease  may  be  dated.  During  ihejir.sf  week 
there  is,  in  some  cases  (but  by  no  means  in  all,  as  has  long  been  taught), 
a  steady  rise  in  the  fever,  the  evening  record  rising  a  degree  or  a  degree 
anil  a  half  higher  each  day,  reaching  l(t;3°  or  104".  The  pulse  is  ra})id, 
from  100  to  110,  full  in  volume,  but  of  h^w  tension  and  often  dicrotic  ;  the 
toi'.gne  is  coated  ami  white;  the  ab(h)men  is  slightly  distended  and  tender. 
I'ldess  the  fever  is  high  there  is  no  delirium,  but  the  i)atient  complains  of 
headache,  and  there  nniy  be  mental  confusion  and  wandering  at  night. 
The  bowels  may  be  constipated,  or  there  m;iy  be  two  or  three  loose  move- 
ments daily.  Toward  the  end  of  the  week  the  s})leen  becomes  enlarged 
and  the  rash  appears  in  the  form  of  rose-colored  s[)ots,  seen  first  on  the 
sidn  of  the  abdomen.  Cough  and  bronchitic  symptoms  are  not  uncomnu)u 
at  the  outset. 

In  the  second  iVcek,  in  cases  of  moderate  severity,  the  symptoms  bc- 
iiiiue  aggravated  ;  the  fever  remains  high  and  the  niorinng  remission  is 
slight.     The  pulse  is  rapid  and  loses  its  dicrotic  character.     There  is  no 


*  Journal  of  Pathology  and  Bacteriology,  April,  18U5. 


.-fflntf'.'.''.  CT-ftiwwaMi 


^ 


13 


SrKCIKIC    INI'MKTiors   DISKASKS. 


Ioniser  li('ii(l;icli(',  but  there  iire  Tiieiital  torpor  ;ni(l  diiliiess.  'I'iie  face  looks 
lieavv  ;  the  li|..s  are  drv;  the  toii<,Mie,  in  severe  easrs,  beeomes  dry  also. 
The  alxioiiiiiial  syinptoiiis  arc  more  marked — iliarriitea,  tympaiiiles,  and 
tetideriiess.  Dealli  may  occur  diiriiit;  this  week,  with  ]»roiiouneed  nerv- 
ous sym|)toms,  or,  toward  the  eml  of  it,  i'l'om  ha-ruorrhaire  or  perfora- 
tion, in  mihl  cases  tiie  fever  declines,  and  by  the  fourteenth  day  may  bo 
normal. 

In  the  third  ircc/r,  in  eases  of  moderate  severity,  the  pulse  ran<res  from 
110  to  i;U);  tho  tempi-rature  now  shows  markeil  mornintr  remissions,  and 
there  is  a  jiradual  decliiu'  in  tiie  fever.  The  loss  of  flesh  is  iu)W  more 
iiotieeable,  ami  the  weakness  is  pronouiu'ed.  'I'lie  diarrlura  and  meteor- 
ism  nuiy  ])ersist.  I'lifavoralile  sym])toms  at  this  stairo  arc  the  pulmo- 
nary complications,  increasini,'  IVeiileness  of  the  heart,  aiul  pronounced 
delirium  with  muscular  tremor.  SiJCitial  dangers  arc  perforation  and 
hu'inorrhaire. 

With  \\h' f(iii)i/i  irrrk,  in  a  majority  of  instances,  convalescence  begins. 
Tho  temperature  gradually  reaches  the  normal  point,  the  diarrlui-a  stops, 
the  tongue  cleans,  and  the  desire  for  food  retui'iis.  In  severe  eases  tho 
fourth  and  even  the  lifth  week  may  pi-csent  an  agi^ravated  jiicturo  of  the 
third  ;  the  ]>atient  grows  weaki'r,  the  pulse  is  more  rapid  aiul  feeble,  the 
tongue  dry,  and  the  alidonu'ii  disteiuled.  He  lies  in  a  condition  of  pro- 
found stupor,  with  low  multci'ing  delirium  and  subsultus  tendinum,  and 
passes  the  fa'ces  and  urine  involuntarily.  Ifeart-failurc  and  secoiulary 
comiilicatioiis  are  the  chief  dangers  of  this  period. 

In  the  //////  till  (I  ttixZ/i  irrcks  protracted  cases  may  still  show  irregular 
fever,  and  convalescence  may  not  sot  in  until  after  tho  fortieth  day.  In 
this  period  wo  meet  with  relaj)ses  in  the  milder  forms  or  slight  roorii- 
descenoe  of  tho  fever.  At  this  time,  too,  occur  many  of  tho  complications 
and  soqiu'la'. 

Special  Features  and  Symptoms. — ^fo'/e  of  OhsoL—Ah  a  rule,  tho 
symptoms  develop  insidiously,  and  the  patient  is  unal)lo  to  fix  delinitoly 
the  time  at  which  ho  began  to  feel  ill.  Tho  following  are  the  most  im- 
portant deviations  from  this  common  course: 

{(i)  Onset  with  Pronounced  Nervous  Manifestations. — Iloadachc,  of  a 
severe  and  intraetal)lo  nature,  is  by  no  means  an  infrofpient  initial  symp- 
tom. Again,  a  severe  facial  neuralgia  may  for  a  few  days  put  the  practi- 
tioner off  his  guard.  In  cases  in  which  tho  patients  have  kept  about  and, 
as  they  say,  fought  the  disease,  the  very  first  manifestations  may  be  pro- 
nounced delirium.  Such  ]iationts  may  even  leave  homo  and  wander  about 
for  days.  In  rare  cases  tho  di.soase  sets  in  with  tho  most  iti tense  cort'bro- 
spinal  symptoms,  simulating  meningitis — severe  headache,  photophobia, 
retraction  of  the  head,  twitching  of  the  muscles,  and  even  convulsions. 
Occasionally  drowsiness,  stupor,  and  signs  of  basilar  nuMiingitis  may  exist 
for  ton  days  or  more  liefore  the  characteristic  symptoms  develop ;  occa- 
sionally the  onset  is  with  mania. 


1 


TYIMIOII)   FKVKIl. 


18 


(//)  11'////  rrtniotDircd  /'iihiio/iitn/  Si/iii/i/iniis. — 'I'lic  initial  br()m;hial 
fiiliirrii  niav  bo  of  f^ivat  scvi.Tity  ami  (lisi;ui.s('  tlu*  other  features  of  tlio 
disease.  More  strikiiiuf  still  ai'e  thosi'  cases  in  wliicli  tlie  disease  sets  in 
with  a  sinjj;le  ehiil,  with  j)ain  in  tin;  .side  and  all  ihe  eharaiiU'rislie  fealuros 


idliiir  i)neuinonia,  or  of  acute  pleurisy. 
(r)   \\'i//i  Inlciisi'  (iitalni-iiih'xIiiKil  Siiiiijiloiii,- 


'V\ 


le  voinitiiif,'  may  ho 


inee 


;ant    and    uneontrollaljle.     ()(;(!asionallv    there    arc;    cases    with    such 


|)ois(»niii'''  niav    no 


iiileiise  voniiling   and   diarrluea   ihat  a  suspicion  of 
ar<>iise<l. 

[il)   Willi  Si/iii/il(ims  of  III!  Anile  .\i'jilirilis. — Snnjky  or  bloody  nrino, 
with  luiich  alhunuMi  and  tubo-oasts. 


[v]   Aiiihiiliilorji  }• 


(inn. 


-I)e,ser\  inij  of  especial  mention  an;  tliose  oases 


(if  typhoid  fever  in  which  the  patient;  keeps  about  and  altenij)ts  to  do 
wurk,  or  pei'haps  takes  a  lonjf  jnuriiey  to  liis  home.  lie  nuiy  come  under 
nliservatian  for  i\w  lirst  time  with  a  temperature  of  1(11"  or  Ki.-t",  and  with 
the  rash  Well  out.  Many  of  the.se  cases  run  a  severe  course,  and  in  general 
hn-pitals  they  ('ontril)ute  lai'gely  to  the  total  mortality.  Finally,  there 
ai'c  rar(!  instances  in  which  the  lirst  symptom  is  perfoi'alion,  or  a  profuse 
liaMiiorrhage  from  the  Ijowels. 

Fdoial  Aspect. — Karly  in  the  disease  tlie  cheeks  are  flushed  and   the 
eyes  hi'ight.     'rowjinl  the  end  of  the  lirst  week   the  expression  liecomes 

established  tlut  expression  is 


umre 
dull 


listless,  and  when  the  disease  i 


s  we 


md   heavy.      There   is   never   the   rajiid   amemia  of  malarial   fever, 
and  tlie  color  of  the  lij)s  and  elieeks  nuiy  be  retained  even  to  the  third 


week. 


mi 


nun 


Fever. — {n)  Ncf/tilar  Course.  (Chart  I.) — In  the  stage  of  invasion 
'  tenipi'rature  rises  steadily  during  the  first  live  or  six  days.  The  even- 
:  temperature  is  about  a  degree  oi'  a  degree  and  a  half  higher  than  the 

iiing  remission,  so  that  a  temiierat'ire  of  104°  or  10."j°  is  not  uncom- 


uiuii  by  the  end  of  the  lirst  week.  Having  n'ached  the  fastigium  or 
height,  the  fever  then  jiersists  with  slight  morning  remissions.  The  tem- 
jicratiu'e  curve  follows  the  nornud  diurnal  variations,  the  maximum  oc;- 
ciwriug  between  four  aiul  eigiit  o'clock  in  the  evening  and  the  minimum 
lietweeii  four  aiul  eight  in  the  morning.  At  the  end  of  the  second  ami 
thi'dughout  the  thii'd  week  the  tem[)erature  liecomes  mori'  distinetly  re- 
iiiiitent.  The  dilfereiice  l)etween  the  morning  and  evening  nuiy  be  thn^e 
or  four  degrees,  and  the  morning  temperature  may  even  be  nornuil.  It 
falls  by  lysis,  and  the  ti  nqierature  is  not  considered  nornuil  until  the 
evening  record  is  at  OS'^r. 

(/')  Variations  in  the  normal  temperature  curve  arc  common.  We  do 
always  st'e  the  gradual  step-like  ascent  in  the  early  stage ;  the  cases 
ihi  not  often  come  under  observation  at  this  time.  When  the  disca.se  sets 
ill  with  a  chill,  the  temneraturo  niav  ri.se  at  once  to  10;3°  or  104°.     In 


iUll 


many  cases  deforvesoence  occurs  at  the  end  of  tl 


i>nd  week  and  the 


teinjieruture  may  fall  rajjidly,  reaching  llu'  iininial  within  twelve  or  twenty 


SPhX'IFIC  INFKCTIOUS   DISKASES. 


C      ^ 


TYPHOID  fp:ver. 


16 


J3 


In 


o 
x: 


a 


I 


limir.-.     All  invorsii  tvpc-  of  tciiiponituro,  h'\<f\\  in  the  inorniiiir  and  low  in 
the  evening,  is  occiisionally  sfcn  but  lia8  no  ('S|)i'cial  sii.niiticiinci'. 

Siiiltlcn  falls  in  tlio  tciniKTaturc  may  occur ;  thus,  us  shown  in  Clmrt 
III,  a  drop  of  JO"  niuy  follow  an  intestinal  ha'niorfhagc,  and  the  fall  nuiy 
Ijc  vciv  apltarcnt  even  hcfoiv  the  Mood  has  a|i|)care(l  in  the  stools,  lly- 
i)cn)vrc.\iu,  temperature  ah  \e  !()(>',  is  not  very  coniuion  in  typhoid  fever 
except  just  before  death,  when  I  have  kmuvn  the  thermonu'tcr  to  re,i;ister 

(r)  I'ost-Tiijilioid  Kh'i'iitiiin.s — Fvvcr  nf  ('{iin'((h;'<C(iici'. — nuiinj;  con- 
valescence, after  the  temperature  has  licen  normal,  jierhaps  for  livt'  or  six 
(lavs,  the  fever  may  rise  suddi'uly  to  Xd'i"  or  Id;)",  and,  after  persisting  for 
fiiun  one  to  three  days  or  even  longer,  falls  to  nornud.  With  this  there  is 
no  eoustitutional  disturbance,  no  furring  of  the  tongue,  no  distention  of 
the  alidoincn.  These  so-cidlctl  recrutleseeuces  are  by  no  means  uneom- 
1111.11,  and  are  of  especial  importance,  as  they  cause  great  anxiety  to  the 
]nactitioner.  They  are  attributed  most  fre(picntly  to  errors  in  diei,  con- 
stipation, emotions,  ami  excitement  of  any  sort,  such  as  st'ciiig  friends. 

There  are  cases  in  Avhich  the  tem])erature  declines  almost  to  the  nor- 
mal at  the  end  of  the  third  week,  the  tongue  cleans,  and  the  patient  enters 
[ippareiitly  upon  a  satisfactory  convalcs(!eiice.  The  evening  temperature, 
however,  does  not  reach  i>S-,")°,  but  constantly  keeps  about  9'J-.j°  or  lou"", 
and  occasionally  rises  to  101)  5°.  This,  in  the  late  stages  of  convalescence, 
1  have  seen  due  to  the  post-tyi)hoid  amemia.  Complications  should  be 
carefully  looked  for,  particularly  insidious  pleurisy  or  bone  lesions. 

In  certain  of  these  cases  the  persistence  of  the  fever  seems  to  bo  really 
a  nervous  phenomenon,  and  there  is  nothing  in  the  condition  of  the 
patient  to  cause  uneasiness  exce(it  the  evening  elevation  of  teni])erature. 
If  the  tongue  is  cleiui,  the  appt'tite  good,  and  there  are  no  intestinal 
rjyinptoms,  it  may  be  disregardcil.  I  have  frequently  found  this  condition 
best  met  by  allowing  the  patient  to  get  up  and  by  stopping  the  use  of  the 
tlicriiiometer.  This  pndonged  slight  elevation  of  the  fever  after  the  dis- 
appearance of  all  tiie  symptoms  is  most  common  in  children  and  in  pa- 
tients of  marked  nervous  temperament. 

('/)  The  Fcvi'V  of  Hie  RvUipac. — This  is  a  repetition  in  many  instances 
of  the  orijrinal   fever,  a  irradual  ascent  and  maintenance  for  a  few  dava 


tl 


ic 


at  a  certain  height  and  then  a  gradual   decline.     It  is  shorter  than 
eriginid  pyrexia,   and  rarely   continues  more  than  two   or   three  weeks, 
(t'liart  I.) 

('■)  Afebrile  Typhoid. — There  arc  cases  described  in  which  the  chief 
features  of  the  disease  have  been  iiresent  without  the  existence  of  fever. 


Th 


ley  are  extremely  rare  in  this  (;oiintry.     Ko  instance  of  the  kind  has 
come  uiider  my  observation.     Fisk,  of  Denver,  has  met  with  it. 

(/)  Chilh  occur  {(i)  sometimes  with  the  fever  of  onset ;  (//)  occasion- 


•iliy  at  intervals  throuirhout  the  course  of 


\H'.    (Il-ease 


am 


illitwed    by 


sue 


Its  (so-called   sudoral  form) ;   (c)  with   the  advent  of  complications, 


16 


SPEC'IKIC   IN'FKCTIOUS   DFSKASKS. 


ploiirisy,  pnouniniiia,  otitis  media,  pcriorititis,  otc. ;  (f/)  with  active  iinti- 
j)yreti(!  treatment  by  tliu  coal-tar  remedies;  (c)  occasionally  diirinj?  the 
jierioii  of  (h'fcrvcscciicc  without  relation  to  any  complication  or  setjiiel, 
prol)al>ly  diii^  to  a  septic  infection,  'riiere  arc*  cases  in  which  throughout 
the  latter  hall"  of  the  disease  ciiills  recnr  with  great  severity. 

Skin. — The  rash  of  typhoid  fever  is  very  characteristic.  It  consists 
of  a  varialih*  nunil>cr  of  rosc-col(;re(l  spots,  which  a]ipcar  fi'oni  the  seveiuli 
to  the  tenth  (hiy,  usually  first  upon  the  abdomen.  'J'he  spots  are  tlatteiied 
papules,  sliglitly  raised,  of  a  rose-red  color,  disaiipeariug  on  pressure,  aiul 
ranging  in  diameter  from  two  to  four  millimetres,  'i'hey  can  he  felt  as 
distinct  elevations  on  the  skin.  Sometimes  each  sjjot  is  capped  hy  a  small 
vesicle.  The  spots  may  he  dark  in  color  and  occasionally  liecome  pete- 
chial. After  persisting  for  two  or  three  days  tlu>y  gradually  disa])i)ear, 
h'aving  a  brownish  stain.  'I'hey  come  out  in  successive  crops,  but  rarely 
appear  after  the  juiddlc  of  the  third  week.  They  are  present  in  the  typ- 
ii'al  rclajise.  The  rash  is  must  abundant  u[)on  the  alxlomcn  and  lower 
thoracic  zone,  often  abounds  upon  tlm  lia'-k,  and  may  spread  to  the  ex- 
tremities or  even  to  the  face.  I  can  not  say  that  in  my  e.xpcrieuco  these 
oases  with  the  more  abuiulant  erupt io.'.  have  been  of  specially  severe  ty|)e. 
The  rash  is  not  always  present.  ^luruhison  states  that  it  is  freciuently 
ab.^ent  in  children. 

A  branny  desfpiamation  is  tiot  rare  in  cases  in  which  the  smlaminal 
vesicles  liavo  been  al)undant  ;  occasionally  the  skin  may  peel  in  large 
thikes. 

The  following  accidental  rashes  are  nu't  with  in  typhoid  fever: 

1.  Enjlhi'ma. — It  is  not  very  uncommon  in  the  first  week  of  typlioid 
fever  to  find  the  skin  of  the  iilulomeii  and  chest  of  a  vivid  red  color;  the 
rash  may  also  spread  to  the  .extremities.  It  may  possibly  in  some  in- 
stances, but  certainly  not  always,  be  duo  to  (|uinine.  I  have  seen  it  much 
more  fre(|uently  in  the  jiast  five  years  (during  which  time  I  have  rarely 
ordered  a  dose  of  (piiniiui  in  this  disease)  than  I  did  in  Montreal,  where 
we  used  quinitie  largely  as  an  antipyretic. 

'i.  The  fitrlic  hlriKtlrc — /*r/i(i»ia/(t. — These  are  pale-blue  or  steel-gray 
spots,  subcuticular,  from  4  to  10  mm.  in  diameter,  of  irregular  outline  and 
most  abundant  about  the  chest,  abdomen,  and  thighs.  They  sometimes 
give  a  very  striking  appearance  to  the  skin.  It  can  be  readily  seen  that 
the  injection  is  in  tlie  di'eper  tissues  and  not  superficial.  This  rash  is 
quite  witluuit  significance.  Since  my  attention  was  called  to  its  associa- 
tion with  body  lice,  1  have  met  with  no  instance  in  which  these  were 
not  present.  Several  French  observe  is  maintain  that  they  arc  due  to 
the  iri'itatiug  effects  of  the  fluid  secreted  by  jH'diculi  (ride  Ilewetson,  J. 
II.  II.  I>i/Ut'tin,  vol.  v.).  They  are  not  })eculiar  to  typhoid  fever  (Duck- 
worth). 

;?.  Sudamimd  and  miliary  eruptions  are  common  in  all  cases  in  whicli 
there  is  profuse  sweating. 


an 


TYI'IIOII)   FKVKIi. 


17 


lino  and 
hu'timos 
[en  that 
t  rasli  is 

associa- 
|se  were 

due  to 
Itson,  J. 
|(l)u('k- 

whieh 


I,  rrticaria  !■<  riooasionally  met  with;  and  lastly  liorpos,  but  tliis  i.-* 
very  iiiicoiiitiinn  in  citinparison  with  its  t'rc(|ncncy  in  malaria  and   pncn- 

nioiiia. 

'I'lit'  hirlii'  n'rrhralr,  a  ihmI  line  willi  white  hdnlers.  can  he  ]ir(idiiciMl  hy 
driiwiii'.'  'he  nail  nver  the  skin.  It  is  a  vaso-niotor  ])hen(iinen(>ii  which,  as 
ill  (it her  fevers,  ean  bo  readily  elicited,  particnlarly  in  nervoii;;  subjects. 
l';.\|i<i.-iire  (if  the  al)d<)nien  may  be  siinicient  to  canse  a  jtinkish  injection, 
which  mav  in  jtlaces  cjian^'e  to  an  ivory  white,  jrivini,'  u  enrioiis  mottled 
a|i|iearanee  to  the  skin  A  similar  appearance  may  he  seen  on  the  arms. 
'I'lic  L'eiieral  tint  may  he  white,  with  irrej^nlar  patches  or  streaks  of  pink 
or  ilark  retl.  The  skin  of  the  palms  of  the  hands  may  lieeome  very  dry 
ami  yellow. 

Sweats. — .\t  the  hei^dit  of  the  fever  the  skin  is  usually  (]i'y.  Profuse 
s\veatiii<r  is  rare,  hut  it  is  not  very  uncommon  to  soo  the  alxlomen  or  chest 
nmist  witli  perspiration,  particularly  in  ti)e  reaction  wlii<'h  follows  the 
hatli.  Sweats  in  some  instances  constitute  a  striking:'  feature  of  the  dis- 
ease. They  may  oceasioiially  be  associated  with  chilly  sensations  or  actual 
chills,  daccoud  and  others  in  France  have  especially  desciribed  this 
suiloral  form  of  typhoid  fever.  'I'here  may  be  recnirrinji  paro.xysins  of 
chill,  fever,  and  sweats  (even  several  in  twenty-four  hours),  and  the  eas(( 
may  he  mistaken  for  one  of  intermittent  fever.  The  fever  toward  the 
mil  of  the  second  week  and  during'  the  third  week  may  be  intermittent. 
'I'lic  charactci'istic  rash  is  usually  present,  and  if  absent  the  nei^Mtive  eoii- 
ililiou  of  the  blood  is  sullicient  to  exehule  malaria.  I  have  seen  cases  of 
this  form  in  .Montreal,  where  there  could  have  heeii  no  suspicion  of  mala- 
rial infection. 

(Julnnii  of  the  skin  occurs: 

1.  ;\s  the  result  of  vascular  obstruction,  most  commonly  of  a  vein,  as 
ill  throMd)osis  of  the  femoral  vein. 

:.'.  In  coniu'ction  with  nephritis. 

;i.  In  association  with  the  ana'iuia  and  cachexia. 

The  hair  is  very  ajit  to  fall  out  after  an  attack  of  typhoid  fever.  In- 
stanees  of  permanent  baldness  are  of  extreme  rarity.  As  in  other  diseases 
assooiated  with  fever  the  nutrition  fif  the  mills  suffers,  and  duriuif  and 
after  convalescence  tran,sverse  ridj^es  are  seen. 

It  is  stated  that  a  peculiar  odor  is  exlialed  from  the  skin  in  typhoid 
fever.  Whether  due  to  a  cutaneous  exhaliitii>n  or  not,  there  certainly  is 
a  very  distinctive  smell  connected  with  many  patients.  I  have  repeatedly 
liiiil  my  attention  directed  to  it  by  nurses.  Kathan  Smith  describes  it  as 
of  a  "semi. cadaverous,  musty  character." 

As  a  serpience,  lines  of  atrophy  of  the  skin  may  develoj)  on  the  abdo- 
111(11  and  lateral  aspects  of  the  thighs,  sinnlar  in  all  respects  to  those  seen 
nfter  prei,niancy.  These  li/teie  atrophinv  are  possibly  due  to  neuritis,  and 
Ihirkworth  has  reported  a  case  in  which  the  skin  adjacent  to  them  was 
liviiera'sthetic. 


'^ 


18 


SI'KCIFKJ    I\I''K(TI()US   DISK  ASKS. 


Circulatory  System. — 'I'lif  hlnKil  prosonts  irnpt»rtunt  clmtifroa.  The 
followitiif  statcniciils  iirc  Iciscd  mi  studies  wliidi  W.  S.  'I'lmvcr  1ms  inatU! 
ill  my  wards:*  hiirin;;  tiic  first  two  wci'i\s  tlicrt'  may  1m'  lillic  or  no  ciiaiip'! 
ill  the  blood.  I'rot'iisi'  sweats  or  copious  diaiiluea  may,  as  llayem  lias 
shown,  CUU80  the  CMU'puseies — as  in  tlit^  eollapst)  sta;,'e  of  cholera — to  rise 
above  normal.  Jn  the  third  week  u  fall  usually  takes  place  in  corpuscles 
and  ha'tno^rlobiii  and  the  luiinbcr  may  sink  rapidly  even  to  l,;i(i(i,(MiO  per 
c.  mm.,  jrradually  risin;;  to  normal  (hu-in<;  convalescence.  When  the  pa- 
tient lirst  <rcts  up,  there  may  be  a  slii:lit  fall  in  the  number  of  the  cor- 
puscles. 'I'licy  diminish  sli,i,ditiy  throujrhout  tho  course,  and  reach  the 
lowest  point  toward  the  end  of  convalescence. 

The  iimount  of  ha-moLrlobin  is  always  rcilnccd,  and  usually  in  a  fjreater 
relative  |)roportion  than  tin-  number  of  red  corpuscles,  and  diiriiif,'  recov- 
ery tho  normal  color  standard  is  reached  at  a  later  period.  'I'lu*  number 
of  colorless  corpuscles  varies  little  from  tho  normal  standard  (<!,()(i()  ±  per 
c.  mm.).  They  diminish  sti_<,ditly  throiiufhout  the  course  and  reach  the 
lowest  jioint  toward  the  end  of  convales(!enco.  The  al)seni'(!  of  leucocyto- 
sis  may  be  at  times  of  real  dia<,Miostic  value  in  distin<,'uishin<f  ty])hoid  fever 
from  various  septic  fevers  and  acute  inllammatory  processes. 

The  accompanying,'  blood  (diart  shows  these  clian<fcs  well.      (Chart  II.) 

The  post-typhoid  ana'iiiia  may  reach  an  extreme  jrrade.  In  one  of  my 
cases  the  blood-corpu-scles  sank  to  l,;i(l(l,(MMi  per  cubic  mm.  and  the  luvmo- 
globin  to  about  twenty  ])er  cent.  These  severe  grades  of  aniemia  are  not 
common  in  iny  experience.  In  the  Miini(di  statistics  there  were  lifly- 
four  cases  with  general  and  extreme  ana'Uiia. 

Of  changes  in  tho  blood  i)lasma  very  little  is  known. 

The  puhc  in  typhoid  fever  })resonts  no  sjiecial  characters.  It  is  in- 
creased in  rapidity  in  proportion  to  the  height  of  the  fever.  As  u  rule,  in 
the  lirst  week  it  is  above  100,  full  in  volume  and  often  dicrotic.  There  is 
no  acute  disease  with  which,  in  the  early  stage,  a  dicrotic  ])ulse  is  so  fre- 
([uently  associated.  Even  with  high  fever  the  pulse  may  not  be  greatly 
Hccelorated.  As  the  disease  progresses  the  jiulse  becomes  more  rapid, 
feebler,  and  small.  In  the  extreme  prostration  of  severe  cases  it  may 
reach  150  or  more,  and  is  a  mere  undulation — the  so-called  running  pulse. 
The  lowered  arterial  j)ressur'i  is  manifest  in  the  dusky  lividity  of  the  skin 
and  coldness  of  the  hands  and  feet. 

During  convalescence  the  pulse  gradually  returns  to  normal,  and  occa- 
sionally becoines  very  slow.  After  no  other  acute  fever  do  we  so  fre- 
(piently  meet  with  bradycardia.  I  liave  counted  the  pulse  ns  low  as 
thirty,  and  instances  are  on  record  of  still  fewer  beats  to  the  minute. 

The  henrt-sonndH  are  at  first  clear  and  loud,  and  free  from  murmur, 
but  in  severe  cases,  as  the  prostration  develops,  the  first  sound  becomes 
feeble  and  there  is  often  to  be  heard,  at  the  apex  and  along  the  left  sternal 

♦  Iteport  on  Typhoid  Fever,  I,  J.  II.  II.  Reports,  vol.  iv. 


TYIMIOII)   FKVKIJ. 


19 


miuU» 

III  liua 
to  rise 
piiscK'S 
lOO  i>er 
the  i»a- 
ho  cor- 
ich  tho 

}:;roater 
If  ri'cov- 
nmiilH'i' 
I)  ±  \wr 
■acli  the 
ncocyto- 
uid  ftver 

hurt  II.) 
tio  of  my 
[V  hii'ino- 
ii  art!  not 
L;re  lifiy- 


It  is  iu- 
a  nilo,  in 
Tiioro  is 
is  so  fre- 
0  greatly 
iro  rapid, 
s  it  may 
|ng  pulse, 
tlie  skill 

intl  occa- 
le  so  fre- 
ts low  as 

lute. 

Imuvmur, 

becomes 

ft  sternal 


iiiiU'irii'i  a  soft  systolio  nitirniur.  'Plic  tirst  soiiiid  may  he  gradually  aiiiii- 
liilati'd,  as  pointed  nut  hy  Stokes.  In  the  extrriiie  rt'cldciiess  (if  tlic  ;;ra\^'r 
fniMis,  the  tirst  and  second  sound  heeoine  very  simihir,  and  the  long  pause 
is  iiiueli  sliortened. 


r>,(H)f),ooo 

OCC  ,  tfl90 

JANU*HY, 

til 

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I 

BUCK.  RED  CORPUSCLES. 


RED,  HAEMAGLOBIN. 

ClIAKT    II. 


MEAN  NORM. 
NUMBEn  OF 

WHITE 
CORPUSCLES 


BLUE,   COLORLESS  CORPUSCLES. 


Of  cardiac  complications,  perirnrdifis  is  rare  and  has  been  met  with 
cliicdy  in  children  and  in  association  with  pneumonia.  It  was  not  pres- 
fiil  in  any  of  my  cases  and  occurred  in  only  fourteen  of  the  two  thou.sand 
^Iiuiich  post-mortems.  /7«r^/o6Vi!>7////.s' is  also  uncommon.  I  have  seen  only 
two  eases;  and  there  were  only  eleven  cases  noted  in  the  Aliinieli  records. 
Myociirditis  is  more  common.  Tlie  following  statement  may  be  maae 
with  reference  to  the  condition  of  the  heart-muscle  in  this  disease  :  In 


20 


SPECIKIO   INFECTIOUS  DISEASES. 


protnictt'd  cases  tlie  niuscle-fibre  is  usually  soft,  flabby,  and  of  a  palo  yel- 
lowisli-browii  color.  The  softeninjf  may  be  extreme,  though  rarely  of  the 
grade  described  l)y  Stokes,  in  whieli,  when  lieh'  apex  uj)  by  the  vessels, 
the  organ  collapsed  over  tlu^  hand,  forming  a  mushroom-like  cap.  ]\Iicro- 
scopieaily,  the  libres  may  show  little  or  no  change,  even  when  the  impulse 
of  the  heart  has  been  extremely  feeble.  A  granular  parenchymatous  de- 
generation is  couimon.  Fatty  degeneration  may  be  present,  particularly 
in  long-standing  cases  with  ana'Uiia.  The  hyaline  change  is  not  common. 
The  segmetitiug  myocarditis,  in  which  the  cement  substance  is  softened 
so  that  the  muscle-cells  separate,  has  also  been  found,  but  probably  as  a 
post-mortem  change. 

('(iiiijilirn/ifi/is  hi.  the  Arhrlcx. — Obliteration  of  large  or  small  arterial 
trunks  is  one  of  the  rare  complications  of  typhoid  fever.  A  consideral)lc 
nuinl)er  of  cases  arc;  scattered  through  the  literature.  The  obliteration 
may  be  due  either  to  endxdisni  or  to  thrombosis.  In  a  majority  of  cases 
the  femoral  artcrv  is  imolved  and  gangrene  of  the  foot  and  leg  occurs. 
In  several  cases  there  has  been  obliteration  of  both  femorals  with  extension 
of  the  clot  into  tiie  aorta  witli  gangrene  of  both  legs.  In  a  case  which 
I  saw  with  Koddick,  of  ^lontreal,  the  obliteration  of  the  left  femoral 
occurred  on  tiie  sixteenth  day.  On  the  twentieth  day  the  j)atient  had 
pain  in  the  right  leg  and  tliei'c  was  no  pulsation  in  the  femoral  artery. 
(Jiingrene  gradually  developed  in  both  feet,  and  death  took  ))lace  in  the 
sixth  week.  In  these  cases  the  condition  is  [jrobably  due  to  throndjosis, 
no!  endtolism,  and  is  associated  with  a  blood  state  which  favors  clotting, 
or  i)ossi!)ly  with  a  local  arteritis.  The  condition  is  not  invariably  fatal. 
Of  twenty  cases  collected  by  Harchoud,*  eight  died.  Keen  collected 
forty-three  cases  of  gangrene  during  or  after  ty[)hoid  fever  (Toner  Lec- 
ture, is;(l). 

Tlinnitbi  ill  till'  IV///.V.— This  is  a  ni'ich  more  frequent  complication, 
and,  according  to  Murchisou,  is  met  with  in  about  one  jier  cent  of  the 
cases.  It  oe(;urs  most  fre(|ueiitly  in  a  crural  vein,  and  more  eoinmonly  in 
the  left  than  in  the  right ;  due  possibly,  as  suggested  by  I^iebermeister, 
to  the  fact  that  in  the  left  common  iliac;  vein,  being  crossed  by  the  r/glit 
iliac  artery,  the  How  of  blood  is  not  so  free  as  in  the  right  vein.  Throm- 
l)Osis  is  indicated  by  eidargeinent  and  o'denia  of  the  limb,  but  gangrene 
never  results  from  obstruction  of  the  vein  alone.  It  is  not  a  very  un- 
favorable coiniilication.  In  one  case  of  my  series  the  throndjus  suppu- 
rated and  there  was  ])ya'Mua.  Occasionally  the  thrombosis  may  extend 
into  the  pelvic  veins  and  into  the  vena  cava.  In  one  instance  the  throm- 
bus was  in  the  right  circuudlex  iliac  vein  alone,  and  the  superficial  veins 
on  the  right  side  of  the  abdomen  wen*  in  conseipience  greatly  etdarged. 
Sudden  death  has  been  caused  by  dislodgment  of  a  thnnubus.  Typhoid 
bacilli  have  been  found  in  the  wall  (»f  the  vein  and  in  the  clot.     A  rare 


I 


*  i'.iris  Tlu'sis,  1881. 


TYPHOID   FHVER. 


21 


e  yel- 
)f  the 

licro- 

ipulse 

IS  dc- 

uliu-ly 

iiinoii. 

ftonod 

ly  as  a 

u'toriiil 
lenible 
enition 
)f  cases 
occurs, 
tension 
e  which 
femoral 
cut,  liad 
1  artery. 
;o  ill  the 
onibosis, 


li'.-ion,  w'lif'h  killed  a  valued  assistant  (Dr.  Oppenheiiuer),  is  thrombosis 
1,1'  riic  <('rti(!al  veins  of  the  pia  mater. 

Inl'aicts  in  the  kidneys,  S2)leen,  and  lunjxs  are  l)y  no  means  uiu'onunon 
ill  tvjiii  'id  fever.  'J'hey  are  associated  usually  with  thromljosis  in  tiie 
.■ii'toiir  .  randy  with  embolism. 

Digestive  System.- — Loss  of  appetite  is  early,  and,  as  a  rule,  the  relish 
i,,r  I'm  I  is  iu)t  re(faine(l  until  convalescence.  'I'liirst  is  constant,  and 
,|i()uli;  be  fully  and  i'reely  gratified.  Even  when  the  nnnd  becomes 
hciiiinibed  and  the  patient  no  longer  asks  for  water,  it  should  be  freely 
n-ivc'  .  'I'he  foiif/iie  presents  the  changes  inevitable  in  a  prolonged  fever, 
but  I  here  are  no  distinctive  characters.  Karly  in  the  disease  it  is  moist, 
swollen,  and  coated  with  a  thin  white  fur,  which,  as  the  fever  progresses, 
l)(^riiiiies  denser.  It  may  remain  moist  throughout.  In  severe  ca.ses,  par- 
liciilarly  those  with  delirium,  the  tongue  becomes  very  dry,  partly  owing 
to  the  fact  that  such  patients  breathe  with  the  mouth  open.  It  may  Ik* 
covcicd  with  a  brown  or  brownish-black  fur,  or  with  (;rusts  between  which 
arc  rracks  and  fissures.  In  these  eases  the  teeth  and  lii)s  may  be  covered 
with  a  dark  brownish  matter  called  sardfs — a  mixture  of  food,  e[)ithelial 
ilfliri<,  and  micro-organisms.  By  ki'ciiing  the  mouth  and  toiigiu'  clean 
from  the  outset  the  fissures,  whi(;h  are  extremely  painful,  may  be  [)re- 
vriiiid.  During  convalescence  the  tongue  gradually  becomes  clean,  and 
llir  fur  is  thrown  oif,  either  insensiijly  or  occasionally  in  Hakes. 

The  secretion  of  saliva  is  often  diminished  ;  salivation  is  rare. 

/'iirotitis,  not  so  fr(M|uent  as  in  typhus  fever,  was  present  in  forty-livo 
of  liie  two  thousaiul  .Munich  cases.  It  tx'ciu'red  in  only  two  of  my  series 
of  fatal  cases.  Tsually  unilateral,  and  in  a  majority  of  cases  going  on  to 
>ii|i|uiration,  it  is  regarded  as  a  very  fatal  c()mplication,  but  recovery  has 
fcllnwed  in  four  or  live  of  my  cases.  It  undoubtedly  may  arise  from  ex- 
tension of  inllamnuitioii  along  Steiio's  dui't.  This  is  [iroliably  not  so  si'ri- 
011-  a  form  as  when  it  aris(>s  from  nietaslatic  inflammation. 

The  submaxillary  gland  may  lie  involved  alone.  Parotitis  may  occur 
after  the  fever  has  subsided. 

'['he  p/i(iri/n.r  may  be  the  seat  of  slight  catarrh.  Sometimes  the  fauces 
lire  deeply  cijiigested.  .Membranous  pharyngitis,  a  serious  and  fatal  (.'om- 
[ilication,  may  come  on  in  the  third  week. 

The  iidslrir  si/i)i})f(iin.^  are  extremely  variable.  .Nausea  and  vomiting 
arc  not  common.  There  are  instancies,  however,  in  which  vomiting,  re- 
sisting all  measures,  is  a  marked  feature  from  the  outset,  ami  may  directly 
cause  death  from  exhaustion.  N'omiting  does  not  often  occur  iti  the  sec- 
ond ami  third  week,  uidesa  associated  with  some  si'rious  com[)licatioii.  In 
a  few  oV  these  cases  ulcers  have  been  fouml  in  the  stomach. 

[ntextinal  si/mpfonis  are  very  inconstant.  Of  the  'i'i'.)  cases  analyzed 
in  the  lii'imrt  on  Tiiplinid  Fcrcr,  /,  from  the  medical  department  of  the 
•lohiis  Hopkins  Hospital,  there  was  looseness  of  the  itowels  In  seventy-six 
cases;    in  twenty-eight  of  these  the  discharges  were  fre({uent.      In   I   'i 


22 


SPECIFIC   INPKCTIOUS  DISEASES. 


cases  the  bowels  were  roguhir  or  constipiitod.  In  seventeen  of  the  twenty- 
two  fatal  cases  diarrlid'a  was  present.  Its  absence  must  not  be  taken  as 
an  indication  that  the  intestinal  disease  is  of  slit^ht  extent.  I  have  seen, 
on  several  occasions,  the  most  extensive  iniiltration  and  ulceration  of  the 


a 

a) 


% 

■; 

3 

i 

3> 

','■■ 

J3 

«-> 

a 

o 

«A. 

<M 

1 

x: 

1 

u, 

O 

.It: 

E 

■>5 

U 

5i 

1 

'i 

1. 

■% 

1—4 

H-, 

S       • 

4i 

s 

o 

4 

t  -»; 

J-C' 

Peyer's  glands  of  the  small  intestine,  with  the  colon  filled  with  solid  fjieces. 
The  diarrhcea  is  caused  less  by  the  ulcer.i  than  by  the  associated  catarrh, 
and,  as  in  tuberculosis,  it  is  probable  that  when  this  is  in  the  largo  intes- 
tine the  discharges  are  more  frequent.  It  is  most  common  toward  iii> 
end  of  the  first  and  throughout  the  second  week,  but  it  may  not  occur 


TYPHOID  FEVEll. 


23 


0) 


o 

-^3 


8) 

3J 


H 

as 
a 


fiVCOS. 

^iitiirrli. 

illl:   -i- 

lini  !.i;  > 

CCCIU' 


until  tlio  tliini  or  oven  tho  fourth  week.  The  nunibor  of  disohiir£ros  raiijros 
fi'diii  tlirci-  to  t'i^lit  or  ten  in  tlu;  twenty-four  liours.  Tiiey  are  usually 
altiindant,  tliin,  yrayish-yellow,  <,'ranular,  of  tho  consistency  and  a})i)eiir- 
ance  of  pea-soup,  aiul  resemble  very  nnu'li,  as  Addison  remarked,  the  nor- 
mal contents  of  the  small  bowel.  'J'lie  reaction  is  alkaline  and  the  odor 
otlVusive.  On  stiindini!:,  the  discharires  sejtarate  into  a  thin  serous  layer, 
cDiitaininji;  albumin  and  salts,  and  a  lower  stratum,  consistin<f  of  ejiitlielial 
lir/iris,  remnants  of  food,  and  numerous  crystals  of  triple  pliosphates. 
Blood  may  he  in  snud!  amount,  aiul  only  reeoj,niizod  by  the  microscope. 
Sloutrhs  of  the  Peyer's  fjlands  occur  either  as  jrrayish-yellow  fraixments  or 
occasionally  as  ovoid  masses,  an  inch  or  more  in  len,<:;th,  in  which  portions 
of  the  bowel  tissue  may  bo  fouml.  'J'he  bacilli  are  not  found  in  the  stools 
until  th';  end  of  the  first  or  the  middle  of  tho  second  week. 

//(uniorr/Kn/e  from  the  bowels  is  a  serious  comj)lication,  occurrinj^  in 
from  tlu'ce  to  live  per  cent  of  all  cases.  It  occurred  in  ninety-nine  of  the 
twd  thousand  Munich  autoi)sies.  There  may  be  only  a  slight  trace  of  Idood 
in  the  stools,  but  too  often  it  is  a  ])rofuse.  free  hamiorrhaire,  whicli  rapidly 
proves  fatal.  It  occurs  most  commonly  between  the  end  of  the  second 
and  the  beginning  of  the  fourth  week,  the  time  of  the  separation  of  the 
sloughs.  Occasionally  it  results  simply  from  the  intense  hypera'tnia.  It 
usually  comes  on  without  warning.  A  sensation  of  sinking  or  collapse  is 
ex[icriciiced  l)y  the  [)atient,  the  temi)crature  falls,  and  may,  as  in  the  an- 
lU'xcd  chart,  drop  eight  or  ten  degrees  in  a  few  hours.  Fatal  collajise  may 
superveim  l)efore  the  blood  ap[»ears  in  the  stool.  ILTmorrhiige  usually 
occurs  in  cases  of  considerable  severity,  (i raves  and  Trousseau  held  that 
it  was  not  a  very  dangerous  symptom,  but  statistics  show  that  death  fol- 


lows 1 


n  from  thirty  to  fifty  per  cent  of  the  cases. 


It  must  not  be  forgotten  that  niela^na  may  also  be  part  of  a  general 
livniorrhagic  tendencv,  in  which  case  it  is  associated  with  petechia'  and 


a'tiiaturia. 


There  may  be  a  special  family  ]iredisposition  to  intestinal  liaMnorrhages 
in  typhoid  fevi'r.  'I'hus  I'ate  *  reports  thirty-four  cases  in  four  genera- 
tions in  ono  family  occurring  l)etwecn  the  years  ISSl  and  1S!)1.  Intestinal 
lia'nu)rrhage  occurred  in  eighteen,  and  was  the  cause  of  death  in  twelve 
cases.  The  bleeding  develojied  on  the  first  day  of  the  fourth  week  in  two 
cases,  during  the  third  week  in  fourteen  cases,  and  during  the  secotul 
Week  in  two  eases.  There  was  apparently  no  other  s[)ecial  ha'morrhagic 
tendency  ie  the  family. 

)l(fv()risiH,  a  fre(|uent  symptom,  is  not  serious  if  of  moderate  grade, 
but  when  excessive  is  usually  of  ill-omen.  Owing  to  defective  totu'  in  the 
walls,  in  severe  cases  to  their  infiltration  with  serum,  gas  accumulates 
in  the  small  and  large  bowels,  jjarticularly  in  the  latter.  It  is  rightly  held 
to  be  to  some  extent  a  measure  of  the  intcnsitv  of  the  local  lesions.     When 


North  Carolina  Medical  Journal,  Soptcinbor,  1894. 


24 


Sl'KCIFIC   IXPECTIOUS   DISEASES. 


extreme,  it  pushes  up  the  diiiphragin  and  interferes  very  much  with  the 
action  of  the  heart  and  hmgs.     It  un(h)ubtedly  also  favors  ])erforation. 

Ab(h«niinai  tenderne.ss  on  j)ressiii'e  and  giir<,diiig  in  tlie  rij(ht  iliae  fossa 
exist  in  a  hirge  ])ru2)ortion  of  all  the  eases.  1'he  tenderness  may  be  more 
or  less  dill'use  over  the  abdomen,  but  it  is  coinmonlv  litnitfd  to  the  ri'dit 
side.  It  is  rarely  excessive  and  may  be  elicited  only  on  deep  pressure. 
(iur<rlin.ir  indicates  simply  the  presence  of  gas  and  fluid  fitces  in  the  colon 
and  ca'iuim. 

Occasionally  severe  pain  may  be  associated  with  the  degeneration  of 
the  abdominal  muscles,  or  with  rupture  of  the  recti  abdominales.  It  is 
stated  that  the  thickened  ileum  nniy  be  felt  in  typhoid  fever,  and  also  that 
the  mesenteric  glands  nuiy  be  ])alpable.  This  is  a  point  of  some  moment. 
The  resistance  and  apparent  tumor  have  led  to  the  diagnosis  of  appendicitis 
anil  ojjeration. 

Perfurdtion  of  an  ulcer  into  the  peritonaeum,  the  most  serious  abdom- 
inal c'Mnplication  of  the  disease,  occurred  in  one  liundred  and  fourteen  of 
the  t\\  f'  '"  mil  Munich  cases,  and  in  twenty  of  the  eighty  of  my  series. 
It  is  usUi.  dicated  by  tlie  onset  of  sudden  acute  })ain  in  the  abdomen, 

and  symptt.;  ,s  of  collapse.  It  is  most  common  at  the  end  of  the  second 
or  in  the  third  week,  l)ut  in  one  of  my  cases  it  ot'curred  as  early  as  tlie 
eighth  day  and  in  another  in  the  sixth  week,  two  weeks  after  the  evening 
tcmi)erature  hail  become  normal.  It  is  not  infrecpiently  associated  with 
iKemorrhage.  The  j)resence  of  itnligestible  food,  severe  voniiting,  exces- 
sive meteorisin,  and  ascarides  have  been  ussigned  as  causes.  This  accident 
is  \\n\v\\  more  common  in  men  than  in  wonu'n.  The  perforation  is  usually 
in  the  ileum,  but  may  occur  in  the  colon.  As  a  rule  it  promi)tly  causes 
symptoms  of  peritonitis — distention  of  the  abdomen,  marked  tenderness, 
rigidity  of  tlie  abdominal  wall's,  vomiting,  a  collapsed,  i)inched  expression, 
and  a  rapid,  sniall  i)ulse.  In  very  severe  cases  with  marked  mental  dis- 
turbance the  symptoms  nniy  not  excite  suspicion,  but  the  temperature 
usually  falls  and  the  symptoms  of  collapse  are  well  marked.  The  diag- 
nosis is  easy,  except  in  cases  in  which  tympanites  and  tenderness  have 
been  jirominent  features,  when  it   may  be  very  ditiicult  to  say  whether 


pc 


rforation  has  occurred.     An  indication  of  value  in  such  instances  is  the 


obliteration  of  the  liver  dulness  by  gas  in  the  ])eritoneal  cavity.  It  is 
somewhat  lessened  by  the  fact  that  extreme  tym])any  nuiy  almost,  if  not 
<|uite,  obliterate  the  liver  dulness.     Perforation  of  the  appendix  is  not 

lin  in  the  risrht  iliac  fossa,     (jieneral 


verv  uncommon,  ami   mav  cause   in 


peritonitis  or  a  localized  abscess  may  result.  Kecovery  from  perforation  is 
undoubtedly  possiiile,  though  rare. 

Peritonitis  without  ])erforation  may  also  occur  by  extension  from  the 
ulcer  or  occasionally  by  rupture  of  a  softened  mesenteric  gland.  It  was 
present  in  'I'i  per  cent  of  the  Munich  autopsies. 

The  .spleen  is  invariably  eidarged  in  typhoid  fever,  and  iii  a  majority  of 
cases  the  edge  can  be  felt  below  the  costal  nuirgin.     By  the  end  of  the  first 


1.4 


TYPHOID   FEVKH. 


25 


th  the 
on. 

,c  fossa 
.!  iiioro 

•ossuro. 
e  colon 

tion  of 
i.  It  is 
Iso  that 
iioincnt. 
nulicitis 

abdom- 

irtcen  of 

ly  series. 

bdonien, 

e  se(!ont.l 

ly  us  the 

'  evenin»f 

ited  with 

ig,  exces- 
iiccitlent 

IS  usually 

tly  causes 
ndernoss, 
pvession, 
Icutal  dis- 
iperaturc 
riu'  diag- 
licss  have 
whether 
Ices  is  the 
|ty.     It  is 
ist,  if  not 
lix  is  not 
(ieneral 
[oration  is 

from  the 
It  was 

luvjority  of 
If  the  first 


i 


week  the  enlargement  is  evident,  unless  there  is  great  distention  of  the 
idloii,  when  the  spleen  may  be  pushed  far  back  and  ditlicult  to  feel.  Kven 
till'  normal  area  of  dulncss  may  not  be  obtainal)le.  1  have  seen  a  very 
iuriri'  spleen  post-mortem,  when  during  life  the  increase  in  size  was  not 
uliservable.  Toward  the  fourth  week  it  diminishes  in  size.  In  four  of 
niv  autopsies  it  weighed  less  than  nortiud.  Infarcts  and  abscesses  are 
iiccMsioiudly  found.  Rupture  of  the  spleen  in  typhoid  fever,  due  to  a 
sliLdit  blow,  has  been  seen  by  Bartholow.  Spontaneous  rupture  may  also 
occur. 

Liver. — Symptoms  on  the  part  of  this  organ  .ire  rare.  Enlargement  is 
occasionally  detected.  Jaundice  is  a  very  rare  complication.  It  may  be 
cither  of  a  catarrhal  nature  or  due  to  pareiiciiymatous  changes.  It  was 
present  in  only  Tl  per  cent  of  the  JvLunich  autopsies.  Abscess  of  the  liver 
is  a  very  rare  serpiela. 

Respiratory  System. — J-Jpista.ris,  an  early  symptom,  precedes  tyjihoid 
fever  luoi'e  commonly  than  any  other  febrile  alt'ection.  It  is  occasionally 
profuse  and  serious. 

f,ar>/ii'/ifis  is  not  very  common.  The  ulcers  and  the  perichondritis 
have  already  been  descril»c(i.  (Ivlcnia  apart  from  ulceration  is  rare.  In 
this  country  tiie  laryngeal  complications  of  ty})lioid  fever  seem  miu'h  less 
frc(iiient  than  on  the  ("ontinent.  I  have  seen  ulcers  in  oidy  four  or  five 
instances,  and  twice  oidy  jjcrichoiulritis,  both  of  which  cases  recovered, 
one  after  the  expectoration  of  large  portions  of  the  thyroid  cartilage. 

liroiicliitis  is  one  of  the  most  frequent  initial  symptoms.  It  is  indi- 
eateil  by  the  presence  of  sibilant  breathing.  It  may  come  f)n  with  great 
severity,  and  in  a  case  at  the  l'hiladel{)liia  Hospital  1  regarded  for  several 
days  the  bronchial  catarrh  as  the  primary  afTection.  The  smaller  tubes 
may  he  involved,  producing  urgent  cough  and  even  slight  cyanosis.  Col- 
la]ise  atul  lobidar  pneumonia  may  also  occur. 

Liihar  piiciiDioiiiii  is  nu't  with  under  two  conditions: 

1.  It  may  be  the  initial  symptom  of  the  disease.  After  an  indisposition 
of  a  day  or  so,  the  patient  is  seized  with  a  chill,  has  high  fever,  pain  in 
the  si(le,  and  within  forty-eight  hours  there  are  •signs  of  consolidation,  and 
the  evidences  of  an  ordinary  lobar  piu'umonia.  IMie  inti'stiiiid  symptoms 
niav  not  develop  until  toward  tlu^  end  of  the  first  week  or  later;  the  pul- 
monary symptoms  persist,  crisis  does  not  occur;  the  aspect  of  the  patient 


changes,  ami  bv  the  end  of  tin 


scco 


nd  week  the  clinical  picture  is  that  of 


typhoid  fever.  Spots  may  then  be  present  and  doubts  as  to  the  nature  of 
the  case  are  .solved.  In  other  instances,  in  the  absence  of  a  characteristic 
ernptiou  the  case  remains  dubious,  and  it  is  impossil)le  to  say  whether  the 
disease  has  been  pneumonia,  in  which  the  so-called  typhoid  .symptoms 
liave  developed,  or  whether  it  was  typhoid  fever  with  early  implication  of 
the  hings.  Whether  this  condiiion  (lc{)ends  upon  the  juieumococcus  or  is 
the  result  f)f  an  early  localization  of  the  typlmid  harillns  has  not  yet  l)een 
settled.     1  have  twice  performed  autopsies  in  cases  of  \\\\s pneiDao-typhuH^ 


26 


SPECIFIC   INFECTIOUS  DISEASES. 


iis  it  is  oalk'd  by  tlio  Frt'iich  iiiul  (icrnuuis,  iiiid  ciui  speak  positively  of  its 
onset  uitli  all  tlie  syiii]it()iiis  of  a  frank  piieiinionia. 

'Z.  Lobiir  pneumonia  forms  a  serious  and  by  no  means  iTifrequent  com- 
plication of  the  second  or  third  week.  It  was  ])resent  in  over  8  per  cent 
of  the  ^lunich  cases.  'J'hc  symjjtoms  are  usually  not  marked.  'I'liere 
may  be  no  rusty  sputa,  and,  unk'ss  sou<(ht  for,  the  coiulition  is  fre.iuentiy 
overlooked.  Infarction,  abscess,  and  gangrene  are  occasional  pulmonary 
complications. 

Ili/pusfdfic  cofif/rstion  of  the  lungs  and  a-doma,  due  to  enfeebled  circu- 
lation in  the  lati-r  ])eriods  of  the  disease,  are  very  common.  The  physical 
signs  are  defective  resoiumcc  at  the  bases,  feeble  breatli-sounds,  and,  on 
deep  inspiration,  moist  rrdes.  Pleurisy  is  by  no  means  an  uncommon  com- 
})licati()n.  It  was  ])resent  in  about  8  percent  of  the  Munich  auto])sies.  It 
may  develoj)  at  the  outset — pleuro-typhoid — or  slowly  during  convalescence, 
in  which  case  it  is  almost  always  purulent.  Another  occasional  pulmo- 
nary complication  is  ka'imi/i/i/si.s^  which  I  once  saw  at  the  height  of  the 
disease.     After  death,  no  lesions  of  the  lungs  or  broiu-hi  were  discovered. 

Nervous  System. — As  already  noted,  the  disease  may  set  in  with  in- 
tense and  persisting  hciidache  or  an  aggravated  form  of  neuralgia.  There 
are  cases  in  whicdi  the  etl'ect  of  tlio  i)ois()n  is  manifested  on  the  nervous 
system  early  and  with  tlie  greatest  intensity.  There  are  headache,  ])hoto- 
phobia,  retraction  oi  the  neck,  marked  twitching  of  the  muscles,  rigidity, 
and  even  convulsions.  In  such  cases  the  diagnosis  of  meningitis  is  invari- 
ably made.  I  have  examined  post  mortem  tliree  such  cases,  in  two  of 
which  tile  diagnosis  of  cerebro-spinal  fi'ver  had  been  nuule.  In  not  one  of 
them  was  there  any  trace  of  meningeal  inflammation,  only  the  most  in- 
tense congestion  of  tiie  cerebral  and  sj)iiud  pia.  Meningitis,  however,  may 
occur,  but  is  extremely  rare,  as  shown  by  the  Munich  record,  iii  which 
there  were  only  eleven  among  the  two  tliousand  cases.  Stokes's  dictum 
'  that  "  there  is  no  single  nervous  syni])tom  which  may  not  and  does  not 
I  occur  inde{)endently  of  any  appreciable  lesion  of  the  brain,  nerves,  or 
,'    spinal  cord,"  is  too  often  forgotten. 

Dcliriiiin^  usually  present  in  very  severe  cases,  is  certainly  less  frequent 
under  a  rigid  plan  of  hydrotherapy.  It  may  exist  from  the  outset,  but 
usually  does  not  develop  until  the  second  and  sometimes  not  until  the 
third  week.  It  may  be  slight  and  only  nocturnal.  It  is,  as  a  rule,  a  quiet 
delirium,  though  there  are  cases  in  which  the  patient  is  very  noisy  and 
constantly  tries  to  get  out  of  bed,  and,  unless  carefully  watched,  may  es- 
cape. Tiie  patient  does  not  often  become  maniacal.  In  heavy  drinkers 
the  delirium  may  have  tlie  character  of  delirium  tremens.  Even  in  cases 
which  have  no  positive  delirium,  the  mental  processes  are  usually  dulled 
and  the  aspect  is  listless  and  apathetic.  In  severe  cases  the  patient  i)asses 
into  a  condition  of  unconsciousness.  The  eyes  nuiy  be  open,  but  he  is  ob- 
livious to  all  surrounding  circumstances  and  neither  knows  nor  can  indi- 
cate his  wants.     The  uriue  and  faeces  are  passed  involuntarily.     In  this 


TYPHOID  FEVER. 


27 


of  its 

t  com- 
•r  cent 
Thorc 
[iientiy 
iiouiiry 

[  circu- 
iliy.sicul 
iintl,  on 
»n  com- 
iies.  It 
i'soencc, 

pulmo- 
;  of  the 
Dvorod. 
rtith  iii- 
There 

nervous 
>,  photo- 

ri<;idity, 

s  iuvari- 
|i  two  of 
\)t  one  tif 

niost  iu- 
|(vei',  may 
|in  which 
dictum 

(loos  not 

lerves,  or 


p^piiflo-wiikoful  state,  or  coma  vigil  as  it  is  callpfl,  the  eyes  are  open  and 
rhc  iiiitient  is  constantly  muttering.  'IMie  lips  and  tongue  are  tremulous; 
there  are  twitcliings  of  the  fingers  and  wrist.s — snbsultus  tendinum  and 
carpliologia.  lie  picks  at  the  hedch)tlies  or  grasps  at  invisil)le  ol)jects, 
'I'liise  are  among  tlie  most  serious  symptoms  of  tiie  disease,  and  always 
indicate  danger. 

(Jonvulsions  are  rare,  even  in  cliihlren.  In  the  oidy  case  wliicli  I  have 
seen  they  devxdoped  suddeidy  on  the  eightli  (hiy,  and  j)ro\XHl  fatal  in  about 
twelve  hours.  Thrombosis  of  the  veins  of  tlie  pia  mater  on  tlie  left  side 
was  found. 

Among  important  complications  and  serpiela^  are  several  nervous  affec- 
tions. 

Xnirifis,  wliich  is  not  uncommon,  may  bo  local,  or  a  widespread  alToc- 
tion  of  the  nerves  of  the  legs  or  both  arms  and  legs. 

l.onil  Xciin'/is. — This  niav  occur  during  the  iieight  of  tlie  fever  or 
after  convalescence  is  established.  It  may  set  in  with  agonizing  i)ain,  and 
with  sensitiveness  of  the  atfected  nerve  trunks.  In  two  instancor'  f  have 
seen  great  tenderness  of  the  muscles,  and  some  of  these  cases  may  be  myt)- 
sitis.  There  may  be  extreme  sensitiveness  of  the  muscles  without  any 
signs  of  neuritis.  The  condition  may  subside  without  leaving  any  atrophy. 
The  local  neuritis  following  typhoid  fever  may  affect  the  nerves  of  an  arm 
or  of  a  log,  and  involve  chielly  tlie  extensors,  so  that  there  is  wrist-drop  or 
fddt-drop  of  the  affected  limb.  Some  of  these  cases  are  very  difficult  to 
separate  from  the  poliomyelitis. 

A  curious  condition,  probably  a  local  neuritis,  is  that  which  was  first 
(ipscribod  by  llandford  as  trndcr  fors,  and  whicdi  appears  to  be  much  more 
comiiion  after  the  cold-bath  treatment.  The  tips  and  pads  of  tiie  toes, 
rarely  the  pads  at  their  basof^,  become  exquisitely  sensitive,  so  that  the  pa- 
tient can  not  bear  the  weight  of  the  bedclothes.  There  is  no  discolora- 
tion and  no  swelling,  and  it  dii^appears  usually  within  a  week  or  ten  days. 

MuUiple  ni'iin'fis  in  typhoid  k-xor  develops  usually  during  convales- 
eoiice.  The  legs  may  be  affected,  or  the  four  extremities.  The  cases  are 
often  difficult  to  differentiate  from  the  subacute  poliomyelitis.  Recovery 
is  the  rule.  Of  four  cases  with  involvement  of  arms  and  legs,  three  re- 
covered comi)letely  and  one  is  now  improving.* 

Poliomyelitis  may  develop  with  the  symjitoms  of  acute  ascending  paral- 
ysis and  prove  fatal  in  a  few  days.  More  frequently  it  is  less  acute,  and 
causes  either  a  paraplegia  or  a  lindted  atrophic  ]iaralysis  of  one  arm  or  leg. 

Among  other  sequences  may  be  mentioned  aphasia,  wiich  is  more  apt 
to  occur  in  young  children,  and  great  slowness  of  speech,  which  may  or 
may  no*^  be  associated  with  mental  weakness. 

True  tcfaiij/  occurs  sometimes,  and  a  number  of  cases  have  developed 
in  certain  epidemics.     It  may  set  in  during  the  full  height  of  the  disease. 


^Neuritis  during  and  after  Typhoid  Fever,  Johis  Hopkins  Iloxitital  livports,  vol.  v. 


28 


SPECIFIC   INFECTIOUS   DISEASES. 


Tliis  coniplipation  is  extrciiu'ly  nire  in  tliis  eomitry,  and  .Tiineway,  so  far 
as  I  know,  lias  alone  ri'portcd  instances. 

I'ost-t'eltrile  iiisa/ii///  is  [lerliaps  more  rre(|iient  after  tyitlioid  lliaii  after 
any  other  disease.  Wood  regards  it  as  confiisional  insanity,  the  result  of 
impaired  nutrition  and  exhaustion  of  tiie  nervous  centres.  Five  cases 
luive  come  under  my  ol)si'rvation,  in  four  of  \vhi(;h  recovery  took  place. 

Distnrhances  of  the  organs  of  the  special  senses  are  rare.  Otitis  media 
occasiomilly  develojjs  and  may  cause  chills  and  septic  symjitoms.  Eye 
affect ioJis  are  rare,  hut  cataract  has  been  kmnvn  to  follow  in  youn(f 
persons. 

Renal  System. —  Hetention  of  urine  is  an  early  symptotu  in  many  cases, 
ami  is  more  freipu'ut  in  some  epidemics  than  in  others.  The  condition 
muy  recur  foi-  several  wei'ks.  The  urine  is  usually  diminished  at  llrst, 
Juis  the  ordinary  fehrile  characters,  ami  the  pigments  are  increased.  Later 
in  the  disease  it  is  more  abundant  and  lighter  in  color. 

Khrlich  has  de.scril)ed  a  reaction,  which  he  believes  is  rarely  met  with 
exce})t  in  tyjjlioid  fever.  This  so-called  tlidzo-rrKrliini  is  ])rodr.ced  as  fol- 
lows:  Two  solutions  are  emjtloyed,  kept  in  separate  bottles:  oiu>  contain- 
ing a  saturated  solution  of  sulphanilic  aci(:  in  a  solution  of  hydrochloric 
aci<l  (50  c.  c,  to  1,000  c.  c.)  ;  the  other  a  ^  ])er  cent  solution  of  sodium 
nitrite.  To  nudsc  the  test,  a  few  cubic  centimetres  of  urine  are  jilaced  in 
a  small  test-tube  with  an  e(|ual  (pnintity  of  a  mixture  of  solution  of  the 
sulphanilic  acid  (40  c.  c.)  and  the  sodium  nitrite  (I  c.  c),  the  whole  being 
thoroughly  shaken.  Oiu'  cubic  centimetre  of  ammonia  is  then  allowed  to 
flow  carefully  down  the  side  of  the  tube,  forming  a  colorless  zone  above 
the  yellow  urine,  and  at  the  junction  of  the  two  a  deep  browiush-red  ring 
will  be  seen  if  the  reaction  is  ])reseut.  With  normal  urine  a  lighter 
brownish  ring  is  produced,  without  a  shade  of  red.  The  color  of  the  foam 
of  the  mixed  urine  ami  reagent,  aiul  the  tint  they  ])roduco  when  largely 
diluted  with  water;  are  characteristic,  being  in  both  cases  of  a  delicate 
rose-red  if  the  diazo- reaction  be  present;  but  if  not,  brownish-yellow. 

It  was  j)resent  in  one  hundred  and  thirty-six  of  one  humlred  and 
ninety-six  cases  exanniu'd  at  my  clinic*  It  may  be  ]»resent  previous 
to  the  occurrence  of  the  rash,  anil  as  late  as  the  twenty-secoml  day.  The 
valui!  of  the  test  is  lessened  by  its  occurrence  in  cases  of  miliary  tubercu- 
losis, and  occasiomdly  in  the  acute  diseases  associated  with  high  fever. 
The  toxicity  of  the  urine  is  mucli  increa.sed  in  typhoid  fever,  and  the 
toxi(!  products  arc  eliminated  in  greater  quantities  in  cases  treated  with 
the  cold  bath. 

T'he  reiuil  complications  in  typlioid  fever  may  be  thus  grouped  : 

{a)  Febrile  albuminuria,  which  is  very  common  and  of  no  f;pecial  sig- 
niticance  ;  thus,  in  the  first  two  hundred  and  twenty-nine  cases  admitted 


M 


*  Hewotson,  The  Urino.  and  the  Oecurrcnco  of  Renal  Complications  in  Typhoid 
Fever.     Jvlms  Hopkins  Uoxpital  Iteportx.  vol.  iv. 


"> 


TVPIIOID   KKVKR. 


'J!> 


ly,  so  far 

liaii  after 
result  of 
ivc  casx'.s 
))laco. 
lis  iiK'dia 
lis.  Kye 
in  yoiuif,^ 

liny  oases, 
condition 
1  at  first, 
cl.    Later 

met  with 
;ed  as  fol- 
>  001 1  tain - 
Iroohiorie 
3f  sodium 
placed  in 
ion  of  the 
hole  heiny 
illowed  to 
mo  above 
-red  ring 
a  litrhter 
the  foam 
Ml  largely 
a  delicate 
■How. 
(Ired  and 
})revious 
ay.     The 
tubercu- 
yh  fever. 
',  and   the 
ated  with 

leeial  sig- 
ad mil  ted 

111  Typhoid 


III  ilic  .loliiis  Hopkins  lIos|iil;il  allMiiiiiiiui'ia  was  iiolcij  in  one  hiindicd 
and  sixlv-foiir,  and  liilic  casls  is  in  one  hiindreil  iiiiij  lliice. 

(//)  Acute  neplirilis  occurring  at  the  onset  or  during  the  height  of  the 
ili^,.,,si.— the  i(i'iihro-l ijiiltiis  of  the  (lernians,  the  //V/vv  liijilmiilr  a  funiir 
n'titi/i' {>['  the  l-'reiich  —  may  set  in,  with  all  the  syni|itonis  of  tiie  most  in- 
tense IirigtiTs  disease,  masking  in  many  instanres  the  true  natui'e  of  the 
iiialadv.  After  an  iiidisiiosiiioii  of  a  U'W  ilays  there  may  lie  fever,  |iaiii  in 
the  hai'k,  ami  the  passage  of  a  small  amount  of  bloody  urine.  In  iweiity- 
oiie  of  till' two  hundred  and  twi'iity-nine  cases  evidence  was  prcsi'iit  of  a 
detiiiite  nephritis — much  alhnmin  and  iiiaiiv  lube  easts.  In  ten  there 
were  also  I'cd  blood-corpuscles,  in  two  the  cases  were  nally  ha'iiiori  tiagic 
iK^pliritis.  Seven  of  these  twenty-one  cases  died — live  from  pcifoi-atioii, 
not  one  from  the  renal  complication. 

(r)  'i'he  nephritis  of  convalescence.  This  is  more  comiuoii  but  less 
sci'ioiis.  Il  develops  after  the  fall  of  the  fever,  and  is  usually  associated 
with  o'dciiia.  Jt  doi's  not  present  characters  dill'ereiil  from  the  ordinary 
post-febrile  nc])liritis. 

{il)  The  reniarkal)lc  lyniphoniatoiis  nephritis,  dcscrilicd  iiy  ]•;.  Wagner 
ami  others,  and  already  referred  to  in  the  section  on  morbid  anatomv, 
pniiliices,  as  a  rule,  no  sym{itoms. 

(r)  I'jinriii  is  a  not  uncommon  com()lication.  Hluiner*  has  studied  ten 
cases  in  my  wai'ds.  In  seven  the  colon  ba<'illiis  was  present,  in  two  the 
typhoid  bacillus,  and  in  one  tlu^  staphylococcus  albiis. 

{/)  I'list-ljijihoiil  jiiirlilis. —  111  this  the  pelves  of  the  kidney,  and  the 
calii'cs  are  at  lirst  coveri'd  with  a  meiiibranoiis  exudation,  but  cro-ion  ami 
iiL'eration  may  snbse(piently  occur.  There  may  be  blood  and  ])us  in  the 
urine.  This  condition  occurred  in  three  of  my  cases,  in  one  of  which  it 
was  associated  with  extensive  nu'inbi-aiioiis  iiillammatioii  of  the  bladder. 

Simple  catarrh  of  the  bladder  is  rare. 

Orrhilis  is  occasionally  met  with  during  convalosconco.  Sa(h'ain  col- 
leeteil  sixteen  cases  in  the  literature,  it  is  usually  associateil  with  a 
i"itarrhal  urethritis.  Induration  or  atrophy  may  occur,  and  more  rarely 
suppuration. 

Osseous  System.  —  .V  multiple  arthritis  occasionally  occui's  ;  more  com- 
moiny  it  is  limited  to  a  single  joint,  and  may  ]iass  on  to  suppuration. 
SpDiUaneous  hixatiiui  may  develop.  Necrosis  of  the  bones  may  occur 
during  the  fever,  but  it  is  most  often  a  lesion  of  convalescence.  Keen 
collected  thirty-seven  cases  ('I'on.'r  I>ecture,  !s:(;).  Paget  dealt  fully 
with  the  clinical  features,  particularly  the  chronic  course  and  slight  tend- 
ency to  spontaneous  recovery.  Some  of  the  cases  developing  during  t  !h^ 
tevi'r  are  due  to  streptocociais  infection;  but  in  a  majority  the  typhoid 
bacilli  are  found,  oven  months  or  yoars  after  convalescence.  'I'he  ril)s  and 
titiiu'  aie  the  favorite  sites.     The  lesion  is  soiiictiim^  a  shiwly  developing 


Hoport  on  Typhoid  Fevor,  No.  H.     Jakns  Ilop/n'ns  llos^iiUd  Rcpoii.s,  vol.  v. 


30 


SPKCIFK"  INFKCTIOUS   DISKASKS. 


iiddc,  wliicli  docs  not  siippiii'iitt'  Tor  iiioiitlis.  Of  six  cases  ivt  tho  .loliiis 
lldlikins  llospitiil  (lui'iii;,'  tlu^  ycai'  ISHl,  culturi's  were  made  IVoiii  five: 
ill  four  llic  Mliertli  bacillus  occurred  alone,  and  in  one  in  conjunction  with 
the  stapiivlocoecus  aureus  (Harold  Parsons). 

There  is  a  rcinarkaltle  tlisorder  of  convalescence  to  which  (iihiu'V  has 
given  the  name  "  tyidioid  spine."  The  patient  has  UHiially  been  i.j)  and 
about,  and  may  have  had  a  slight  jar  or  shock,  after  which  he  comjilains 
of  great  ])ain  in  the  back,  and  of  pain  on  nujving  the  legs.  The  condition 
may  persist  for  weeks  without  fever  or  any  signs  of  I'ott's  disease,  spon- 
dylitis, or  neuritis;  but  there;  are  usually  marked  nervous  or  hysterical 
symjjtoms.  The  outlook  is  good,  it  is  not  known  njxm  what  this  con- 
dition depends.     It  seems  to  l)e  a  neurosis  rather  than  a  perispondylitis. 

'['he  iiiiisrirs  may  be  the  seat  of  the  degeneration  already  referred  to, 
but  it  rarely  causes  any  symptoms.  Ihemorrhage  occasionally  occurs  into 
the  muscles,  and  late  in  jirotracted  cases  ubscesscs  may  develop,  sometimes 
in  or  between  tiie  abdominal  muscles. 

Association  of  other  Diseases.  — Erysipelas  is  a  rare  complica- 
tion, most  comnmiily  met  with  during  convalescence.  In  l,4'-.'(l  cases  at 
Basic  it  occurred  ten  times.  Criesiiiger  states  that  it  is  met  with  in  '4 
per  cent. 

Measles  may  devtlop  during  tlie  fever  or  in  convalescence.  Chicken- 
j)().\  and  noma  hs.ve  been  reported  in  children.  Pseudo-menibranons  in- 
llaiiimations  nii'.y  occur  in  the  jiharynx,  lar\nx,  or  genitals.  Malarial  and 
typhoid  fevevs  may  be  associated,  but  a  majority  of  the  cases  of  so-called 
ty])ho-nialarial  fever  are  either  remittent  or  true  typhoid. 

Typhoid  fever  may  attack  an  individual  the  subject  of  tuberculosis. 
In  four  of  my  eighty  cases  tuberculous  lesions  coexisted  with  those  of 
typhoid  fever.  Miliary  tuberculosis  occasionally  ili'velo})S  after  it,  but  my 
jH'rsonal  experience  does  not  warrant  the  belief  held  by  some  writers,  that 
there  is  a  greater  susce])tibility  to  tuberculosis  after  typhoid  than  after 
other  fevers.  Acute  miliary  tuberculosis  and  tyjihoid  fever  have  been 
met  with  in  the  same  subject. 

In  ei)ilepsy  and  in  chronic  chorea  the  fits  and  movements  usually 
cease  during  an  attack,  and  in  ty[)hoid  fever  in  a  diabetic  subject  the 
sugar  may  be  absent  during  the  height  of  the  disease. 

Varieties  of  Typhoid.  —  Typhoid  fever  presents  an  extremely 
complex  symptomatology.  Many  forms  have  been  described,  some  of 
whicli  present  exaggeration  of  common  symptoms,  others  modification  in 
the  course,  others  again  greater  intensity  of  action  on  certain  organs.  As 
we  have  seen,  when  the  nervous  system  is  specially  involved,  it  has  been 
called  the  cerebro-spinal  form  ;  when  the  kidneys  are  early  and  severely 
alTected,  nephro-typhoid  ;  when  the  disease  begins  with  })iilm()nary  symp- 
toms, pneumo-tyj)hoid  ;  with  jtleurisy,  pleuro-typhoid  ;  when  the  disease 
is  characterized  throughout  by  profuse  sweats,  the  sudoral  form  of  the 
disease.     It  is  a  mistake,  I  think,  to  recognize  or  speak  of  these  as  varie- 


1 


TYIMIOII)   FEVKU. 


81 


Johns 
n  five : 
L)U  with 

noy  has 

mplains 
n\(lilion 
ic,  spoii- 
ystcric'iil 
his  con- 
ilylitis. 
erred  to, 
?urs  into 
)nietimes 

■omplica- 
)  cases  at 
nth  in  'i 

Chicken- 

■iinons  in- 

hirial  and 

so-called 

)erpnlosis. 

those  of 
t,  hut  my 
iters,  that 

iKin  after 
mve  hccn 

p  nsually 
Ihject  the 


tics.  It  is  enoufrh  to  rcTiionilier  that  typhoid  iimy  set  in  oecasionally  with 
svtiiiitiiins  loeali/ed  in  certain  or^Miis,  and  tiial  many  of  its  symptoms  ui'o 
cxiicinflv  ineonstant — in  one  epidemic  uniform  and  t  •.\t-l)ook-iil\e,  in 
aiiiitlier  sii;.dit  or  not  met  witli.  Tins  thversilied  s_vmptomatolo};y  Inw 
led  tn  many  clinical  errors,  and  in  the  al»scnce  of  tin-  salutary  lessons  of 
iiiurliid  anatomy  it  is  not  surprisiuij;  that  practilioners  have  so  often 
licrti  led  astray.  Wo  nuiy  reco^niize,  with  Murchisou,  the  followiug 
varieties  : 

1.  The  iiiihl  and  nhortire  forms.  It  is  very  importatd  for  the  practi- 
tioner to  recoijiuzc  the  milil  type  of  typhoid  fever,  often  spoken  of  us 
^f.isiric  fever  or  even  re;,nirded  as  simple  fel)ricnla.  In  this  form,  the 
tvphiis  Im'ssinius  of  (Iricsinifcr,  the  symptoms  are  similar  in  kind  hut 
ah(i;,'ether  less  intense  than  in  the  j,n'aver  attacks,  aIthou<,di  the  onset  may 
he  .-inldi-n  and  severe.  The  temperature  randy  reaches  Jo;J",  and  the 
fever  of  onset  may  not  show  the  frradual  ascendinjj  evening'  record.  The 
spleen  is  enlarffcd,  the  rose-spots  may  be  marked  ;  ofti'ii  they  are  very 
I'ew  in  number.  The  dlarrluea  is  variabh  ,  sometimes  it  is  not  ])resent. 
In  smdi  cases  the  symptoms  may  persist  for  from  sixteen  to  twenty  days. 

In  the  abortive;  f(»rm  the  .sym])toms  of  onset  may  he  nuiiked  with  shiv- 
erinix  and  fever  of  lO'.i^  or  even  hii^her.  The  date  of  onset  is  often  deli- 
nite,  a  point  upon  which  Jiir:fea.HH  lays  irri'at  stress,  Ko.se-spots  may 
oecur  from  the  second  to  the  fifth  day.  Early  in  the  secoml  week  or  at 
the  eml  of  the  tirst  week  the  fever  falls,  often  with  [imfuse  sweating,  aiul 
convalescence  is  estaldished.  In  this  aliortive  form  ridapse  luay  occur  ami 
may  occiasiomdly  jtrove  severe.  When  ty()hoid  fever  prevails  exti'nsively 
these  cases  are  not  uncommon.  I  agree  with  J.  ('.  Wilson,  who  states  that 
they  are  not  nearly  so  common  in  this  country  as  in  Kuropo. 

'i.  The  f/rure  form  is  usually  characiterized  by  high  fever  and  pro- 
nonnced  jiervous  symptoms.  In  this  category,  too,  coiue  the  very  severe 
eases  setting  in  with  pneumonia  ami  Ih'ight's  disease,  and  with  the  very 
uitense  gastro-intestinal  or  cerehro-spinal  symptoms.  , 

;5.  The  hife/it  or  amhulatonj  form  of  typhoid  fever,  which  is  particu- 
laiiy  ei.nimon  in  hosj)ital  i)ractice.  The  syniptoms  are  often  very  slight, 
and  the  patient  .scarcely  feels  ill  enough  to  go  to  bed.  lie  has  languor, 
perhaps  slight  diarrho'a,  but  keeps  about  and  may  even  attend  to  his  work 
tlu'ougliout  the  entire  attack.  In  other  instances  delirium  sets  in.  The 
worst  cases  of  this  form  are  seen  in  sailors,  who  keep  up  ;Md  about,  though 
feeling  ill  and  feverish.  When  brought  to  the  hospital  they  often  develop 
syiiipidiiis  of  ii  nnjst  severe  type  of  the  disease.  I lannorrhage  or  perfora- 
tion may  he  the  first  symptom  of  this  amhidatory  type.  Sir  W.  Jenner 
lias  ealled  attention  to  the  dangers  of  this  form,  atul  partictdarly  to  the 
jrrave  prognosis  in  the  case  of  persons  wdu)  have  travelled  far  with  the  dis- 
ease in  |)rogress. 

Hifinorrhagic  typhoid  is  a  rare  and  very  fatal  form,  characterized  hy 
cutaneous  and  mucous  hivmorrhajjes.     The  term  should  be  restricted  to 


32 


SI'KCIFIC   INFKCTlors  PISKASKS. 


the  oas«\s  with  iniilii|il('  liK'c(liiij,'s,  and  iiot  iisnl  to  ili'sigmite  cases  witli 
lin'iiiorrliaf^'c  t'roiii  the  liowcls. 

All  dfrhrili'  tv|)linii|  I'cvcr  is  rci'(>i,Mii/.('il  l)y  autluu's.  Ijichcnncistcr  wavs 
that  tlic  cases  were  iKit  iiiM'iiiiiiiiiin  at  Hash'.  'I'lic  |iatifiits  |)i'('scMt('(l  his- 
sitmh',  (h'pi'i'ssidii,  hi'adai'iic,  t'uncil  t(iii,:.':it',  loss  of  a|)|M'tilc,  sh»\v  piilsi', 
and  cvt'ii  tlii'  sjiots  and  I'ldargcd  spli-cii.  1  have  no  prr.soiial  kn(twlc'ilg(f  of 
Hiicli  cases. 

Typhoid  Fevor  in  Children.— Cases  arc  not  uncointnon  under  tho  ago 
(»f  ten,  l)iil  the  disease  is  rare  in  iid'ants  under  two  years  of  age.  Cases 
have  been  re|iorte(|,  however,  in  sucklings  (nine  months,  l-'nller;  four  and 
u  iialf  nmnlhs.  Ogle),  and  perforation  has  heen  met  with  in  an  infant  five 
days  old.  Mpistaxis  rarely  occnrs  ;  the  rise  in  temperiiture  is  less  gradnal ; 
the  initial  bronchial  catarrh  is  often  ohservi'd.  The  nervous  symptoms  tire 
often  prominent;  there  tire  wakcfidness  and  delirium;  diarrho'a  is  often 
al)scnt.  The  rash  may  he  very  slight,  lait.  the  most  copious  eruption  I 
have  ever  seen  was  in  a  child  of  eight.  Tlu-  aiidonwnal  symptoms  tire 
often  slight.  Fatal  lui'inorrinige  and  jierfuration  are  rare.  Among  the 
se(|iiela',  aphasia,  noma  and  hoiie  lesions  may  he  mentioned  as  more  com- 
mon in  children  than  in  adults.  The  mortality  of  typhoiil  fever  in  chil- 
dren is  low.  In  fatal  cases  only  a  carefid  bacteriological  examination 
can  deciile  whether  the  swollen  I'eyer's  patches  and  mesenteric  gland.s — 
not  nncotnmon  in  children  with  fever — depend  upon  an  iid'ection  with 
tyi)hoid  bacilli. 

Ciiltiires  have  been  made  from  the  f(etiis  delivered  at  tlie  ei  'nonth, 

which  lived  live  days.  I.iings,  spleen,  liver,  intestines  sliow^..  a.uerth's 
bacillus. 

Typhoid  Fever  in  the  Aged.— After  the  fortietli  year  tlic  disease  rnns  a 
less  favorable  course,  and  the  mortality  is  very  lugh.  Of  sixty-four  fatal 
eases,  seven  were  over  forty  years  of  age  ;  one  was  aged  sixty-three,  am)ther 
seventy.  The  ft'ver  is  not  so  liigh,  but  comj'lications  are  more  common, 
))articidai'ly  imeumoiiia  ami  heart  failure. 

Typhoid  Fever  in  Pregnancy. — The  disease  is  rare  in  pregnant  wojnen. 
Only  one  case  occurred  anmng  nearly  four  hundred  cases  nmU'r  my  care 
during  the  jiast  six  years.  The  majority  of  the  patients  are  uiteeted 
during  the  first  half  of  ])regnancy.  In  mort>  than  lialf  the  cases  abortion 
or  premature  delivery  follows,  usually  in  the  second  week  of  the  disease. 
The  fu'tus  may  itself  be  infected,  and  the  typlioid  bacilli  have  been  culti- 
vated from  it.  'I'he  mortality  in  pregnant  women  witli  typhoid  fever  is 
liigh — luneteen  in  luiu'ty-one  ca.ses  (Urieger).  The  experience  of  IJrand 
and  of  the  physicians  of  the  Lyons  school  would  show  that  tlie  cold-bath 
treatment  is  not  only  not  contraindicated,  but  most  etlicacious. 

Relapse. —  Kelai)ses  vary  in  fre(juency  in  dilferent  e])idemics,  and,  it 
woidd  appear,  in  dilferent  places.  'I'he  percentages  of  dilferent  authors 
range  from  o  ])er  cent  (Murchison),  11  per  cent  (Hiinnder),  to  lo  or  18 
per  cent  (Imniernumn).     In   Wagner's  clinic,  from   IS8^  to  1880,  there 


J 


TVI'llnlli    l'KVi;i:. 


88 


well'  llirclapscs  ill  .'iiil  ciiscs.  1".  (  .  Sliaiiiick  rcpdrts  'il  rcliipscs  in  \:i\) 
ijiM-;.  |{.  li.  Ma('l)i)iiiu'll  1  ri'Iii|>sc  ill  l(i(i  cusi's.  A  ivliipsc  is  a  n'iK;ti- 
limi,  sniiii'tiiiu's  iiiiiy  a  siiiiiiiiai'v,  111"  the  (ii'i;.''iiial  alta>'l\.  \  nii  Ziciiissi'ti 
iiisi.-ts  corrt'clly  that  luoul'  the  ilnrr  iiii|Mirtaiit  .<\iii)il()(iis — step-like  tciii- 
|iri'atun'  at  onset,  roseola,  ami  eiilari^fil  spleen  .-.lioiiM  he  ]ireseiil  to  di'- 
icriiiiiie  the  (liiigiiosis  of  a  relap.-".  Tlie  intestinal  lesions  are  repeated, 
ili()iii;h  with  less  intensity  ami  rej^jiiiarity.  It  is  to  lie  I'arel'iilly  ilistin- 
iMiislieil  from  the  fever  of  eonvaleseeiiiH'  -  or  reeruilfseriiee  already  de- 
si  rihi'd,  which  is  usually  transitory,  not  lasting  longer  than  a  day  or  two. 
There  ai'e  oeeasioiial  instanees  in  wnieh  the  fever  persi.-ts  for  four  or  livo 
(lavs  without  rose-spots,  or  without  enlai'jieiiieiit  of  the  splet'ii,  and  it  may 
he  iinpossilile  to  determine  whether  there  has  lu'eii  a  relapse  or  not.  Tho 
true  relapse  UHually  sets  in  after  complete  defervescence.  Irvine  noted  tho 
average  duration  of  the  interval  in  his  cases  at  a  little  over  live  days.  In 
eleven  of  Shall  lick's  cases  the  relaps(>  lieifaii  liid'ore  complete  deferves- 
ceiiee.  The  onset  is  usually  abrupt,  tliou^h  the  step-like  ascent  is  soine- 
liiiies  well  seen,  as  in  Chart  I.  The  eruption  may  he  seen  as  early  as  tlio 
third  or  fourth  day.  'I'he  atta<d\  is  usually  less  severe  and  of  .shorter  diirii- 
tioii.  Of  .Murehisoii's  lifty-tlireu  cases  the  mean  duration  of  the  lirst 
attack  was  about  twenty-six,  of  the  interval  eleven,  (d"  the  relapse  tifteeii 
(lavs,  'i'he  mortality  of  the  relapse  is  not  hiirh.  There  may  Ih'  u  third  or 
fourth  relaj)se.     Da  Costa  has  twice  seen  lie  rela[)ses. 

The  relapse  is  a  reinfeittion  from  within,  hut  we  are  still  (piite  ii;iiorant 
of  the  conditions  favorin_<f  it.s  occurrence.  It  is  m)t  at  all  likidy  that  any 
special  methods  of  treatment  favor  the  rehqise,  though  hydrotherapy  lius 
labored  under  this  reproach. 

Diagnosis. — If  the  ]iatieiit  is  soon  from  the  outset  tliere  is  rarely  any 
(lilliriilty  in  diagnosing  typhoid  fever  of  typical  course.  In  the  prcfebrile 
period  the  headache,  weakness,  loss  of  appetite  and  epistaxis  are  extremely 
suirgestive,  and,  with  an  aseemling  pyrexia,  scarcely  lu-cd  the  distinctive 
rush  to  clinch  the  diagnosis. 

The  early  and  intense  localization  of  the  symptoms  in  certain  organs  is 
a  freipieiit  source  of  error  in  diagnosis. 

Cases  coming  on  with  severe  headaeh(>,  jdiotopliobia,  delirium,  twitch- 
in;:  of  the  muscles  and  retraction  of  Ww  head  are  almost  invariably 
rcpu'ded  as  eerebro-sj)imil  meningitis,  rnder  siudi  eirciin»staiu>es  it  may 
for  A  few  days  be  impossible  to  make  a  satisfactory  diagnosis.  I  have 
tlirice  performed  autopsies  on  cases  of  this  kimi  in  which  no  suspicion  of 
typhoid  fever  had  been  present ;  the  intense  cerebro-spinal  manifestations 
having  dominated  the  scene.  Until  the  appearance  of  abdominal  symp- 
toms, or  the  rash,  it  may  be  quite  im])ossible  to  determine  the  nature  of 
ilio  (?ase.  Cerebro-spinal  meningitis  is,  however,  a  rare  disease;  ty})hoid 
fever  a  very  common  one,  and  the  onset  with  severe  nervous  symptoms  is 
by  no  means  infrequent.  Fully  one  half  of  the  cases  of  the  so-culled 
hi'ain-fever  belong  to  this  category. 


11 


84 


SPECIFIC   IXFECTIOCS  DISEASES. 


'I.    \ 


I  have  already  spokon  of  the  niisloadinfj  pulmonary  symptoms,  which 
r.-'.'.'usionally  dcvolop  at  the  very  outset  of  the  disease.  The  bronchitis 
rarely  causes  error,  tliough  it  may  be  intense  and  attract  the  chief  at- 
tention. More  dilHcult  are  the  oases  selling  in  with  chill  and  followed 
ra])idly  by  pneumonia.  I  iuive  brought  such  a  case  l)efore  the  class 
one  week  as  typical  pneumonia,  and  a  fortnight  later  shown  the  .same 
case  as  undoubtedly  one  of  typlioid  fever.  Jn  another  case,  iji  which  the 
onset  was  with  delinite  pneumonia,  no  spots  developed,  and,  though  there 
were  diarrhoea,  meteorisiu,  aiul  the  n.o  t  pronounced  nervous  symptoms, 
the  doubt  still  remains  whether  it  was  a  case  of  typhoid  fever  or  one  of 
pneumonia  in  which  .severe  secondary  symi)toms  developed.  '^Phere  is 
less  danger  of  mistaking  the  piuMunoiiia  which  develops  at  the  height  of 
the  disease,  ami  yet  this  is  ])ossible,  as  in  a  case  admitted  a.  few  years 
ago  to  my  wards — a  man  aged  .'^evenly,  insensible,  with  a  dry  tongue, 
tremor,  ecchymoses  upon  the  wrists  and  ankles,  no  rose-spots,  eidarge- 
ment  of  the  spleen,  and  consolidation  of  his  right  lower  lobe.  It  was  very 
natural,  particularly  since  there  was  no  history,  to  regard  such  a  case  as 
senile  piuuimonia  with  j)rofouiul  constitutioiud  disturbance,  but  the  au- 
topsy showed  the  characteristic  lesions  of  typhoid  fever. 

From  malarial  fever,  typiioid  is,  as  a  rule,  readily  recognized.  There 
is  no  such  disease  as  typho-nudarial  fever — that  is,  a  separate  and  distinct 
nndady.  Typhoid  fever  and  malarial  fever  in  rare  instaiu-es  may  coexist 
in  the  same  patient.  Of  nearly  tV)ur  hundred  cases  of  typhoid  fever,  all 
witli  blood  examinations,  and  a  majority  of  them  coming  from  nudarial 
regions,  in  not  a.  single  instaiu'c  were  the  malarial  ])arasites  found  in  the 
blood.  There  is  now  no  excuse  whatrvcr  for  the  eontiniu'd  use  ])y  prac- 
titioners of  the  term  typho-midarial  fjver,  and  still  less  for  the  falsifica- 
tion of  vital  statistics  by  sending  death  certificates  sigtu'd  with  this  diag- 
nosis. The  jirineiple  is  bad  aiul  the  practice  is  worse,  since  it  gives  a 
false  sense  of  security,  and  nuiy  prevent  proper  measures  of  i)ro2)hy- 
laxis. 

In  regions  where  malarial  fever  ]irevail.s,  the  autumnal  type  may  pre- 
sent a-  striking  similarity  in  its  early  days  to  typhoid  fever.  DilTcrentia- 
ti(Mi  may  be  made  oidy  by  the  blood  examimition.  There  may  be  no 
chills,  the  remissions  may  be  extrenu'ly  slight,  there  is  a  history  perhaps 
of  vKiJin'sp,  weakness,  diarrluea.  ]H'rba])s  vomiting.  The  tongue  is  furred 
ami  white,  the  cheeks  iluslu'd,  tiu'  spleen  slightly  enlarged,  aiul  the  tem- 
perature continuous,  or  with  very  slight  remissions. 

A  low,  long-continued  fever  in  obscure,  deep-seated  suppuration,  with- 
out chills  or  sweats,  :nay  siiinilate  typhoid.  The  presence  or  ab.senco  of 
leucocytosis  would  be  an  important  aid. 

Acute  miliary  tubercidosis  is  not  infrequently  mistaken  for  typhr  il 
fever.  The  points  in  difTerential  diagnosis  will  be  discussed  under  tmit 
disease.  TuIhm'c  mous  peritonitis  in  certain  of  its  forms  may  closely  simu- 
late typhoid  fever. 


J* 

'Si 


TYPHOID   FEVER. 


86 


;,  which 
oiuihilis 
■hief  at- 
f  olio  wed 
he   class 
he  san\e 
hich  the 
igh  there 
■mptoms, 
?)\'  one  of 
There  is 
height  of 
few  years 
V  tongue, 
,  enlarge- 
t  was  very 
1  a  case  as 
it  the  an- 

>,!.     There 
nil  distinct 
nay  coexist 
,d  fever,  all 
n  malarial 
mid  in  the 
St'  hy  prac- 
10  falsifica- 
|i  this  diag- 
it  gives  a 
lof  propliy- 

e  may  pre- 
iDitTerentia- 
may  be  no 
hry  perhaps 
liie  is  fnrreil 
nd  the  tcm- 

[ation,with- 
absence  of 

for  typhc  il 

nnder  tiiat 

llosely  simu- 


Tiincture  of  the  spleen  for  tlio  purpose  of  obtaining  cultures  is  justiti- 
ubl.'  oil!*  Ill  e.xceptiomil  circumstances. 

Prognosis. — The  mortality  ranges  from  10  to  'M)  per  cent.  Of  tho 
ciiiiriiiv'us  number  of  deaths  analyzed  by  Murchison,  the  mortality  was 
iicarlv  rJ  per  cent.  The  death-rate  at  the  Montreal  (ier  i  Hospital, 
for  twenty  years,  was  11-^  per  cent.  In  recent  years  tiie  .iu)rt!dity  in 
tyiilinid  t'l'ver  hfis  certainly  diminisiied,  and,  under  the  i  Ihicnco  of  Hraiui, 
the  reintroduction  of  hydrotherapy  has  reduced  the  n:or'  .aty  in  institu- 
tions in  a  remark;d)lo  'r..i''.ner,  even  as  low  as  a  or  (i  per  cent.  Es])e('ially 
iiiifavi)ral)le  symptoms  are  high  fever,  delirium  with  toxic  synijitoms, 
h;ini(,rrliage — though  by  some  this  is  not  thought  very  unfavorable — and 
peritonitis. 

Si((/(l('ii  Dvtith. — It  is  dinicult  in  many  cases  to  explain  this  most  lam- 
entable of  accidents  in  the  disease.  Tliere  are  cases  in  which  neither 
HToliral,  renal,  nor  cardiac  changes  have  been  found  ;  ti\ere  are  instaiu-es 
too  in  whii'li  it  does  not  seem  likely  that  there  conld  havi'  bi'cn  a  special 
localization  of  the  toxic  poisons  in  the  pneuinogastrie  centres.  MclMu'- 
dran,  in  reporting  a  case  of  the  kind,  in  whiidi  the  post-mortem  showed  no 
adecpiate  cause  of  death,  snggi'sts  that  the  experiments  of  .McWilliam  on 
sudden  cardiac  failure  probal)ly  explain  the  occurrence  of  death  in  eer- 
tiiiii  of  the  cases  in  wliich  neither  end)olism  nor  uraemia  is  present.  I'nder 
eunditions  of  abnormal  mitrition  there  is  sometimes  induced  a  slate  of 
(liliriinii  roi'dis,  which  may  develop  s[)ontaneously,  or,  in  the  case  of  ani- 
mals, on  slight  irritation  of  tlu(  heart,  with  the  result  of  extri'me  irregu- 
larity and  tiiudly  failure  of  action.  Sudden  death  occurs  more  frequi'Utly 
in  men  than  in  women,  according  to  Dewevre's  statistics,  in  a  proportion 
of  114  to  'iij.  It  may  occur  at  the  luight  (>f  the  fever,  and,  as  pointed  out 
by  (iraves,  may  also  happen  during  convalescence. 

Fat  subjects  stand  typhoid  ft'ver  badly.  The  mortality  in  women  is 
greater  than  in  men.  The  complications  and  dangers  are  more  serious 
in  the  ambulatory  form  in  whicdi  the  patient  has  kept  about  for  a  week  or 
ton  days.  Karly  involvement  of  the  nervous  system  is  a  had  indication  ; 
and  the  low,  muttering  delirium  with  tremor  means  a  close  light  for  life. 
Prognostic  signs  from  the  fever  alone  are  deceptive.  A  temperature 
almve  1(14°  may  be  well  borne  for  many  days  if  the  nervous  system  is  not 
involved. 

Prophylaxis. — In  cities  the  i»revalenee  of  typhoid  fever  is  directly 
itrnportionate  to  the  inellieii'ticy  of  the  dra.,iage  and  the  water-supply. 
Tlure  is  no  truer  indication  of  the  sanitarv  condition  of  a  town  than  the 
returns  of  the  mimber  of  cases  of  this  disease.  With  the  improvement  in 
lirainage  the  mortality  in  many  cities  has  been  reduced  one  half  or  even 
mere.  One  of  the  njost  striking  instances  is  alTorded  by  the  city  of  Muiiieh. 
^  nil  Ziemssen  has  published  charts  illustrating  the  extraordinary  reduc- 
tion in  the  ])revalence  of  typhoid  fever  since  the  comjtletion  of  the  drain- 
age system  of  that  city.      The  average  yearly  numlier  of  admissions  to 


36 


SPECIFIC  INFECTIOUS   DISEASES. 


hospitiil  of  oases  of  typlioid  fovor  was,  between  the  years  1HC>Ci  and  ISSO, 
"1(11,  while  fi'oni  ISSI  to  ISSS  inclusive  the  avei'a<:e  was  only  about  10(1. 
During  this  same  period  tlie  ty[)hoi(l  mortality  of  tiie  whole  city  pri'sun ted 
ii  yearly  average  of  ;i()S,  but  from  1S81  to  1888  the  yearly  average  was 
ojdy  40. 

Hy  most  rigid  metliods  of  disinfection  much  may  be  done  to  prevent 
the  spread  of  the  infeetion. 

The  following  ])roe.edures,  suggested  by  Fit/,,  sliould  be  carried  out  in 
liosj)ital  practice,  and,  with  modilieations,  in  private  houses: 

1.  "  Mattresses  and  pillows  (when  lial)le  to  !»cc(ime  s<jiled)  are  to  be 
lirotcctecl  Ijy  clo.-<e- lit  ting  rubber  covers. 

2.  "  Hed  and  body  linen  are  to  be  changed  daily.  Hed-sprcads,  blank- 
ets, rubber  sheets  and  rnbl)er  covers  are  to  be  changed  at  oni;e  when  soiled. 
Avoid  shaking  any  of  the  articles. 

;{.  "  All  changed  linens,  bath-towels,  nibl)er  sheets  and  covers  are  to 
l)e  ininiediately  wrapped  in  a  slieet  soaketl  in  carbolic  aind  (one  to  foity). 
IJemove  tlieiu  to  the  rin.<e-house  as  soon  as  possil)le,  and  soak  six  liours  in 
carbolic  acid  (one  to  forty).  Then  boil  the  linen  for  a  half-hour,  and  wash 
with  soft  soap.  'I'he  rubl)er  sheets  and  covers  are  to  be  rinsed  in  cold 
water,  dried,  and  aired  for  eight  liours.  The  bed-spieads  and  blankets 
are  to  be  n'wvt]  eight  hours  daily. 

4.  "  Fee(iiiig-utensils,  immedately  after  using,  are  to  be  thoroughly 
cleansed  in  Isoiling  water. 

;■).  "  |)ejections  are  to  be  received  into  a  bed-pan  containing  half  a 
])int  of  carbolic  ae'd  (one  to  twenty).  The  nates  are  to  be  cleansed  with 
])aper,  ami  afti'rward  with  u  compress  cloth  wet  with  carbolic  acid  (one  to 
forty). 

(!.  "Add  two  (piarts  of  carbolic  acid  (one  to  twenty),  in  divi(k'd  por- 
tions, to  the  contents  of  the  bed-])an  ;  mix  thoroughly  by  shaking  and 
tlirow  the  li(|uid  into  the  hopper.  The  bed-])an  and  hopper  are  to  be 
clean.se(l  wit!;  carbolic  acid  (one  to  twenty)  and  wipeil  dry.  The  cloth 
used  for  t; 


u'  aoovc 


])urpose  is  to  be  at  once  burned. 


7.  "'I'he  corpse  is  to  be  covered  with  a  sheet  wet  with  carbolic  acid 
(one  to  forty). 

H.  "After  the  discharge  of  the  patient  from  the  hospital,  the  imit- 
tresses  are  to  be  aireil  every  day  for  a  week.  The  bedstead  is  to  bo  washed 
with  corrosive  sublinnite  (one  to  one  thousand). 

0.  "These  directions  are  to  be  followed  until   the  patient  is  free  fro 


tn 


fe 


ver. 


When  epidemics  are  prevalent  the  drinking-water  and  the  milk  used 
in  families  should  be  boiled.  These  precautions  should  be  taken  also  by 
recent  residents  in  anv  localitv,  and  it  is  much  safer  for  travellers  to  drink 


litrht 


wines  or  n 


lineral  water  rather  than  ordinary  watitr  or  milk.     (Jare 


should  be  taken  to  thoroughly  cook  oysters  which  have  been  fattened  or 
freshened  in  streams  eoutamiiiated  with  sewage. 


TYPHOID  FEVER. 


37 


1  1880, 
.ut  100. 
escntod 

prevent 

I  out  in 

re  to  bo 

s,  blank- 
ill  soiletl. 

rs  ar.'  to 
to  forty). 

boni's  in 
and  wasli 
1  ill  cold 

l)lankets 

loroughly 

|n,£r  balf  a 
used  with 
d  (one  to 

ided  por- 
kin<i  and 
are  to  be 
The  clotli 

jolie  acid 

tlio  n\at- 
1)0  washed 

Ifree  from 

Inilk  used 

ji  also  by 

to  drink 

Ilk.     Care 

Itteued  or 


Treatment.— (")  General  Management.— Tlie  profession  was  lon^ 
in  ji.iDiiiii^  that  ty})lu)id  fever  is  not  a  disease  to  be  treated  by  niedieiiU'S. 
Ciiit  fill  nursing  and  a  regulated  diet  are  the  essentials  in  a  majority  of  the 
,'a.~c.-!.  Tlie  patient  should  be  in  a  well-ventilated  room  (or  in  summer 
(lilt  (if  (li)ors  during  the  day),  strictly  confined  to  bed  from  the  outset,  and 
there  rt'inain  until  convalescence  is  well  established.  The  bed  shoidd  lie 
siuirle,  not  too  high,  and  the  mattress  should  not  be  too  hard,  'i'he  woven 
wiw  lied,  with  soft  hair  mattress,  upon  which  are  two  folds  of  blanket, 
r'liiidiincs  the  two  great  qualities  of  a  sick-bed,  smoothness  aiul  elasticity. 
A  rul)i)er  cloth  should  be  placed  under  the  sheet.  An  intelligent  nurse 
should  bo  ill  charge.  When  this  is  impossible,  the  attending  physician 
should  write  out  specific  instructions  regarding  diet,  treatment  of  the  dis- 
(iKiri^cs.  and  the  bed-linen. 

(//)  Diet. — Those  forms  of  food  should  be  given  which  are  digested 
with  the  greatest  ease,  and  which  leave  behind  tlie  smallest  amount  of  resi- 
due to  f(irrn  faeces.  Milk  is  the  most  suitable  food.  If  used  alone,  three 
pints  at  least  may  be  given  to  an  adult  in  twenty-four  hours,  always  diluted 
with  water,  lime-water,  or  aerated  waters.  Partially  peptonized  milk,  when 
nut;  'listasteful  to  the  patient,  is  occasionally  serviceabh;.  The  stools  <d'  a 
imtieiit  on  a  strict  milk  diet  should  be  examined  with  great  care,  tf)  see 
if  the  milk  is  entirely  digested.  Fever  patients  often  receive  more  than 
th»'\  can  utilize,  in  which  case  masses  of  curds  are  seen  in  the  stools,  or 
luiii'dscopically  fat-corpuscles  in  extraordinary  abundance.  I.'nder  these 
ciicuuistances  it  is  best  to  substitute,  for  part  of  the  milk,  mutton  or 
chii'kcii  broths,  or  beel'-juice,  or  a  clear  ronsdiiDtii',  all  of  which  may  be  made 
vn-y  |ialatablo  by  the  addition  of  fresh  vegetable  juices.  Some  patients 
will  take  whey  or  buttermilk  when  the  ordinary  milk  is  distasteful.  Thin 
liiuicy-grnel,  well  strained,  is  an  excellent  food  for  typhoid-fever  jiatieiits. 
Kl'its  ir.ay  be  given,  either  beaten  up  in  ii  or,  better  still,  in  the  form  of 
alhuiiieii-water.  This  is  prepared  by  strainiri'.!'  the  whites  of  t'^^ga  through 
a  cluih  and  mixing  them  with  an  e(pial  ((uantity  of  water.  It  may  be 
thivoreil  with  lemon,  and,  if  the  patient  is  taking  spirus,  whisky  or  biuiidy 
i<  verv  eoiivenientlv  iriveii  with  this.     Patients  who  are  unaiile  to  take  iiiilk 


can  sill); 


ust  f 


or  a  time  o 


n  this 


aloie 


lie  patient  should  be  encouraged  to  drink  water  freely,  whirl 


1  mav  i>c 


lili'iisantly  cold.  Iced  tea,  barley-water,  or  lemonade  may  also  I'c  given, 
and  there  is  no  objection  to  eolTee  or  cocoa  in  moderate  <juantities.  Fruits 
are  not,  as  a  rule,  allowable,  thoiigii  the  juice  of  lemon  or  orange  mav 
he  given.  Typhoid  ]iatients  should  be  fed  at  stated  intervals  throitgli 
the  (lay.  At  night  it  depends  upon  the  general  condition  of  the  p.Mient 
whether  ho  should  be  aroused  from  slee|),  or  not.     In  mild  cases  it  is  not 

to  disturb  the  jiatient.     When  there  is  stupor,  however,  the  patient 
mid  be  roused  for  food  at  the  regular  intervals  night  and  day. 
Aleoliol  is  not  necessary  in  all  teases,  but  may  be  given  when  the  weak- 

is  marked,  the  fever  liigli,  and  the  pidse  failing,      in  young  healthy 


wel 


SiK 


IK'S; 


38 


SPKCIFIC    IXFI'X'TIOUS   DISKASHS. 


iulnlts,  wirliout  nervous  syruptonis  and  \vithoiit  vcM-y  liigli  fover,  alcohol  is 
not  rc'(iiiirc(l ;  but  in  any  case,  when  the  heart-boat  is  feeble  ajul  tlie  first 
sound  l)e('omes  obscure,  if  there  are  a  niuttcrinij  delirium,  subsultus  tendi- 
nuni  and  a  dry  toiiLTue,  brandy  or  whisky  should  hv,  freely  given.  In  sucli 
a  ease  fi-orn  ciglit  to  twelve  ounces  of  l)randy  in  the  twenty-four  hours  is  a 
moderate  amount. 

It  would  be  too  much  like  hoisting  the  teetotaler  with  his  own  petard 
to  attril)Ute  the  high  rate  of  mortality  at  the  liondon  'IVmperance  lIos])i- 
tal — tifteeii  to  sixteen  per  cent  during  the  past  twcmty  years — to  failure  to 
employ  alcohol. 

{(')  Hydrotherapy.— The  persistent  pyrexia  is  in  itself  a  danger,  but 
perhaps  not  the  chief  (hmger.  Cases  with  higli  fever  alone,  without  delir- 
ium or  signs  of  involvement  of  the  nervous  system,  are  not  nearly  so  serious 
as  tliose  eases  in  which,  with  a  temperature  of  104°,  there  are  pronounceil 
lu'rvotis  symptoms.  For  the  fever  and  its  concomitants  there  is  no  treat- 
ment .so  eflicacious  as  that  by  cold  water,  introduced  at  tlie  end  of  the  last 
century  by  Currie,  of  Liverpool,  and  of  late  years  forced  upon  the  ])rofe.s- 
sion  by  Urand,  of  Stettin.  In  institutions  a  rigid  .system  of  liydrotherapv 
.should  b(^  carried  out.  At  my  clinic  the  following  plan  is  followed  : 
Every  third  hour,  if  the  temperature  is  above  l()'-i-o°,  the  patient  is  placed 
in  a  l)ath  (at  10°  i-'ahr.),  which  is  wheeled  to  the  bedside.  In  this  he  re- 
nuiins  from  fifteen  to  twenty  minutes,  and  is  tlien  taken  out,  wrapped  in 
a  dry  sheet  and  covered  with  a  light  blanket.  Enough  water  is  used  to 
cover  the  ])aticnt's  body  to  the  neck.  The  head  is  sitonged  during  the 
bath,  and,  if  there  is  much  torpor,  cold  water  is  poured  over  it  from  a 
height  of  a  foot  or  two.  The  limbs  aiul  trunk  are  rubbed  thoroughly 
either  with  the  hand  or  with  a  suitable  "  rubber."  The  rectal  temperature 
is  taken  immediately  after  the  bath,  and  again  three  quarters  of  an  hour 
later.  'I'he  patient  often  complains  bitterly  when  in  the  bath,  and  shiver- 
ing and  blueness  are  almost  a  constant  sequence.  Food  is  usually  given 
with  a  stinudant  after  the  bath.  'I'he  oidy  contra-itidications  are  })erito- 
nitis  aiul  luemorrliage.  Neither  broiudutis  nor  pneumonia  are  so  regardeij. 
The  accom])anying  chart  shows  tlie  number  of  baths  aiul  the  influence  on 
the  fever  during  two  days  of  treatment.  The  good  effects  of  the  baths 
are:  (1)  the  reduction  of  the  fever;  (•;)  the  intellect  becomes  clearer,  the 
stupor  lessens,  and  the  muscular  twitchings  disappear;  (;{)  a  general  tonic 
action  on  the  nervous  system  and  particularly  on  the  heart;  (4)  insomiiiii 
is  les.sened,  the  patient  usually  falling  asleep  for  two  or  three  hours  after 
each  bath;  and  (.">),  most  important  of  all,  the  mortality  is,  under  tin- 
plan  of  treatment,  reduced  to  a  miiunHim.  This  Jintiid  mctluxl,  as  it  is 
called,  has  steadily  advanced  in  favor  both  in  hospital  and  jirivate  priie- 
tice.  ami  in  spite  of  the  difViculties  and  the  unpleasant  features  neces.sari!y 
connected  with  it,  there  is  no  plan  of  treatment  which  gives  such  results. 
In  the  hospitals-  whi('h  carry  out  a  striet  hydrothera]iy  the  death-rate  is 
about  seven  per  cent,  while  in  other  insntutions  the  death-rate  is  from  ti  ii 


J 


% 


■ft  5 


I 


-A' 


TVIMIOII)   FKVKli. 


39 


iilcohol  i~ 

1  tho  iirsi 

Itus  tendi- 

In  such 

hours  is  ii 

>wn  petanl 
ice  llospi- 
)  failure  t<i 

angor,  but 
hout  (k'lir- 
y  so  serious 
)roiiouii('('il 
is  no  treat - 
I  of  the  hist 

the  ])rofes- 
tdrotherapy 
s  folh^wed  : 
nt  is  })hiet'il 
I  tliis  lie  rc- 
\vra})ped  in 
r  is  used  to 

during  the 
•r  it  from  a 

thoroughly 

|tcnii)eratui'(' 

of  an  hour 

and  shivcr- 
Isually  givrii 

s  are  perito- 

so  regardoil. 

lintluence  on 

lof  the  baths 

clearer,  tlir 

[cneral  tonic 

|4)  insoniniii 

hours  aft'i' 

under  this 

ViihI,  as  it  is 

[rivate  jirai'- 

iiecessarily 

iuch  results. 

Ileath-rate  is 
is  from  tin 


Id  lil'tccn  per  cent.  Last  year,  in  the  Metropolitan  Kever  Hospitals  {Lon- 
don), the  death-rate  was  seventeen  ]>er  cent.  Of  the  .■).")()  cases  under 
jiiv  care  since  the  introduction  of  the  method  in  tiu!  .lohns  Hopkins  Hos- 
]iit;d  the  mortality  has  been  in  five  years  l^'O'i  per  cent.  Anu)ng  the  most 
>tiikiiig  figures  are  those  recently  published  by  Hare,  from  the  iirisbane 
iii)S|iital,  Australia.  Under  the  expectant  plan,  J,H.'58  ea.ses — mortality, 
1  ts  [HT  cent ;  incomplete  bath  treatment,  171  ca,.ses — mortality,  ri-3  i)er 
ciiit  ;  strict  bath  treatment,  T!)7  cases — mortality,  7  j)er  cent. 

Junius IJ IS 


r 

lOll 
lOS 
107 
lOG 
IW 
101 
103 
102 
101 
100 

•n 

08 

97 

96 
T.inp- 

misf 

llisp, 

Sti.ols 

I'rinc 
Piiy  of 


3  ■■•■:••;  •••&■;■■■!■■;■•*•:■■:•■«•:  ■•!--|*r  ■!■•;■-•»••■•••>•■;  ■S-!-----;  ■•»•;•■■:  ••ig-;--:--i3-;-- :■•-■■■. 

rt.: .,...;.. a.;. .;..:... ^.;. . «...!S.j.. :.. J*.:. .;...:. £..;..;. .g.;..^;..;..j.. §.*..:. .a.:...;.. 5. ;..;..;...   . 

Ii:i::|ii::i::|::ti::;::l:ji|r:^^ 

..:..,.. .:...y.;.. ;...;..  fiJ'. .;.... .;..:..;..:..;  ..:..i,..i..;..j..i...;  •■i--i-f--ii-;--i-- v:--i—t"i-:--»  ■•■  ••»■■■:•• 


\..^,..\..•..i.^..•f.J..^yA.■l■i■4.^i■-^-^\■•l■^i.■^  :        . 

:..;.. ■...;.-!.. ;...:..!..;..J...;..;.. J... |..:.,j...|.4--:-.4-.:..;— ;..;■■:  :..:...:..i.,;.    M.G.H. 

■^i*;!y:'rj/j/yi^.*;'.L.!!!?-.LJ?s'.'.''-''.'..^^^^  '''"  '       l"!??^ J'''.l       '"" 

"?'..J'<.1.  l-..^?j..i'.V:  ..:*LJ...'?J'l;..)'^.!'?.^..-*?'.L**.?°.K'.;..^-^. *..!''  !  .;..  !'!.^.!..'\'..'t.i..:*'.  ..'..: 


I       I 


I  1 


I       I       I       I       I       I       I       I 


r.i 


(MART   IV. 

'i'lie  luken'arm  bath,  gradually  cooled,  may  be  used  in  private  practice 
when  the  IJrand  method  is  not  practicable.  A  bath  at  from  90''  to  80°, 
and  cooled  down  10°  or  T-i"  by  pouring  cold  water  on  the  patient,  will  be 
lomul  very  satisfactory.  When  an  insuperable  objection  to  the  bath 
exists,  other  hydrotherapeutic  measures  may  lie  taken.  'J'he  body  may  be 
.■^|iotiged  with  tepid  or  cold  water  every  time  the  temjierature  rises  above 
l"'.''."!".  If  done  thoroughly,  taking  limb  by  limb  first,  and  then  the 
trunk,  occupying  from  twenty  minutes  to  half  an  hour  in  the  process,  the 
rectal  temperature  may  be  reduced  two  or  even  three  degrees.  In  private 
jiractice,  when  the  bath  is  not  availal)le,  the  cold-pack  is  a.  good  substitute. 
The  patient  is  wrapped  in  a  sheet  wrung  out  of  water  at  (iO"  or  GA",  and 
<'<il(l  water  is  sprinkled  over  him  with  an  orilinary  w;itcring-pot.  This  is 
\crv  illicacious  in  cases  with  pronounced  nervous  symptoms. 


40 


SPECIFIC   INFECTIOUS  DISEASES. 


Medicinal  antipyretics  are  rarely  indicated.  Quinine,  which  was  em- 
ployed so  much  in  former  years,  lias  a  slight  though  positive  action,  but 
its  use  has  very  wisely  been  restricted.  The  same  may  be  said  of  the 
more  recent  antipyretics.  Personally,  I  abandoned  their  employment 
some  years  ago.  If  given,  antifebrin  is  the  most  suitable  in  doses  of  from 
four  to  eight  grains.  The  action  is  prompt,  and  it  is  less  depressing  than 
antipyrin. 

{(/)  Antiseptic  Medication. — Very  laudable  eiuieavors  have  been  nuido 
in  many  quarters  to  introduce  methods  of  treatment  directed  toward  the 
destruction  of  the  typhoid  bacilli,  or  the  toxic  agent  which  they  produce, 
but  so  far  without  success.  Good  results  liavc  been  claimed  from  the 
carbolic  and  iodine  treatment.  Others  advocate  corrosive  sublimate  or 
calomel,  /3-naphthol,  and  the  salic.'in  preparations.  I  can  testify  to  the 
inefficiency  of  the  carbolic  acid  and  iodine  and  of  the  /8-naplithol.  Witli 
the  mercurial  ])rei)arations  I  have  no  experience.  Fortunately  for  tlie 
patients,  a  majority  of  these  medicines  meet  one  of  the  two  objects  which 
lIi})pocrates  says  the  physician  should  always  have  in  view — they  do  no 
harm.  Burney  Yeo  advocates  the  use  of  chlorine  water  and  quinine. 
The  solution  is  made  in  the  following  manner  :  Into  a  twelve-ounce  bottle 
put  thirty  grains  of  potassic  chlorate,  ami  pour  in  sixty  minims  of  strong 
hydrochloric  acid.  Fit  a  cork  into  the  mouth  of  the  bottle  and  keep 
it  closed  until  it  has  become  filled  with  a  greenish-yellow  gas.  Shake 
the  mixture  well,  and  then  pour  water  into  the  bottle  little  by  little, 
closing  the  bottle  and  shaking  well  at  each  addition,  until  the  bottle  is 
full.  It  is  well  not  to  fill  tlie  bottle  too  quickly  with  water,  or  the  chlo- 
rine will  be  driveii  out  by  the  water,  instead  of  being  dissolved  in  it.  To 
twelve  oun(>es  of  this  solution  add  twenty-four  to  thirty-six  grains  of  qui- 
nine and  an  ounce  of  syrup  of  orange-peel.  The  dose  is  an  ounce  every 
two,  three,  or  four  hours,  according  to  the  severity  of  the  case.  Irriga- 
tion of  the  colon  has  been  recommended,  with  a  view  of  washing  out  the 
toxic  matters  (Mosler,  Scibort). 

(e)  Eliminative  and  Antiseptic  Treatment.— Based  on  an  entirely  er- 
roneous view,  that  the  bacterial  growth  is  chiefly  in  the  intestine  itself. 
Thistle  and  others  have  advocated  wluit  is  known  as  the  eliminative  and 
antiseptic  treatment.  The  elimination  is  accomplished  by  thorough 
evacuation  of  the  bowels  daily,  and  the  other  factor  in  the  treatment  is 
the  use  of  intestinal  antiseptics,  of  which  salol  is  recommended.  If,  as  in 
cholera,  the  bacilli  developed  and  produced  the  poison  in  the  intestinal 
contents,  there  might  be  some  reasonableness  in  this  method,  but  the 
bacilli  multiply  in  the  intestinal  walls,  and  in  the  mesenteric  glands,  and 
in  the  spleen.  They  are  sometimes  not  found  in  the  stools  until  the  end 
of  the  second  week.  An  im[)ortant  objection  to  the  use  of  purgatives  is 
the  fact  that  in  any  large  series  of  cases  those  with  diarrluea  do  badly. 

To  check  bacterial  activity,  as  aimed  at  by  advocates  of  this  plan, 
would,  be  a  disastrous  interference  with  the  normal  processes  in  the  bowel. 


TYIMIOID   KKVKR. 


41 


vas  em- 
ion,  but 
of  the 
loyment 
of  from 
ing  tlian 

en  made 
vard  the 
proiUiee, 
[roni  the 
iniate  or 
[y  to  tlie 
)1.     With 
y  for  the 
cts  which 
hey  do  no 
I  quinine, 
nee  bottle 
;  of  strong 
and  keep 
IS.     Shake 
(  by  little, 
ie  bottle  is 
the  chlo- 
in  it.     To 
ins  of  qui- 
nce every 
Irriga- 
iiy;  out  the 


No  one  liiis  boon  foolish  ciiongii  yet  to  olaim  tliat  so-callcil  int(>stitial  aiiti- 
st'ptics  can  kill  tlic  pathogenic  and  spare  the  nseful  organisms. 

( /■)  Specific  Method. —  K.  Fraenkd  has  used  the  dead  cultures  of  typlinid 
liacilli  grown  in  t hymns  bouillon  ;  O-.')  c.  c,  and  on  the  following  day  1  c.  c 
of  the  culture  is  injected  dcef)  into  the  innscular  tissue  in  the  lati'ral  gluteal 
ivi:ii>n.  'I'Ihmi  tlie  injections  are  reju-ated  every  secdiid  day,  each  time  in- 
i'ivii<ing  the  dose  1  c.  c.  ('lulls  nuiy  follow  the  first  or  second  injection. 
\\  nil  the  contiiuumee  tiie  fever  becomes  more  remittent  in  tyi»e,  and  deiVr- 
vcMTiice  may  occur  in  a  comparatively  short  time,  sometimes  by  crisis, 
111  iiriv-s(fven  cases  treated  in  this  way  the  general  results  were  goixl. 

li'iimpf  has  iise(t  the  cidtiires  of  the  bacillus  py.K  vicieus  prejiarcd  and 
ibfil  in  this  way,  with  good  results,  losing  oidy  two  ;,.it  of  thirty  ])atients. 
I,;niiliert  reports  twenty-eight  cases,  of  which  lifteen  showed  beiielil ; 
till  re  was  one  death. 

Atl'Mupts,  too,  have  been  maile  to  use  the  bloocl  serum  of  (.'oiivalescent 
tvplinid  patients,  but  no  satisfactory  results  iiave  been  yet  obtained. 

('/)  Treatment  of  the  Special  Symptoms.— The  abdominal  i)ain  ami 
lviii|i;mites  are  best  treated  l)y  fomentations  or  turpentine  stuju'S.  The 
laitir,  if  well  ajjplied,  give  great  relief.  Sir  William  denner,  at  his  clinic, 
iiM'il  to  lay  great  stress  on  tlie  advantages  of  a  well-applied  turpentine 
stujM'.  He  directed  it  to  be  applied  as  follows:  A  ilannel  roller  was 
lilarnl  ln'iieath  the  patient,  ami  then  a  double  layer  of  thin  tlaiiiiel,  wrung 
(lilt  iif  very  hot  water,  with  a  drachm  of  turpentine  mixed  with  tiie  water, 
was  applied  to  the  alxlonu'U  and  covered  with  the  emis  of  the  roller. 

'I'lie  iiir/rorlsni  is  a  dithcult  an<l  distressing  symptom  to  treat.  When 
the  gas  is  in  the  large  bowel,  a  tid)e  may  be  passed  or  a  turpentine  enema 
^'ivcii.  I'or  tympanites,  witli  a  dry  tongiu\  turpentine  was  extensively 
ustij  liythe  older  Dublin  physicians, and  it  was  introduced  into  this  eoiin- 
ti'v  hy  the  late  (leorgi'  H.  Wood,  rnfortunately,  it  is  of  very  little  service 
ill  tJH'  severer  cases,  which  too  often  resist  all  treatment.  Sometitnes,  if 
lii'ct'  juice  and  albumen-water  are  substituted  for  milk,  the  distention 
k'ssi'iis.     Charcoal,  bismuth,  and  fl-naphthol  may  be  tried. 

For  the  (/idrr/iwn,  if  severe — tliat  is,  if  there  are  more  than  three  or 
I'liiir  stools  daily— a  standi  and  opium  enema  may  be  given;  or,  by  the 

or 
acid 


iiHiiilli.a  combination  of  bismuth,  in  large  doses,  with  Dover's  jiowder 
II'  acid  diarrluea  mixture,  acetate  of   lead    (irrs.  '2),  dilute  aceti< 


t 


iiii'i 


( 'H  1, ")-•*(»),  and  itcetate  of  morphia  (gr.  ji-i).     'i'he  stools  should  be  exam- 
t(i  see  that  the  diarrlnea  is  not  agirravated  liy  the  presence  of  curds. 
Cdiififi/xifioii  is  present  in  many  cases,  aiul  though  1  have  lu'ver  seen  it 
liaiiu,  vet  it  is  well  everv  tiiird  or  fourth  dav  to  lmvc  an  ordiiiarv  enema. 


have 


never  used  the  initial  dose  of  calomel,  which  is  so  hi'ddv  rect 


im- 


iiiiiidcd  by  some  practitioners.      If  a  laxative  is  needed  during  the  course 
»f  tile  disease,  the  Ilunyatli-janos  or  I'^riedrii'lishall  water  may  lie  given. 
llir,n(irr/i(i(/('  from  the  bowels  is  liest  treated  with  full  doses  of  acetate 


I 


>l  I 


and  opi 


urn. 


As  absolute  rest  is  essential,  the  t^-natcst  care  should 


42 


SPKCIFIC  INFKCTIOUS  DISEASES. 


1)1'  tukfii  in  tilt'  use  of  llic  beil-pan.  It  is  porhtiiKS  better  to  allow  tlu' 
piitietit  to  pass  the  motions!  into  the  draw  sheet.  Ice  may  be  freely  given, 
and  the  amount  of  food  should  bo  restricted  for  eijjht  or  ten  hours.  If 
there  is  a  teiuleney  to  (;olla])se,  stimulants  should  be  given  and,  if  necessary, 
hypodermic  injections  of  ether.  The  })atient  may  ha  .spared  the  usual 
styptic  mixtures  with  which  he  is  so  often  drcuehod.  Tur])entino  is 
warmly  recommended  by  certain  authors. 

Pcrifonitis. — In  a  nuijority  of  the  cases  this  is  an  inevitably  fatal 
complication.  The  only  hope  lies  in  restriction  of  the  inilammation. 
Cases  have  uncpiestioiudily  recovered.  Morj)hia  should  bo  given  sul)- 
cutaneously.  If  the  peritonitis  be  due  to  jierforatiijn,  the  question  of 
laparotomy  may  be  discussed.  Van  Hook's  statistics  give  19  laparotomies 
in  tyjihoid  fever  with  4  recoveries.  During  IHD-l:  there  were  5  additional 
cases  with  3  recoveries,  making  in  all  "ZA  cases  with  ()  recoveries.  If  of 
these  cases  we  reject  those  which  ap])ear  somewhat  doubtful,  "  then  the  cor- 
rect statistics  revised  up  to  date  stand  17  cases  Avith  3  recoveries"  (Abbe). 

For  the  progressive  /irart-veftkiit'ss  alcohol,  str3'chr. ine  hypodermically 
in  full  doses,  digitalis,  and  hypodermic  injections  of  other  may  be  tried. 

The  nervouti  si/nijifoins  of  typhoid  fever  are  best  treated  by  hydrother- 
ajjy.  One  special  advantage  of  this  jjlan  is  that  tlio  restlessness  is  allayed, 
the  delirium  quieted,  and  sedatives  are  rarely  needed.  In  the  cases  which 
.set  in  early  with  severe  headache,  meningeal  symptoms  and  high  fever,  the 
cold  bath,  or  in  private  practice  the  cold-pack,  should  be  emjdoyed.  An 
ice-cap  may  be  placed  on  the  head,  and  if  necessary  mori)hia  administered 
hypodermically.  The  practice,  in  such  cases,  of  ai)plying  blisters  to  tlic 
nape  of  the  neck  and  to  the  extremities  is,  to  paraphrastj  Iluxham's  words, 
an  ti II wlioJc,v))iK'  si'vrn'fi/,  which  should  long  ago  have  been  discarded  bv 
the  profession.  For  the  iwcturnal  restlessness,  so  distressing  in  sonu' 
cases,  Dover's  powder  should  be  given.  As  a  rule,  if  a  hypnotic  is  indi- 
cated, it  is  best  to  give  oi)ium  in  .some  form.  I'ulmonary  complication 
should,  if  severe,  receive  appropriate  treatment. 

In  ])rotract('(l  cases  very  si)ecial  care  should  bo  taken  to  guard  against  bc/- 
sores.  Absolute  cleanliness  and  careful  drying  of  the  parts  after  an  evacu- 
ation should  be  enjoine<l.  The  patient  should  be  turned  from  side  to  side 
and  ])ropped  with  pillow.s,  and  the  back  can  then  be  sponged  with  spirits. 
On  the  first  appearance  of  a  .sore,  the  water  or  air  bed  should  be  u.sed. 

(//)  The  Management  of  Convalescence.— Convalescents  from  typhoiil 
fever  frequently  cause  greater  anxiety  than  patients  in  the  attack.  'J'lu' 
question  of  food  has  to  be  met  at  once,  as  the  patient  develops  a  ravenons 
ap])etite  and  clamors  for  a  fuller  diet.  My  custom  has  been  not  to  allnw 
solid  food  until  the  temperature  has  been  normal  for  ten  t.'uys.  This  is.  1 
think,  a  safe  rule,  leaning  perhaps  to  the  side  of  extreme  caution  ;  but,  afu  r 
all,  with  eggs,  milk  toast,  milk  puddings,  and  jellies,  the  ]iatient  can  tako 
a  fairly  varied  diet.  Many  leading  })ractitioners  allow  solid  food  to  a  pa- 
tient so  soon  as  he  desh'cs  it.     Peabody  gives  it  on  the  disappearance  nf 


siiMial 


A 


TVIMIOII)   FHVKU. 


43 


lUow  Uu' 
jly  given, 
lour.s.  If 
iiceesrtivry, 
the  usual 
)uutine  is 


ably  fiital 
inunation. 
riven  sub- 
question  ol" 
purotomii's 
acblitional 
•ies.     If  til' 
len  the  cor- 
■s"  (Abbe). 
odevniieuUy 
be  tried, 
hydrother- 
;8  is  allayed, 
cases  whieli 
jh  fever,  llio 
[doyed.     An 
.dininistcred 
isters  to  tlio 
am's  words 
iscarded  by 
ng  in  souu' 
lotic  is  indi- 
oniplicatinii 

against  hnl- 
er  an  evacn- 
side  to  siiii' 
with  spirits. 
je  used, 
l-om  typhoi'l 
jttack.    Tlu' 
Is  a  ravenous 
jiiot  to  all'iw 
This  is.  1 
In  ;  but, afur 
lent  can  takt' 
l[ood  to  a  l':i- 
lipearance  "i 


I 


tlu-  fiver;  tlie  lah'  .\iislin  l-'lint  was  also  in  favor  of  giving  .s(did  food 
,.;iilv;  and  Naunyn,  at  the  Strasl>nrg  Medical  Clinic,  told  nic  that  this 
was  his  practice.  I  had  an  early  Ics.-ion  in  this  iiiatt<'r  which  I  have  never 
|',irL''iitti'?i.  A  young  hul  in  the  Montreal  (icneral  llospftiil.  in  whose  case 
I  u;is  much  interested,  pas.scd  throngh  a  toleraltly  sharp  attack  of  typhoid 
|'r\(r.  'Two  weeks  after  the  evening  teniperatnre  had  hccu  normal,  aiid 
(iiilv  a  dav  or  two  before  his  intenilcd  discdiarge,  he  ate  several  nmttoii 
cliiips.  ;ind  within  twenty-four  hours  was  in  a  state  of  collap.se  from  pi'r- 
t'niaiioii.  A  small  transver.se  rent  was  found  at  the  bottom  of  an  ulcer 
which  was  in  process  of  healing.  It  is  not  ea.sy  to  .say  why  solid  food, 
liaiiiiiilarly  meat.s,  .should  di.sagree,  hut  in  so  many  instances  an  indis<'re- 
lidii  in  ilii't  is  followed  by  slight  fever,  the  so-callcfl  frhris  ninn's,  that  it 
is  ill  the  best  interests  of  the  patient  to  restrict  the  diet  for  some  time 
;;l!ii'  I  he  fever  has  fallen.  An  indiscretion  in  diet  may  indeed  precipitate 
a  ivlapse.  'I'he  patient  nniy  lie  allowed  t(»sit  up  fora.sliort  timeahout  the 
(lid  iif  the  first  we(d<  of  convalescence,  and  the  ])criod  may  be  jirolongeil 
uiih  a  gradual  return  of  strength.  He  shoidd  move  ahoiit  slowly,  and 
when  the  v>eather  is  favorable  should  be  in  the  open  air  as  mutdi  as 
|)(issihle.  The  patient  should  ho  guardeil  at  this  period  against  all  un- 
necessary excitement.  Emotional  disturhance  not  infre([ueutly  is  the 
cause  of  a  recrude.'^cence  of  the  fever.  Constipation  is  not  uncommon  in 
ciinvale.sccnce  and  is  best  treated  by  euemata.  A  ])rotracteil  diarrho'a, 
wliich  is  usually  due  to  ulceration  in  the  colon,  may  retard  recovery.  In 
,-iich  casi's  the  diet  should  be  restricted  to  milk,  ami  the  ]>atient  sluuild 
he  ceiUincd  to  bed  ;  largo  doses  of  bismuth  and  astringent  injections  will 
I  rove  useful. 

The  recrudescence  of  the  fever  does  not  ref[uire  special  treatment. 
The  treatment  (»f  the  relapse  is  essentially  that  of  the  original  attack. 

Among  the  dangers  of  convalescence  nuiy  be  mentioned  tuberculosis, 
which  is  .said  by  Murchison  to  ])v  more  common  after  this  than  after  any 
other  fever.  There  are  facts  in  the  literature  favoring  this  view,  but  it  is 
a  rare  setpience  in  this  country. 


II.  TYPHUS   FEVER. 

Definition. — An  acute  infectious  disea.so  characteri.sed  by  sudden 
I 'inset,  a  maculated  rash,  marked  lU'rvous  symi)toms,  and  a  termimitiou, 
jiisuallv  hy  crisis,  about  the  end  of  the  second  week. 

Etiology. — The  disease  has  long  been  known  under  the  names  of 
^li"-^|iital  fever,  spotted  fever,  jail  fever,  camp  fever,  and  ship  fever.     In 
jCiiinany  it   is  known  ns  cxantlivmalic  typhu.s,  in  cr)utradistinction   to 
wuhnninal  typhus. 

Typhus  is  noAV  a  rare  disease.     Sporadic  ea.ses  occur  from  time  to  time 
lu  the  large  centres  of  population,  but  epidemics  are  infrequent.     In  this 


44 


SPKCIKIC    INKKCTIors    MISKASMS. 


I 


coiuitrv  (liiriiij;  the  piist  ten  vcai'.s  tlicir  liavi'  lu't'ii  very  few  oiithrciiks.  In 
New  York  in  ISSl-'S-^  scvi'ii  IiiiikIi'ciI  tuitl  ihirty-livo  ciisort  wore  ti(lniittt'<| 
into  the  liivcrsiilc  llospitiil;  in  I'liiladi'lpliia  a  small  cpidcniic  occuri'fd 
ill    1SS;{  at  tlic  I'lilladclphiu  Hospital. 

Till'  special  clciiiciits  in  tlic  i'li(dii;;y  ol'  typhus  aiv  oviTcrowdiiij^r  and 
poviTtv.  As  ilii'scli  tci'srly  puts  it,  '•  Die  (icscliiclili,' dcs  l'y|)liiis  ist  die 
di's  niciiscliliclit'ii  i'lli'iids."  Ovcfcrdwdiii;:,  lack  (d'  (dcanlincss,  intcin- 
pcrancc  and  bad  fond  ai'c  prcdispusini^  causes.  'I'lio  di.^iuso  still  lurks  in 
the  worst  (piartcrs  id'  lioiidoti  and  (ilas^'ow,  and  is  seen  occasionally  in 
New  York  and  I'hiladelphia.  It  is  more  coiiiiiioii  in  (ireat  Uritain  and 
Ireland  than  in  other  parts  of  Kni'ope.  Miindiison  held  that  the  disease 
niij^ht  orii,diiate  spontaneously  under  ra\drai)le  coiidilioiis.  'This  opinion 
is  HUjr,i(este(l  by  the  occurrence  ol"  local  outbreaks  under  eircmnstances 
which  render  it  ditliciilt  to  explain  its  importation,  but  the  analojrv  (d' 
otlu'r  infectious  diseases  is  directly  aifaiiist  it.  In  1S(7  there  occurred  a 
local  outbreak  of  typhus  at  the  House  of  liefiige.  in  -Montri'al,  in  \vlii(di 
city  the  disea.se  had  not  existed  for  many  yciir.s.  The  overcrowd iiij,'  was 
so  great  in  the  basement-rooms  of  tlui  refuge  that  at  night  there  were  not 
more  than  eighty-eight  cubic  feet  of  .sjiace  to  ea(di  person.  Kleveii  per- 
sons were  alTected.     It  was  not  po-ssible  to  trace  the  source  of  infei-tion. 

Typhus  is  one  of  the  most  highly  contagious  of  febrile  atfeetions.  In 
epitlemics  nurses  and  doctors  in  attendance  upon  the  sick  are  almost  inva- 
riably attacked.  There  is  no  di.seasc*  wliicdi  has  so  many  victims  in  the 
profession.  In  the  extensive  epidemic  in  the  early  and  middle  jiart  of  tlii- 
century  niany  luindred  pliysieians  died  in  the  discharge  of  their  duty. 
Casual  attemhuice  niion  cases  in  limited  epidemi(!s  does  not  fippear  to  be 
very  risky,  but  when  ca.s(^s  are  aggregate<l  together  in  wards  the  poi.son 
appears  concentrated  and  tllo  <langer  of  infection  is  much  enhanced. 
Bedding  anil  clothes  retain  the  poison  for  a  long  time. 

The  microbe  of  typlius  fever  has  not  yet  been  determined.  Strepto- 
bacilli,  diplococci,  and  an  a.soomycete  have  been  described  in  the  blood 
and  tissues,  but  the  (piestion  still  remains  open  for  investigation. 

Morbid  Anatomy. — The  anatomical  changes  are  tho.se  which  result 
from  intense  fever.  The  blood  is  dark  and  fluid,  the  muscles  are  of  ii  deep 
red  color  and  often  show  a  granular  degeneration,  particularly  in  tl  r 
heart;  the  liver  is  enlarged  and  .soft  and  may  have  a  dull  clay-like  lustre; 
the  kidneys  are  swollen;  there  is  moderate  enlargement  of  the  s]tleon,  and 
a  general  liyi)erplasia  of  the  lymph-folliides.  Peyer's  glands  are  not  ulcer- 
ated. Bronchial  catarrh  is  usually,  and  hyimstatic  congestion  of  the  luiii:-^ 
often,  present.     The  skin  shows  the  p(!te(diial  rash. 

Symptoms. — Incubation. — 'i'his  is  ]>laced  at  about  twelve  days,  but 
it  may  be  less.  There  may  be  ill-defined  feelings  of  discomfort.  As  a  rul'. 
however,  the  inrfisinn  is  abrujit  and  marked  by  chills  .-^r  a  single  rigor. 
followed  by  fever.  The  chills  may  recur  during  the  first  few  days,  and 
there  is  headache  with  pains  in  the  back  and  legs.     There  is  early  pro" 


nilKl 


TYIMirs   l-'KVKU. 


45 


'iiks.    In 

iidmittt'il 
oi'cninvd 

diiij.'  iiiiil 
lUS  isl  tlir 
IS,  iiitcin- 
l  liirks  in 
ioniilly  ill 
•ituin  and 
111'  disease 
is  opinion 
lunstanees 
analo;j;v  of 
M'cuned  a 
1,  in  whieli 
wding  was 
v  were  not 
eleven  pcr- 
iifeetion. 
ctions.     In 
Iniosl  inva- 
tinis  in  tlie 
])art  of  this 
their  dnty. 
pear  to  l)e 
the  poison 
enhanced. 

I.     Strcpto- 
the  blood 

ivhich  resuh 

Ire  of  a  deep 

larly  in  tl  »■ 

dilie  lustre; 

spleen, and 

[e  not  nleei- 

i)f  the  luni:- 

,e  days,  hut 

As  a  rule. 

linglo  rig"!'- 

|\v  days,  an  1 

early  pro-- 


I 


tr.i!i"ii,  and  the  patient  is  j,'la<l  to  take  to  his  bed  at  once.  The  teinpera- 
tiiie  is  lii^'l'  lit  1'''"'''  '■""'  '"">'  attain  its  ii!;i\iniiiin  on  tlie  second  or  tliiid 
(l;iv.  The  piiNe  is  full,  rapiii.  and  not  so  fr('(|iiently  dicrotic  us  in  tvpliuid. 
'l'i:i'  iiinL'iie  is  fiirrcil  and  wiiite,  :ind  there  is  ;in  e.iiiy  tciideiii'V  tn  drv- 
iio.-.  'I'lie  face  is  (lushed,  the  eyes  are  con,irt'Sted,  the  e\pits>i(>n  is  dull 
iiiiii  .-tii|iid.  N'oiiiitinij  may  lie  a  distressintf  syniptnin.  in  severe  I'lises 
iini.:,!!  -vniplonis  are  present  from  tin'  outset,  either  a  milil  febrile  delir- 
iiiiii  '•'■  an  excited,  active,  almost  maniacal  condition.     i>i'(»iicdiial  catarrh 

i>  cnlllllinn. 

St aj?t!  of  Eruption.— From  the  third  to  the  fifth  day  the  eruption  ap- 
peal-^ lirst  upon  the  abdomen  and  upper  part  of  tlu'  chest,  and  then 
iipdii  the  extremities  and  face;  ilevclopin<;  so  rapidly  that  in  two  or 
tiller  days  il  is  idl  out.  I'liere  ai\' two  elements  in  tiie  eruption:  a  siib- 
eiiiiciilar  mottliiijf,  "a  line,  irre;,nilar,  dusky  red  mottling,  as  if  below 
the  surface  of  the  skin  some  little  distance,  and  si'cn  tlii'ougli  a  semi- 
(ipafjiie  medium"  (liiiehaiian) ;  and  distinct  jiapular  ros(^-spots  which 
change  to  peteehiiL'.  In  .some  instances  the  petechiul  rash  comes  out 
with  the  rose-spots.  CJollio  describes  the  rash  as  consisting  of  three  jiarts 
— roso-eolorcd  spots  which  disajjpear  on  pressure,  dark-red  spots  which 
arc  modified  by  pressure,  and  ])etecbia'  upon  which  pressure  produces 
ii(»  etl'ect.  In  children  the  rash  at  first  may  present  a  striking  resem- 
l.hince  to  measles,  and  give  as  u  whole  a  curiously  nu)ttled  appearance  to 
ihc  skin.  The  term  mulberry  rash  is  sometimes  applied  to  it.  In  mild 
cases  the  eruption  is  slight,  but  even  then  is  largely  jjctechial  in  character. 
As  the  rash  is  largely  ha'inorrhagic,  it  is  pernument  and  does  not  disajipear 
after  death.  Usually  the  skin  is  dry,  so  that  sudaminal  vesicles  are  not 
ooiiiiiioii.  It  is  stated  by  some  authors  that  a  distinctive  odor  is  present. 
I  hiring  the  second  week  the  general  symptoms  are  usually  much  aggra- 
vated. The  prostration  becomes  more  marked,  the  delirium  more  intense, 
and  the  fever  ri.ses.  The  patient  lies  on  his  ba(;k  with  a  dull  e.\j)ressionl('SS 
face,  flushed  cheeks,  injected  conjiuu^tiva',  and  contracted  ])upils.  The 
pulse  increases  in  frerpiency  and  is  feebler,  the  face  is  dusky,  and  the 
ooiiditidii  becomes  more  serious.  l{etention  of  urine  is  common.  Coma- 
vigil  is  frecpient,  a  condition  in  which  the  patient  lies  with  open  eyes,  but 
quite,  unconscious.  Snbsultus  tendinum  and  jticking  at  the  bedclothes 
!uv  fi('<|iiently  seen.  'I'he  tongue  is  dry,  brown,  and  cracked,  and  there  are 
siinlis  (III  the  teeth.  Respiration  is  accelerated,  the  heart's  action  becomes 
nion'  and  more  enfeebled,  and  death  takes  ]dace  from  exhaustion.  In 
favorahle  ca.scs,  about  the  end  <d"  the  second  week  occurs  the  crisis,  in 
whieli.  often  after  a  deep  sleep,  the  ])atient  awakes  feeding  much  better 
and  witli  a  clear  m'lid.  The  temperature  falls,  ami  although  the  prostra- 
tiiiu  may  be  extreme,  convalescence  is  rapid  and  relapse  very  rare.  This 
jatinipt  termination  by  crisis  is  in  striking  contrast  to  the  mode  of  termi- 
nation in  typhoid  fever. 

Fever. — The  temperature  rises  steadily  during  the  lirst  four  or  live 


40 


SIM'XMKIC    INKKCTIOl'S   DISKASKS. 


(Iiiy3,  ninl  the  iiioniiii;,'  n'MiissiiiiiM  arc  not  iiiarkc(|.  'I'lic  iimxinuim  tcrn- 
iMTiitiin!  is  usually  rcarlnd  l»y  the  lil'tli  day,  wlidi  tin-  lt'iii|it'ratiirc  may 
rciicli  U>.V\  |0(l\(»r  lo;'^.  Ill  iiiiltl  cuscs  it  seldom  rises  altove  lo;}". 
Alter  rearliiiiif  its  maximum  I  lie  teiiiperuturo  i;enerally  eoutiuues  willi 
sli;i;lit  mornin;,'  remissions  until  the  twelfth  or  fourteenth  day,  when  the 
crisis  occurs,  (lurinir  which  the  temperature  nuiy  fall  below  normal  with- 
in twelve  or  twenty-four  hours.  I'rc'edini,'  a  fatal  termination,  there  is 
usually  a  rapid  rise  in  the  fcvi-r  to  KiS'  or  even  !(»!»". 

The  heart  nuiy  cai'Iy  show  sitins  of  weakiu'ss.  'The  lirst  souml  hecomes 
feehle  and  almost  inaiulihle,  ami  a  systolic  murmur  at  the  apex  is  not  in- 
frccpU'iit.      Hypostatic  conifcslion  of  the  lunirs  occurs  in  all  severe  cases. 

The  hrain  symptoms  are  usually  more  jtronounced  than  in  typhoid, 
and  the  delirium  is  more  constant. 

'I'he  uriiu'  in  typhus  slutws  the  usual  fel)rile  increase  nf  urea  and  uric 
acid.  'I'he  chlorides  diminish  or  disappear.  Alhiimen  is  present  in  a 
lar>;e  proportion  of  the  cases,  hut  nephritis  seldom  occurs. 

\'ariati(jns  in  the  course  of  the  disease  nrv  mitiirally  common.  'I'hop' 
are  maliuMuint  eases  which  rapidly  prove  fatal  within  lw(»  or  three  days; 
the  so-called  /i//)/iiis  sitfrrfnis.  On  the  other  hand,  diirini;  epidemics  there 
are  extremely  mild  cases  in  which  the  fever  is  slight,  the  delirium  absent, 
and  convalescence  is  estal)lisheil  by  the  tenth  day. 

Complications  and  Sequelae.— Uroncho-pncumonia  is  i)erliaps 
the  most  eonnnon  complication.  It  may  jiass  on  to  gangrene.  In  certain 
epidemics  gangrene  of  the  toes,  the  haiuls,  or  the  nose,  and  in  children 
iionui  or  eaiu'rum  oris,  have  occurred.  Meningitis  is  rare.  J'aralyscs, 
which  are  jirobably  due  to  the  post-febrile  neuritis,  are  not  very  uneonimo;'. 
Septic  ])r()cesses,  su(di  as  parotitis  and  abscesses  in  the  subcutaneous  tissues 
uiul  in  the  joints,  are  occasionAlly  met.  Nejjliritis  is  rare,  llaanatemesis 
may  occur. 

Prognosis. — The  mortality  ranges  in  dilTerent  e{)idemics  from  Vi  to 
20  per  cent.  It  is  very  slight  in  the  young.  Children,  who  are  (piite  as 
frequently  attacked  as  adults,  rarely  die.  After  middle  age  the  mortality 
is  high,  in  some  epidemics  ;'»(>  per  cent.  Death  usually  occurs  toward  the 
close  of  the  secoiul  week  and  is  due  to  the  toxicmia.  In  the  third  week 
it  is  nuire  commonly  due  to  i)neunu)nia. 

Diagnosis. — During  an  epidemic  there  is  rarely  any  doubt,  for  the 
disease  presents  distinctive  general  characters.  Isolated  cases  may  be  very 
dillicult  to  distinguish  from  typhoid  fever.  While  in  typical  instance-; 
the  eruption  in  the  two  aifections  is  very  dilTerent,  yet  taken  alone  it  nuiy 
be  deceptive,  siiu;e  in  tyt)hoid  fever  a  roseolous  rash  nuiy  be  abundant  and 
there  is  occasionally  a  subcuticular  mottling  and  even  petechias  Tlir 
dilTerence  in  the  onset,  particularly  in  tlie  temperature,  is  nuirked ;  but 
cases  in  which  it  is  im[)ortant  to  nuike  an  accurate  diagnosis  are  not  usu- 
ally seen  imtil  the  fourth  or  fifth  day.  The  suddenness  of  the  onset,  tho 
greater  frequeiu-y  of  the  chill,  and  the  early  prostration  are  the  distiucti\i' 


■*  <, 


TYi'iiis  Fi;\  i:i{. 


JT 


II  atul  uric 
jseiit  in  ;i 


fcatiin'st  in  typhus.     'rii<>  liriiin  sviiiptnnis  too  nri'  carlitT.     It   is  easy  to 
l,i,t  di.uii  on   paper  clalioratc  (lill'crciitial  (lisiiiiciions,  wliidi  arc    prac- 


ih  :i 


U    list 


■less  at  tlic   Itcdsidc,  particularly  wlicii   the  di- 


;easr    is    iiol   pi'e- 


\;iihiiu'  as   an    epnieinic 


In 


sporadic  cases  the  dia^rnosis  is  sonielinies 


I'M  rrllic 
t'laii   mice 


Iv  dillietilt.      I  have  seen   Mnrchisoii   hinisell'  in  donht,  and   nioro 


I  have  known  a  dia<niosis  to  he  dei'erre(|  until   tiie  siil 


III  iiitii 


A, 


(T//'-.  Severe  cei'ehro-spiiia'  '"ever  may  closely  siniidate  typhus  at  the  (»iit- 
scr,  liiil  the  diiij^nosis  is  usually  clear  within  a  few  days.  .Maliirnant  vari- 
(ila  also  has  certain  Features  in  coinnioii  with  severe  typhus,  hut  the 
(.'iiMici'  t'Nlciil   of  the   liM'tiiorrhaui'S   and    the  hleedini,'  from  the  mucous 


llicliilillllle. 


make  the  dniirtiosis  clear  within  a  short    time 


he  rash  iit 


lii>l  reseiiiiiles  that  of  measles,  hut  in  this  disease  the  eruption  is  hriirhter 
nd  in  color,  often  eri'scentic  or  irrcjrular  in  arrani^eiiu'iit,  and  appears 
lii.M  III  the  face. 

'I'lie  frcfiticncy  witli  wliich  other  diseases  are  mistaken  for  typliiis  is 
sill. nil  hy  the  fact  that,  diiriii;^  and  followiiijf  the  epidemic  of  ISSj  in  NCw 
Vdik  olio  hundred  and  eii^hl  cases  were  wronirly  diau'iiosed — one  tdi,dith 
(if  the  entire  niimher — and  sent  to  the  I»*iver<iile  Hospital  ( !•'.  W.  ( 'liapiii). 

Treatment.— I'rai'licallv  the  ueneral   manaL'enient   of  the  (lisease  is 


lIKi' 


liai  ol 


tv))lioid   fever.      Ilvdrotheraiiv  should 


ll 


lorouirlilv  and  svs- 


ti'inatically  employed.  .IiulLdiii,'  from  the  <food  results  whi<di  we  liavt! 
(iliiained  hy  this  method  in  typhoid  cases  with  nervous  symptoms  much 
may  lie  expected  from  it.  Certain  authorities  havo  spoken  a^Minst,  it,  hut 
il  -liuiild  he  iri veil  a  more  extended  trial.  .Medicinal  antipyretics  are  less 
siiitahle  than  in  typhoid,  as  tlu*  teiidciKiy  to  lieart-weakness  is  often  more 
pfoiiounced.  As  a  riili^  the  jtatients  re<jiiire  from  the  outset  a  snitportinix 
ti'ciiliui'ut  ;  water  should  1)e  freely  j^iveii,  and  ah.'ohol  in  suitahie  doses 
accordin;^  to  the  condition  of  the  pulso. 

'I'lio  ])owels  may  he  kept  open  by  mild  aperients.     The  so-called  spe- 
cilic  medication,  hy  sulphocarliolatcs,  the  sulphides,  carholic  acid,  etc.,  is 


IKi 


f  commended  hy  those  who  have  had  the  lari^est  oxperieiice.  The  spe- 
riiil  nervous  symptoms  and  the  pulmonary  symptoms  should  he  dealt  with 
as  ill  typhoid  fever.  In  epidemics,  when  the  conditions  of  the  elimato 
iuv  suitahie,  the  cases  are  best  treated  in  tents  in  the  ojien  air. 


III.     RELAPSING     FEVER    {F.hrin  ncnnrnx). 

Definition. — A  spoeitic  infectious  disease  caused  l)y  the  spirneha'te 
(si)irillum)  of  Ohermeier,  characterised  l)y  a  detinito  febrile  paroxysm 
which  usually  lasts  six  davs  ami  is  followed  by  a  remission  of  about  the 
siuiip  length  of  time,  then  by  a  second  paroxysm,  which  may  be  repeated 
three  or  even  four  times,  whence  the  name  relapsiiii,'  fever. 

Etiology. — This  disease,  which  iias  also  the  naiiu's  "  famine  fever'' 
and  "  seven-day  fever,"   has   been    known  sinee   the  early  part  of  the 


48 


SI'KCII-'IC    INI'ECTlors   DISRASKS. 


('ii^litcentli  coiiturv.  iiiid  li:is  from  tiiiic  ti>  time  cxtt'iisivcly  prevailed  in 
KiirojK'  and  in  Ireland.  It  is  eoninion  in  India,  where  tliu  cnnditions  For 
its  development  seem  always  to  be  (tresent,  and  wiiero  it  has  been  spe- 
cially studied  l)y  N'andyke  Carti-r,  of  Boniliay.  It  was  first  seen  in  this 
country  in  1S44,  niieii  cases  were  admitted  to  the  I'liihulelphia  Hospital, 
which  are  (lescril)e(l  i)y  Meredith  Clymer  in  his  work  on  fevers,  l-'lint  saw 
ca.ses  in  lS,")(i-",">l.  In  isc'.t  it  prevaileil  ,  vtensively  in  epidennc  form  in 
New  York  and  I'hiladelphia ;  since  then  it  has  not  appeared. 

The  special  conditions  under  which  it  develops  iire  very  similar  to 
tliose  of  typhus  fever.  Overcrowdinir  and  delicient  food  are  the  condi- 
tions whi(di  seem  to  promote  the  rapid  spread  of  the  vii'us.  Neither  n<n\ 
sex,  nor  season  seems  to  have  any  specia'  inllueiice.  It  is  a  contas,nous 
disease  and  may  l)e  coinmniucati'(l  from  person  to  person,  l)iit  is  not  so 
contairioiis  as  t\|»hus.  Murchison  tliiid\s  it  may  l»e  trans])(jrted  by  foniitos. 
One  iittacdv  does  n  *  confer  immunity  from  sul)sc(pient  attacks.  Jn  IHI.') 
()l)ermeier  described  an  orii'anism  in  the  blood  which  is  now  recognised 
as  the  specilie  aj^i-nt.  This  s[)irillum,  or  more  correctly  spirochivte,  is 
from  three  to  six  times  the  len-^th  of  the  diameter  of  a  red  blood-cor- 
puscle, and  form-:  a  narrow  spiral  filanu'nt  which  is  readily  seen  moving 
aiiu)ng  the  re<l  corpuscles  during  a  paroxysm.  They  are  present  in  the 
blood  oidy  during  the  fever.  Shortly  before  the  t'risis  and  in  tlu,  inter- 
vals tlu'y  are  not  found,  though  small  glisteiung  bodies,  whicli  are  stated 
to  be  their  spores,  appear  in  the  blood.  The  disease  has  been  produced 
ill  human  beings  by  inocidation  of  the  blood  dui'ing  the  paroxysm.  It 
has  also  been  produced  in  monkeys.  Nothing  is  yet  known  with  refer- 
ence to  the  life  history  of  the  spiroclia'te. 

Morbid  Anatomy. — There  are  no  characU'ristic  anatomical  ajipcar- 
ances  in  relapsing  fever.  If  death  takes  place  during  the  paroxysm  t]»e 
spleen  is  large  and  soft,  and  the  liver,  kidneys  and  heart  sliow  cloudy 
swelling.  Tiiere  mav  be  infarcts  in  the  kidneys  and  spleen.  The  bone 
marrow  has  bei'u  found  in  a  condition  of  hyperpl.sia.  Ecehyn  uses  are 
not  uncommon. 

Symptoms. — The  iiirn/iit/iini  a])poars  to  be  short,  and  in  some  in- 
stances the  attack  devtdops  promptly  after  exposure;  more  fre(piently, 
however,  from  live  to  seven  days  elapse. 

The  iiintsiitu  is  abrupt,  with  (dull,  fever,  and  intense  pain  in  the  back 
and  lindts.  In  young  persons  there  i  lay  be  nausea,  vomiting,  and  convul- 
sions. The  temi  I'raturc  rises  rapidly  and  mi;y  reach  1(14'^  on  the  evening 
of  the  first  day.  Sweats  arc  comn'o?i.  i'he  pulse  is  rapid,  ranging  from 
ll(»  to  i;{0.  There  may  be  delirium  if  thv  fever  is  high.  Swelling  of  the 
spleen  can  lie  detected  early.  .laundice  is  (ommon  in  sonu;  epidenncs. 
'J  he  gastric  sympt(»irs  imiy  lu-  severe.  There  are  seldom  intestimil  symp- 
toms. Cough  may  be  jiresent.  Occasionally  herpes  is  noted,  and  there 
may  Ih"  nuliary  vi'sicles  and  petechia'.  During  the  paroxysm  the  blooil 
invariably  shows  the  s]iiruciiicte,  and  there  is  usually  a  leucucylosis  (Uu- 


RKLAPSIN(i    FKVKR. 


49 


ik'd  in 

'  > 

)ns  for 

■\ 

■n  spe- 

':t 

in  tills 

% 

OSpltill, 

1 

lilt  saw 

1 

(irni  111 

1 

illar  to 

1 

condi- 

i 

her  a<;e, 

itai?ious 

m 

not  so 

M 

foniite;^. 

M 

In  1H;:J 
L'ognisod 

n 

jhivtc,  is 

■A-l 

(»od-eor- 

^\ 

nioving 

t  in  tlio 

lu  inter- 

ire  stated 

produced 

;Ysni.     It 
ih  refer- 

-i. 

1 

1  a))pear- 

xysni  tlve 

w  cloudy 

The  hone 

I  OSes  are 

some  in- 

•ecjuently, 

the  hack 

d  convul- 

e  evening 

:ing  from 

ing  of  the 

'pi-lemics. 

iial  syinp- 

iind  tluTC 

the  hlood 

tosis  (Ou- 

.,,.\v).  After  persisting  with  severity  ir  even  witii  an  inereasing  intensity 
I  ,!  live  or  six  liavs  the  crisis  occurs.  In  tlieeoui'si'  dT  u  few  iuiurs,  aceom- 
|,;i!iiiMi  hv  profuse  sweating,  sonielinies  hy  (liarrho'a,  the  temperature  falls 
In  nnriiial  i>v  even  snhnorinal,  and  the  period  of  apyrexia  liegins. 


•J       :!       1 


'^     <\     m    11    i'.>    i:t    It    i:>    n!    ir    i«    lo   '.'d   mi    ■,•■,•   yn   '.m 


1 1'  li 


I    Nl    |. 


ll.Vi)' 


iiiliigSISiliiiiiiieillilB 

siimMgEiggaaiinmei 


yiygnig!KIPl£giBiiHSi 

SiiiSllSiBiBSBdiBBBBBiliiSi 

i38iB!5aBHBBBSBiilll!B!B5SriS™ll 


t'liAKT  V. —  Hcliipsiiifj  fever  (Miiichisoii). 


The  crisis  may  occur  us  early  as  the  third  day,  or  it  may  bo  delayed  to 
the  tenth;  it  usually  comes,  however,  about  the  eiul  of  the  lirst  week. 
Ill  delicate  and  eUlerly  persons  there  may  be  collapse.  'I'he  convalescence 
is  rapid,  and  in  a  few  days  the  patient  is  up  and  about.  'I'hen  in  a  week, 
usiuiUy  on  the  fourteenth  day,  he  again  has  a  rigor,  or  a  series  of  (diills; 
the  fever  returns  and  the  attack  i.  re])eated.  A  second  crisis  occurs  from 
liie  twentieth  to  the  twenty-third  day,  and  again  the  patient  recovers 
rapidly.  As  a  ridi^  the  relapse  is  shorter  than  the  origiiud  attack.  A 
secdiid  and  a  third  may  occur,  atul  there  are  instances  on  record  id"  I'ven  a 
foiiith  and  a  fifth.  In  epidemics  there  are  cases  which  terminate  by  crisis 
oil  the  seventh  or  eighth  day  without  the  occurrence  of  relapse.  In  pro- 
tracted eases  the  convalescence  is  very  tedious,  as  the  ])atient  is  much 
exhausted. 

K'elapsing  fever  is  not  a  very  fatal  disease.  Murdiison  states  that  the 
iiiDrtality  is  about. 4  per  cent.  In  the  enfeebled  and  old,  death  may  occur 
at  the  height  of  the  lirst  jtaroxysm. 

Coniplications  are  not  freijucnt.  In  some  epidemics  nephritis  and 
lii'inaluria  have  occu  red.  I'neuinonia  apju'ars  to  Ijc  frei|iiciit  ami  may 
iiilcniipt  the  typical  course  of  the  disease.  'I"he  acute  enlargement  of  the 
siiltiii  may  end  in  rupture,  and  the  ha'initrrhage  from  the  stomach,  which 
lia>  iieen  met  with  oecasiomdly,  is  j)rol»ably  associated  with  this  eiilarge- 
itiiii!.  Post-febrile  par,ilyses  may  occur,  '/phtlialmia  has  followed  cer- 
tain epidemics,  and  may  prove  a  very  tedious  and  serious  coniplicatioii. 
.'aiiiiilicc  has  already  been  mentioned.  In  pregnant  wnnien  iii)ortioii  iisu- 
aii\  lakes  place. 


I\ 


9.^*mmmmmmm;mmmmis^a 


maasBsnaamm 


''Wf' 


60 


SI'KCIFIC   INFKCTIOUS   DISKASKS. 


Diagnosis. — Tlio  onset  and  goncml  symptoms  nuiy  not  at  first  bo 
(listhuitive.  At  the  bc^xinniiif^  of  an  opidt'iiiic  tlie  cases  are  nsually 
rejfanled  as  anomalous  typhoid ;  but  once  the  typical  course  is  followed 
in  a  case  the  diairnosis  is  clear.  The  blood  exanunation,  which  shonld  be 
made  in  all  doubtful  eases  of  fever,  affords  a  detinite  criterion  by  whidi 
the  diagnosis  can  readily  l)e  made. 

Treatment. — 'I'he  paroxysm  can  neither  be  cnt  short  nor  can  its 
re(Mirrcnce  be  prevented.  It  nu,i,dit  be  tlu)n<j;ht  that  (piinine,  with  its  pow- 
erful action,  would  ci'rtainly  meet  the  indications,  but  it  does  not  seetn  to 
have  the  slijihtest  iidhuMice.  The  disease  must  bo  treated  like  any  other 
continued  fever  by  careful  nursing,  a  regular  <liet,  and  ordinary  hygienic 
measures.  Of  special  symjjtoms,  pains  in  the  back  and  in  the  limbs  ami 
Joints  demand  o[»ium.  In  enfeebled  i)ersonB  the  collajise  at  the  crisis  may 
bo  serious,  and  stimulants  with  ammonia  and  digitalis  should  be  giveu 
freelv. 


IV.  SMALL-POX  (  Vario/n). 


Definition. — An  acute  infectious  disease  characterised  by  an  erup- 
tion which  passes  through  the  stages  of  ])apule,  vesi(;le,  pustule  and 
crust.  The  mucous  membranes  in  contact  with  the  air  may  also  be 
atl'ected.  Severe  cases  nmy  be  complicated  with  cutaneous  and  visceral 
luemorrhages. 

Etiology.  —  It  has  not  yet  been  determined  in  what  country  small- 
pox origiiuitcil.  The  disease  is  said  to  have  existed  in  Chiiui  many  centu- 
ries before  Christ.  The  prs/a  )ini(/ii((  described  by  (lalen  (ami  of  which 
Marcus  Aurelius  died)  is  believed  to  be  sniall-pox.  In  the  sixth  century 
it  prevailed,  and  subse(|uently,'at  the  time  of  the  Crusades,  became  wide- 
spread. It  was  brottght  to  America  by  the  Spaniards  early  in  the  sixteenth 
century.  Tlu^  first  accurate  account  was  given  by  Hhazes,  aii  Arabian  |)hy- 
sit'ian  who  lived  in  the  ninth  century,  aiul  whose  admirable  description  is 
available  in  (Ireenliiirs  translation  for  the  Sydenham  Society.  In  the 
seventeenth  century  a  thorough  study  of  the  disease  was  made  by  tlie  illus- 
trious Sydenham,  who  still  renniins  oiu'  of  the  mo.>t  trustworthy  authori- 
ties on  the  subject. 

Special  events  in  the  history  of  the  disease  are  the  introduction  of 
inoculation  into  Europe,  by  Lady  Mary  Wortley  Montagu,  in  1718,  and 
the  discovery  of  vaccination  by  .lenner,  in  171)8. 

Small-pox  is  one  of  the  most  virulent  of  contagious  dis(>ases,  and  per- 
sons exposed,  if  uni)rote{Ued  by  vaccination,  are  almost  invariably  attacked. 
There  are  instances  on  record  (»f  persons  insusceptible  to  the  disease.  It  is 
said  that  Diemerbroeck,  a  celebrated  I'trecht  professor  in  tho  seventeenth 
century,  was  not  only  himself  exem])t,  but  likewise  many  members  of  his 
family.  One  of  the  nurses  in  the  small-pox  department  of  the  .Montreal 
General  Hospital  stated  that  she  hail  never  been  successfully  vaccinated, 


SMALL-POX. 


51 


first  be 

usually 

[ollowod 

\()U1<1  1h! 

)V  wiiii'h 

•  oan  its 

its  pow- 

t  seem  to 

my  otlior 

hygii'uic 

iiubs  iuitl 

•risis  uiiiy 

be  giveu 


J  au  crup- 
istulo  anil 
ly  also  be 
111  visceral 


aiiii  -111'  icrtaiiily  had  no  mark.  Such  instances,  however,  of  natural  im- 
nuinitv  are  very  rare.  An  attack  may  not  protect-  for  life.  There  are 
uiiilMiibtetl  ca.ses  of  a  second,  repufeil  instances,  indeed,  of  a  third  attack. 

|,/,. — Sinall-i)()x  is  common  at  all  ages,  bnt  is  particularly  fatal  to 
vomiLr  children,  'i'he  fii'fiis  in  iilrro  may  be  attacked,  but  oidy  if  the 
mother  JHTsclf  is  the  subject  of  tlie  disease.  The  child  may  be  born  with 
ilir  i;i-h  out  or  with  the  scars.  Morecommoidy  the  f(etus  is  not  alTected, 
ami  (  hildrcii  iiorn  in  a  sm;dl-pox  hospital,  if  vaccinated  immediately,  may 
(■.>cajM'  the  disease;  usually,  however,  they  die  early. 

N/. — Males  aiul  females  are  equally  alTected. 

liitcr. — Anu^ng  aboriginal  races  small-pox  is  terribly  fatal.  When  the 
di,-t a.-e  was  liist  introduced  into  America  the  Mexicans  died  by  thousands, 
and  tiie  North  Americiin  Indians  have  also  been  frerpiently  tlecimated  by 
this  plague.  It  is  stated  that  the  negro  is  especially  susceptible,  aiul  the 
mortality  is  greater — about  42  per  cent  in  the  black,  against  !i9  per  cent 
in  the  white  (W.  M.  Welch). 

Till'  full fdf/itan  develo])s  in  the  system  of  the  small-pox  patient  and 
is  reproduced  in  the  pustules.  It  exists  in  the  secretions  and  excretions, 
and  in  the  exhalations  from  the  lungs  and  the  skin.  The  dried  scales  con- 
stitute liy  far  the  most  importajit  elenu^nt,  and  as  a  dust-like  powder  are 
ilistribnted  everywhere  in  the  room  during  convalescence,  becoming  at- 
tiK'hed  to  clothing  and  various  articles  of  furniture.  The  disease  is  ])roba- 
bly  ooiitagiinus  from  a  very  early  stage,  though  I  think  it  has  not  yet  l)een 
detcrndned  whether  the  contagion  is  active  before  the  eruption  develops. 
The  poison  is  of  unusual  tenacity  and  clings  to  infected  localities.  It  is 
roiivcNed  by  persons  who  have  been  in  contact  with  the  sick  and  by  fonntes. 
Diuiiig  I'pidemics  it  is  no  doul)t  widely  spread  in  street-cars  and  public  eon- 
veviutces.  It  must  not  be  forgotten  that  an  unprotected  ])erson  may  con- 
tiiict  a  very  virulent  form  of  the  disease  from  the  mild  varioloid. 

The  disease  smoulders  here  ami  there  in  dilTerent  localities,  iind  when 
ooiiditioiis  arc  fiivorable  becomes  ei)idenuc.  IVrhajts  the  most  remarkable 
instance  in  nuxlcrn  times  of  the  rapid  extension  of  the  disease  occurred  in 
Montreal  i>i  1885.  Small-jHix  had  been  prevalent  in  that  city  between 
istuand  18T5,  wdien  it  dic(l  out.  in  ]>art  owing  to  the  exhaustion  of  suit- 
iilile  material  and  in  part  owing  to  the  introduction  of  aiumal  vaccination. 


Tlie  health  r 


v\mv 


ts  show  that  the  citv  was  free  from  the  disease  uidil  L^S,"). 


Kuring  these  years  vaccination,  to  whi(di  immy  of  the  FrtMudi  Canailians 
iuv  oppo.sed,  was  miu'li  neglected,  so  that  a  large  uni)rotecte(l  popidaliuu 


sri'i'W 


up 


in  the  citv.    On  I"\'bruarv 'iSth  a  Pii]lm:in-car  conductor,  who  had 


travelled  from  Chicago,  where  the  disease  had  been  slightly  ]trcvalent,  wiis 
iiilmitted  into  the  II6t(d-l)ieu,  the  civic  snuill-pox  hospital  being  at  the 
time  closed.  Isolation  was  not  carried  out,  aiul  on  the  1st  of  April  a  serv- 
Mtit  ill  the  hospital  died  of  snudl-pox.  Fcdlowing  her  decease,  with  a  neg- 
ligence abs(dute!y  crimiuid,  the  autboriti(>s  of  the  hospital  dismiss(>d  all 
I'iitients  presenting  no  syni})toms  of  contagion,  who  coiilil  go  home.     The 


m 


i)"^ 


SI'KCIFIC    INFKCriors    DISKASKS. 


diseiuso  si)roii(l  like  lire  in  dry  jfrass,  and  witliiii  nine  niontiis  tliore  died  in 
the  city,  of  small-pox,  li,H'A  {lorsons. 

Tlic  nature  of  the  contajrion  of  sinall-iiox  is  still  nnUnowu.  AVciirerl 
and  otlitTs  have  deserihed  inici'o-ortranisnis  in  the  pock,  hut  they  are  the 
ordinary  pus  cocci,  ami  the  part  which  they  play  in  tiie  alTection  is  liy 
no  tneans  certain.  Still  less  detinite  are  the  ohservations  on  the  occur- 
rence of  sporo/oa  in  the  pocks.  It  is  not  a  little  reinarkahle  that  in  a 
disease  which  is  riLfhtly  repirded  as  the  ty])e  of  all  infectious  maladies, 
the  spi'cilic  virus  still  remains  unknown. 

Morbid  Anatomy. — A  .section  of  a  papule  as  it  is  passing,'  into  tlic 
vesicular  staj^o  shows  in  the  ir/)'  iinicosniii,  close  to  the  true  skin,  an  area 
in  which  tlu^  c<'lls  are  sniocttli,  <rranular,  and  do  not  take  the  staininir  lluid. 
This  represents  a  focus  of  coaj^ndation-necrosis  due,  according,'  to  Weiufert. 
to  the  pre.seneo  of  nucrococci.  Around  this  area  there  is  active  intlamma- 
tory  reaction,  and  in  the  vesicular  stayc  the  rete  niucosum  presents  re- 
ticuli,  or  spaces,  which  contain  sci'um,  leucocytes  and  liltrin  lilamonts.  'I'he 
central  depression  or  uinhilication  corresponds  to  the  area  of  jtrimai'y 
necrosis.  In  the  staire  of  maturation  the  reticular  spaces  hecome  tilled 
with  leucocyte-s  ami  many  of  the  cells  of  the  rete  muco.  iim  become  vesicu- 
lar. 'I'he  papilla'  of  the  true  skin  i)elow  the  pustule  are  swollen  and  inlil- 
trate<l  witli  end»ryoiuc  cells  to  a  variable  decree.  If  the  suppuration  ex- 
tends into  this  layer,  scarring  inevitai)ly  results;  but  if  it  is  conlined  to  the 
upper  layer,  it  does  not  necessarily  follow.  In  the  lia-morrhai^dc  cases, 
red  corpu.scles  pass  out  in  larire  nund)ers  from  the  ves.sels  and  occupy  the 
vesicular  spaces.  'I'hey  inliltrate  also  the  deeper  layers  of  the  epidermis 
in  the  skin  adjacent  to  the  i)apides.  l-'rcqui'Utly  a  hair-follicle  p.asses 
throUL'h  the  centre  of  a  papule. 

In  the  mouth  the  luistules  nuiy  be  seen  uitoii  the  tongue  and  the  buccal 
mucosa,  and  on  the  palati'.  The  eru|)tion  maybe  abun(hint  also  in  the 
))harynx  and  the  upper  part  of  the  (esophagus.  In  except ionallv  rare 
oases  the  eruption  extends  down  the  o'sophaLTUs  and  even  into  the  stom- 
acli.  Swcllinjf  ui  the  Peyer's  follicles  is  not  uncommon;  the  itustules 
have  been  seen  in  the  rectum. 

In  the  larynx  theerupl'on  may  be  associate*!  with  a  fibrinous  exudate 
and  sometimes  with  (edema.  (><'casionally  the  inllammation  passes  dee]ily 
ami  involvt'S  the  cartilages.  In  the  ti'achcii  and  bronchi  there  nuiy  be 
ulcerative  erirsions,  but  true  pocks,  such  as  are  seen  on  the  skin,  do  not 
occur.  Thei'e  are  no  special  lesions  of  the  Iuults,  but  conjieslion  and  broii- 
clio-pneumoiua  are  vcrycommo.i.  The  liver  is  sometimes  fatty.  .\  dilTuse 
hepatitis,  associated  with  intense  coiiircstion  of  the  vessels  ami  mi<fratioii 
of  the  leucocytes,  lias  been  described  ;  \Vei<(crl  has  noted  small  areas  of 
iitMM'osis. 

'I'here  is  nothinir  s]iecial  in  the  condition  of  the  blood,  and  even  in  the 
most  malignant  cases  there  are  no  microscopic  alttrations.  In  the  blood- 
dro[),  however,  it   will   be   seen  that   the  corpuscles,  instead  of  forndn^' 


SMAI.I.-1'OX. 


(lied  in 


^V(•i<r('l•t 

•  arc  till' 

(11   is   liy 

('  occiir- 

lat   in  :i 

iiiiliulii's, 

into  till' 

■;* 

,  iin  area 

-.v. 

njj;  iluiil. 

Woijjcrt. 

,^ 

inaniiiia- 

'sciits  re- 

nts.   'I'lii- 

priinarv 

nio  lilii'd 

;;v 

U'  vcsicu- 

^ 

aiui  inlil- 

i 

•at  ion  fx- 

■ '  w 

uh\  to  tiic 

1 

i^ic  cases. 

,     A 

•ciipv  tlic 

1 

I'pidcrniis 
•le    passes 

'^i 

he  liuccal 

i 

■  ^ 

so  in  tiic 

:' 

lally   v:ii'e 

-;; 

tllC  St(Hll- 

■; 

imslnles 

'i 

s  exudate 

es  di-cply 

'JM 

I'  may  Ite 

n,  do  not 

a 

iiid  ln'oii- 

A  dilTiise 

iiigratioii 

■  areas  of 

..i 

lell  in  tlie 

i 

lie  Itlood- 

1  t'orinin<r 

1 

roideaux.  airurcirate  tou'ctlicr  in  irrciriilar  clumps.  The  heart  occasionally 
siiows  invocardial  chaiij;i's,  pareiichymaloiis  and  fatty;  endocanlilis  and 
pericarditis  are  uncomiiioii.  i"'rcnch  wi'ilci's  have  deserilied  an  endarteritis 
of  the  coronary  vessels  in  coiiiu'ction  with  small-pox.  'I'lie  spleen  is  mark- 
edlv  cnlarired.  Apart  from  the  cloudy  swcilinir  and  areas  of  coaL,nilat ion- 
necrosis,  lesions  of  the  kidneys  are  not  comnion.  \ephritis  may  occur 
duiinir  convalesceneo.  Chiari  has  called  attention  to  the  freipiency  of 
iivhitis  in  this  diseasi'.  There  are  scattered  areas  of  iiei'iosis  with  cell  in- 
lihi'ation. 

In  the  ha'inorrhaiiic  foi'iii  extravasafioiis  are  found  on  the  serous  and 
iiiiicous  surfaces,  in  the  pari'iichynia  of  or^irans,  in  the  connective  tissues, 
,111(1  about  the  nerve-sheaths.  In  <ine  instance  1  found  the  entire  retro- 
prritoiieal  ti.ssuo  infiltrated  with  a  larjio  coairulum,  and  there  wore  also  ex- 
l(iisive  extravasations  in  the  course  of  the  thoracic  aorta.  lla'niorrlia<res 
in  the  Ijoiie-marrow  have  also  heeii  described  by  (Jolud.  'I'liere  may  be 
li;eiiiorrha,ifes  into  the  muscles.  Politick  has  described  the  spleen  as  very 
liiiii  and  hard  in  ha'iiiorrhai;ic  small-pox,  and  such  was  the  case  in  seven 
iiislMiices  which  I  examiiu'd.  The  liver  has  lieeii  desi'ril)ed  as  fatty  in 
thr-e  rajtid  I'ases,  but  in  live  (tf  my  seven  cases  it  was  of  iiurmal  size, 
(Iciise.  and  tirm.  In  two  it  was  larirc  and  fatty:  but  one  man  had  necro- 
sis of  the  tibia,  and  the  other  was  a  drunkard.  The  ecchymo.ses  are  scat- 
iiiiil  over  the  meninires  of  the  brain  ami  cord,  and  in  one  case  there  was 
a  clot  in  the  rii^dit  vcntri(tle.  In  five  of  the  cases  there  were  areas  of  lia'in- 
(irrlia,t,nc  infarction  of  the  liiii,ir.  In  four  instances  the  pelves  of  the 
kidney  weri'  blocked  with  dark  clots,  which  extended  into  the  calices  and 
the   ureters.      In   one  instance   the  coats  of   the   liladdi'r   were   uiii- 


iloUll 


iiiriiily  Ineniorrhaii:!!'  ami  not  a  trace  <i|  normal  tissue  coulii  be  seen.  1  he 
cMravMsations  in  the  mucous  memliraiie  td'  the  stomach  ami  intestines 
numerous  and  lar^^'e.     I'eyer's  glands  wi'iv  swollen  and  prominent   in 


WrVv 


lour  instances. 

Symptoms. — Three  forms  of  siiiall-]iox  are  deserilied  : 

I.   l'(iri(i/(i  rent  ;  {n)  hiscrete,  (!•)  Coiillnciit. 

".'.  \'tirii>l(i  /Hi'iiHirr/idi/iiii  .•  {a)  I'lirpura  variolosa  or  black  small-jiox  ; 
(/'I  lla'TiiorrhaLiic  piistul.ir  form,  variola  lia'inorrhaLiica  [nistiilosa. 

:;.   \  iiridhiiil,  or  siiiall-pox  modilied  by  vaccination. 

1.  Variola  Vera. — Tlie  atTection   may  1 nvcniciitly  deserilied  under 

\;ii'iuiis   sialics:    (a)    hnuliitlUin. — "  l-'roiii    nine   to    lifleeii   days;    ofleiiest 

Ke."  1  have  .seen  it  develop  on  theciublh  day  after  exposure  to  in- 
■i!i"ii.and   there  are  well-autheiitii'aled  instances   in  which   the  st aire  of 


tu. 


liii'ii 


i.ilioii  has  iieeii  pntloiiL^'d  to  twenty  days.      It  is   unusiial  for  patients 
111  iiiiiipiain  of  any  .symptoms  in  this  sta,iie. 

(M  liii'iisiiiii. —  In  adults  a  chill  and  in  children  a  convulsion  are  com- 

thin    the  first 


lere    may   be    repeated 


cllll 


wi 


mull   initial   symptoms. 

l\V(ni\  fuiii-  hours.      Intense   front; 

\iiiiiiM'.L:  are  very  constant  features.     The  pains  in  the  back  and  in  the 


licatlai'lie.  -c  err    liimhar   iiaiiis,  an< 


iA 


SPFX'IFIC   IN'FECTIOUS   DISKASKS. 


linibs  arc  more  sov(>r('  in  []u>  initial  stafje  of  this  tiiaii  of  any  otlicr  crup- 
tivo  I'l'VI'I',  and  tiii'ir  coinbination  with  hcadaclic  and  voinitinjf  is  so  sug- 


40  0° 

8          3          4          r.          0          7          S          !1         10         11         I^>        i:i         11        l.-j         10        ir         IH 

mBmmmummnnamBmi 

as'tt" 

SS'O" 

iil!iiBB]|[[HBBB[[[ 

llilHMlBlliBliBPBI 

mmmmmmmimmmmimtmuuKm 

Initial  P^ever  Eruption. 


Siippufntive  B'ever. 
("iiAKT  VI. — True  siiiall-pox. 


go.stivo  that  in  cpidoniics  ])roeautioiiarv  nioasurcs  may  often  he  taken 
several  days  before  the  eruption  decides  positively  the  nature  of  the  dis- 
ea.se.  'i'he  temperature  rises  (piiekly,  and  may  on  tlie  lirst  day  be  103° 
or  1(1+°.  'i'he  pulse  is  rapid  and  fidl,  not  often  dicrotic.  In  severe  cases 
there  may  l)e  marked  delirium,  i)articularly  if  the  fever  is  high.  The 
]>atient  is  restless  and  distres.sed,  the  face  is  Hushed,  and  the  eyes  are 
bright  and  clear.  The  skin  is  usually  dry,  though  occasionally  there  are 
profu.se  sweats.  One  cannot  judge  from  these  initial  syniptoms  whether  a 
case  is  likely  to  be  discrete  or  conlluent,  as  the  most  inten.se  backache  and 
fever  may  ])reeede  a  very  mild  attack.  Convulsions  are  not  uncommon  in 
children. 

In  this  stage  of  invasion  the  so-called  ijiitial  rashes  may  occur,  of 
which  two  forms  can  be  distinguished— the  dilTuse,  scarhitinal,  and  the 
macular  or  measly  form;  either  of  which  maybe  associated  with  ])etechia' 
and  occupy  a  variable  extent  of  surface.  In  some  instances  they  are  gen- 
eral, but  as  a  rule  they  are  limited,  as  pointed  out  by  Simon,  eitlier  to  the 
lower  abdominal  areas,  to  the  inner  surfaces  of  the  thighs,  and  to  the  lat- 
eral thoracic  region  or  to  the  axilla*.  Occasionally  they  arc  found  over 
the  extensor  surfaces,  ])articularly  in  the  neighborhood  of  the  knees  and 
ell)ows.  'i'iiese  rashes,  usually  purpuric,  are  often  associated  with  an 
erythematous  or  erysipelatous  blush.  The  scarlatinal  rash  may  come  out 
as  early  as  tlu*  second  day  and  be  as  diffuse  and  vivid  as  in  a  true  scarla- 
tina. Th(  measly  rash  may  also  be  diffuse  and  identi(!al  in  character  with 
that  of  measles.  Urticaria  is  only  occasionally  seen.  It  was  present  once 
in  my  Montreal  cases.  Apparently  these  iiutial  rashes  are  more  abundant 
in  some  epidemics  than  in  others;  thus  they  were  certainly  more  numerous 
in  the  Montreal  epidemics  between  ISTO  and  IST")  than  they  were  in  the 
more  extensive  epidemic  in  lSSr».     They  occur  in  from  10  to  IG  per  cent 


SMAr>L-l'()X. 


65 


r  erup- 

so  sug- 


1)0  taken 
'  the  (lis- 
,-  be  103° 
/{•re  cases 
r\x.  The 
eyes  are 
tliere  are 
i-hether  a 
aclie  and 
nmion  in 

occur,  of 
and  the 
}K'techiie 
are  gen- 
■r  to  the 
1)  tlie  hit- 
liuul  over 
noes  an<i 
with   an 
Iconic  out 
('  searla- 
Icter  with 
icnt  once 
libundant 
lunierons 
're  in  the 
per  cent 


■I 


of  cases.  In  the  cases  unih-r  niy  care  in  the  small-jtox  (K'partinent  at  the 
Munlri'al  (iciieril  ll<is|iilMl  tlie  pcrcenta^'e  was  i;i.*  As  will  l)i'  suhsc- 
i|iiiiitlv  ruciitiiini'd  tlicse  initial  raslies  have  coiisidcrahlc  diii<,MU)stic  value. 

('•)  /■.'rii/i/io/i. — (1)  In  the  f/isrir/e  f'l.rm^uaunWy  <>ii  the  fourth  day, 
siiKill  red  spills  appear  on  the  I'lii'dicad,  ])articularly  at  the  junction  witli 
ilic  hair, and  on  tiie  wrists.  Within  the  first  twenty-four  hours  from  their 
.ippcarance  they  occur  on  other  [tarts  of  the  face  and  on  the  extreiuitii'S, 
iiml  ;i  few  arc  seen  on  the  trunk.  As  the  rash  comes  out  the  tem|)eraturc 
f.ill-.  llie  jreueral  symptoms  sul)side,  nnd  the  j)atient  feel.s  conifortahle.  On 
ihe  lil'tli  or  sixth  day  the  papides  chanirc  into  vesicles  with  clear  stimnuts. 
Ka.-li  one  is  elevated,  circular,  and  presents  a  little  depression  in  the  cen- 
tre, the  ,<o-ealled  undiilicatioii.  About  the  eiirhth  dav  the  vesi(dcs  chan;.fe 
into  pustules,  the  uml)ilicati(ai  disappears,  the  Hat  top  assumes  a  globular 
t'nriii  and  liecomes  grayish  yellow  in  color,  owing  to  the  contained  pus. 
'I'liiie  is  an  areola  of  injection  ai)out  the  pustules  and  the  skin  between 
llieni  is  swollen.  This  maturation  lirst  ti-kes  place  on  the  face, ami  follows 
the  iinler  of  the  apj)t'arance  of  the  erupfiou.  'I'he  temperature  now  rises — 
serond.iry  fever — ami  the  general  symptoms  return,  'i'he  swelling  about 
the  pustules  is  attended  with  u  good  deal  of  tension  and  pain  in  the  face; 
the  evelids  be(!omo  swollen  atul  clo.scd.  There  is  a  well-marked  leuco- 
(  vt(i.-is  in  tlic  stage  of  suppuration.  In  the  discrete  form  the  temper- 
ature of  maturation  does  not  usually  remain  high  for  more  than  twenty- 
•nur  or  iweuty-six  hours,  so  that  on  the  tenth  or  eleventh  day  the  fever 
(lisajipears  and  the  stage  cd"  convalescence  begin.s.  The  pustides  rapidly 
dry,  lirst  on  tiu'  fac(>  and  then  on  the  other  parts,  and  l)y  the  fourteenth  or 
tiftreiith  day  des(piamation  may  he  far  ailvanced  on  the  face.  Tlii're  may 
he  in  addilion  vesicles  in  the  mouth,  pharynx,  aiul  hirynx,  causing  soil- 
ness and  swelling  in  these  jiarts,  with  loss  of  voice.  Whetiier  pitting  takes 
jilace  depends  a  good  di'al  upon  the  .severity  of  the  disease.  In  a  majority 
of  eases  Sydenham's  statement  holds  good,  tliat  "  it  is  very  rarely  the  case 
that  tlu'  distinct  sniall-jtox  leaves  its  mark." 

(".')  7'/h'  Coiijliieiif  Fanii. — With  the  same  initial  symptoms,  though 
usually  of  greater  severity,  tlio  rash  appears  on  the  fourth,  or,  according  to 
Sydeidiani,  on  the  tliird  day.  The  more  the  eruption  shows  itself  before 
the  fdurlli  day,  tlie  more  sure  it  is  to  become  continent  (Sydenham).  The 
Jiiipules  at  lirst  may  he  isolated  and  it  is  (uily  later  in  the  stage  of  matu- 
ratiiui  that  the  eruption   is  conilueiit.     Hut    in  severer  eases  the  skin   is 


s«(i|len  and  hypcra'tuic  and  the   papules  ai 


re  verv  close  tosrcthcr.      On  the 


feet 
linili 


and   hands,  too,  the   papules 


art^ 


thicklvset;  more  .si'attcred  on   the 


and  (pdte  discrete  on  the  trunk.  With  the  appearance  of 
the  erni»tion  the  symptoms  subside  and  the  fever  remits,  but  not  to  the 
same  extent  as  in  the  discrete  form.  Occasionally  the  temperature  falls 
to  normal  and  the  ])atient  may  be  very  comfortable.  Then,  usually  on 
the  eighth  day,  the  temperature  again  rises,  the  vesicles  begin  to  change  to 


iti 


Tl'f  Initial  Hashes  of  Siimll-pox.     Ctiniula  Modiciil  and  Surgical  Journal,  1875. 


.')♦; 


SPHCIKIC   INFI'X'TIOUS  DISKASKS. 


pustiilos,  tlie  liy|HM'iViiiiii  about  tlu'iii  beennio.s  iiitciisi',  tlio  swolliiifj  of  the 
face  and  hands  iiicrcawo?,  and  by  tlio  tenth  (hiy  the  piistidcs  havo  fully 
niaturati'd,  niauy  df  tlicin  liavi'  coalcsct'd  autl  tho  entire  Kkin  of  the  head 
and  extremities  is  a  superlicial  abscess.  The  fever  rises  to  U)',]°  or  104  , 
the  pulse  is  frotn  llo  to  r.'(),  and  there  is  often  deliriutn.  As  pointed  out 
by  Sydenham,  salivation  in  adults  and  diarrluea  in  children  are  coinnioi. 
symptoms  of  this  stai^'c.  There  is  usually  much  thirst.  The  eruption 
may  also  be  i)resent  in  the  mouth,  and  usually  the  itharynx  and  larynx  are 
involved  and  the  voice  Vs  husky,  (ircat  swelling;  of  the  cervical  lymphatic 
jrlands  occurs.  At  this  stajic  the  patient  presents  a  t«'rrible  picture,  un- 
eipudled  in  any  other  disease;  one  which  fully  justifies  the  horror  and 
frij^ht  with  which  small-pox  is  associatccl  in  the  jtublic  mind.  Even  when 
the  rash  is  coidlueiit  on  the  face,  hands,  and  feet,  the  i)ustides  renniin 
discrete  on  the  trunk.  The  daiijrcr,  as  pointed  out  by  Sydeidiam,  is  in 
proportion  to  the  number  upon  the  face.  "  If  upon  tlu'  \'uvv  they  are  as 
thick  as  sand  it  is  no  advantaijc  to  have  them  few  and  far  bctwi'cn  on  the 
rest  of  the  body."  In  fatal  cases,  by  the  tenth  or  eleventh  day  the  pulse 
{Tets  feebler  and  more  rapid,  the  delirium  is  nuirked,  there  is  subsultus, 
sometimes  diarrluea,  and  with  these  symj)tonis  the  patiei\t  dies.  Jn  other 
instaiu-es  between  the  ei,i,dith  and  eleventh  day  luemorrhaiiic  symptoms 
develop.  When  recovery  takes  place,  the  patient  enters  on  the  eleventh 
or  twelfth  day  tlie  period  of — 

{(I)  /h'siiTdfid)!. — The  ]instules  break  and  the  pus  exudes  and  forms 
crusts.  'i'hrou<fhout  the  third  week  the  desiccation  proceeds  and  in  cases 
of  moderate  severity  the  secondary  fever  subsides;  but  in  others  it  may 
persist  UJitil  the  fourth  week.  The  crusts  in  confluent  small-pox  adhere 
for  a  long  time  and  the  ))roeess  of  scarrinjjf  may  take  three  or  four  weeks. 
The  crusts  on  the  face  fall  olf, 'but  the  touirh  epidermis  of  the  hands  and 
feet  may  be  shed  entire.  We  had  in  the  small-pox  department  of  the  .Mon- 
treal (ieneral  Hospital  several  moulds  in  epithelium  of  tlie  hands  and  feet. 

'i.  HsBmorrhagic  small-pox  occurs  in  two  forms.  In  one  the  special 
symptoms  a]»pear  eai'ly  and  death  follows  in  froTn  two  to  six  days,  'i'his 
is  the  so-calleil  petechial  or  black  small-pox— /^^/'/n/w  ntriolosa.  In  the 
other  form  the  case  progresses  as  one  of  ordinary  variola,  and  it  is  not 
until  the  vesicular  or  pustular  stage  that  haemorrhage  takes  place  into  tlic 
pocks  or  frotn  the  mucons  membranes.  This  is  sometimes  called  vdritila 
fi(riiiiirr/i(r(/icft  /)i<sfi/fosfr. 

lla'iiu)rrhagic  snudl-pox  is  more  common  in  some  e[)idemics  than  in 
others.  It  is  less  frerpient  in  children  than  in  adults.  Of  twenty-seven 
cases  admitted  to  the  small-pox  department  of  the  Montreal  (Jeneral  Hos- 
pital there  were  three  under  ten  years,  f(»nr  between  fifteen  and  twenty. 
nine  between  twenty  ami  twenty-five,  seven  between  twenty-five  and  thirty- 
tivp,  three  between  thirty  five  and  forty-five,  and  one  above  fifty.  Younsr 
and  vigorous  persons  seem  more  liable  to  this  form.  Several  of  my  cases 
were  above  the  average  in  muscular  develo])ment.     Men  are  more  fro- 


SMAFJi-POX. 


6T 


iifT  of  the 
Mw  fully 
till'  head 
°  or  104  , 
linteil  out 

cotnmoi. 

oruptioti 
larynx  ure- 
lyiuphatit' 
icturt',  un- 
orror  uinl 
\\vn  when 
li's  remain 
\lnun,  is  in 
tlu'V  are  iis 
wn  on  the 
:  the  pulse 
■^  sjihsultiis, 
In  other 

symptoms 
l\o  (.■k'venlh 

and  forms 
d  in  cases 
rs  it  m;iv 
)(t\  atUiere 
ur  weeks, 
hands  and 
f  the  Mon- 
Isand  fet  t. 
the  special 
ays.     This 

sii.     In  the 
(1  it  is  not 
(•('  into  tlic 
lied  variohi 


ies  than  in 
wenty-seven 
eneral  Hms- 
\m\  twenty, 
and  thirty- 
[tv.  You  II 2 
)f  my  cases 
le  more  fre- 


(iiiriitlv  afTected  than  women;  tlins  in  my  list  there  were  twenty-one 
iiiiilr-  anil  oidy  six  females.  'I'lie  inlhieiu'e  of  vaccination  is  siiown  in  tiie 
|':i(  I  I  hat  (if  tile  cases  fiinrteeii  were  tinvaccinatcd,  while  not  one  of  llii' 
thirlern  who  had  seal's  iiad  lieeii  revaceinated. 

'I'lie  elinieai  featuri'S  (d'  tiie  forms  (»f  h,emorrlia<;ic  small-jiox  are  some- 
what dill'ereiit. 

\\\  /iiirpiini  nirio/iisd  the  illness  starts  with  the  usual  ,syin|itonis,  hut 
with  more  intense  constitutional  disturhance.  On  tiie  cNeniuL''  of  the 
..^(.(■ciiiil  or  on  the  third  day  tiiere  is  a  dilTuse  iiypciicniic  rasii.  ]»artieulaily 
ill  the  ;,n'oins,  with  small  }iunctifonn  ha'morriia;.'es.  The  rash  extends, 
lirronics  more  distiiu'tly  ha'tnorrlia^ric,  and  the  spots  increase  in  size. 
F.rchvmoses  appear  on  the  conjunctiva-,  and  as  early  as  the  thinl  day 
till  IT  iiKiy  lie  ha'morrliai,'es  from  the  tniicoiis  incmhranes.  Death  may 
t;d\i'  placi'  liefore  the  rasii  appears.  This  is  truly  a  terrihle  alTcetjon  and 
Well  developed  cases  present  a  frii;litful  appearance,  'i'lie  skin  may  have 
a  uniformly  piiriili>li  hue  and  the  iinlorlniiate  victim  may  even  look  |ilum- 
eiiloied.  The  face  is  swolli'ii  and  lar^'c  coiijnnntival  ha'tnorrhajjcs  with 
llie  deeply  sunken  cornea'  j:ivc  a  ^diaslly  appearance  to  tin-  features. 

The  mind  may  remain  clear  to  the  en<l.  Death  occurs  from  the  third 
to  the  sixth  day;  thus  in  thirteen  of  my  cases  death  took  jilai-e  on  or  he- 
fore  this  dale.  The  earliest  death  was  on  the  third  day  and  iliere  were 
no  inices  of  pa)tules.  There  may  he  no  mucous  Inemorrhaj^es  ;  thus  in 
one  i;ise  of  a  most  virulent  characler  death  occurred  without  hieedinj; 
ciii'ly  on  the  fourth  day.  IlaTiiaturia  is  ]ieiliaps  most  commoti,  next  lue- 
mateiiiesis,  ami  niehena  was  noticed  in  a  third  of  tin;  cases.  Metrorrhafifia 
was  noticed  in  one  only  of  the  six  females  on  my  list.  Ila-moptysis  oe- 
ciirrcd  in  live  cases.  'I'lie  pulse  in  this  form  of  small-pox  is  I'apid  and 
ortcti  hard  and  small.  'J'he  respira- 
tiniis  are  irrcatlv  increased  in  Ire- 
'|iu'iiey  atid  out  of  all  })ro))ortion  to 
the  intensity  of  the  fever.  In  the 
ease  of  a  ne.rro,  whose  respirations 
the  iiiiirnimr  after  admission  were 
:i;' and  temperature  KH",  after  ex- 
ainiuiiii:  the  limits  and  tindini;  noth- 
ing to  account  for  the  increa.<cd 
hrealliinsT,  my  suspicions  were 
•u'uine  1,  and  even  on  the  (lark  skin 
I  was  alile  on  careful  inspection  to 
detect  ha'inorrhages  in  and  ahout 
tlio  papules. 

The  annexed    chart  is  from  a 
case  of  iiiali<fnant  small-pox  whi(di 

caiiie  on  ahriiptly  on  Thursday,  October  '24,  1ST4,  and  which  terminated 
early  on  the  fourth  day.     It  shows  the  moderate  temperature  range. 


104 
103 

!'•    J4 

IS 

j« 

r 

i 

i 
: 

1 

i""] 

lOS! 

\ 

^  / 

\ 

101 

i 

■ 

\/ 

100 



•  : 

90 

- ■! 

........ 

Uny  of 
Dlsiime. 

I 

•> 

a 

4 

p 

I. 


CiiAKT  Vll. —  Ilii-morrhagic  smiill-|M)x. 


58 


SIM'Xil'IC   IN'l''M('TI()irs   DISKASMS, 


In  nin'iilii  piisfiilusfi  fiiniKirr/iiiffici'  lUv  discasi'  pnt^^rcssoa  as  an  ordi- 
nary cuso  of  M'Vt  re  variola,  ami  ilu!  lui'inorrlia^ics  do  not  ilivclop  until  tlie 
vt'si(!ular  or  pustular  sla;,'*'.  'I'lie  oarliir  llic  lia-nioirhagc  tlio  ^ri'utor  is 
tin-  (laii^'cr.  'I'licri:  arc  nndoiibtrdly  instiiin'cs  of  rccovcrv  when  tin:  lilttcd- 
injr  lias  takni  plac'i' at  lliu  slai^f  (d'  nii'liiration.  IJlci'din^  from  tln'  inii- 
coiis  nK'nihrant-s  is  also  coninion  in  this  form,  and  tlif  ;{rrat  majority  of 
the  cases  jH'osf  falal,  usually  <»n  tlio  Huvcnth,  ci^^ditli,  or  niiilli  day. 

'riicrc  is  a  form  <d'  ha-niorrliai^ii-  sinall-pox  in  wliirli  blccdin;;  takes 
place  into  the  jiocks  in  the  vesicular  staj^e  ainl  is  followed  hy  a  rapid 
ahortion  id'  the  rash  and  a  speedy  recovery.  Si\  instances  of  this  kind 
eanie  under  my  ol)ser\ation.*  In  four  (he  Ineniorrha^fe  took  phu'e  on  the 
f<»iirth  <iay ;  in  t\v(»  on  the  lifth  day,  just  at  tiie  time  id"  transition  of  the 
j)a[»ule  into  the  vesicle.  K.\l  ravasalion  takes  place  ehielly  into  the  pocks 
on  the  lower  extremities  and  truidv,  in  oidy  two  instances  oceurrin<^  in 
tho.se  of  the  arms.  The  eruption  in  all  proved  abortive,  and  no  patient:* 
under  my  care  with  an  eipial  extent  of  eruption  made  such  rapid  recover- 
ies. With  the.se  cases  are  to  he  <frouped  tlio.se  in  which  the  lianiorrlia<,'i's 
occur  in  the  pustules  of  the  le^s  in  patients  who  have  in  their  deliriiuii 
got  out  of  heil  and  wandered  alioiit.  'I'liis  inodilied  form  of  luemorrhugie 
small-pox  is  also  described  by  Sclu'by-Iiuch. 

■^-  Varioloid. — This  term  is  applied  to  the  inodilied  form  of  small-po.x 


wliicli  a 


IVect.- 


persons  wiio   liavi 


n   vaci 


■iiiated.     It    niav  set    in    with 


ubruptnesrt  and  severity,  the  tem|K'iaiure  reachini,'  !(>:}.      .More  common- 
ly it  is  in  every  respect  milder  in  its  initial  symptoms,  thoiiirh  the  head- 


icbe  and  liaci\acnc  niav  oe  verv  distressin<r, 


Tl 


le  paiaile 


a|i|i(.'ar  o 


n  th 


eveiiinjf  of  the  third  or  on  the  fourth  day.  They  are  few  in  number  and 
may  l)e  eonliiied  to  the  face  and  hand.s.  The  fever  drops  at  once  and 
the  |)aticnt  feels  perfectly  comforlaltle.  The  vesieiilation  and  maturation 
of  the  poidvs  taki'  place  rapidly  and  llien;  is  no  secondary  fever.  There 
is  rarely  any  .scarrin,i(.  As  a  rule,  when  small-pox  attacks  a  person  who 
has  liei'ii  vaccinated  within  live  or  six  years  the  disease  is  mild,  but  there 
are  instances  in  wliii  h  it  is  very  severe,  and  it  may  even  prove  fatal. 
There  are  several  forms  of  rash  ;  thus  in  what  has  h 


cen  known  as 


liorii- 

pox,  crystalline   pox,  and  wart-pox  the  papules  come  out    in  numbers  on 
the  third  or  fourth  dav,  and  bv  the  lifth  or  sixth  day  have  vlried  to  a  hard, 


horny  consistence. 

Writers  describe  a  ntrin/a  sine  eni/ifiane,  wh'w.h  is  met  with  durins; 
epidemics  in  youn<f  persons  who  have  been  well  vaccinated,  and  who  pre- 
.sent  simply  the  initial  .symptoms  of  fever,  headache  and  backache,  la 
a  .somew  hat  extensive  experience  in  .Montreal  I  do  not  remember  to  have 
met  with  an  instance  of  this  kind  or  to  have  heard  of  one. 

We  do  not  now  see  the  nioililied  form  of  sinall-j)ox,  resulting  from 
inoculation,  in  wliicii  by  the  seventh  or  eighth  day  a  pustule  forms  at  the 


Clinicttl  Notes  on  Siniill-pox.    Montreal,  1876. 


J. 


SMALLPOX. 


59 


80!;t  <f   inncnliitifin  ;  (1h  ii  frcwnil   fever  sets   iti,  niid  with   it,  iilioiit   the 
,1,  \,  mil  (hiy,  a  ;.'eliei'ai  eril|itinii,  usually  iimilnl  in  de^Tee. 

Complications. — ConsithTing  the  seveiil\  of  many  <>(  the  cases 
i;iiil  tiu'  j^eiionil  eharueter  of  the  disi'ase,  assoeiated  with  inidti|ile 
fiM  I   of    siipiiiimtioii,    tiie    uojnpliculiuiis    in    siiiall-|»(>.\    are    remaikalily 

few. 

I„iryii>,'itis  is  serious  in  three  ways  :  it  may  prodnif  a  fatal  ledema  of 
thi'  ;.'li''lis;  it.  is  lial)le  to  extend  and  involve  the  cail  ila;.'es,  |irodiieini( 
necni.-is  ;  ami  l»y  diininisiiing  the  seiisihiliiy  of  the  lar\  iix,  it  allows  irri- 
liiiiiii:  |i:i,ii(les  to  reach  the  lower  ai''-i>as.'-a,ircs,  where  ihcv  excite  Imm- 
cliiii^  or  hron*'ho-])neumonia. 

r.i(i!ii'ho-)»ueuiiioiiia  is  imh  id  one  of  the  most  common  com|ilicatioiis, 
iiinl  is  almost  invariahly  jircseiit  in  fatal  cases.  Lohar  |incumonia  i,-  rare, 
i'lcarisy  is  coirimon  in  some  epidemics. 

The  cardiac  comiilications  are  also  rare.  In  the  height  of  the  fever  a 
svstnlic  murmur  at  the  apex  is  not  uncommon  ;  hut  cmlocardilis,  cither 
-iiiiplcor  malignant,  is  rarely  met  with,  i'ericarditis  too  is  very  uncorn- 
nic'U.  MyrK'arditis  Hcems  to  he  more  frci|ueiit,  and  may  he  as-sociiited  with 
endarteritis  of  the  coronary  vessels. 

Of  roiiiplicatioiis  in  thi?  digestive  system,  parotitis  is  rare.  In  severe 
cases  there  is  extensive  pseudo-diphtheritic  angina.  \'<«initing,  which  is 
so  iiKirkcd  a  s\mplom  in  the  early  stage,  is  rarely  pcrsi-lciit.  Hiai'rho'a 
is  niii  luicommoii,  a~  noted  hy  Sydcidiam,  and  is  very  <'onstantly  prcsi'Ut 
in  cliiMi'cn. 

Alliiiriiiiniria  is  frctpieiit,  hut  true  nephritis  is  rare.  Inllanijnation  of 
the  IrMes  and  of  the  ovaries  may  occur. 

AiiHiTig  the  most  interesting  and  .«erions  cotnplications  are  those  per- 
t;iiiiiiig  to  the  nervous  system.  In  children  convid>ions  are  common  In 
adnlls  the  delirium  of  the  early  stage  may  jjcrsist  and  hecome  violent,  and 
finally  snhside  into  a  fatal  eomu.  Post-fehrile  in.sanity  is  occasionally  met 
with  diu'ing  convalescence,  and  very  rarely  epilepsy.  Many  of  the  old 
wrilcrs  spoke  of  jtaraplegia  in  connection  with  the  intense  hackatdie  of 
the  ciuiy  -tage,  hut  it  is  prohahly  associated  with  the  .M'vcre  agonising 
hiiiiliar  and  crural  pains  and  is  not  a  true  paraple^Ma.  It  must  he  sepa- 
nitril  from  the  form  occurrini,'  in  I'onvalescence,  which  may  he  due  to 
piriplii  lid  neuritis  or  to  a  dilfusc  myelitis  (Westphal).  The  iieuriti.s 
may  as  in  diphtheria  involve  the  phar\.,x  alone,  or  it  may  he  multiple. 
•T  tliis  nature,  in  all  prol)ahilitv,  is  the  so-called  pseudo-tahes,  or  dhi.rir- 
raridJiipip.  Hemiplegia  and  aphasia  have  heeii  met  with  in  a  few  in- 
Htanro,  ihe  result  of  encephalitis. 

.AiiKiiig  the  most  constant  and  trnnlile.some  comi>lications  of  .small-pox 
are  tliovp  invcdving  tlio  skin.  During  convalescence  l)oiln  are  very  fre- 
qiiciit  Mild  may  he  severe.  Aone  and  ecthyma  are  also  met  with.  Local 
L'unLrnuc  in  various  parts  may  occur. 

Artliniis  may  develop,  usually  in  the  period  of  des([uamation,  and  may 


60 


SPKCII'IC   INKKCTIOUS   DISKASKS. 


])iiss  nil  to  sti|t|iuriiti(tn.         'tito  lU'cmsis  of  tlic  liotic  is  somctitiics  mot 
Willi. 

Sjwfiiil  Snisrs. — 'I'iit'  eve  ulTcctiuiis  wliicii  were  fdrrncrly  Hf>  comiiion 
iitid  si'i'idiis  arc  not  now  sd  rr('(|iifiit,  owiiiir  td  tiic  can'  wliicli  in  ;;ivrii  tn 
k('»'|iiii;:  till'  cull jiiiictivii'  I'lcaii.  A  catarrlial  ami  luiriilciit  cDiijiinctivitis 
is  coiiiiiioii  ill  si'ViTi'  cases.  'Tlic  sfcirtiuiis  caiisf  aillii'siuiis  of  tlic  cvclitls, 
and  unless  jjreat  eure  i.s  tal<eii  a  (lill'iise  l<eratiti.><  is  exeiteil,  wiiicli  inav  ^ro 
oil  to  uleeralioii  ami  perforalioii.  Iritis  is  not  very  iiiieoiiiiiioii.  (Hilis 
nu'iiia  is  uii  oeeasioiial  eoiii|)lieaiioii,aiiil  iisiially  results  from  an  exti'iisioii 
of  disease  tliroiii,di  the  I'lustacliian  tulu's. 

Prognosis.  —  In  nnin'otected  persons  siiiall-|io\  is  a  vei'v  fatal  ilisease. 
In  dilTereiit  e|iideiiiies  the  death-rate  is  from  ^'."1  to  ;;,■>  per  eeiit.  In  Wil 
liiini  .M.  Weleh's  report  from  the  Miinieipal  Hospital,  I'hiladelphia,  of 
!i,S:il  eases  of  Variola,  l,."»;54 — i.  e.,  .'")418  per  cent — died,  while  of  ^MC'.i 
cases  of  varioloiil  only  ^'S— i.  e.,  l"-i!)  per  cent — died.  'The  ha'morrlia;:ir 
fortii  is  invariably  fatal,  and  ii  majority  of  those  attacked  with  the 
severer  confluent  forms  die.  In  yoiin;:  children  it  is  particularly  fatal 
In  the  Montreal  epiih'iiiic!  <>{  liSS">  and  lNS<>,  (if  ;(,lli4  tleaths  there  were 
'"i,*!!  under  ten  years.  The  intemperate  and  dehilitated  succiiml)  iiioie 
I'didily  to  the  disease.  As  Sydeiihaiii  observed,  the  daiij^'er  is  directly  pro- 
[lortioiiale  to  the  intensity  (»f  the  discasi'  on  the  face  and  hiiiids.  "  When 
the  fever  increases  after  the  appearance  of  the  pustules,  it  is  u  liad  si<,'ii ;  hut, 
if  it  is  lessened  011  their  appt-araiice,  that  is  a  <,'ood  si^ni  "  (IMia/es).  Very 
hifxh  fever,  with  delirium  and  suhsiiltus,  arc  symptoms  of  ill  omen.  'I'he 
disease  is  particularly  fatal  in  prc^fiiant  women  and  ahorlion  usuiilly  takes 
l)lace.  It  i.s  not,  however,  uiiifoniily  fatal,  ami  I  ha\e  twice  known  .scvtie 
cases  to  recover  after  miscarriajifc.  Moreover,  abortion  is  not  inevitable. 
Very  .severe  pharyntritis  and  laryn^iilis  are  fatal  coinplicatioiis. 

Death  rcsulls  in  thi'  early  static  from  the  action  of  the  poi.son  upon  the 
nervous  .system.  In  the  later  sta^'es  it  usually  occurs  aliout  the  eleveiiih 
or  twelfth  day,  at  tlii'  hciirht  of  the  eruption.  In  I'hildri'ii,  and  occasiou- 
uUy  in  adults,  the  laryni^cal  and  pulmonary  coniplicalioiis  prove  fatal. 

Diagnosis.  — nurinj,' an  epidemic,  the  initial  chill,  followed  by  fever, 
headache,  voinitiii<r,  and  the  severe  pain  in  tin-  back,  are  .symi)toms  whicti 
should  |iut  the  atteiidini,'  physician  <iii  his  j,Miard.  Mistakes  arise  in  tlir 
initial  staj^o  owing  to  the  presence  of  the  scarlatinal  or  measly  raslir- 
wliicli  may  IxM'Xtremely  deceptive*.  The  scarlatinal  rash  has  not  alwav- 
the  intensity  of  the  true  rash  of  this  disease.  In  niy  .Montreal  cxpeiiciur 
I  did  not  meet  with  an  instance  in  which  this  rash  led  to  an  error,  thoiiLdi 
I  heard  of  several  eases  in  which  the  mistake  was  made.  These  arc  doubt- 
less the  instances  to  which  the  older  writers  refer  of  scarlet  fever  and 
small-pox  occurring  to;.'etlicr.  The  measly  nisli  cannot  always  be  dis- 
tiiiiruished  from  true  measles,  instiinces  of  whi(di  may  be  mistaken  for  the 
initial  rash.  I  found  in  the  ward  one  morning  a  young  man  who  lial 
been  sent  in  on  the  previous  evening  with  a  diagnosis  of  small-pox.     IK' 


SMAI.L-l'oX. 


61 


inies  iiu't 
(•((imiion 

iiiiftivitiH 
ic  cyi'lulf. 
Ii  miiy  ^'o 
n.  Otitis 
(.'Xli'iisioii 

itl  disease. 
Ill  Wil 
elpliia,  tii 
'.  of  -.M'i'.t 
morrluij;i( 

witli    th.' 
larly  fatal. 
tliiTe  were 
•unil)  more 
rt'clly  pi't'- 
.     "When 
[  si.ijir,  Vml, 
;cs).     Very 
nen.     'I'lie 
iially  lakes 
own  seviTc 

iiievilalile. 

n  upon  tlie 
.(•  eleventh 
oecasiuu- 
I"  fatal. 
Ll  l»y  fever, 
lonis  which 
ise  in  tin' 
iisly  rashc- 
Inot  iilwa.N^ 
t'xpel'ieiici' 
•or,  tlioiii:h 
are  doiihl- 
fever  ainl 
|iys  he  tli-- 
vn  for  the 
I  who  lia'l 
l-pox.     IK' 


hinl  ;i  fiiiliiiu  macular  rash  with  dislinct  small  pa|>nles,  which  liail  not 
lioui Ml'  ihu  sliotly  hardness  of  variola.  In  the  c\cmii,<;  this  rasli  was  lest* 
iiiMikcd,  and  as  I  felt  sure  that  u  mistake  had  liecn  made,  he  was  disin- 
i'l'cicd  and  sent  Imnn'.  In  another  in.stanee  a  child  lidieved  to  ha\e  small- 
|Mi\  »ius  udmitltd,  l)Mt  if,  proved  to  have  simply  measles.  Neither  of  these 
);i.»e.>  took  small|iox.  In  a  tliiid  ease,  which  I  saw  at  the  C^ity  llospitui, 
till'  nmitled  papular  ra.-l  was  mistaken  for  small-po\  and  the  youn;:  man 
Milt  to  till!  hospital.  I  saw  him  the  day  after  admis>iun,  when  there  was 
tin  ijiiestion  tliut  tins  disease  was  tiM'asles  and  not  \:iriola.  I.csh  fortunate 
than  ilie  fither  ciisert,  he  took  .small-pox  in  a  very  severe  form.  'The  jjen- 
eral  condition  of  the  )iatienl  and  the  nature  of  the  prodroimil  symptoms 
aiv  often  heller  jriddes  than  the  eharaeter  id"  Ihi'  rash.  In  any  ease  it  is 
iiiit,  well,  as  a  rule,  to  send  a  patient  to  a  stnall-po\  hos|iiijd  until  theehar- 
acleri-tic  pajnile-s  appear  about  the  foi-ehcaij  and  on  the  wrists. 

Ill  the  most  malignant  t\pe  ><\'  h;emorrlia;:ic  sniall-po\  the  patient  may 
(lie  hcfore  the  characteristic  rash  develops,  thonirli  as  a  ride  small,  shotty 
papules  may  he  felt  .dxiut  the  wrists  or  at  the  roots  of  the  hair.  In  onlv 
OIK!  of  twenty-seven  cases  of  ha'morrliai:ic  siiiall-pi'\.  in  which  death 
occurred  on  the  third  day.  did  inspection  fail  to  rcvcal  the  papules.  In 
tlin'i!  I'asos  in  which  death  took  ])lace  on  the  fourth  day  the  characteristi*- 
rash  was  hei,'inninif  to  ap|iear. 

'rii(3  disease  ni:iy  he  mistaken  for  cerehro-spinal  fcvcr,  in  which  ]iurpiirie 
sviniitniiis  are  not  unootnnioii.  A  foiir-\t  ar-oM  child  was  taken  suddenly 
ill  with  fever,  pains  in  the  bai'k  and  head,  and  on  the  secoiiil  or  third  day 
peterjiie  appeared  on  the  skin.  There  was  retraction  of  the  heail,  and 
marked  rii^idity  of  tiie  liml)S.  Th  •  juvmorrhaifes  heeame  more  ai)iindant ; 
and  liiially  lia'inatemesis  occurred  and  the  child  ilied  on  the  sixt'i  day.  At 
the  post-inorteiii  there  were  no  lesions  of  eerchro-spinal  fever  and  in  the 
ileeplv  ha'mori'liafiic  skin  the  papules  could  he  readily  seen.  The  post- 
iiinrleiii  diagnosis  of  small-pox  was  unhappily  conlii'incd  hy  the  mother 
takiiii:  the  di.sease  and  dyiii^r  of  it. 

It  iniirht  he  tlioii<rlit  scarcely  jiossihle  to  mistake  any  other  disease  for 


sma!! 


ox  in  the  i)iistiilar  stairc 


I  had  an   instance  of  a.  voiinir  man 


sent  to  me  with  a  copious  imstiilar  eruption,  (diielly  on  the  trunk  and  cov- 
ered portions  of  the  hodv,  which,  so  far  as  tlie  pustules  them.selves  were 
eeiieerned,  was  almost  identical  with  that  of  variola;  hut  tlie  history  and 
the  (iistrihiition  left  no  (piestioii  that  ii  was  a  pustular  syphilide.  It  is  not 
to  he  forjjotten,  however,  that  fever,  which  was  absent  in  this  case,  tnav  he 


present  in  certain  mstaticcs  o 


f  dilT 


ISC  pustular  svphili.s. 


Lastlv.  (diickeii- 


>met lines  it  is  not  easy 


pex  and  small-i)ox  may  be  confounde(|.      Indeci 

to  (listiiijjuisli  between  them,  thouirh  in  well-defined  cases  of  varicella  the 


nil 


)re  vesicular  character  of  the  pustules,  their  irre^Milarity,  the  short  staire 
of  invasion,  the  .slight  eonstifutional  disturbance,  and  the  greater  ititensity 


of  the  rash  on  the  trunk,  shoiihl   make  the  d 


lai/nosh 


dear.     It  is  stated 


that  the  Chicago  case,  which  wa.s  the  starling-point  in   Montreal  of  thti 


02 


SPKClFiC   INFKCTIOIS    DISI^ASKS, 


('[)iili'iiii(:  of  liSS."),  was  rc^'anletl  as  varicella  and  not  isolated.  If  po,  the 
iiiislaUc  was  ouo  wliicli  Icii  to  ono  oi'  tlio  most  fatal  of  iiiodiTii  outbreaks 
of  the  disease. 

(Jiaiiders  in  the  piislidar  form  lias  hecn  inistakoii  for  sniall-pox,  and  ! 
know  of  an  instanct;  (ilnrinj^  an  ej)i(leinie)  wliicii  wjis  isolated  on  the  snj)- 
jxisition  that  it  was  variola. 

Treatment.  —  In  the  interests  of  pnljlie  health  eases  of  stnall-pox 
sluvidd  iiivarialtly  lie  i'einove<l  ti>  special  hospitals,  since  it  is  impossible  to 
take  the  proper  precautions  in  private  houses.  'I'he  j,'eneral  hyirieiiie 
arrani;enients  of  the  room  ><lu)uld  be  suitable  for  an  infectious  disease. 
All  unnecessary  furniture  and  t!ie  ctirtains  and  carpets  shoulil  be  removed 
'I'lu'  <^ri'atest  care  should  be  taken  to  kee[)  the  patient  thoriinj;hly  cleai 
and  the  linen  shotdd  be  frcfiuenlly  chani'cd.  Tiie  oi'dciothin^  hhoiild  be 
liirlit.  It  is  cui'ious  that  the  nld-fashioncd  notion,  which  Sydenham  tried 
so  hard  to  cDuibat,  that  .small-pox  patient  ^  shonlil  be  kept  In  t  aiul  warin, 
still  prevails;  and  I  have  fre(pU'ntiy  had  to  protest  a.LTiiinst  the  patieni 
hein^,  as  Sydenham  expresses  i*.  -tilled  in  his  bed.  Special  care  should  In 
taken  to  sleriiize  lhorou<.'!iIy  evcrythinic  that  has  been  m  contact  with 
the  |)alieut. 

in  the  (.  lystai^'e  the  pain  in  the  back  and  limbs  re([uii'cs  opium, 
whit'h,  as  advised  by  Sydeidiam,  may  in  fi'ccly  iriNcii.  Tiie  diet  should 
consist  of  milk  and  broths,  and  of  ""all  articles  which  <,Mve  no  trounle  t(- 
dij,^>stion."  Cold  drinks  may  be  freely  ^iven.  IJailey-water  aiul  the 
Scotch  horse  (oatnu-al  and  wan-r)  an?  b(»th  nutritious  and  palatable. 
After  the  [treliminary  vomit iui^,  which  is  often  very  hard  to  check  '••. 
ordimirv  measures,  the  apjictile  is  usiiallv  irood,  and,  if  the   tiiroa*    is  i 


very  sore,  [)atients  with   the  c( 


inlliiciit    foiMu   take    n(tu'-ishmcnl 


we 


u); 
In 


the   ha'morrha;.fic    cases    the    vomiting   is   usu.dly   a-Lrravatin;,'   ami    per- 


sistent. 


The  i'l'vcr  when  hi<i;h  ?nust  lu*  kept  within  linuts,  and  it  i-s  best  i  )  use 


'itl 


u'r  cold   sponuMiLT  oi-   the  cold    iialh. 


\\  hen  t  he   p\  rexia  i. 
Id 


MOO 


ined 


with  delirmm  and  subsnitus,  Ihe  patient  should  be  placed  in  a  bath  at  .o  , 
and  this  re[teati'd  as  often  as  every  three  lutiirs  i'"  IIk^  temperature  rises 
above  KCJ".  When  it  is  not  practicable  to  .i,'ive  the  cold  bath,  the  cold  pack 
can  lie  ciii|i|oyi'd  'TIkmc  measures  are  much  prid'erablc  in  suiall-[)ox  to 
the  admiiiislratioii  of  medicinal  antipyretics. 

The  treatmenr,  of  tlw  eruption  has  naturally  e!iijfai:cd  the  s|)ecial  alien- 
tioii  of  till'  profession,  'i'lic  <|ucstiiui  of  the  preventing'  of  pitlinj;,  so  much 
dis(Ui.sseil,  is  really  no!  in  Ihe  hands  of  the  physician.  It  depends  ontirciv 
U|ion  the  depth  to  which  the  individual  pustules  reach,  .\ftcr  try'Uir  all 
sorts  of  remedies,  such  as  punetni  inj^  the  pustules  with  nitrate  of  silver,  or 
treating,'  them  with  iodine  and  various  ointments,  I  came  to  Sydenham's 
conclusion  that  in  ;,Miardiiiir  the  face  ai^ainst  beiiiLj  dislii,Mireii  bv  thv.  s'ars 
'"the  on'y  elTect  of  oils,  linimeiMs,  and  the  like,  was  to  make  the  while 
scurfd  slower  in  "oining  olT."     '1  iiere  is,  I  believe,  sometiiinj,'  in  prot(H:tin;^ 


III' 


SMALL-POX. 


t;3 


'  so,  tlu' 
iilbreiiks 

x,  iintl   ! 
tlu'  siip- 

iii:ill-p<)X 
issihlo  l(» 
livilit'iii'' 
s  tlisi'iisf. 
n'Uiovcd 
ily  cU'iii  , 
,li(>ulil  !»■ 
iim  tricil 
ml  wiTiii, 

lt>   jliltiflU 
.-llollltl  111 

tiiel  willi 

I'S  opiiuii, 
rt  should 
t  i(iii>)K'  t<< 
r  iiiid   till' 

|i;d;itiilili'. 

clu'ck    1';. 

iia'    is  not 


and    [KT- 


4  I  )  use 
iiioiiu-t 
liii  at  10" 


lure  rises 

I  old  \Mr\< 
-IIO.V    l<> 


al  ulW'U- 
so  iiiuclt 
!  (Mitii'i'ly 
irvMiLT  id  I 
■;ilvi  r,  oi 
llctdiam's 
\\\w,  s'iirs 
llic  whili' 
Irotoiiliiig 


till' ripiiii'n  P'M'"'''** '"''"'"  ''"'  1 ';-"'' U  i"" I  tlio  coiistaii,  ajiplicatioti  uti  tlit- 
face  iiiid  hands  (d'  liiil  snaked  in  cnld  water,  to  whieli  am  ix'pties  smdi  as 
i,,,il„,ii,  ;:iid  or  liieliloridn  may  he  added,  is  |ierha|'s  the  iiiosi  siiilahlc 
licaliiieiil.  It  i'-i  vi'i'V  ideasaiil  to  the  palient,  and  for  ilie  I'aee  it  is 
«tll  to  make  :»  mask  in  lint,  wliieii  (an  then  lie  eovered  with  Mijed  silk. 
Wlii'ii  till'  crusts  l)(\irin  to  form,  the  idiiid"  point  is  to  keeji  them  llKprtniirhly 
iiini.-t,  uhieh  may  l>e  done  hy  oil  or  L;iyeerin.  This  previni-  the  desieea- 
tiiiii  and  dilTiisioii  (d"  the  Makes  (d'  epiilermis.  X'aseline  i-;  |iarl  ieiilarly  iisi'- 
fiil,  and  at  this  stai,'t'  may  he  freely  used  upon  the  fae  •.  It  freipiently 
i-flii'Vcs  lh(!  ilehiiii,'  also.  l'"or  the  odor,  \vhi(di  issomel'ines  so  v\  .-leler- 
istic  iVid  iiisaL,M'eealile,  the  diliile  carholii'  soliiiioiis  are  prolialily  hest.  If 
the  cniplion  is  ahiiiidant  on  the  sealp,  the  hair  sliou!  I  hr  cut  short  to 
iMvvi'ii!  miiltiiiiT  and  deeompo.-ilioii  of  the  eriisls.      lliiiiii;:  eoiuah'seenee 


friMjunii  li 


iithiny;  is  ad\  isalile.  heeaiise  it    helps  to  sofleii  the  crusts.     'I'lie 


riirc  ef  the  eyes  is  pari  itulaiiy  import;, m.  The  liiis  >hould  he  ihoroiiirhly 
,lr;iiiMil  three  or  hmr  times  a  da\,  and  llie  eon  jiind  iva'  \\a>hed  uilh  some 
aiiliseplic   sohuion.      in    the  eoiilliieiil    eases,  w  lu'ii    the  eyelids  are   mmdi 


swollen  ami 


lis  can  he  |ii'e\enle(l 


the  lids  uliieil  together,  it  is  oiilv  hv  \val(difiiliiess  thai  kerati- 


The  mouth  and  throat  shoiilil  he  kept   (dean,  and  if 


(•ri'M>  lol'lii  111  Hie  hose  tlie\  slioliiM  l)e  solleiieij  hy  IreijUclit  ilijecl  lolis. 
he  i;iii  lie  L;'iven,  and  is  very  ji'r.aieful  when  there  is  miu  h  aiiuina.  In 
iiioi.cralc  cases,  so  soon  as  the  (v\tv  suiisides  the  patient  should  lie  al!'  1 
to  i.'1'l  up,  a  practice  whiidi  Sidenham  w.arinly  iirired.  'I'lie  diarrluea,  when 
•iVcrc,  should  he  checked  with  pareirofie.  When  the  pilhe  ln'conies  feidile 
;iiii|  rapid,  stimulants  mav  lie  frcch  o-iveii.      'i'hc  delirium   i>   occasionallv 


.iiiiiiiacal  and  may  reijuirc  (dilond'orm,  liit  for  the  nervous  >\  mptoins  the 
^^j,||  I, J  ^H  !i;illi  or  c(d(l  pack  is  the  hest.  l''or  t  he  se\  ere  ha'niorrhai,'cs  id'  the  maliir- 
iriiit  cases  n  'hinircan  he  done,  and  it  is  only  cruel  to  (lren(di  the  unforiu- 
i;;il('  I  la  lie  111  wilh  iron,  eru'il.  und  oi  her  driiLis.  S\  mptonis  of  ol),>triiction  in 
liic  larynx,  usually  !'rom  oMlciua.  ni.iy  call  for  Irathcoiomy.  In  the  lale 
j        ^m    M;iL''S  of  the  disease,  should   the  |.atient    he  extremely  dehilitated  and  tlie 


ilijcci   of  ahscesses  aiid   hed-sores,  he   may   he   placed   oil   a   waler-hcd  or 


!va 


led  hv  the  e.iniini 


lolls  warm    li;i 


h.      I>urii 


uif  eouvalc-cciicc  the  jiaticnt 


>li()iil(i  hathc  (hlily  and  use  carholic  x.ap  freely  in  order  to  licI  riil  id' the 
'I'lisls  and  .scahs.  The  patient  should  not  he  considered  free  from  danircr 
til  (itlicrs  until  the  skin   is  perfectly  smixdh  and  clean,  and  free  from  any 


iniei' 


of  .sea lis.      I  have  not  mentioned  an\  of  the  so-called  spccilics  or  the 


iiiirnia 


I  ant 


isepllcs,  Wlilell    iiave    heeil    adv 


ised  in  sm  h   iiiimhers  ;  hecaii^ 


■I  t'.ir  as  I    know,  the  e\perienc(!  (d'  tluKSc  who  have  .seen  the  most  of  the 
lixas'.!  docs  not  favor  their  use. 


ll 


Oi 


SPECIFIC  INFECTIOUS  DISEASES, 


V.  VACCINIA  (Co!t--joo.j)-VACCI NATION. 

Definition.  —  An  cniiitivc  disetisoof  tlio  cow,  the  virus  of  wliicth,  inocu- 
liiti'd  iiit(»  iiiuii  (vaccination),  produces  a  loi-al  i)ock  with  con.slilulional  dis- 
turl)aiic(',  whicli  atVoi'ds  i)rotcctioii,  more  or  less  lu'rniancut,  from  siuall-pox. 

'I'iic  vaccine  is  <(ot  cilhcr  directly  fnnu  the  calf —animal  lymi»h — in 
which  the  disease  is  propaj^ated  at  regular  stations,  or  is  obtained  from 
persons  vaccinated  (huminised  lynipli). 

It  was  in  llllS  that  I'ldward  Jeiiner,  a  frii'ud  and  impil  of  Hunter, 
practisiii<f  in  (iloiu;estersliire,  announce(l  that  persons  accidentally  inocii- 
hited  with  the  cow-pox  were  suhsecpu'iitly  iiisusceptihlo  to  small-po\. 
Ki'iiMi  that  time  the  prni'css  has  extendeil  over  the  civilized  world  ami 
proved  an  iiu-alculalde  l)oon  to  humanity. 

The  priM'ise  nature  of  vaccinia  is  still  in  dispute,  ^^any  refrard  it  as  n 
specilic  disease  in  the  row  aiialDiious  to  sheep-pox  and  Imrse-pox.  Others 
think  that  it  is  oidy  small-pox  mmliiicd  l)y  passinji^  throu;,di  the  cow. 
Material  from  a  small-p(tx  pustule  iiiocidatcd  in  a  calf  produces  a  vesicle 
like  cow-pox,  which  may  he  inoculated  from  animal  to  animal,  aiid  whicli 
successfully  protects  the  calf  from  suhscipient  inoculations  with  vacciii(> 
matter.  Children  inoculated  with  this  so-called  varinja-vaccine  lymph 
are  protected,  and  the  pocr  produced  is  similar  to  that  of  ordinary  vai - 
cinia.  There  is  no  jfeneralized  eruption,  and  the  disease  produced  in  the 
child  is  not  contajrious,  and  protects  airaiii>t  small-pox. 

(^iii>t,  11.  ('.  Krnst,  and    Martin   have  cultivated    micrococci  from  t'. 
vaccine  lymph.      Lately,  Copemau  aiul    Klein   ha\c  ilcscrii)cd  independ- 
ontly  a  hacillus,  while  Pfeilfer,  Kultcr,  and  others  have  found   protozoa  in 
tlic  vaccine  vesicle. 

Phenomena  of  Vaccination. — In  a  jwimary  vacciiuition,  at  tin' 
('lid  of  twcniy-roiir  or  thirty-six  hours  1  here  is  seen  at  the  p(»int  of  insci- 
lion  of  the  virus  a  slii,dit  papular  elevation  surroundi  1  hy  a  reddish  zone. 
The  papule  irradually  increases  and  on  the  liftli  or  si\lh  day  sliows  a  dell- 
uite  vesicle,  the  niarudiis  of  which  are  rai.sed  while  the  centre  is  depres.seil. 
15y  the  ei;:hth  day  the  vesicle  has  attaiiu'd  its  maximum  size.  It  is  roun^l 
and  distended  with  a  limpid  Ihiid,  the  marj^dn  hard  and  promiiu'nt,  an! 
the  umhilication  is  more  distinct.  Hy  the  tenth  day  tlu^  vesicht  is  >iiii 
larj^'e  and  i.^  snrrouiidi'il  hy  an  extensive  areola.  The  skin  is  also  swollen, 
indurated,  and  often  painful.  On  the  eleventh  or  twelfth  day  the  hypera- 
mia  diniiiushes,  the  lymph  heconu's  juorc  opa(pie  and  l)e<j;ins  to  dry.  I'lV 
the  end  of  the  >ccoiid  week  the  vesicl((  is  convcrte(l  into  a  hrowni.sh  sca^ 
which  irradually  heconu'S  dry  and  hard,  and  in  ahout  a  week  (that  is,  aI):Mit 
the  twenty-first  or  twenty-fifth  tlay  from  the  vaci'ination)  separates  an! 
li'aves  a  I'ircular  })itted  .scar.  If  the  points  of  inoculation  have  been  cl< ->' 
together,  the  vesicles  fuse  and  may  form  a  large  condiitied  vesicle.  Con- 
stitutional symptoms  of  a  more  or  less  marked  degree  follow  the  vaccina- 
tion. I'sually  on  the  third  or  fourth  day  the  temperature  ri.ses,  aiul  may 
])ersist,  increasing  until  the  eighth  or  nintiiday.     In  (duldren  it  iscomni'  ': 


A  *" 


VACCL\IA-VA(X;iXATION. 


ti  liav<'  witli  the  fovor  restlessness,  partioiiliirly  tit  niu^lit,  Jiiul  ii'rit!il>ilit\  : 
but  ii- ii  rule  tliese  syni|it()ms  arc  trivial.  If  the  iiio.'iilatinn  is  iiia<le  on 
tln'iii:ii,  tlie  axillary  irlaiuls  lu'Cdiiie  lari,'e  and  sore;  if  on  the  let.',  (lie  iii- 
;riiiiial  glands.  The  duration  of  the  iniiniinity  is  extremely  variable,  dif- 
fcriiiu'  in  ditTerent  individuals.  In  some  instances  it  i.-  pfrninnriit,  iuit  a 
ijiiiiiy  of  persons  within  ten  or  twelve  years  aijain  become  siisc(']ilii)lc. 
i;,  vMccination  shonhl  be  jteri'ornicd  between  the  tcntii  iiiid   fifti'cnth 


III 


vt'ur,  alio  wnencver  sniall-jidx  is  epKk'inu 


Tlu!  sns  'cptiliiiii V  to  re\ai-i'i- 


iiaticii  is  curiously  varialilc,  and  when  smMil-imx  is  prcv;iltnt  it  is  not  wi 
if  un-iiecessfuK  to  be  couiciit  wit li  a  single  aticnipt.     The  vesicle  in  n 


vai'cin 


;ition  is  usnallv  smaller,  has  less 


ri'siiliiiig  scar  is  less  jicrtt'ct. 


nd  the 
Particular  care  should   itc  taken  to  watch 


induration  iind  bypera'inia,  a 


the  vesicle  of  revaeei nation,  as  it  not  infre<|uently  liappens  that  a  spnriou.- 


1" 


is  j'oriiieil,  which   reaches  its  hcii^iit  earh  and  dries  to  a  scab  liv  th 


ciglitli  or  ninili  day.     1" 
Miiiiclinies  qiiit(!  severe. 


le  con>titutional  symptoms  iii  rcvacciiial  ion  are 


An  irregular  course  is  uncouinion  in  primary  vaccinal ioii,  but 


Wc  (»■(•;!- 


M'liiallv  niec 


t  with   iiistaiUH's  in  whi(di   the  vesicle  de\cl 


ops  ra}tidlv   w  III 


iiiui'li  itching,  has  not  the  charaelerisiic  ilatteiied  a|i|iciiraiii'e,  the  lymph 
early  liecomes  opaipie,  and  the  crust  forms  Ijy  the  si'veiilh  or  eighth  diiy. 
Ill  >ucli  eases  ihv  operation  should  again  be  iierformed  with  fresh  lymjiii. 
Hi'ticntJizi'd  Varrinid. — It   is  not   unco 


VlclllltV   Ol 


lie  primary  sore 


nunon  to  .see  vesicles  in  tlio 
)mmon  is  a  true  generalized  |»ustiilar 
rash,  develo]»ing  in  dilTerent  parts  of  the  lioily,  often  beginning  about,  the 
u lists  and  on  the  back.  The  .secondary  pocks  may  continue  to  make 
their  appearance  for  live  or  six  weeks  after  vaccination.  In  children  the 
disease  may  prove  fatal.     They  may  be  most  almndant  on  the  vaccinat*  tl 


liiiiii, 


and  ilevtdop  usually  about  the  eighth  to  the  tenth  d.ay. 


Complications.- Tn  unhealthy  snliject.s,  or  as  a  result  of  uncleanli- 
iicv-.  or  sometimes  injury,  the  vesicles  infl.aine  and  deep  excav.aretl  ulcers 
nsiilt.  Sloughing  and  deep  cellulitis  may  follow.  In  debilitated  children 
iliiic  may  be  with  this  a  jmrpuric  rash,     i'lrysijudas  may  occur,  or  then  may 


deep  gangrelK/US  u 


Iceration.     Such  instances  are  ran-,  but  1  have  seen 


t'Ai,  whiidi  proved  fatal.  In  on"  there  was  deep  >loughing  and  in  the  other 
i!"-ipelas.  Cases  of  local  dermatitis  must  not  be  mistaken  for  crysipehis. 
.\iuong  the  most  enmmon  complications  are  certain  skin  eruptions,  some 
111'  wliii  h  are  ilui'  to  the  vaccine  virus  ;  others  result  from  a  mixed  infci'rion. 
More  fiHMpient,  ]ierhaps,  is  the  erythematous  or  roseolous  rash.  « 'ont.agin«s 
impetigo  can  also  be  inoculiited  with  the  virus,  and  may  a])pear  a.-  a  v'tti- 
iial  eru|)tion.  In  a  few  instances  tetanus  has  developed  and  proved  fatal. 
\  ijiKstion  of  special  i'liportance  with  referem'e  to  vaccination  is  the 
hansmission  of  other  dH>t-u.ses.  I''<ir  a  time  piiysieiuns  were  unwilling  to 
ai'kiiowledge  that  constitutional  disorders  (!ould  l)e  transmitteil  by  .accina- 
tioii,  but  it  is  now  universally  recognized  that  such  transmission  may  take 
place,  and  this  has  emphasizeil  the  serupuluus  cure  which  sluaiUl  be  taken 
ill  the  performance  of  the  o[)erutiou. 


f 


II 


S-- 


66 


SPECIFIC   IN'FKCTiol'S   DISMASKS. 


Vaccino-Syphilis. —  I''ora  ktuiwlcdi^'cof  this  iiKist  serious  of  all  iifcidenta 
iltiriiif^  viicciiKiiioii  we  arc  lari^cly  iinlflitcil  to  .loiiatlian  lliitcliiiisnii.  It  is 
11  true  iiistaiicc  of  a  iiiixi'd  iiiffclion.  'I'lic  vacciiu' vcsick's  tako  us  ii  rule 
their  usual  course,  aud  it  is  not  uutil  liicy  luive  healccl  or  are  in  process  of 
heaiiii;,'  that  the  local  cliauircs  characici'islic  of  syiihilis  are  niauifcsted. 
'I'lie  fact  thai  sy|diilis  mki\  lie  t  raiisuiit  ti'd  in  this  way  should  put  the  prac- 
titioner on  his  i/uard  ill  sclcctiiiir  hmiiaiiised  lyuiph.  lie  shoiihl  take  it 
only  from  siihjccts  wilh  wlmse  coiisiiiiitioii  he  is  perfectly  familiar. 
Fortunately,  the  instances  arc:  extrcmi'ly  rare.  'Ihcy  are,  in  fact,  much 
less  fnMiuent  than  is  usually  sup[tosed,  and  in  a  niajority  of  the  eases  in 
which  vacciiio-syphilis  is  suspected  the  condition  i>  really  that  of  inilamt'd 
and  indurated  vaccinal  ulcer.  As  the  siihject  is  of  daily  intt-rest  to  the 
practitioner,  and  one  which  he  may  a!  Miiy  moment  he  called  upon  to  de- 
cide, 1  lu-re  insert  a  lalile  of  dilTercnlial  features  lietweeii  vaccinal  ulci'rs 
and  vaccino-syphilis,  and  iictwecn  the  \accinalion  rashes  and  the  secondary 
syphilitic  eruptions,  compiled  liy  ('.  \'..  Shelly*  from  i"'oiirnier's  lectures. 

\  A<(INd-s\  I'll  II.IS.  VACilNAIloN     ll.CKKS. 

("h.iiicn'  developed  on  (he  site  of  I'lccration  iilTeets  all   the  punet- 

usually  one  (U'  two  only  of  the  \ac-  ures  as  a  rule, 
cinaliou  piincliires. 

Inllammaliuii  is  slij^lit.  liillammalion  and  ulceration  .se- 

vere. 

Lossof  suhslancesiiperiicial  only.  I'leer  deeply  excavattiil. 

Suppuration    scanty    or   al<sent,  .Much  sup]turation. 

scalis  or  crusts  formetl. 

litirder(>f  chancresmooth,  sliifht-  .Mai%'in  of  ulcer  irregular,  as  in 

ly  elevated,  ^vadiially  niert;in,L(  into  "  soli  chancre."'' 
iloor. 

Surface  of  Iloor  smoolh.  I-'loor  of  ulcer  uneven,  sujijiurat- 

intr. 

Ind.iralion    "  parchment  -  like"'  Induration  inllaminatory  only, 

and  specific,  not  mercl\  iiillammatoiy. 

Inllaiiimatorv  ai^i.la  verv  >lii:ht.  .\reola    infl.iminai<iry   and    erv- 

sipclutous  in  character. 

(ilaiid    swelling'  I'onstani,   indo-  (ihind  swellin;,'  often  ahseiil ;  if 

lent  (syphililii')  liuho.  present,  merely  inllaminatory. 

('oinplicaliciis  rare.  Complieatioiis^ — sloii<^Iiin<;,    ery- 

sipelas, el'.'.^ofteii  present. 

ChaiKri'  never  developed  before  I'leeration  i.s  itresent    twelve  o. 

the  lifteeiith  day  after  vaicination  ;  tifleen  days  after  vaccination  and  i> 

usually  not   until  after  three  to  ii\c  fully    developed    hy    the    twentieth 

weeks;    still     in    its    earlier    staj,'e  day  u''ter  vaccinal  ion. 
twenty  days  after  vaticination. 


Fuv.'lcr's  l>i(lioiiiirv  of  Medicine     .\rticle  V.uciiml 


loit. 


VACCINIA-- VACCINATION. 


uviidonta 
111.  It  is 
us  !i  rule 
inici'ss  di' 
iiiit'cslctl. 
tlic  pnif- 
il  1:iko  it 

fiiiiiiliar. 
ict,  iiiurli 
I'  ciiscs  ill 

iiillaiiu'd 

st     to     till' 

Hill  to  dc- 
Kll  iilci'iv 
secoiuiiiry 
lectures. 

lie  punct- 


nilioii  fie- 


,|  ,  iiSIiAliY    SVI'llIMI  II'    i:iil   I'TION 
,luc  ["  true  vaei-iiio-sypliilid. 


liar,  as  in 

.u|)[mnit- 

[•y  only. 

luiul    ery- 

l)seiil ;  if 
Iry. 
jilt:,    cry- 

Iwelve  or 

In  ami  i~ 

wciitit'tli 


i 
I 


A|i(ii'ars,  at  the  eai'liest,  nine  or 
tell  Wicks  ul'ter  vaccination. 

1,'rijiiii'es,  in  every  case,  tiic  pre- 
i.xi-i(  nee  of  a  sj)eeilic  ulcer  (ciiaiicrc) 
ill  till  ,-ite  of  vaccination. 

I'.x'iiliits  the  cliaraelers  of  a  iriie 
s|icciti('  eruption. 

I'Vvcr  often  sH^.^it. 

liiists  for  a  \nu'^  tinie. 

I'siially  acconijianit'il  hy  specilie 
ajipcaranees  on  mucous  niciiiiiranes. 


VACCINATION     ItASIM'.S 

(inchi(iin^'roseolavuccinal  is,  miliaria 
vaccinalis,  vaccinia  ImiIIosm,  vaccinia 
haTiioirhairicn);  alsoaccidciilal  erup- 
tions—  rulieola,  .scarlatina,  lichen, 
Jirticaria,  cti;. 

.\  true  vaccinal  rash  appears  l)e- 
iwccii  tiic  ninth  anil  tiftceiith  day 
after  vaccination. 

.Mtsciicc  of  iiiociihil inii  ciiaiicre. 


K:';:ption  does  nol  e.\liil)it  spe- 
cilie characters. 


r'cvcr  always  present. 
Kvan-sceiit. 


VAC•('1N()-S^  I'll  I  MS. 


HeLrins  wiih  a  loi'al  infi'cUoii, 
cliancre  aiiii  iinlolciit  luilio. 

Typiiiiil  (levclopniciit  in  four 
sta^rcs,  viz.,  iiicui»ation,  chancre, 
sciuiid  ineuhation,  <feiieraiizatioii 
(sceondary  erupt  ions,  etc.). 

Never  appears  earlier  than  tlu' 
ninth  or  tenth  week  after  vaccina- 
tion. 


UKUKnri  AKV     SV  I'll  I  MS      SHOWIN'O 

ITS i:  1,1'    Allot  I'    niK     11  mi;    ok 

VA»'<INAI1(»\. 

\o  cIkiiici'c  :  hegins    with    gen- 
eral plicniiinena. 

lias    no    typical    development   in 
colli. eclion  willi  vaccination. 


Time  of  development  (piitc  indo- 

[iciident  of  Viieciiiatioii. 

I.-  attended  liy  the  charuetoristic 
Kvpliilitie  liodily  aspect. 

(Mlier  iiianifestation.s  of  heredi- 
tary sy|ihilis  may  he  present. 

Tile  history  may  indicatesyphilis. 


Choice  of  Lymph. — Ifiunaniseil  lymph  should  ho  taken  on  the 
iiiJli  dav  and  oiilv  from  perfectly  formed,  nnhroken  vesicles,  which 
liave  iiad  a  typical  course.  PriidviiiLi;  or  scrafcliin:,'  the  surface,  the 
Tx  -'I'  'St  care  being  taken  not  to  draw*  hlood,  allows  the  lymph  to  ex- 
ii'li .  aid  it  may  then  he  collected  on  ivory  points  or  in  capillary  tiihes. 
Tlie  chilli  from  which  the  lymph  is  taken  should  he  healthy,  stroiifr, 
if  I  known  to  he  of  ujood  stock,  free  from  tiil>ereuloiis  or  .syphilitic 
I'l  (it.     I  nder    thoisc    eircumstancoj   huiiuinised   lymph,  one   or    two    re- 


I'M 
I 


G8 


SI'KCIFIC    INFHCTIOUS   DISEASES. 


I    1, 


Tiiovt's  fiMin  tlic  ojilf,  i.s  iisimlly  very  sjitisfactory  in  its  iictioii  and  is  per- 
fectly rcliul)l('. 

Ill  till'  case  of  the  calf  tlie  most  scrupulous  care  should  lie  exercised  in 
the  vaccine  farms  to  secure  animals  which  ar(>  healthy  and  stron;f.  'I'lic 
risk,  however,  that  the  calf  has  any  disease  which  can  he  transiuitted  to 
man  is  exccedinirly  sliiflit,  a?  tiiliei'ciilosis  is  very  rare  in  oiittle  when  yoiinir. 
rii(|iicsti(iiiaiily,  iiowever,  tliere  mav  he  risk  in  the  case  of  a  calf  horn  of 
tulierciiloiis  parents,  and  special  care  should  be  taken  in  the  selection  nf 
])roper  aniniiils.  There  is  no  e-<sontial  dilTerence  in  the  pocks  whicli  fol- 
low humanised  lymph  and  bovine  lymph,  it  was,  I  believe,  a  common 
experience  in  Montreal  that  children  inociilateil  with  bovine  lyni|ih  had 
more  constitutional  disturbance  and  often  sorer  arms  than  those  vaccinated 
with  iiiimaiiised  lymph  at  one;  or  two  ri'iiioves. 

Ill  the  performance  of  the  operation  that  part  of  the  arm  about  the  in- 
sertion of  the  (hdtiiid  is  usually  selected.  Mothers  "  in  society"  prefer  to 
have  <X\r\  l)ai)ies  vaccinateil  on  the  Icl'.  'I'hi'  skin  should  be  cleansed 
and  put  upon  the  stretch.  Then,  wiili  a  lancet  or  the  ivory  point,  cross- 
scratidies  should  be  made  in  one  or  more  places.  When  tlii'  lymph  has 
drieii  on  the  points  it  is  best  to  moisten  it  in  warm  water.  The  clothini,' 
of  the  (diild  should  not  be  adjusted  until  the  spot  has  dried,  and  it  should 
be  protccteil  for  a  day  or  two  with  lint  or  a  soft  liamlkeridiii'f.  If  erysipe- 
las is  prevalent,  or  if  there  are  cases  of  suppuration  in  the  same  Imuse.  it 
is  Wi'll  to  apply  a  pad  of  antiseptic  cotton.  Vaccination  is  usually  per- 
fi)rmed  at  the  secdiid  or  third  month.  If  unsuccessful,  it  should  be  re- 
peated from  time  to  time.  .\  person  I'xposed  to  the  contaiiion  of  small- 
pox should  always  be  revaccinated.  This,  if  successful,  will  usually  pro- 
tect ;  but  not  always,  as  there  are  many  instances  in  which,  though  the 
vaccination  takes,  variola  also  appears. 

The  Value  of  Vaccination.— -\'ac"iiiation  is  not  claimed  to  be  an 
invMrial)le  and  permanent  preventive  ui'  sniall-[iox,  hut  in  an  immense  ma- 
jority of  cases  successful  inoculation  renders  the  person  for  many  year- 
insusceptible,  ('onimunities  in  whi(di  vaccination  and  revaccination  are 
tlioroii'ildy  and  systematieally  earrie  !  out  are  those  in  wlii(di  small-pox 
has  the  fewest  victims.  On  the  other  hand  communities  in  which  vacci- 
nation and  revaceinalion  are  persistently  luirlectcd  are  those  in  which  epi- 
demics are  most  ])revalent.  In  the  (Jcrmaii  army  the  practice  ttf  revaccina- 
tion has  stampeil  out  the  disease.  Xotliiiiij;  in  recent  tinien  has  been  more 
instructive  in  this  connection  than  the  fatal  statistics  of  Montreal.  Tli' 
epidemic  which  started  in  ISTO-'Tl  was  severe  in  Lower  Canaila,  and  per- 
sisted in  Montreal  until  is;r».  A  <,'reat  deal  of  feeling  had  been  aroused 
amons;  the  Fremdi  Canadians  by  the  occurrence  of  several  serious  eu.ses  of 
ulceration,  ))o.ssiblyof  syphilitic  disease,  followinj?  vaccination  ;  and  scvend 
airitators,  anion<r  them  a  Frencli  ])hvsician  of  some  standing,',  aroused  i 
popular  and  \\ide-s|ircad  prejudice  airainst  tlie  practice.  There  were  in 
deeil  vuceinatiou  riots.     The  introduclion  of  unimal  lymph  was  distiu/tly 


VACCINIA— VACCIXATION. 


♦;i> 


i 


hiMU'ticiil  in  cxtoiidiii^'  the  |iractict'  iiiiioiii:  tlic  lowor  classes,  but  (■(i!ii|iiil- 
,»(irv  v:i' '  iiiiitidii  cmild  not  hv  carrit'tl  out.  lid  ween  the  years  iM^ti  ami 
ISSl  a  riiusidcraltlo  uuprotcc'ted  population  {^ivw  up  and  tiic  matnials 
\vric  rij"' i'or  an  I'xtensive  cpidcniic  'I'Ik' soil  iiad  liccn  prcparcil  wiih 
til,.  irir:i;(st  caro  and  it  oidy  nccilcd  tlic  introduction  of  iiu>  .-ceil,  wliich  in 
due  time  came  as  ali'cady  stated  with  the  I'ullinan-car  conductor  from 
Cliic;!:;  >,  on  till'  '-iSth  of  Ki'hriuii'y,  !S,s,"i.  Within  the  next  ten  nionllis 
tli(iii>:i!ids  of  persons  were  stricken  with  the  disi'ase,  and  ii.Ki-l  died. 

Allhou,i,d»  the  ell'ects  of  ii  single  va<'cination  may  wear  out,  as  wo  .sav, 
aiul  the  individual  airain  hecome  su.-ceptihie  to  small-pox,  yet  the  niortal- 
iiv  ill  siK'li  I'ii-ses  is  very  iniich  lower  than  in  ])ersoiis  who  have  never  heen 
viiii'inaied.  'I'lic  mortality  in  jiersoiis  who  have  liecu  vaccinated  is  from 
(',  til  >  per  cent,  whereas  in  the  unvaecinated  it  is  at  least  '.]'>  per  cent. 
Miii'Miii  pointetl  out  soiiic  years  airo  that  there  is  a  dclinite  ratio  Itctweeii 
tin'  luimher  of  deaths  and  the  numi)er  of  good  vaccination  marks  in  ]»ost- 
vaci'inal  sniall-pox.  With  good  marks  the  piorlality  is  hetwi'cn  ;}  and  4 
jiir  coiit,  and  with  iiidilTerent  marks  at  least,  l(t  or  II  |ier  cent.  W.  ^^. 
Wclcli's  statistics  of  .^.(MHI  cases  on  this  point  give  with  good  cicatrices  S 
juT  I  eiit ;  with  fair  cicatrices,  II  per  cent;  with  po(ir  cicatrices,  ".ii  per 
cent;  post-vaeeinal  cases,  IG  jier  cent;  unvaceinuted  ca.ses,  58  per  cent. 


VI.  VARICELl-A  {Chivhu- !,<,,■). 

Definition.  —  An  acute  contagious  disease  of  children,  cliuractei'ised 
\<\  an  ei'uptioii  of  Vesicles  on  the  skin. 

Etiology. — 'I'lie  disi'ase  occurs  in  epidemics,  hut  sporadic  cases  aro 
al-H  met  with.  It  may  prevail  at  the  same  time  as  small-pox  or  may  I'ol- 
inw  or  precede  epidemics  of  this  disease.  An  attack  of  chicken-pox  is  no 
|ii'iitection  against  small-jiox.  It  is  a  disease  of  cLililliood  ;  a  majority  nf 
till'  eases  occur  l)et\veen  the  second  and  sixth  year-'.  It  is  rarely  seen  in 
adults.     Till:  specific  germ  has  not  yet  heen  discovered 

There  can  he  no  (piestion  iliat  varicella  is  an  alTection  quite  distinot 
frniii  variola  and  without  at  jiresent  any  relation  whatever  to  it.  An  at- 
lark  of  the  one  does  not  confer  immunity  from  an  attack  of  the  other. 
The  case  which  Sharkey  reported  is  of  special  impoiSanee  in  this  connee- 
:m\.  A  boy,  aged  live,  was  admitted  to  St.  Thomas'  Hospital  with  u 
vi'~i(iilar  eruption,  and  was  isolated  in  a  ward  on  the  same  floor  as  the 
>iiiall-pox  ward.  The  disease  was  ])ronounced  (dii'kcn-pox,  however,  by 
Sir  Uisdon  llennctt  and  Dr.  Hristowc.  The  jiatieiit  was  then  removed 
;iiid  vaccinated,  with  a  result  of  four  vesic'es  which  laii  a  pretty  normal 
oiiirse.  On  the  eighth  day  fi'om  tlie  vaceination  \\w  child  became  fever- 
ish. On  the  following  day  the  papules  appeared  and  the  child  had  a  well- 
lit'veldped  attack  of  suii'11-pox  with  secondary  fever. 

Symptoms. — .After  a  period  of  incubation  of  t.  n  or  lififrti  d.ixs  the 
t'liild  becomes  reverish  and  in  some  instances  has  a  sliulit  chill.     There 


(0 


SI'KCIKIC   INKKCTlorS    DISKASKS. 


iii.'iv  Itc  vmniiini:  and  ]i!iihs  in   tlic  li;icl\  tiinl   lci,"'s.     ('(Hiviilsioiis  arc  run 


Till'  friiiiiiiiii   ii-ii,illv  ilc\il(i|is  within   t\vciil\-f 


mil-   hour.' 


1 1   IS  lirst  seen 


iipuii  till'  iniiik,  ritlicr  (III  till-  liiicls  or  (Ui  the  (  lif<t.  It  iii;iy  lici;iii  uti  tin 
I'nrciiciiil  ami  I'.n'i'.  At.  lirst  in  the  t'firiii  nf  raised  red  |ia]iiilrs,  tlicy  arc  in 
11  I'cw  liniirs  lraiis!'(.riiic(l  into  liciiiis|ilicri(Ml  vesicles  ('(Hitaiiiinif  a  <lcar  oi- 
tiirliid  lliiid.  As  a  rule  iliere  is  no  ntnliilieaiioiu  hut  in  rare  insiaiiees  the 
pneks  are  Hat leiied,  and  a   feu  may  e\cii    lie   iiinhilieali'd.      'I'hey  arc  (irien 


•  iVdiil  in  sjiape  and  lixij' 


iiHirc  siiiierlieial  than  the  Nariolmis  voiidcs.     'I'll 


skin  ill  the  neinhlmilKMid  is  neither  inrdtrated  imr  liy|ierM'iiiic.  At  the 
end  (if  thirlv-si\  (ir  I'urty-eiirht  Ikhii's  the  cdntciil-  nf  the  vcsiidcs  are 
|)iiriiletit.  'riie\  hetriii  to  >hii\el  and  (liirinLT  the  third  ami  I'diirth  da\^ 
are  converted  into  dark  hrownish  crusts,  which  lull  oil'  and  as  a  rule  leave 
no  scar,  l-'ivsh  cro)is  apiicar  diiriiiir  the  lirst  two  or  three  days  n\  the  ill- 
ness, so  that  on  tlic  fourth  day  one  can  nsnally  sec  |)o(d\s  in  all  staircs  of 
ilcvclopmciit  and  decay.  They  ai'c  always  discrete  and  the  niinihcr  may 
varv  from  ciLilit   or  ten   to  several   hiindi'cds.     .\s  in  variola,  a  scarlatii 


lal 


rash  occasionally  |irecc(les  the  devcIo|iiiien 


t  ut  the  cru|itioii. 
hich 


There  arc  one  or  two  niodilicatioiis  <d"  the  rash  which  arc  interest in^^ 
The  vesicles  may  hecomc  very  lar^'c  and  deve|o|t  into  rc<;ular  bulhc,  look- 
ing.'ictt  unlike  c'ihyma  or  |iciii|>hiu'iis  (varicella  hiillosa).  Tlii;  irritation 
of  the  ra.-h  mav  he  e\ces-ive.  and  if'the  (diild  scratidies  the  pocks  ulceiat 
iiii;  >ores  may  form,  which  on  heaiinu  leave  ii^'ly  scars.  ln(lcc(|,  cicatrice- 
after  clii(d\cn-]io.\   ai'c   not   so   very   iini'oinmoii.     Tlmy  are   in   my  c\|ieri- 


eiicc  more  comiiion   than   after  varioloid 


lie  t« 


ver  in  varicella  is  sliirht. 


hilt  it  d< 


le-;  not  as  a  rule  (|i-a|i|iear  with  the  a|ipearaiice  ( 


T  the   rash.     T 


coarse  (d'  the  di>ca^e  is  in  a  lar^^c  majority  of  the  cases  favorahic  and  m. 
ill  elTects  follow.  The  disease  may  recur  in  the  same  individual.  There 
are  instances  in  wliiih  a  person  has  jiad  three  atta(d<s. 

In  delicate  (diildreii,  particularly  the  tnherciiloiis,  jxaiiirreiic  (varicella 
eseh.'irotica)  may  occur  alioiil  the  vesicles  ( I  liitchinson)  ;  or  in  other  parts. 
Hs  the  Hcrotiim. 

Cases  have  been  (lescrihed  (.\ndrew)  of  liicmorrha,L''i(  varicella  with 
eiilaiieoiis  ecchvnioses  and  hleedinir  from  the  mucous  mcmhraiies. 


N'ephriiis  may  occur.      Infantile  hcmipH'U'iii  has  developed  duriiiix 
iltack  of  the  disease 


r  an 


heath  has  followed  in  an  uiicoinplicatetl  casi-  from 
i-xtcnsive  iiivolvcineii!,  of  the  skin  (Nishet). 

The  iliiiijiiiisis  is  as  a  rule  ea.sy,  particularly  if  the  patient  lui.s  hein 
.seen  from  the  out-^et.  \\'licii  a  case  comes  under  observation  for  the  first 
time  with  the  rash  \\v\\  out,  there  may  be  considerable  diniciilty.  The 
abundance  of  the  rash  on  the  trunk  in  varic(dla  is  most  important.  Thi 
po(d(s  in  varicella  are  more  sujierlieial.  more  bleb-like,  have  not  .so  deepl\ 
an  inliltrated  arc(da  about  them,  and  may  usually  be  seen  in  all  ataj^cs  of 
(levelopiiieiit.  They  rarely  at  the  outset  have  the  hard,  shotty  fcelinij  of 
small-pox.  The  L'cneral  synipt(uns,  the  greater  intensity  of  the  onset,  tin 
proloiiE^ed  period  of  invasion,  and  the  more  frc<|iK'nt  occiirnMice  of  prodro- 
mal rashes  in  small-pox  are  important  points  in  the  diagnoshs. 


SCAULHT    I'I'lVKU. 


1 


No  sjiofial  (rrtiimnit  is  rof|iiirt'(l.     If  the  rash  is  al)im(laiit  on  the  face 
I  at  care  shoiihl  be  tikeii  to  prevent  the  ehiUl  from  scratching  the  pus- 
i,     s.     A  sootliing  hHion  sliould  l)e  applied  on  lint. 


VII.    SCARLET    FEVER. 

Definition. — An  infectious  disease  ehamcterised  hy  a  dilTiise  exan- 
tlii  n  and  an  angina  of  variable  intensity. 

Etiology.  —  We  owe  tlie  recognition  t)f  scarlet  fever  as  a  distinct  dis- 
ea-  to  f5ydeii!iani,  lu-fore  whose  time  it  mm  conf(»nndeil  with  measles.  It 
is  ii  wide-spread  atlectiou,  occurring  in  nearly  all  parts  of  the  globe  and 
iitliii'kiiig  all  ra<'es. 

The  disease  occurs  sporadically  from  time  to  time,  and  then  under 
uii;. iiown  conditions  becomes  widespread.      Kpidemics  vary  in  severity. 

Among  predisposing  factors  age  is  most  important.  A  large  ])ropor- 
liiiii  nt'  the  cases  occur  before  the  tenth  year.  Of  an  enormous  nunilier  of 
fai.il  lasc.'i  tabulated  by  Murchison  over  !•(>  percent  occurred  in  children 
iiiiilcr  this  age.  Adults,  however,  are  by  no  means  exempt.  \'ery  young 
infants  are  rarely  attacked.  A  certain  number  exposed  to  the  contagion 
t'siape.  In  a  family  of  children  uU  more  or  less  expo.se(l  one  or  two  nuiy 
not  take  the  disease,  whereas,  as  a  rule,  all  exposed  to  measles  take  it. 
Tlie  susceptibility  seems  to  vary  in  families,  and  we  meet  occasioiudly  with 
sad  instances  in  which  three  or  more  members  of  a  family  succumb  in 
rapid  succession. 

Males  and  fenuiles  are  equally  alTected. 

Mpidemics  prevail  at  all  .seasons,  but  ix-rhaps  with  greater  intensity  in 
iiutiinin  and  winter. 

The  contagion  of  scarlet  fever  is  probal)ly  not  develojied  until  the  erup- 
tion appears,  and  is  ])articularly  to  bo  dreaded  during  desquamation.  No 
doubt  the  poiscm  is  spread  largely  by  the  line  scaly  jmrt ides  which  are 
(lilTused  with  the  dust  throughout  the  nxun.  Even  late  in  the  disi'ase, 
after  des(p,it  -ation  has  lu'cn  a]iparcntly  comi)letcd,  a  patient  has  con- 
veyed the  coi\tagio!i.     The  ])oison  clings  with  great  ju'rsistenco  to  eloth- 


uu 


>f  all  kiiuls  and  to  articles  of  furniture  in  the  roon 


n  no  disease  is 


a  LM-eater  tenacity  (lisplayed.      Hedding  and  clothes  which   liave  i>een  put 
awav  for  months  or  even  for  vears  mav,  unless   th(M-oughly  disinfecteil. 


iimvey  contagion.  Physicians,  nurses,  and  others  in  contact  with  tiic 
suk  may  carry  the  jioison  lo  persons  at  a  distance.  It  is  remarkalde  that 
ill  'he  case  of  ))hysicians  this  does  not  more  frequently  occur.  I  know  of 
liiit  one  instance  in  which  I  carried  the  cojitagion  of  this  diseas(>.  The 
piiison  probat)ly  is  not  widely  spread  in  the  afmosjihen^  Observations 
have  been  recently  niadt^  which  indicate  that  the  poison  n)ay  be  convevetl 
in  milk.  The  epidemic  investigated  by  Power  ami  Klein  in  i.niidon  in 
Iss")  was  traced  by  them  to  milk  obtained  from  a  dairy  at  lleiidon,  in 
which  the  cows  were  found  to  be  sutTerina:  from  a  vesicular  alTci'tion  of 


i:, 

3ri 


m 


m 


72  SPKCIFIC   INKKcTKtrs   DISKASKS. 

tilt!  inMcr.  'I'lic  iiatiin'  <>f  this  (Hsciisc  of  the  cow  is  doiilitfiil,  liowovcr. 
( 'rooksliuiik  iiiaiiitiiiiis  tliat  it  was  cow-pox,  ami  iiad  tiotliiiig  to  du  witii 
scarlet  fi'vcr, 

SoiiH!  writers  iiiaiiitaiii   tliat   scarl<'t    fever  mav  lie  associateil  witii  de- 


fective lioiise-di'aiiiai'e.     Tossiliiv  tiie  virus  may  occasioiiallv  Uiiiii  eiilr 


111 


tl 


lit}' 


uiice 


lis  w;iv. 


Tlie  altacls  does  not   necessarily  ]»roteet    pcnnanently.      'I'liere  are  in- 


stall 


CCS  oi  a  scci 


iiid  and  even  a  liiird  attaci\. 


Siir^M(\'il  and  puerperal  scarlatinas,  so  calle(|,(leinaiid  a  word  under  this 
si'ction.  While  scarlet  fever  may  attack  a  person  after  operation,  or  a 
woman  in  childbed,  the  majority  of  the  cast's  discrihctl  as  such  represent, 
I  l»elie\e,  only  the  red  rash  of  seplica-mia.  In  the  cases  wiiitdi  I  havo  seen 
the  rash  was  rarely  so  widespread  as  in  scarlet  fever;  the  tonijiio  hail  not 
the  special  features,  nor  was  the  throat  alTccted.  hesqiiaiiiation  is  no  cri- 
terion, as  it  occurs  whenever  hypcra'iiiia  of  the  skin  persists  for  any  length 
of  lime.  It  is  interesting  to  note  that  these  cases  have  hecoine  rare  with 
the  gradual  disappearance  of  septica-mia.  I.  K.  Atkinson  Kiiggests  that 
these  rashes  are  in  many  cases  due  to  (piinino. 

The  specific  germ  of  the  disease  is  still  unknown.  Stroptooncci  nro 
found  in  the  skin,  in  the  lilood  stmictimcs,  ami  in  the  organs  of  fatal 
cases.  It  has  even  heeii  urged  that  the  di.sea.sti  is  only  h  form  of  stroji- 
tococeiis  inl'ectifiii.  Throat  lesions  of  the  most  malignant  type  may 
occur  without  the  presence  of  the  Locnicr  hacilliis,  hut  in  the  infec- 
tious pavilions  of  hospitals  the  scarlet  U'M'V  cases  are  very  apt  to  he 
complicated  with  true  diphtheria;  much  more  so  than  in  private  ))rac 
tice.  'i'he  slre[»tocucL'iis  pyogenes  is  the  cuinmun  organism  of  llu!  otitis 
media. 

Morbid  Anatomy.  —  Kxcept    in   the   luemorrhagic  form,  the  skin 

There  are  no  sneciilc  lesions. 


after  death    shows  no  traces  of   the   ra-^h. 


Those  which  occur  in   the  internal  organs  arc  due  partly  to  the  fever  an 
partiv  to  infection  with  pus-organisi 


lis. 


le  aiiatoinical  cliaiiijes 


III    the 


th 


iroat   areilioseot   simple  iiillamma 


tioii,  follicular  tonsillitis,  and,  in  extreme  grades,  of  pseiido-meiiihraiioiis 
angina.  In  severe  cases  there  is  iiileiise  lymphadenitis  and  much  iullain 
niatory  (edema  of  the  tissues  (d'  tlio  neck,  wliitdi  may  go  on  to  suppuration. 
or  even  to  gangrene.  Streptococci  are  found  aliiindantly  in  the  glands 
and  in  the  areas  of  su]»piiratioti.  (>f  changes  in  the  digestive  orgaii.s,  a 
catarrhal   stale  of   the  irastro-intcsl iiial  mucosa  is  not   uncomiiKUi.     Tli'' 


liver  mav  siiow  i 


iitei'stitial  chaiiges  (Klein).     The  spleen  is  often  enlarged. 

Kndocanlitis  and  pcricanlitis  are  not  infriupieiit.  Myocardial  change^ 
are  le.ss  common.  The  renal  changes  are  the  most  important,  and  lia\  • 
been  thoroughly  studied  by  Coats,  Klebs,  Wagner,  and  other.s.  The  spi - 
cial  neidiritis  of  the  disease  will  be  considered  with  the  di.sea.se.s  of  th'' 
kidney. 

AlTectioiis  of  the  respiratory  organs  are  not  fre<pieiit.     \Vlieii  deut!i 


m. 


tv: 


S(  AUI.KT    FKVHU. 


78 


I.  -nils  frtim  till'  j)S('U(l()-ni('iiilirimoiiH  aiiiriiiM,  hronclio-prnMirnoniii  in  lui* 
I    >  nniiiHii).     ( 'ircl)rn-s|iiii;il  cliaii^'fs  iirt'  rare. 

Symptoms.-   Incubation.--"  Kroiu  one  to  seven  days,  ofU'iicst  two  to 


.,i,r. 


Invasion.- -'I'll*'  oiiset  is  as  a  rule  sihMcii.  It  may  1m  preceded  hy  a 
,-M.lii.  .-eareely  iii)li(real>le,  indispusitioii.  .\m  aetiia'  eliill  is  rare.  N'miiil- 
III.'  iiiid,  in  Voiiiij;  eliildreii,  eon\  iiisioiis  are  coininoii.  'I'lio  fever  is  in- 
teii-r;  rising  rajtiilly,  it  may  (ni  the  lirst  day  reaeli  101'^  or  even  In,*)', 
'ill'-  -kin  is  nnusmiUy  dry  and  to  the  toiieli  j^ives  a  .sen.sation  of  very  pnti 
p'lit  iieat.  'I'iie  t<»n<.Mie  is  furred,  and  as  early  as  the  lirst  day  there  may 
lie  iciinplaint  of  dryness  of  the  throat.     CoUirh  and  catarrhal  symptoms 


lire  lllieo 


mmoii.     'The  face  is  often  llnslu'd  and  tlie  patient  has  all  the  ol 


•tl\e 


features  of  an  acnte  fever. 


Eruption. — I'snallv  on  tile  si nd  day,  in  some  instances  within  twen- 

Iv  fwiir  hours,  the  rash  develops  in  the  form  of  scattered  red  points  on  a 
(jicp  suheuticniar  flush.  it  appears  first  on  the  neck  and  chest,  and 
sppiids  so  rapidly  that  hy  the  evening,'  of  tho  second  day  it  may  have  in- 
Miilnl  the  entire  skin.  In  pronoimced  ca.ses  the  rash  at  its  heiirht  has 
a  \i\i(l  scarlet  hue.  tpiite  distinctive^  and  unlike  that  seen  in  any  other 
cniplive  disease.  It  is  entirely  hypcra-ndc,  and  the  ana'mia  produceil  l)y 
piiv-ure  instantly  disa]>pears.  In  some  cases  the  rash  docs  not  liecomc 
iiiiifnnii  hut  remains  |)atchy,  and  intervals  of  normal  skin  separate  larirc 
li\|MT;i'Miii;  area.s.  Tiny  jiapnlar  elevations  may  sometimes  he  .seen,  but 
tlii'\  lU'e  not  so  common  as  in  measles.  At  thi!  heiffht  of  the  eruption 
sihlaiiiinal  vesicles  may  devehtp,  the  fluid  of  wluch  tmiy  become  turlml. 
The  entire  skin  may  at  the  same  time  be  covered  with  small  yellow  vesi- 
ell-  uii  a  deep  red  backiri'oiind.  I'l'onounceil  cases  of  this  type  were  called 
liy  the  olilci  writers  snirhtlimi  niilittrix.  'V\w  blood  shows  an  early  leuco- 
I'Uosis.  which  is  often  extreme  in  fatal  cases. 

<  >iiii>ionally  there  are  petechia',  which  in  the  malitrnant  type  of  the 
ili-i  ase  become  wide-sjiread  and  lar^'e.  The  eru[ition  does  not,  always  ap- 
pear upon  the  face.  There  may  be  u  good  deal  of  swellini:  of  the  skin 
whii-h  feels  nncomfortaliK  and  ti'iise.  'J"he  itching  is  variaiile ;  not  as  a 
rule  intense  at  the  height  of  the  eruption.  After  persisting  for  two  or 
tlirtf  (lays  the  rash  gradually  failes.  The  rash  caii  (tftcii  i)e  seen  on  the 
iiiiiroiis  membranes  of  the  palate,  the?  cheeks  and  the  tonsil 
til 


iriviiiLT  to 


esi'  parts  a  vivid  re<l,  punctiform  appearance.  The  tongue  at  lirst  is  red 
iit  the  tip  and  e(|ges,  furred  in  the  centri';  and  through  the  white  fur  are 
eflrii  seen  the  swollcii  reil  papilla',  wlii(di  give  the  so-called  "  sti'awbcrry  " 
ti|i|iiaraiice  to  the  tongue.  In  a  few  days  the  "  fur "  dcs<puimates  and 
liavis  the  surface  red  and  rough,  and  it  is  this  condition  which  sonic 
wiiirr-;  call  tin  "  ^' rawbcrry,"  or,  better,  the  "•raspberry"  tongue.  The 
liitalJ!  uften    .as  a  *v'ry  heavy,  sweet  o(|or. 

Till'  pharyngeal  ninptoms  vai'y  extremely.     There  mav  be 

I    flight  red'U'v-:,  with  swelling  <.»f  the  pillars  of  the  fauces  and  of  ihi' 


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Wl'BSTER,  N.Y.  MSiO 

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SPECIFIC   INFECTIOUS  DISEASES. 


lOS-S" 


1040" 


lO-J 


100-4' 


98-6' 


Eruption. 
Chart  VIII.— Scarlet  fever  (Striimpell). 


2.  A  more  intense  grade  of  swelling  and  infiltration  of  these  parts 
with  a  foUicnlar  tonsillitis. 

3.  Membranous  angina  with  inten.se  inflammotion  of  all  the  plu-ryn- 
geal  structures  and  swelling  of  the  glands  below  the  jaw,  and  in  very  se- 
vere cases  a  thick  brawny  induration  of  all  tlie  tissues  of  the  neck. 

The  fever,  which  sets  in 
with  such  suddenness  and  in- 
tensity, may  reach  105°  or  even 
106°.  It  i^ersists  with  slight 
morning  remissions,  gradually 
declining  with  the  disappear- 
ance of  the  rash.  In  mild  cases 
the  temperature  may  not  reach 
103° ;  on  the  other  hand,  in 
very  severe  cases  there  may  be 
hyperpyrexia,  the  thermometer 
registering  108°  or  even  before 
death  109°. 

The  pulse  presents  the  ordi- 
nary febrile  characters,  ranging 
in  children  from  120°  to  150°,  or  even  higher.  The  res])irations  show  an 
increase  proportionate  to  the  intensity  of  the  fever.  The  gastrointestinal 
symptoms  are  not  marked  after  the  initial  vomiting,  and  food  is  usually 
well  taken.  In  some  instances  there  are  abdominal  pains.  The  edge  of 
the  spleen  may  be  palpable.  The  liver  is  not  often  enlarged.  With  th.e 
initial  fever  nervous  symptoms  are  present  in  a  majority  of  the  cases ;  but 
as  the  rash  ^oraes  out  the  headache  and  the  slight  nocturnal  wandering  dis- 
appear. The  urine  has  the  ordinary  febrile  characters,  being  scanty  and 
high  colored.  Albuminuria  is  by  no  means  infrequent  during  the  stage  of 
eruption,  but  the  amount  is  slight.  Careful  examination  of  the  urine 
should  be  made  every  day.  There  is  no  cause  for  alarm  in  the  slight  trace 
of  albumen  which  is  so  often  present,  not  even  if  it:  is  associated  with  a 
few  tube-casts. 

Desquamation. — With  the  disappearance  of  the  rash  an.l  the  fever  the 
skin  looks  somewhat  stained,  is  dry,  a  little  rough,  and  gradually  the  up- 
])or  layer  of  the  cuticle  begins  to  separate.  The  process  usually  begins 
about  the  neck  and  chest,  and  flakes  are  gradually  detached.  The  degree 
and  character  of  the  desquamation  bear  some  relation  to  the  intensity  of 
the  eruption.  AVhen  the  latter  has  ham  very  vivid  and  of  long-standing, 
large  flakes  may  be  detached.  In  rare  instances  the  hair  and  even  the 
nails  have  been  shed.  It  must  not  be  forgotten  that  there  are  cases  in 
which  the  desquamation  has  been  prolonged,  according  to  Trousseau,  even 
to  the  seventh  or  eighth  Aveek.  The  entire  process  lasts  fi-om  ten  to  fifteen 
or  even  twenty  days. 

There  arc  cases  of  exceptional  mildness  in  which  the  rash  may  be 


SCARLKT   FEVER. 


75 


i 


the 

but 

dis- 

ty  ami 

age  of 

urine 

trace 

with  a 

,-er  the 
le  up- 
begins 
degree 
sity  of 
vnding, 
^en  the 
cases  in 
lU,  even 
fifteen 


may 


be 


poarooly  perceptible.  During  epidemics,  when  several  childron  of  a  house- 
liold  are  allected,  it  sometimes  happens  that  a  child  sickens  as  if  of  scarlet 
fever,  and  has  a  sore  throat  and  the  "strawberry  tongue"  without  the  de- 
velo])ment  of  any  rash.     This  is  the  so-called  srarhtfina  sine  erupt innc. 

These  slight  cases  of  scarlet  fever  may  be  followed  by  the  severest  at- 
tacks of  nephritis. 

MALIGNANT  SCARLET   FEVER. 

Atactic  Form. — This  presents  all  the  characteristics  of  an  acute  intoxi- 
cation. The  patient  overwhelmed  by  the  intensity  of  the  poison  may  die 
within  twenty-four  or  thirty-six  hours.  The  disease  sets  in  with  great 
severity — high  fever,  extreme  restlessness,  headache,  and  delirium.  The 
tein})erature  may  rise  to  107°  or  even  108°,  and  rare  cases  have  been  ob- 
served in  which  the  thermometer  has  registered  even  higher.  Convulsions 
may  occur  in  children.  The  initial  delirium  rapidly  gives  jjlace  to  coma. 
The  dyspnoea  may  be  urgent ;  the  pulse  is  very  rapid  aiul  feeble. 

HsBmorrhagnic  Form. — In  some  instances  haemorrhages  occur  into  the 
skin.  There  are  hematuria  and  epistaxis.  In  the  erythematous  rash  there 
are  at  first  scattered  petecluje,  which  gradually  become  more  extensive, 
and  ultimately  the  skin  may  be  universally  involved.  Death  may  take 
jtlace  on  the  second  or  on  the  third  day.  While  this  form  is  perhai)s 
more  common  in  enfeebled  children,  I  have  twice  known  it  to  attack  per- 
sons apparently  in  full  health. 

Anginose  Form. — The  throat  symptoms  may  appear  early  and  progress 
rapidly.  The  fauces  and  tonsils  are  swollen.  Membranous  exudation 
forms.  It  may  extend  to  the  posterior  wall  of  the  pharynx,  forward 
into  the  mouth,  and  njtward  into  the  nostrils.  The  glands  of  the  neck 
rapidly  enlarge.  Necrosis  occuis  in  the  tissues  of  the  throat,  the  fcetor  is 
extreme,  the  constitutional  disturbance  profound,  and  the  child  dies  with 
tlie  clinical  picture  of  a  malignajit  diphtheria.  Occasionally  the  mem- 
brane extends  into  the  trachea  aiul  thu  bronchi.  The  Eustachian  tubes 
and  the  middle  ear  are  usually  involved.  In  cases  in  which  death  does 
not  take  })lace  rapidly  from  toxamiia  there  may  be  extensive  aljscess  forma- 
tion in  the  tissues  of  the  neck  and  sloughing.  In  the  separation  of  deep 
sloughs  about  the  tonsils  the  carotid  artery  may  be  opened,  causing  fatal 
lia}inori'hage. 

Complications  and  Sequelse.— (^/)  Nephritis. — At  the  height  of 
the  fever  there  is  often  a  slight  trace  of  albumin  in  the  urine,  which  is 
nut  of  special  significance.  In  a  majority  of  cases  the  kidneys  escape 
without  greater  damage  than  occurs  in  other  acute  febrile  affections. 

Nephritis  is  most  common  in  the  second  or  third  week  and  may  de- 
velop after  a  very  mild  attack.  It  may  be  delayed  until  the  third  or 
fiiiirth  week.  As  a  rule,  the  earlier  it  develops  in  the  disease  the  more 
intense  it  is.  It  varies  greatly  in  intensity,  and  three  grades  of  cases  may 
hi'  recognized  : 


76 


SPECIFIC   INFECTIOUS   DISEASES. 


]  I.' 


1.  Very  severe  cases  witli  suppression  of  urine  or  the  passage  of  a 
small  qvumtity  of  dark  bloody  urine  laden  witli  albumin  and  tube-casts. 
Vomiting  is  constant,  there  are  convulsions,  and  the  child  dies  with  the 
symptoms  of  acute  uriemia. 

2.  Less  severe  cases  without  any  serious  acute  symptoms.  There  is  a 
pnfl'y  appearance  of  the  eyelids,  with  slight  onlema  of  the  feet;  the  urine 
is  diminished  in  quantity,  smoky  in  appearance,  and  contains  albumin 
and  tube-casts.  The  kidney  symptoms  then  dominate  the  entire  case,  the 
dropsy  persists,  and  there  may  be  effusion  into  the  sei'ous  sacs.  The  case 
may  drag  on  and  become  chronic,  or  the  patient  may  succumb  to  urannic 
accidents.  Fortunately,  in  a  majority  of  the  cases  the  disease  yields  to 
judicious  treatment  and  recovery  takes  place. 

3.  Cases  so  mild  that  they  can  scarcely  be  termed  nephritis.  The 
urine  contains  albumin,  and  a  few  tube-casts,  but  rarely  blood.  The 
cedema  is  extremely  slight  or  transient,  and  the  convalescence  is  scarcely 
interrupted.  Occasionally,  however,  in  these  mild  attacks  serious  symp- 
toms may  supervene.  (Edema  of  the  glottis  may  prove  rapidly  fatal,  and 
in  one  case  of  the  kind  a  child  under  my  care  died  of  acute  effusion  into 
the  pleural  sacs. 

There  are  instances  of  redema  without  albuminuria  or  signs  of  neplivi- 
tis.  Possibly  in  some  of  these  cases  the  wdema  may  be  hsemic  and  due  to 
tiie  ana'mia;  but  there  arc  instances  in  which  marked  changes  have  been 
found  in  the  kidney  after  death,  even  when  the  urine  did  not  show  the 
features  characteristic  of  nephritis. 

{b)  Arthritis. — During  the  subsidence  of  the  fever,  rarely  at  its 
height,  pains  and  swellings  in  the  joints  nuiy  develop  and  present  all  the 
characteristics  of  acute  rheumatism.  In  all  probability  it  is  not  however 
true  rlieumatism,  but  is  analogous  to'  gonorrheal  synovitis.  The  disease 
may  pass  on  to  suppuration,  in  which  case  it  most  commonly  involves 
only  a  single  joint. 

(c)  Cardiac  Complications. — Simple  endocarditis  is  not  uncommon, 
and  many  cases  of  chronic  valvular  diseai^e  originate  probably  iu  a  latent 
endocarditis  during  this  disease.  Malignant  endocarditis  is  rare.  Peri- 
carditis is  probably  not  more  frequent,  but  is  less  likely  to  be  overlooked 
than  endocarditis.  It  usually  develops  during  convalescence;  the  effu- 
sion may  be  sero-fibrinous  or  purulent.  The  cardiac  complications  are 
sometimes  found  in  association  with  arthritis.  ^Myocarditis  is  not  un- 
common. 

(d)  Pleurisy  may  foWow  p7ieymo)iia.  though  this  is  rare.  More  often 
it  occurs  during  convalescence,  is  insidious  in  its  course,  and  as  a  rv)'' 
purulent.  This  serious  complication  of  scarlet  fever  is  not  sufficiently 
recognized.  It  was  one  upon  which  my  teacher,  K.  P.  Howard,*  in  Mont- 
real, specially  insisted  in  his  lectures.     Sheriff,  in  a  number  of  the  same 

*  Canada  Medical  and  Surgical  Journal,  December,  1872. 


SCARLET   FEVKU. 


77 


j<mrniil,  reports  two  cases,  occurring;  at  the  same  time  in  brothers,  one  of 
whom  died  suddenly  after  a  slight  exertion. 

{i')  Eiir  CompUratioHs, — These  are  common  and  serious.  Tliey  are 
(hie  to  extension  of  the  inflammation  from  the  throat  through  the  Eu- 
stachian tubes.  It  is  one  of  the  most  frequent  causes  of  deafness.  The 
severe  forms  of  membranous  angina  are  almost  always  associated  with  in- 
lliuumatioii  of  the  middle  ear,  which  goes  on  to  suppuration  and  to  per- 
foration of  the  drum.  The  suppuration  may  extend  to  the  labyrinth  and 
rapidly  produce  deafness.  In  other  instances  tiiere  is  suppuration  in  the 
mastoid  cells.  In  the  necrosis  which  follows  the  middle-ear  disease,  tlie 
facial  nerve  may  oe  involved  and  paralysis  follow.  Later,  still  more 
serious  complications  may  follow  the  otitis ;  such  as  thrombosis  of  the 
lateral  sinus,  meningitis,  or  abscess  of  the  brain. 

( /")  Adenitin. — In  compa  ively  mild  cases  of  scarlet  fever  the  sub- 
maxillary lymph-glands  may  be  swollen.  In  severer  cases  the  swelling  of 
the  neck  becomes  extreme  and  extends  beyond  the  limits  of  the  glands. 
Acute  phlegmonous  inflammations  may  occur,  leading  to  wide-spread  de- 
struction of  tissue,  in  which  vessels  may  be  eroded  and  fatal  liaMuorrhage 
ensue.  The  suppurative  processes  may  also  involve  the  retro-pharyngeal 
tissues. 

The  swelling  of  the  lymjih-glands  usually  subsides,  and  within  a  few 
weeks  even  the  most  extensive  enlargement  gradually  disappears.  There 
are  rare  instances,  however,  in  which  the  lymphadenitis  becomes  chronic, 
and  the  neck  remains  with  a  glandular  collar  which  almost  obliterates  its 
outline.  This  may  prove  intractable  to  all  ordinary  measures  of  treat- 
ment. A  case  came  under  my  observation  in  which,  two  years  after  scar- 
let fever,  the  neck  was  enormously  enlarged  and  surrounded  by  a  mass  of 
firm  brawny  glands. 

{(j)  Nervous  Complications. — Chorea  occasionally  develops  in  connec- 
tion with  the  arthritis  and  endocarditis.  Sudden  convulsions  followed  by 
hemiplegia  may  occur.  Two  instances  of  progressive  paralysis  of  the 
limbs  with  wasting  came  under  my  observation  at  the  Philadelphia  In- 
firmary for  Nervous  Diseases.  The  history  was  that  of  subacute,  ascend- 
ing spinal  paralysis,  but  it  is  probable  that  they  were  instances  of  multi})le 
neuritis.    Mental  symptoms,  mania  and  melancholia,  have  been  described. 

(//)  Other  rare  complications  and  sequelae  are  u'dema  of  the  eyelids, 
without  nephritis  (S.  Philips),  symmetrical  gangrene,  enteritis,  noma,  and 
perforation  of  the  soft  palate  ((Joodall). 

Diagnosis. — The  diagnosis  of  scarlet  fever  is  not  diflficult,  but  there 
lue  (Mises  in  which  the  true  miture  of  the  disease  is  for  a  time  doubtful. 
'I'lu'  following  are  the  most  common  conditions  with  which  it  may  be 
confounded  : 

1.  Jciife  Exfoliating  Dermatitis. — This  pseudo-exanthem  simulates 
sciulet  fever  very  closely.  It  has  a  sudden  onset,  with  fever.  The  erup- 
lioii  spreads  rapidly,  is  uniform,  and  after  persisting  for  five  or  six  days 


78 


SPECIFIC  INFECTIOUS  DISEASES. 


V 


'     fi 


begina  to  fiulc.  Even  before  it  1ms  entirely  gone,  desquamation  usually 
begins.  Some  of  those  cases  cannot  bo  distinguisliod  from  scarlet  fever  in 
the  stage  of  eruption.  Tlie  throat  symptoms,  however,  are  usu.ally  absent, 
and  the  tongue  rarely  shows  the  changes  which  are  so  marked  in  scarlet 
fever.  In  the  desquamation  of  tiiis  alfection  the  hair  and  nails  are  com- 
monly alTocted.  It  is,  too,  a  disease  liable  to  rocur.  Some  of  the  instances 
of  second  and  third  attacks  of  scarlet  fever  have  boon  cases  of  this  form  of 
dermatitis. 

1^.  Mcddeft^  which  is  distinguished  by  the  longer  jwriod  of  invasion, 
the  characteristic  nature  of  the  prodromes,  and  the  later  apjwaranco  of  the 
rash.  The  greater  intensity  of  the  measly  rash  upon  the  face,  the  more 
papular  character,  the  irregular  crescentii!  distribution,  are  distinguishing 
features  in  a  majority  of  the  cases.  Other  points  are  tlu  al)sence  in 
measles  of  the  sore  throat,  the  peculiar  character  of  the  desquamation, 
and  the  absence  of  ioucocytosis. 

3.  Ri'dheln. — The  rash  of  rubella  is  sometimes  strikingly  like  that  of 
scarlet  fever,  but  in  the  great  majority  of  cases  the  mistake  could  not 
arise.     In  cases  of  doubt  the  general  symptoms  are  our  best  guide. 

4.  Septiccvmia. — As  already  mentioned,  the  so-called  puerperal  or  sur- 
gical scarlatina  shows  an  eruption  which  may  be  identical  in  api)earanco 
with  that  of  true  scarlet  fever. 

5.  Diphtheria. — The  practitioner  may  be  in  doubt  whether  he  is  deal- 
ing with  a  case  of  scarlet  fever  with  intense  membranous  angina,  a  true 
diphtheria  with  an  erythematous  rash,  or  coexisting  scarlet  fever  and 
diphtheria.  In  the  angina  occurring  early  in,  and  during,  the  course  of 
scarlet  fever,  though  the  clinical  features  may  be  those  of  true  diphtheria^ 
Loofiler's  bacilli  are  rarely  present.  On  the  other  hand,  in  the  membra- 
nous angina  occurring  during  conval.oscence,  bacilli  are  usually  present. 
The  rash  in  diphtheria  is,  after  all,  not  so  common,  is  limited  usually  to  the 
trunk,  is  not  so  persistent,  and  is  generally  darker  than  the  scarlatinal  rash. 

Scarlatina  and  diphtheria  may  coexist,  but  in  a  case  presenting  wide- 
spread erythema  and  extensive  membranous  angina  with  Loeffler's  bacihi, 
it  would  puzzle  Hippocrates  to  say  whether  the  two  diseases  coexisted,  or 
whether  it  was  only  an  intense  scarlatinal  rash  in  diphtheria.  Desquama- 
tion occurs  in  either  case.  The  streptococcus  angina  is  not  so  apt  to  ex- 
tend to  the  larynx,  nor  are  recurrences  so  common ;  but  it  is  well  to  bear 
in  mind  that  general  infection  may  occur,  that  the  membrane  may  spread 
downward  with  great  rapidity,  and,  lastly,  that  all  the  nervous  sequelae  of 
the  Klobs-Loofflor  diphtheria  may  follow  the  streptococcus  form. 

6.  Drug  liai<hes. — These  are  partial,  and  seldom  more  than  a  transient 
hyperaimia  of  the  skin.  Occasionally  they  are  ditfuse  and  intense,  and  in 
such  cases  very  deceptive.  They  are  not  associated,  however,  with  tlu' 
characteristic  symptoms  of  invasion.  There  is  no  fever,  and  with  care  the 
distinction  can  usually  be  made.  They  are  most  apt  to  follow  the  use  of 
belladonna,  quinine,  and  iodide  of  potassium. 


SPARLET  FEVER. 


79 


Prognosis, — Epidomics  difTor  in  severity  ami  the  death-rate  is  ex- 
tniiit'ly  variable.  Among  the  better  ohisses  tlie  death-rate  is  mucli  less 
thuii  in  hospital  practice.  There  are  physicians  wlio  liave  treated  consecn- 
tivi'lv  a  iiiindred  or  more  cases  without  a  death.  On  the  other  hand,  in 
hospitals  and  among  tlie  poorer  classes  the  death-rate  is  considerable, 
ranging  from  5  to  10  per  cent  in  mild  epidemics  to  ^0  or  IJU  per  cent  in 
the  very  severe. 

The  younger  the  child  the  greater  the  danger.  In  infants  under  one 
year  the  death-rate  is  very  high.  The  great  proportion  of  fatal  cases 
occurs  in  chiUlron  under  six  years  of  age. 

'riie  unfavorable  symptoms  are  very  high  fever,  early  mental  disturb- 
aiifc  with  great  jactitation,  the  occurrence  of  hasmorrhages  (cutaneous  or 
visceral),  intense  membranous  angina  with  cervical  bubo,  and  signs  of 
laryngeal  obstruction. 

Nephritis  is  always  a  serious  complication  and  when  setting  in  with 
suppression  of  the  urine  may  quickly  prove  fatal.  It  is  noteworthy,  how- 
cyci',  that  a  large  majority  of  the  cases  of  scarlatinal  nephritis  recover. 

Treatment. — The  disease  cannot  be  cut  short.  In  the  presence  of 
tlie  severer  forms  we  are  still  too  often  helpless.  There  is  no  disease  in 
which  the  successful  issue  ajid  the  avoidance  of  complications  depends 
more  upon  th  skilled  judgment  of  the  physician  and  the  care  witii  which 
his  instruction.-   ire  carried  out. 

The  child  slmuld  be  isolated  and  placed  in  charge  of  a  competent 
nurse.  The  temperature  of  the  room  should  be  constant  aiul  the  ventila- 
tion thorough.  The  child  should  Avear  a  light  flannel  night-gown,  and 
the  bedclothing  should  not  be  too  heavy.  The  diet  shoidd  consist  of 
milk,  broths,  and  fresh  fruits;  and  water  should  be  freely  given.  With 
the  fall  of  the  tem})erature,  the  diet  may  be  increased  and  the  child  may 
gradually  return  to  ordinary  fare.  When  desquamation  begins  the  child 
should  be  thoroughly  rubbed  every  day,  or  every  second  day,  witii  sweet 
oil,  or  carbolated  vaseline,  or  a  5-per-cent  hydro-naphthol  soap,  which 
pi'events  the  drying  and  the  diffusion  of  the  scales.  An  occasional  warm 
bath  may  then  be  given.  At  any  time  during  the  attack  the  skin  may  be 
sponged  with  warm  water.  The  patient  may  be  allowed  to  get  up  after 
the  temperature  has  been  nornud  for  tea  days,  but  for  at  least  three  weeks 
fi'oin  this  time  great  care  should  be  exercised  to  prevent  exposure  to  cold. 
It  must  not  be  forgotten,  also,  that  the  renal  complications  are  very  apt  to 
develop  during  the  convalescence,  and  after  all  danger  is  apparently  past. 
Oiilinary  cases  do  not  require  any  medicine,  or  at  the  most  a  simple  fever 
mixture,  and  during  convalescence  a  bitter  tonic.  Tlie  bowels  should  be 
carefully  regulated. 

Special  symptoms  in  the  severe  cases  call  for  treatment. 

When  the  temperature  is  above  103°  the  extremities  may  be  sponged 
with  tepid  water.  In  severe  cases,  with  the  temperature  rapidly  rising,  this 
will  not  suffice,  and  more  thorough  measures  of  hydrotherapy  should  be 


80 


SPECIKIC    INFECTIOUS    DISEASES, 


practised.  Witli  proiionnood  (leliriiiiii  iind  nervous  symptoms  tlie  cold- 
pack  should  be  used.  AVlieii  the  temperature  is  risiii^f  rajjidly  hut  tlic 
chikl  is  not  delirious,  he  should  he  placed  in  a  warm  hath,  the  temperature 
of  which  can  he  gradually  lowered.  The  bath  at  a  temperature  of  80"  is 
beneficial.  In  giving  the  co'd-pack  a  rubber  sheet  and  a  thick  layer  of 
blanket  should  he  laid  upon  a  sofa  or  a  bed,  and  upon  this  u  sheet,  wrung 
out  of  cold  water.  The  naked  child  is  then  laid  upon  it  and  wrapped  in 
the  blankets.  An  intense  glow  of  heat  quickly  follows  the  preliminary 
chilling,  and  from  time  to  time  the  blankets  may  be  unfolded  and  the 
child  sj)rinkled  with  cold  water.  The  good  effects  whicdi  follow  this  plan 
of  treatment  are  often  striking,  particularly  in  allaying  the  delirium  and 
jactitation,  and  procuring  rpiiet  and  refreshing  sleep.  I'arents  will  object 
less,  as  a  rule,  to  the  warm  bath  gradually  cooled  than  to  any  other  form 
of  hydrotherapy.  The  child  may  be  removed  from  tho  warm  bath,  placeii 
upon  a  sheet  wrung  out  of  tolerably  cold  water,  and  then  folded  in 
blankets.  The  ice-cap  is  very  useful  and  may  be  kept  constantly  applied 
in  cases  in  which  there  is  higli  fever.  ^Medicinal  antipyretics  are  not  of 
much  service  in  comparison  with  cold  water. 

The  throat  symptoms,  if  mild,  do  not  require  much  treatment.  If 
severe,  tlie  local  measures  mentioned  under  diphtheria  should  be  used. 
Cold  applications  to  the  neck  are  to  be  preferred  to  hot,  though  it  is  some- 
times difficult  to  get  a  child  to  submit  to  them.  In  connection  with  the 
throat  symptoms  the  ears  sliould  be  specially  looked  after,  and  a  careful 
disinfection  of  the  throat  by  suitable  antiseptic  solutions  should  be  prac- 
tised. When  the  inflammation,  extends  through  the  tubes  to  the  middle 
ear,  the  practitioner  should  either  himself  daily  examine  the  condition  of 
the  drum,  or,  when  available,  a  specialist  should  be  called  in  to  assist  him 
in  the  case.  The  careful  watching  of  this  membrane  day  by  day  and  the 
puncturing  of  it  if  the  tension  becomes  too  great  may  save  the  liearing  of 
the  child.  With  the  aid  of  cocaine  the  drum  is  readily  punctured.  The 
operation  may  be  repeated  at  intervals  if  the  pain  and  distention  return. 
No  complication  of  the  disease  is  more  serious  than  this  extension  of  the 
inflammatory  process  to  the  ear. 

The  nephritis  should  be  dealt  with  as  in  ordinary  cases,  and  indications 
for  treatment  will  be  found  under  the  appropriate  section.  It  is  worth 
mentioning,  however,  that  Jaccoud  insists  upon  the  great  value  of  milk 
diet  in  scarlet  fever  as  a  preventive  of  nephritis. 

Among  other  indications  for  treatment  in  the  disease  is  cardiac  weak- 
ness, which  is  usually  the  result  of  the  direct  action  of  the  poison,  and  is 
best  met  by  stimulants. 

Many  specifics  have  been  vaunted  in  scarlet  fever,  but  they  are  all 
useless. 


iMEASLKS. 


81 


VIII.  MEASLES. 


Definition. — An  ncuto,  hi<;lily  infortions  tli.sonU'r,  cliurantoriscd  by 
nii  iiiitiiil  ooryzu  and  a  rapidly  s])r(.'adinj,'  eruption. 

Etiology. — The  infoi'tion  of  measles  is  very  intense  and  Imniunity 
iicniiist  attack  not  nearly  so  coninion  as  in  scarlet  fever.  It  is  a  disease  of 
cliililliiMKl,  but  unproti'cted  adults  are  liable  to  tho  infection.  Indeed, 
iiii;i>l('s  is  more  freipient  in  adults  than  is  scarlet  fever.  Within  the  iirst 
M\  inonths  of  life  the  liability  is  not  so  marked,  thoujjfh  I  liavis  known  in- 
r.iiiis  of  a  month  and  of  six  weeks  to  bo  attacked.  'J'ho  sexes  are  e((ual1y 
jillccted.  The  conta<fion  is  comnuinicated  by  the  breatli  and  by  the  secre- 
liiiiis,  particularly  those  of  tho  nose.  It  may  be  conveyed  by  a  third  per- 
son and  by  fomites. 

The  disease  is  practically  endejnic  in  largo  centres  of  population,  and 
from  time  to  time  sjjreads  and  prevails  epidemically.  It  occurs  at  all  sea- 
sons. ])ut  prevails  more  extensively  during  tho  colder  mouths.  There  is 
no  infectious  disease  in  which  recurrence  is  more  frequent.  Thoro  may 
\)v.  a  second,  third,  or  even  a  fourth  attack. 

The  contagion  of  tho  disease  is  unknown.  No  one  of  the  various  or- 
giinisins  which  have  been  described  meets  tho  requirements  of  Koch's  law. 

Morbid  Anatomy. — Measles  itself  rarely  kills,  but  tho  complica- 
tions and  sequelaa  combine  to  make  it  a  very  fatal  alTection  in  children. 
There  are  no  characteristic  post-mortem  appearances.  The  skin  changes 
iue  those  associated  with  an  intense  hyperannia. 

There  is  a  catarrhal  condition  of  the  mucous  membranes,  particularly 
of  the  bronchi.  The  fatal  cases  show  almost  invariably  either  broncho- 
pneumonia, capillary  bronchitis  with  patches  of  collapse,  or  less  frequently 
lobar  pneumonia.  Tlie  bronchial  glands  are  invariably  swollen.  Pleurisy 
is  less  common.  During  convalescence  from  measles  thoro  is  a  special  lia- 
bility to  tubercnlous  invasion,  and  tuberculous  broncho-pneumonia  claims 
a  large  number  of  victims.     The  bronchial  glands  may  also  be  affected. 

The  gastro-intestinal  mucosa  may  be  hypera?mic.  Swelling  of  Foyer's 
glands  is  not  at  all  uncommon  and  may  reach  a  very  intense  grade  in  the 
patches. 

Symptoms. — Incubation. — "From  seven  to  eighteen  days ;  oftenest 
fourteen."  The  disease  has  boon  frequently  inoculated.  In  such  cases 
tho  incubation  period  is  less  than  ten  days. 

Invasion. — The  disease  usually  begins  with  symptoms  of  a  feverish 
cold.  There  are  shiverings  (not  often  a  definite  chill),  marked  coryza, 
snoozing,  running  at  the  nose,  redness  of  the  eyes  and  lids,  with  photo- 
phobia, and  within  twenty-four  hours  cough.  These  early  catarrhal 
svnqitoms  are  more  marked  in  measles  than  in  any  other  infectious  disease 
of  ohildren.  There  may  be  the  symptoms  so  commonly  associated  M'ith 
an  on-coming  fever — nausea,  vomiting,  and  headache.     The  tongue  is 


82 


SPKCfFIC   INFKCTlorS   DISKASKS, 


104  0' 


loa-a" 


100-4' 


908' 


Initial  Fever. 
Chart  IX.— Measlos  (Strllnipell). 


Eni]>tivc  P'ever. 
Eruption. 


V''"\ 


furred.     K.xuininjition  of  tho  throat  nmy  sliow  ii  reddish  hyperti'iniii  or  in 

some  instances  ii  distinct  jjiinctiforni  rash.     Occasionally  this  spreads  over 

I       '.>       .1       I       r,       ti       7       H        the  whole  mucous  memhrane  of 

the  mouth  with  the  except ioti  of 
the  tongue.  The  tempei'ature  at 
this  stage  is  usually  high,  reach- 
ing from  103°  to  104°,  ascend  in;; 
gradually  through  the  second  ami 
third  days. 

Eruption.  —  Usually  on  tlif 
fourth  day,  when  tho  fever  and 
general  symptoms  have  reached 
their  height,  the  rash  ajipeais 
upon  the  cheeks  or  forehead  in 
the  form  of  small  red  papules, 
which  increase  in  size  ami  spread 
over  the  neck  and  thora.x.  When 
the  eruption  becomes  well  devel- 
oped the  face  is  swollen  and  cov- 
ered with  reddish  blotches,  which  often  have  rounded  or  crescentic  out- 
lines. Ilei'e  and  there  is  an  intervening  portion  of  unaiTected  skin.  At 
this  stage  the  cervical  lym])h-glands  may  be  slightly  swollen  and  sore; 
sometimes  also  the  glands  in  the  groins,  axilla",  and  at  tho  elbows.  The 
papules  can  now  be  felt  with  the  finger.  Sometimes  they  are  quite  shotty, 
but  do  not  extend  deep  into  the  skin.  On  the  trunk  and  extremities  the 
swelling  '  '"  skin  is  not  so  noticeable,  the  color  of  the  rash  not  so  in- 
tense and  less  uniform.  The  mottled,  blotchy  character  of  the  rash 
ajtpears  inosi  clearly  on  the  chest  or  the  abdomen.  The  rash  is  hypera?mic 
and  disappears  on  pressure,  but  in  the  more  malignant  cases  it  may  be- 
come ha'morrliagic.  The  general  symptoms  do  not  abate  with  the  occur- 
rence of  the  eruption.  They  persist  until  the  end  of  the  fiftli  or  the  sixth 
day,  when  in  the  majority  of  the  cases  all  the  symptoms  become  miti- 
gated. Among  the  peculiarities  of  the  rash  may  be  mentioned  the  de- 
velopmeTiL  of  numerous  miliary  vesicles  and  the  occurrence  of  petechia', 
which  :ire  seen  occasionally  even  in  cases  of  moderate  severity. 

Desquamation. — After  persisting  for  two  or  three  days  the  rash  gradu- 
ally fades  and  desquamation  occurs  in  the  form  of  very  fine  branny  scales, 
which  may  be  difficult  to  see  and  are  wholly  unlike  the  coarse  exfoliation 
in  scarlet  fever. 

The  catarrhal  symptoms  gradually  disappear  and  convalescence  i-^ 
rai)idly  established. 

In  epidemics  of  measles  atypical  cases  are  common.  The  rash  may 
appear  early,  within  thirty-six  hours  of  the  onset  of  the  symptoms;  or, on 
tlie  other  hand,  it  may  be  delayed  until  the  sixth  day.  As  in  other  exan- 
thems,  when  many  cases  occur  in  a  household,  one  of  the  children  ma\ 


i 


MEASLES. 


8;i 


hftvp  all  till'  itiitiiil  symptoms  and  "sickt-n  for  the  disease,"  os  it  is  said, 
but  iin  eniinioii  appear. 

Tlu'  most  soriims  vurioty  of  measles  is  that  in  which  hiemoiTliajres  oc- 
,,„,.— till'  iiitirbUU  hwmorrlKujict.  In  general  practice  these  cases  arc  very 
iiiiciiiiimon.  Occasionally  in  institutions,  particularly  when  the  hygienic 
surniuiHliiigs  are  bad,  oiu;  or  two  cases  develop  during  an  epidemic.  It 
has  l)ccn  frerpiently  seen  in  camps  anil  when  the  disease  is  freshly  im- 
|ii)i't((l  into  a  native  population,  as  in  the  Fiji  Islands,  During  the  civil 
\\.\\\  as  shown  by  Smart's  statistics,  some  cases  occurred. 

Ill  this  form  tlie  disease  sets  in  with  much  greater  intensity,  the  rash 
iMCdines  petechial,  hiemorrhages  occur  from  the  mucous  meml)ranes,  the 
(uiistiliitional  depression  is  very  great,  and  death  occurs  early  from  tox- 
D'liiia, 

Complications  and  Sequelse.— These  are  met  with  chiefly  in  the 
iis|iiiatnry  system.  The  danger  conies  from  the  existing  bronchitis, 
whicii  is  apt  to  extend  into  the  smaller  tubes  and  lead  to  collapse  and 
l)n)iKho-pn'.'iimonia.  When  limited  in  extent  this  causes  only  aggrava- 
tidii  of  the  cough  and  persistence  of  the  fever  (symptoms  which  gradually 
aliate),  and  convalescence  is  rapid ;  but  in  debilitated  children,  more  par- 
ticularly in  institutions  and  among  the  lower  classes,  this  complication  is 
extremely  grave  and  is  responsible  for  the  high  death-rate  from  measles 
ill  the  community.  In  some  instances  the  clinical  picture  is  that  of  a 
siitl'oeative  catarrh,  the  result  of  a  wide-spread  involvement  of  the  smaller 
tiilx's.  The  description  of  the  condition  will  be  found  under  the  section 
Hroiieho-pneumonia.  Lobar  pneumonia  is  less  common  and  jierhaps  less 
dangerous. 

Laryngitis  is  not  uncommon  :  the  voice  becomes  husky  and  the  cough 
cnuipy  in  character.  (Edema  of  the  glottis  is  very  rare.  Pseudo-mem- 
branous inflammation  of  the  i)harynx  and  larynx  may  occur  and  prove 
fatal.  In  debilitated  infants  severe  stomatitis,  cancmm  oris,  or  ulcerative 
vulvitis  may  develop. 

Catarrhal  inflammation  of  the  middle  ear  is  not  very  uncommon,  and 
may  proceed  to  suppuration  and  to  ])erforatioii  of  the  drum.  The  con- 
junctival catarrh  rarely  leads  to  further  trouble,  though  occasionally  the 
iiiliammation  becomes  purulent. 

Intestinal  catarrh  is  common  in  some  ei)idemics,  and  there  may  be  the 
syiiiptonis  of  acute  colitis. 

Nephritis  is  an  exceedingly  rare  complication. 

Of  the  sequela}  of  measles,  tuberculosis  is  the  most  important — either 
an  involvement  of  the  bronchial  glands,  a  miliary  tul)erculosis,  or  a  tuber- 
culous broncho-pneumonui. 

Among  the  rarer  sequelte  of  measles  are  paralyses.  Hemiplegia  is 
very  ny-e,  but  cases  of  paraplegia  have  been  described.     Thomas  Barlow  * 


Medico-Cliirurgical  Society's  Transactions,  1887. 


84 


SPKCIFIC   IN'FKCTIOLS   DISEASES. 


I   • 


reports  a  fatal  case  in  wliitli  tin-  Hyrnptonis  ocvAirrcd  early,  the  paraly- 
sis fxtt'iidcd  rapidly  and  involved  the  upper  liinl»H,  and  death  tooii  pluec 
on  tlie  ideventh  day.  Marked  vascular  <  lian<,'e.s  were  f<»und  in  tlie  >,'rii\ 
matter  of  the  spinal  cord,  and  were  heliuved  to  depenil  on  an  early  diHsenii- 
nated  myelitis.  Kxamitiation  of  tho  peripheral  nerved  was  not  made. 
Similar  eases  aro  met  with  in  the  literature,  ami  ihey  prohahly  come  under 
tho  division  of  t!iu  jiost-fehrih^  ]>oIyneuritis,  thoii;,'h  t)f  course  it  is  not  ini- 
possihle  that  some  of  tiiem,  such  as  Ihirlow's  case,  niuy  bu  due  to  u  rajjidly 
ascend in<?  myelitis. 

Diagnosis. — From  scarlet  fever,  with  which  it  is  most  likely  to  be 
confounded,  measles  is  distinj^uished  by  the  lon^rer  initial  stayo  with  char- 
acteristic 8ymi)toms,  and  tho  blotchy  irref,'ular  character  of  tho  rash, 
whicdi  is  so  unlike  the  dilTu.so  uniform  erythenui  of  scarlet  fever.  Occa- 
sionally in  measles,  when  tho  throat  h  very  sore  and  the  eruption  pretty 
ditfuse,  thoro  may  at  first  bo  ditKculty  in  deterniininf^  which  disease  is 
present,  but  a  few  days  should  sufiico  to  make  the  diagnosis  clear.  As  a 
rule  there  is  no  leucocytosis.  It  may  be  extremely  dilli<'ult  to  distint^uish 
from  rothelii.  I  have  more  than  once  known  ]iractitioners  of  Iar<re  ex- 
l)erience  niuible  to  ajjrree  upon  a  diagnosis.  The  shorter  prodronud  stage. 
the  slighter  fever  in  many  ca.se.s,  aro  perha])s  tho  most  imporUint  features. 
It  is  ditlicult  to  speak  delinitely  ab(  ut  Mie  distinctions  in  the  rash,  though 
perhaps  the  more  uniform  distributu.n  and  the  absence  of  the  cresceutie 
arrangement  are  more  constant  in  ritholn. 

The  conditions  under  which  measles  may  be  mi-staken  for  small-pox 
have  already  been  described.  Of  drug  erujitions,  that  induced  by  copaib.'t 
is  very  like  measles,  but  is  readily  distinguished  by  the  absence  of  fever 
and  catarrh. 

Prognosis. — The  mortality  bills  of  large  cities  show  what  a  serious 
disease  measles  is  in  a  community.  Among  the  eruptive  fevers  it  ranks 
third  in  the  death-rate.  The  mortality  from  the  di>ea.so  itself  is  not 
high,  but  the  pulmoiuiry  complications  render  it  one  of  the  most  serious 
of  the  diseases  of  children. 

In  some  epidemics  the  disease  is  of  great  severity.  In  in.stitutions  and 
in  armies  the  death-rate  is  often  high.  The  fever  itself  is  rarely  a  source 
of  danger.  The  extension  of  the  catarrhal  symptoms  to  the  finer  tubes  is 
the  most  serious  indication. 

Treatment. — Confinement  to  bed  in  a  well- ventilated  room  and  a 
milk  diet  aro  tho  only  measures  necessary  in  cases  of  uncomplicated 
measles.  Tho  fever  rarely  reaches  a  dangerous  height.  If  it  does  it  may 
be  lowered  by  sponging  or  by  the  tepid  bath  gradually  reduced.  If  the 
rash  does  not  come  out  well,  warm  drinks  and  a  hot  bath  will  hasten  it- 
maturation.  The  bowels  should  be  freely  opened.  If  the  cough  is  dis- 
tressing, paregoric  and  a  mixture  of  ipecacuanha  wine  and  squills  ^should 
be  given.  The  patient  should  be  kept  in  bed  for  a  few  days  after  the 
fever  subsides.     During  desquamation  the  skin  should  be  oiled  daily, 


Ill'liKI-l-A. 


85 


iiiid  wiirin  baths  given  tn  fucilitiitc  tlic  process.  Tlie  cniivalesccMice 
I'roiii  iiieiisles  is  tiic  most  iin|portiiiit  stiij^e  of  tlie  diseiise.  Walclii'uliu'HS 
iiul  eiire  may  prevent  serimis  pulinoiiary  (•omi>liciitioiis.  Tlio  fretjuency 
uiili  wliich  the  mothers  of  cliiidreii  witli  simph'  or  tiil)ereiilou.s  broiieho- 
niiriiinoniii  tell  (is  tlmt  "the  child  caiiirht  cold  al'ter  measles,"  and  the 
mteiriplatioii  of  tiie  mortality  hills  should  malvo  us  extremely  careful  iu 
.riir  management  of  tliis  alTcciion. 


IX.  RUBELLA  (H'llheln,  Otrmnn  Measlen), 

'i'his  exanthem  lias  also  tlio  names  of  ruhvaUt  uolliu..  or  epidemic  rose- 
(ii;i,  and,  as  it  is  supposed  to  present  features  common  to  both,  has  been  also 
kimwn  as  hybrid  nu-aslcs  or  liylirid  scarlet  fever.  It  is  now  generally  re- 
i.Mnlcd,  however,  as  a  scjiarate  ;iiid  distinct  aiTcction. 

Etiolog;y. — It  is  proj)agate(l  l)y  contagion  and  sjjreads  with  great 
nipidity.  It  frequently  attacks  adults,  and  tho  occurrt'm  i  of  either 
measles  or  scarlet  fever  in  childhood  is  no  protection  against  it.  The 
(■|iidemics  of  it  are  often  very  extensive. 

Symptoms.— These  are  usually  mild,  and  it  is  altogether  n  less  seri- 
ous atfoction  than  measles.  Very  exceptioiudly,  as  in  the  epidemics  studied 
iiy  Chcadle,  tho  symotoms  are  severe. 

The  stage  of  incubation  ranges  from  ten  to  twelve  days. 

In  till'  .stage  of  invasion  there  are  chilliness,  headache,  i)ains  in  tho 
liack  and  legs,  and  coryza.  There  nuiy  be  very  slight  fever.  In  30  per 
cent  of  Edwards's  cases  the  temperature  did  jiot  ri.se  above  100°.  Tho 
(hiration  of  this  stage  is  somewhat  variable.  The  rash  usually  appears  on 
the  Hrst  day,  some  writers  say  on  the  .second,  and  others  again  give  tho 
duration  of  the  stage  of  invasion  as  three  diiy.s.  (irittith  places  it  at  two 
(lays.  The  eruption  comes  out  first  on  the  face,  then  on  the  chest,  and 
gradually  extends  so  that  within  twenty-four  hours  it  is  scattered  over  the 
whole  body.  It  may  be  tho  first  symptom  noted  by  tho  mother.  Tho 
eruption  consists  of  a  number  of  rouiid  or  oval,  slightly  raised  spots,  pink- 
ish-red in  color,  usually  discrete,  but  sometimes  confluojit. 

The  color  of  the  rash  is  somewhat  brighter  than  in  measles.  Tho 
])atches  are  less  distinctly  crescentic.  After  persisting  for  two  or  three 
days  (sometimes  longer),  it  gradually  fades  and  there  is  a  slight  fur- 
funiceous  desqnanuition.  The  rash  i)ersists  as  a  rule  longer  than  in  scar- 
let, fever  or  measles,  and  the  skin  is  slightly  stained  after  it.  The  lym- 
phatic glands  of  the  neck  are  frequently  swollen,  and,  when  the  erujjtion 
is  very  intense  and  diffuse,  the  lymph-.5lands  in  the  other  parts  of  the 
body, 

'f'huie  are  no  special  complications.  Tho  disease  usually  progresses 
favorably;  but  in  rare  instances,  as  in  those  reported  by  Cheadle,  tho 
symptoms  are  of  greater  severity.     Albuminuria  may  occur  and  even 


86 


SPECIFIC  INFECTIOUS  DISEASES. 


nepliritis.  Pneumonia  and  colitis  have  been  present  in  some  epidemics. 
Icterus  lias  been  seen. 

Diag^jiosis. — The  mildness  of  the  case,  the  slightness  of  the  jirodromal 
symptoms,  the  mildness  or  the  absence  of  the  fever,  the  more  dilfuso 
character  of  the  rash,  ha  rose-red  color,  and  the  early  enlargement  of  the 
cervical  glands,  are  the  chief  points  of  distinction  between  rotholn  and 
measles. 

The  treatment  is  that  of  a  simple  febrile  affection.  It  is  well  to  keep 
the  child  in  bed,  though  this  may  be  difficult,  as  the  patient  rarely  feels 
ill. 

X.    EPIDEMIC    PAROTITIS    (Mumps). 

Definition. — An  infectious  disease,  characterized  by  inflammation  of 
the  parotid  gland.  The  testes  in  males  and  the  ovaries  and  breasts  in 
females  are  sometimes  involved. 

etiology. — The  nature  of  the  virus  is  unknown. 

The  affection  has  all  the  characters  of  an  epidemic  disease.  It  is 
said  to  be  endemic  in  certain  localities,  and  probably  is  so  in  large 
centres  of  population.  At  certain  seasons,  particularly  in  the  spring  and 
autumn  months,  the  uumber  of  cases  increases  rapidly.  It  is  met  most 
frequently  in  childhood  and  adolescence.  Very  young  infants  and  adults 
are  seldom  attacked.  Males  are  somewhat  more  frequently  affected  than 
females.  In  institutions  and  schools  the  disease  has  been  known  to  attack 
over  90  per  cent  of  all  the  children.  It  may  be  curiously  localized  in  a 
city  or  district.  The  disease  is  contagious  and  spreads  from  patient  to 
patient. 

A  remarkable  idiopathic,  non-specific  parotitis  may  follow  injury  or 
disease  of  the  abdominal  or  pelvic  organs.  Stephen  Paget*  has  collected 
101  cases  of  this  kind,  the  majority  of  which  were  not  associated  with 
septic  processes  (see  Diseases  of  the  Salivary  (.! lands). 

Symptoms. — The  period  of  incubation  is  from  two  to  three  weeks, 
and  there  are  rarely  any  8ym])toms  during  this  stage.  The  invasion  is 
marked  by  fever,  which  is  usually  slight,  rarely  rising  above  101°,  but  in 
exceptionally  severe  cases  going  up  to  103°  or  104°.  The  child  com- 
plains of  pain  just  below  the  ear  on  one  side.  Here  a  slight  swelling  is 
noticed,  which  increases  gradually,  until,  within  forty-eight  hours,  there  is 
great  eidargement  of  the  neck  and  side  of  the  cheek.  The  swelling  passes 
forward  in  front  of  the  ear,  and  back  beneath  the  sterno-cleido  muscle.  Tlu- 
other  side  usually  becomes  affected  within  a  day  or  two.  The  submaxil- 
lary glands  may  also  be  involved.  The  greatest  inconvenience  is  experi- 
enced in  taking  food,  for  the  patient  is  unable  to  open  the  mouth,  and 
even  speech  and  deglutition  become  difficult.  There  may  be  an  increase 
in  the  secretion  of  the  saliva,  but  the  reverse  is  sometimes  the  case.     There 

*  British  Medical  Journal,  March  19.  1887. 


'^U.? 


EPIDEMIC   PAROTITIS. 


87 


is  seldom  great  .pain,  but,  instead,  an  unpleasant  feeling  of  tension  and 
tic-litnt'ss.     There  may  be  earache  and  slight  impairment  of  hearing. 

After  persisting  for  from  seven  to  ten  days,  the  swelling  gradually 
subsides  and  the  child  rapidly  regains  his  strength  and  health.  Uelaj)se 
rarely  if  ever  occurs. 

Occasioiuilly  the  disease  is  very  severe  and  characterized  by  high 
fever,  delirium,  and  great  prostration.  The  patient  may  cvc'i  lapse  into 
a  typhoid  condition. 

One  of  the  most  remarkable  features  of  the  disease  is  a  tendency  to 
involvement  of  the  testes,  usually  as  the  aifection  of  the  salivary  glands 
subsides.  (3ne  or  both  testicles  nuiy  be  involved.  The  swelling  may  be 
great,  and  occasionally  effusion  takes  place  into  the  tunica  \aginalis. 
The  orchitis  may  develop  before  the  parotitis,  or  in  rare  instances  may 
be  the  only  manifestation  of  the  infection  {orchitis  jntrot idea) .  The  in- 
flammation increases  for  three  or  four  days,  and  resolution  takes  placv^ 
'gradually.  Occasionally  there  may  be  a  muco-purulent  discharge  from 
the  urethra.  In  severe  cases  atrophy  may  follow,  fortuiuitely  as  a  rule 
only  in  one  organ;  occurring  in  both  before  puberty  the  natural  devel- 
opment is  usually  checked.  The  proportion  of  cases  of  orchitis  varies 
ill  different  epidemics;  211  cases  occurred  in  f!99  cases,  and  103  cases  of 
atrophy  followed  103  instances  of  orchitis  (Comby).  Orchitis  is  rarely 
seen  before  puberty. 

A  viilvo-vaginitis  sometimes  occurs  in  girls,  and  the  breusta  may  be- 
eonie  enlarged  and  tcTuler.  IMastitis  has  been  seen  in  boys.  Involvement 
of  the  ovaries  is  rare. 

Complications  and  Sequelse.— Of  thebo  the  cerebral  affections 
are  perhaps  the  most  serious.  As  already  mentioned,  there  may  be  de- 
lirium and  high  fever.  In  rare  instances  meningitis  has  been  found, 
lloiniplegia  and  coma  may  also  occur.  A  majority  of  the  fatal  cases  are 
associated  with  mcTiingeal  symptoms.  Tiiese,  of  course,  are  very  rare  in 
comparison  with  the  frequency  of  the  disease;  yet,  in  the  Index  Catalogue, 
under  this  caption,  there  are  six  fatal  cases  mentioned.  In  some  epi- 
deniies  the  cerebral  complications  are  much  more  marked  than  in  others. 
Acute  mania  has  occurred,  and  there  are  instances  on  record  of  insanity 
following  the  disease. 
t  Arthritis,  albuminuria,  with  convulsions,  acute  nricmia,  endocarditis, 
■uui  peripheral  neuritis  are  occasional  complications. 

S,  jipuration  of  the  gland  is  an  extremely  rare  complication  in  genuine 
iiliopathic  mumps,  (i-ngrene  has  occasionally  occurred.  The  special 
senses  may  be  seriously  involved.  Many  cases  of  deafness  have  been  de- 
seribed  in  connection  with  or  following  mumps.  It,  unfortunately,  may 
be  perinaneiit  Affections  of  the  eye  are  rare,  but  atrophy  of  the  optic 
nerve  lias  been  described.     The  lachrymal  glands  may  be  involved. 

riie  iliagnosis  of  the  disease  is  usually  easy.     T'he  position  of  the 
swilling  in  front  of  and  below  the  ear  and  the  elevation  of  the  lobe  on  the 
7 


88 


SPECIFIC  INFECTIOUS  DISEASES. 


aflfected  side  definitely  fix  the  locality  of  the  swelling.  In  cliildren  in- 
flammation of  the  parotid,  apart  from  ordinary  nuimps,  is  excessively 
rare. 

Treatment. — It  is  well  to  keep  the  patient  in  bed  during  the  height 
of  the  disease.  Tlie  bowels  should  be  freely  opened,  and  the  jjatient  given 
a  light  liquid  diet.  No  medicine  is  recpiired  unless  the  fever  is  high,  in 
which  case  aconite  may  be  given.  Cold  compresses  may  be  placed  on  the 
gland,  but  children,  as  a  rule,  prefer  hot  ap])lications.  A  pad  of  cotton 
wadding  covered  with  oiled  silk  is  tlie  best  application.  Suppuration 
is  almost  unknown,  and  need  not  be  dreaded,  even  though  the  gland  be- 
come very  tense.  Sliould  rcuncss  and  tenderness  develop,  leeches  may 
be  used.  With  delirium  and  liead  symptoms  the  ice-cap  may  be  applied. 
In  a  robust  subject,  unless  the  signs  of  constitutional  depression  are  ex- 
treme, a  free  venesection  may  do  good.  For  tlie  orchitis,  rest,  with  sup- 
port and  protection  of  the  swollen  gland  with  cotton-wool,  is  usually 
sufficient. 


;  :■?!:: 


:1|-    ^: 


1,  J      ^i 


XI.  WHOOPING-COUGH. 

Definition. — A  specific  affection  characterized  by  convulsive  cough 
and  a  long-drawn  inspiration,  during  which  the  "  whoop"  is  produced. 

Etiology. — The  disease  occurs  in  epidemic  form,  but  sporadic  cases 
appear  in  a  community  from  time  to  time.  It  is  directly  contagious  from 
person  to  person;  but  dwelling- rooms,  houses,  school-rooms,  and  other 
localities  may  be  infected  by  a  sick  child.  It  is,  however,  in  this  way  less 
infectious  than  other  diseases,  and  is  probably  most  often  taken  by  direct 
contact.  The  nature  of  the  virus  is  still  doubtful,  many  organisms  hav- 
ing been  described  in  the  sputum.  The  observations  of  Afanassjew  in 
1887  have  been  the  most  satisfactory.  lie  has  cultivated  a  sliort  bacillus, 
which  grows  with  well-marked  characters,  and,  when  inoculated  into  the 
trachea  of  animals,  produces  a  catarrhal  condition  of  the  mucous  meui- 
brane.  Cornil  and  Babes  conclude  that  the  organism  has  not  character- 
istics sufficiently  pronounced,  or  an  influence  on  animals  sufficiently 
characteristic,  to  enable  us  to  say  that  it  is  specific.  None  of  the  more 
recent  observations  are  more  conclusive.  Epidemics  prevail  for  two  or 
three  months,  usually  during  the  winter  and  spring,  and  have  a  curious 
relation  to  other  diseases,  often  preceding  or  following  measles,  less  fre- 
quently scarlet  fever. 

Children  jotween  the  first  and  second  dentitions  are  commonly  affected. 
Sucklings  are,  however,  not  exempt,  and  I  have  seen  very  severe  attacks 
in  infants  under  six  weeks.  It  is  stated  that  girls  are  more  subject  to  tlie 
disease  than  boys.  Adults  and  old  people  are  sometimes  attacked,  and  in 
the  aged  it  may  be  a  very  serious  atfection.  Many  persons  possess  innim- 
nity  against  the  disease,  and,  though  frequently  exposed,  escape.  As  ii 
rule,  one  attack  protects.  Delicate  ana'tnic  children  with  nasal  or  bron- 
chial catarrh  are  more  subject  to  the  disease  than  others.     According  to 


WHOOPING-COUGH. 


89 


111- 
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land  in 
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AS   !l 

pr  bron- 
Iding  to 


the  United  States  Census  Reports,  tlie  disease  is  more  than  twice  as  fatal 
in  till'  negro  race  than  in  others. 

Morbid  Anatomy. — Whooping-cough  itself  has  no  special  patho- 
Idtrii'iil  cliaiiges.  In  fatal  cases  pulmonary  complications,  particularly 
bniiK^ho-pneumonia,  are  usually  present.  Collapse  and  compensatory  em- 
plivsi'ina,  vesicular  and  interstitial,  are  found,  and  the  tracheal  and  bron- 
chiiil  glands  are  enlarged. 

Symptoms. — Catarrhal  and  paroxysmal  stages  can  be  recognized. 
There  is  a  variable  ])eriod  of  incubation  of  from  seven  to  ten  days.  In 
the  catarrhal  xfaf/e  the  child  has  the  symptoms  of  an  ordinary  cold, 
which  may  begin  with  slight  fever,  running  at  the  nose,  injin^tion  of 
the  eyes,  and  a  bronchial  cough,  usually  dry,  and  sometimes  giving  indi- 
cations of  a  spasmodic  character.  The  fever  is  usually  not  high,  and 
slight  attention  is  paid  to  the  symptoms,  which  are  thought  to  be  those 
of  a  -iimiile  catarrh.  After  lasting  for  a  week  or  ten  days,  insk'ad 
of  subsiding,  the  cough  becomes  worse  and  more  convulsive  in  char- 
acter. 

'^\\Q  paroxysmal  stage,  marked  by  the  characteristic  ccugh,  dates  from 
the  first  appearance  of  the  "  whoop."  The  lit  begins  with  a  series  of  from 
tiftecn  to  twenty  short  coughs  of  increasing  intensity,  and  then  with  a 
(iccp  inspiration  tlie  air  is  drawn  into  tlie  lungs,  making  ihe  "  whooii," 
which  may  be  heard  at  a  distance  ami  from  which  thedi-sease  takes  its 
I'.une.  This  loud  inspiratory  sound  may  sometimes  precede  the  series  of 
^p.isinodic  expiratory  efforts.  Several  coughing-fits  may  succeed  each  other 
until  a  tenacious  mucus  is  expectorated.  This  may  be  small  in  amount, 
hut  after  a  series  of  coughing-fits  a  considerable  quantity  may  be  expec- 
loiated.  Not  infrequently  it  is  brought  up  by  vomiting  or  by  a  combina- 
tion of  cough  and  regurgitation.  There  may  be  only  four  or  five  of  these 
attacks  in  the  day,  or  in  severe  cases  they  may  recur  every  half-hour. 
During  the  attack  the  thorax  is  very  strongly  compressed  by  the  powerful 
expiratory  etforts,  and,  as  very  little  air  passes  in  through  the  glottis,  there 
are  signs  of  defective  aeration  of  the  blood  ;  the  face  becomes  swollen  and 
congested,  tlie  veins  are  prominent,  the  eyeballs  protrudj,  and  the  con- 
]unctiv;e  become  deeply  engorged.  SutToeation  indeed  seems  imminent, 
when  with  a  deep,  crowing  inspiration  air  enters  the  lungs  and  the 
I  "lor  is  ([uickly  restored.  Children  are  usually  terrified  at  the  onset,  and 
run  at  once  to  the  mother  or  nurse  to  be  supported  during  the  attack. 
I'lnv  diseases  are  more  jiainful  to  witness.  In  seven;  [laroxysms  vomiting 
is  frc(|uent  and  the  sphincters  may  be  opened.  The  urine  is  said  to  be 
of  high  specific  gravity  (1022-1033),  pale  yellow,  and  to  contain  much 
uric  aciil. 

An  ulcer  under  the  tongue  is  a  very  common  event,  and  was  thought 
iU  one  time  to  be  the  cause  of  the  disease. 

During  the  attack,  if  the  chest  be  examined,  the  resonance  is  defective 
111  the  expiratory  stage,  full  and  clear  during  the  deep,  crowing  inspiration  ; 


I 

1 

1 
i 

t 

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1 

1 

'iiilii 


90 


SPECIFIC  INFECTIOUS  DISEASES. 


but  on  auscultation  during  the  latter  there  may  be  no  vesicular  murmur 
heard,  owing  to  the  slowness  with  which  the  air  passes  the  narrowed  glot- 
tis.    Bronchial  rales  are  occasionally  heard. 

Anujng  circuni?tancc'S  which  precipitate  an  attack  are  emotion,  such 
as  crying,  and  any  irritation  about  the  throat.  Even  the  act  of  swallowiiii,' 
sometimes  seems  sufficient.  In  a  close  dusty  atmosphere  the  coughiui:- 
fits  are  more  I'roquent.  After  lasting  for  three  or  four  weeks  the  attacks 
become  lighter  and  finally  cease.  In  cases  of  ordinary  severity  the  coiir.so 
of  the  disease  is  rarely  under  six  weeks. 

The  complications  and  sequehv  of  whooping-cough  are  important. 
During  the  extensive  venous  congestion  haemorrhages  are  very  a})t  to 
occur  in  the  form  of  petechia?,  particularly  about  the  forehead,  ecchymo- 
sis  of  the  conjunctiva?,  epistaxis,  and  occasionally  lutmoptysis.  ILTmctr- 
rhage  from  the  bowels  is  rare.  Convulsions  are  not  very  uncommon,  due 
perhaps  to  the  extreme  engorgement  of  the  cerebral  cortex.  \'ery  rarely 
hemiplegia  or  monoplegia  follows.  Sudden  death  has  been  caused  l)y 
extensive  subdural  lufmorrhage.  Whooping-cough  nuist  be  regarded  as  a 
very  unusuiU  cause  of  cerebral  palsy  in  children.  It  was  associated  with 
three  cases  of  my  scries  of  one  hundred  and  twenty  cases,  but  in  none  of 
them  did  the  hemi2)legia  come  on  during  the  jiaroxysm,  as  in  a  case 
reported  by  S.  West. 

The  persistent  vomiting  may  induce  marked  ana?mia  and  wastinj:. 
The  ])ulnionary  complications  which  follow  whooping-cough  are  extreiucly 
serious.  During  the  severe  coughing-spells  interstitial  emphysema  may  he 
induced,  more  rarely  pneumothorax.  I  saw  one  instance  in  which  ruptiuc 
occurred,  evidently  near  the  root  of  the  lung,  and  the  air  passed  along  tho 
trachea  and  reached  the  subcutaiu'ous  tissues  of  the  neck,  a  condition 
which  has  been  kiu)wn  to  become  general.  Broncho-pneumonia,  with  its 
accompanying  collapse,  is  the  most  frequent  pulmonary  complication  and 
carries  off  a  large  number  of  children.  It  may  be  simple,  but  in  a  con- 
siderable ])roportion  of  the  cases  the  process  is  tuberculous.  Pleurisy  is 
sometimes  met  with  and  occasionally  lobar  pneumonia.  Enlargement  of 
the  bronchial  glaiuls  is  very  common  in  whooping-cough  and  has  beoii 
thought  to  cause  the  disease.  It  may  sometimes  be  sufficient  to  produce 
dulness  upon  the  manubrium.  During  the  spasm  the  radial  pulse  is 
small,  the  right  heart  engorged,  and  during  and  after  the  attack  the 
cardiac  action  is  very  much  disturlted.  Serious  damage  may  result,  and 
possibly  some  of  the  cases  of  severe  valvular  disease  in  children  who  havf 
had  neither  rheumatism  nor  scarlet  fever  may  be  attributed  to  the  terrilile 
heart  strain  during  a  proionced  attack  of  whooping-cough.  Koplik  re- 
gards the  swelling  about  the  face  and  eyes  as  an  important  sign  of  tlic 
heart  strain.  Serious  renal  complications  are  very  uncommon,  but  albu- 
min 7iot      frequently  and  sugar  occasionally  are  found  in  the  urine. 

Diagnosis. — So  distinctive  is  the  "  whoop"  of  the  disease  that  the 
diagnosis  is  very  easy;  but  occasionally  there  are  doubtful  cases,  particu- 


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care,  and 


WIIOOPING-COUGH. 


91 


];iilv  during  epidemics,  in  which  a  scries  of  expiratory  coughs  occurs  with- 
(iiii  any  iiis])iratory  crov/. 

Prognosis. — Taken  with  its  complications,  whooping-cough  must  bo 
r(_<ii'*lt'<l  i'^  ^  ^'^U  ^''^"'^  affection.  According  to  Dolan,  it  ranks  third 
;iiiioiig  the  fatal  diseases  of  children  in  England,  where  the  deatii-rate 
per  million  from  this  disease  is  five  thousand  annually.  '^I'he  younger 
the  infant  the  greater  is  the  probability  of  serious  complications.  Tbe 
(U'iitlis  are  chiefly  among  cliijdreu  of  the  poor  and  among  delicate  in- 
fants. 

Treatment. — Parents  should  be  warned  of  the  serious  nature  of 
wliiKiping-cough,  the  gravity  of  which  is  scarcely  appreciated  by  the  pub- 
lic Particular  care  should  be  taken  that  cliildren  suspected  of  the  disease 
are  not  sent  to  the  public  schools  or  exposed  in  any  way  so  that  other  chil- 
(IrtMi  can  become  contaminated.  There  is  more  reprehensible  neglect  in 
coniipction  with  this  than  with  any  other  disease.  The  patient  should  be 
isolated,  and  if  the  paroxystns  are  at  all  severe,  at  rest  in  bed.  Fresh  air, 
night  and  day,  is  a  most  essential  element  in  the  treatment  of  the  disesise. 
The  medicinal  treatment  of  whooping-cough  is  most  unsatisfactor}'.  In 
the  catarrhal  stage  when  there  is  fever  the  child  should  be  in  bed  and  a 
saline  fever  mixture  administered.  If  the  cough  is  distressing,  ipecacuanha 
wine  and  paregoric  may  be  given.  For  the  paroxysmal  stage  a  suspiciously 
lorg  list  of  remedies  has  been  recommended,  twenty-two  in  one  popular 
text-book  on  therapeutics.  If  the  disease  is  due,  as  seems  proliable,  to  a 
gorni  growing  upon  and  irritating  the  bronchial  mucosa,  a  germicidal  plan 
of  treatment  seems  highly  ratioiud  and  persistent  attempts  should  be  made 
to  discover  a  suitable  remedy.  Quinine  is  one  of  the  best  remedies.  One 
sixth  of  a  grain  may  be  given  three  times  a  day  for  each  month  of  age,  and 
one  grain  and  a  half  for  each  year  in  chiklren  under  five  years.  Resc  'n 
in  one-por-cent  solutions,  swabbed  frequently  on  the  throat;  two  or  three 
grains  of  iodoform  to  an  ouiu^e  of  starch  powder ;  a  spray  of  carbolic  acid 
—have  all  been  warmly  recommended.  J.  Lewis  Smith  advises  the  use  of 
the  steam  atomizer  with  a  solution  of  carbolic  acid,  chloride  of  potassium 
and  bromide  of  potassium  in  glycerin.  Bromoform,  in  doses  of  one  to  five 
minims  suspended  in  syrup,  has  been  warmly  recommended  of  late.  Jacobi 
regard?  belladonna  as  the  most  satisfactory  remedy.  lie  gives  it  in  full 
doses,  as  much  as  one  sixth  of  a  grain  of  tlie  extract  to  a  child  of  six  or 
eiglit  months  three  times  a  day.  It  should  be  given  in  sufficient  doses  to 
prrnluce  the  cutaneous  flush.  For  the  nervous  clement  in  the  disease  anti- 
juriu  has  been  used  with  apparent  success. 

After  the  severity  of  the  attack  has  mitigated  and  convalescence  has 
begun,  the  child  should  be  watched  with  the  greatest  care.  It  is  just  at 
this  period  that  the  fatal  broncho-pneumonias  are  apt  to  develop.  The 
t'ougli  sometimes  persists  for  months  and  the  child  remains  weak  and  deli- 
cate, t'hange  of  air  should  be  tried.  Sucli  a  patient  should  be  fed  with 
care,  and  given  tonics  and  cod-liver  oil. 


92 


SPECIFIC  INP1<;CTI0US  DISKASES. 


XII.    INFLUENZA  {La  Orippe). 

Definition. — An  inft'ctions  disease  cliaracterizoii  by  great  prostration 
and  olton  catiUTli  of  tlio  nmcous  nionihranos,  particularly  tiie  respiratory 
and  gastro-intcstinal.  There  is  a  marked  liability  to  serious  complications, 
particularly  pneumonia. 

J'^pidemics  appear  at  intervals  and  spread  with  extraordinary  rapidity, 
so  that  in  a  few  weeks  an  entire  continent  may  be  involved.  The  dis- 
ease has  been  known  for  several  centuries,  and  there  have  been  within  the 
past  fifty  years  several  extensive  outbreaks,  notably  those  of  18:33, 1847-'48, 
and  the  epidemic  of  188(t-'!>0,  which  has  recurred  each  year  with  varying 
severity,  lessening  last  winter  (l8!)4—'95).  Many  of  the  epidemics  have 
started  in  Russia,  lience  the  name  Russian  fever.  In  October  of  1889  it 
prevailed  extensively  in  St.  l*etorsburg.  During  November  and  December 
it  spread  to  Germany,  France,  and  western  Europe,  appearing  in  London 
about  the  end  of  December.  Cases  appeared  in  this  country  about  Christ- 
mas, and  the  disease  rapidly  bec^ame  epidemic.  The  elaborate  report  of 
the  Verein  f.  innere  >r(>di(!in  (1892),  tlie  report  of  I'arsons  (Local  Govern- 
ment Hoard's  Report,  189:i-'9;5),  and  the  work  of  Pfeiffer,  from  Koch's 
Institute,  are  the  three  most  notable  productions  of  the  last  visitation. 

etiology. — The  disease  is  highly  contagious,  and  probably  is  spread 
only  frotn  the  sick  to  the  sound.  Independent  of  all  meteorological  con- 
ditions, like  other  rapidly  spreading  affections  it  is  conveyed  along  lines 
of  travel. 

The  bacillus  isolated  by  Pfeiffer,  which  is  accepted  by  leading  authori- 
ties as  the  cause  of  the  disease,  is  a  small,  non-motile,  organism  which 
stains  well  in  Loeffler's  methylene  blue,  or  in  a  dilute,  pale-red  solution  of 
carbol-fu(!hsin  in  water.  On  culture  media  it  grows  only  in  the  presence 
of  haemoglobin.  The  bacilli  are  present  in  enormous  numbers  in  the  nasal 
and  bronchial  secretions  of  patients,  in  the  latter  almost  in  pure  cultures. 
They  persist  often  after  the  severe  symptoms  have  subsided. 

Morbid  Anatomy. — Uncomplicated  cases  recover.  In  the  delicate 
and  aged  alone  do  we  see  fatal  results,  and  theti  only  from  the  intensity 
of  the  fever  or  the  profound  depression.  Injection  and  swelling  of  the 
pharyngeal  and  laryngeal  mucosa,  bronchitis,  and  a  catarrhal  condition  of 
the  stomach  atui  intestines  may  be  present. 

The  complications  are  very  varied.  Severe  bronchitis,  lobar  and  lobu- 
lar pneumonia,  and  nephritis  may  exist. 

Symptoms. — The  period  of  incubation  is  "from  one  to  four  day* ; 
oftenest  three  to  four  days."  In  many  cases  the  attack  closely  resembles 
an  ordinary  catarrh  Avith  slight  fever,  dryness  and  swelling  of  the  niisiil 
mucosa,  and  then  increase  in  the  secretion.  In  the  severer  cases  tlio 
coryza  is  subsidiary  or  absent,  and  the  symptoms  are  those  of  an  infection 
of  varying  grades  of  severity.  Headache,  pain  in  the  back  and  legs,  aiul 
a  general  soreness  as  if  bruised  or  beaten,  are  more  pronounced  in  inllu- 


INFLUENZA. 


93 


cnza  tlian  in  any  other  disorders  2xcept.  dengne  and  small-pox.  Delirium 
iii;iv  he  niiirkod.  Associated  with  these  are  a  prostration  and  cardiac  wouk- 
ncss  out  of  proportion  to  the  intensity  of  the  fever,  and  sometimes  V(;ry 
alarming.  The  pulse  is  feeble,  small,  and  intermittent.  Deatli  may  revsult 
(iirectlv  from  heart-failure,  as  in  cases  mentioned  by  Wilks.  ICndocarditis 
and  i)ericarditis  are  rare  compli  itions.  Persistent  irregularity  of  the 
heart's  action,  bradycardia,  tachycardia,  and  pseudo-angina  attacks  have 
been  frequent  se(piehe. 

Herpes  is  common  ;  diffuse  erythema  sometimes  occurs,  and  a  few  in- 
stiinces  of  purpura  have  been  observed.  Albuminuria  and  cystitis  may 
develop.  Conjunctivitis  is  a  frequent  event;  iritis,  iind  in  rare  instances 
optic  neuritis,  have  been  observed.    Acute  otitis  is  a  common  complication. 

Serious  nervous  complications  are  marked  delirium  and  meningitis, 
the  latter  usually  in  association  witli  pneuinonia.  Hristowe  has  reported 
several  cases  of  abscess  of  the  brain  following  influenza.  Periplieral  neu- 
ritis is  not  very  uncommon.  Severe  and  persistent  vertigo  is  a  distressing 
sequel.  Mental  disorders  are  not  infrequent.  Inajititude  for  mental 
exertion,  depression  of  spirits,  even  insanity,  may  follow  an  attack. 

Affections  of  tlie  respiratory  organs  are  the  most  .serious.  Many  cases 
present  an  intense  bronchitis,  involving  tlie  large  and  small  tubes  and 
eouiiug  on  with  high  fever,  sometimes  with  delirium.  The  sputum  is 
viscid,  and  brought  up  in  little  lumps  or  balls.  In  children  the  bronchitis 
may  be  complicated  with  broncho-pneumonia.  By  far  the  most  serious 
and  fatal  complication  is  piicHvioiiiii,  whicli  may  follow  the  bronchitis,  or 
set  in  with  well-characterized  .symptoms.  Sometimes  the  symptoms  are  at 
fh'st  obscure  and  the  pneumonia  atypical.  Thus,  after  an  initial  rigor,  with 
some  dyspnoea  and  high  fever,  the  local  signs  may  be  masked,  and  it  may 
not  be  until  the  tliird  or  fourth  day,  or  even  later,  that  the  physical  signs  of 
a  pneumonia  are  detected.  The  sputa  may  not  be  rusty  until  the  fourth  or 
fifth  day.  The  crisis  maybe  deferred  or  the  defervescence  may  be  by  lysis. 
A  considerable  proportion  of  the  cases,  however,  run  a  normal  course.  In 
the  aged  and  weak  a  broncho-pneumonia  of  the  lower  lobes,  Avithont  high 
fever,  is  a  not  infrequent  complication.  Abscess  of  the  lung  may  follow. 
I'leiirisy  is  not  an  uncommon  complication,  and  empyema  may  develop. 

The  gastro-intestinal  symptoms  may  be  marked  ;  thus,  with  the  initial 
fever,  there  may  be  nausea  and  vomiting.  Diarrhcea  is  not  uncommon ; 
indeed,  the  brunt  of  the  entire  jirocess  may  fall  upon  the  gastro-intes- 
tinal mucosa. 

The  (UagnoHis  of  the  disease  ofTers  no  difficulties  when  it  occurs  in  epi- 
demic form.  Coryza  is  not  always  present,  and  the  symptoms  may  be 
those  of  general  fever  with  great  prostration.  In  other  instances  the  bron- 
eJiitis  may  be  an  important  feature.  The  severe  prostration,  fever,  de- 
lirium, with  the  initial  bronchitis,  and  occasionally  epistaxis,  may  lead  to 
the  diagnosis  of  typhoid  fever.  The  complications  are,  as  a  rule,  readily 
recognized,  though  at  first  the  symptoms  of  the  pneumonia  may  be  some- 


94 


SPECIFIC   INFECTIOUS  DISEASES. 


what  indefiiiito.  Tlio  biicteriologioal  diagnosis  can  sometimes  bo  made  by 
examining  the  bronchial  sputum,  but  cultures  are  as  a  rule  necessary. 

Treatment. — Isolation  should  bo  i)ractiscd  when  possible,  and  old 
peo})le  should  be  guarded  against  all  possible  sources  of  infection,  Tlic 
secretions,  nasal  and  bronchial,  should  be  thoroughly  disinfected.  In  every 
case  the  disease  should  be  regarded  as  serious,  and  the  patient  should  be  con- 
fined to  bed  until  the  fever  has  completely  disai)peared.  In  this  way  alone 
can  serious  complications  be  avoided.  From  the  outset  the  treatment  should 
be  supporting,  and  the  patient  should  be  carefully  fed  and  well  nursed.  The 
bowels  should  be  opened  by  a  dose  of  calomel  or  a  aalinti  draught.  At  night 
ten  grains  of  Dover's  powder  may  be  given.  At  the  onset  a  warm  bath  is 
sometimes  grateful  in  relieving  the  pain  in  the  back  and  limbs,  but  great 
care  should  be  taken  to  have  the  bed  well  warmed,  aiid  the  ])a1ient  should 
be  given  after  it  a  drink  of  hot  lemonade.  If  the  fever  is  high  and  there 
is  delirium,  small  doses  of  antipyrin  may  be  given  and  an  ice-caj)  applied 
to  the  head.  The  medicinal  antipyretics  should  be  used  with  caution,  as 
profound  prostration  sometimes  develops  in  these  cases.  Too  nnich  stress 
should  not  be  laid  upon  the  mental  features.  Delirium  may  be  marked 
even  with  slight  fever.  In  the  cases  with  great  cardiac  weakness  stimulants 
should  be  given  freely,  and  during  convalescence  strychnia  in  full  doses. 

Th?  intense  bronchitis,  pneumonia,  and  other  complications  should 
receive  their  appropriate  treatment.  The  convalescence  requires  careful 
management,  and  it  may  be  weeks  or  months  before  the  patient  is  restored 
to  full  health.  A  good  nutritious  diet,  change  of  air,  and  pleasant  sur- 
roundings are  essential.  The  depression  of  spirits  following  this  disease 
is  one  of  its  mo-.t  unpleasant  and  obstinate  features. 


I 


XIII.   DENGUE. 

Deflnition. — An  acute  infectious  disease  of  tropical  and  subtropical 
regions,  characterized  by  febrile  paroxysms,  pains  in  the  joints  and  mus- 
cles, and  sometimes  a  cutaneous  rash. 

The  disease  was  first  noted  in  Java.  During  this  century  many  epi- 
demics of  it  have  been  reported,  particularly  in  India,  Afi-ica,  and  the 
southern  United  States.  S.  II.  Dickson  gave  the  most  satisfactory  account 
of  the  disease  as  it  appeared  in  Charleston  in  1828.  Since  that  time  there 
have  been  three  or  four  wide-spread  epidemics,  confined  chiefiy  to  the  Gulf 
States  and  rarely  extending  beyond  the  32d  parallel. 

etiology. — Many  observers  regard  it  as  contagious.  The  disease 
spreads  from  place  to  place,  and  is  conveyed  by  ships  and  along  railroads. 
It  is  remarkable  among  epidemics  as  practically  affecting  all  members  in  a 
community  who  have  not  been  protected  by  a  previous  attack.  Matas,  in 
his  excellent  account,  states  that  one  attack  does  not  protect  from  subsequent 
infection.  It  attacks  all  races  equally.  The  disease  is  stated  to  attack  animals. 

McLaughlin,  of  Texas,  has  found  in  the  blood  of  patients  a  micrococcus, 
which  he  regards  as  the  special  agent  and  has  been  able  to  cultivate. 


DENGUE. 


95 


epi- 
tlie 
:ount 
thtM-e 

Gulf 

oiids. 
in  ii 
IS,  ill 
:{ueiit 
nirtls. 

)CC11S, 


As  tho  disease  ia  never  fatal,  no  observations  have  been  made  upon  its 
patliiilo^Mc'iii  anatomy. 

Symptoms. — The  period  of  incubation  is  from  three  to  five  days, 
(luring  which  the  patient  feels  well.  The  attack  sets  in  suddenly  with 
luuilache,  chilly  feelings,  and  intense  aching  pains  in  the  joints  and  nuis- 
clr.-i.  The  fever  rises  gradually  and  may  roach  as  high  as  KKi"  or  107°. 
The  pulse  is  rapid  and  there  are  the  other  phenomena  associated  with 
iieuto  fever — loss  of  appetite,  coated  tongue,  slight  nocturnal  delirium,  and 
concentrated  urine.  In  the  initial  stage  there  may  be  an  erythenuitous 
ni«li.  In  a  majority  of  the  cases  the  paii\s  in  the  muscles,  joints  and  bones 
iU'c  of  a  most  aggravated  character,  and  the  i)atients  speak  of  them  as  of  a 
boring  or  breaking  character,  hence  the  i)0])ular  name  "  break-bone  fever." 
The  large  and  small  joints  are  affected,  sometimes  in  succession,  and  they 
become  swollen,  red,  and  painful.  The  pains  shift  about,  and  in  some 
cases  cutaneous  hypenvisthesia  has  been  noted.  In  some  instances  there  is 
a  tendency  to  hiemorrhage,  from  either  the  nose,  lungs,  stonuich,  or  bow- 
els. Eugene  Foster  speaks  of  having  seen  black  vomit,  similar  to  that  of 
yellow  fever,  and  in  three  instances  alarming  luemorrhage  from  the  bow- 
els, which  in  one  case  persisted  for  three  months  and  caused  death. 

I'he  fever  gradually  reaches  its  height  by  the  third  or  fourth  day,  and 
the  patient  enters  upon  the  apyretic  period,  which  may  last  from  two  to 
four  days,  and  in  which  he  feels  prostrated  and  stiff.  At  this  time,  in  a 
large  number  of  cases,  an  eruption  is  common  which,  judging  from  the 
description,  has  nothing  distinctive,  being  at  times  macular,  like  measles, 
at  others,  diffuse  and  scarlatiniform,  or  papular,  or  lichen-like.  In  other 
instances  the  rash  has  been  described  as  urticarial,  or  even  vesicular.  A 
second  paroxysm  of  fever  then  occurs,  and  the  pains  return.  Certain 
writers  describe  inflammation  and  hypenemia  of  the  mucous  membrane 
of  the  nose,  month,  and  pharynx.  Enlargement  of  the  lymiih-glands 
is  not  uncomnion,  and  may  persist  for  weeks  after  the  disappearance 
of  the  fever.  Convalescence  is  often  protracted,  and  there  is  a  degree  of 
niL'utal  and  physical  prostration  out  of  all  proportion  to  the  severity  of 
the  primary  attack.  By  far  the  most  distressing  symptom  is  the  pain, 
which  all  who  have  experienced  the  disease  s])eak  of  as  agonising  and  in- 
tolerable, and  more  severe  than  that  experienced  in  any  other  acute  fever. 

Complications  are  rare.  Insomnia  and  occasionally  delirium,  resem- 
bling somewhat  the  alcoholic  form,  have  been  observed.  A  relapse  may 
occur  even  as  late  as  two  weeks.  Briefly,  the  course  of  the  disease  maybe 
described  as  consisting  of  a  febrile  paroxysm  of  three  or  four  days;  a  re- 
uiission  of  variable  duration,  which  may  be  wanting ;  and  a  second  parox- 
ysm of  about  three  days.  The  average  duration  of  a  moderate  attack  is 
from  seven  to  eight  days. 

The  diagnosis  of  the  disease  rarely  offers  any  special  difficulties,  pre- 
vailing as  it  does  in  epidemic  form,  and  attacking  all  classes  indiscrimi- 
nately.   Isolated  cases  might  be  mistaken  at  first  for  acute  rheumatism. 


m  SPKf'IFir   INPECTIOUH   mSKASES. 

Soiithorii  iiliysicians  say  tliut  occaHionully  yellow  fever  and  denguo  may 
be  eojif(»iiii(k'(|. 

Treatment. — Tlii.s  is  entirely  sviiotonrntic;.  Qninino  is  stated  to  he 
a  proidiyliictic,  hut  on  in.su(li<!ient  (^'rounds.  Hydrotlicrapy  may  !)(■  cm- 
idoyt'd  to  rt'(hi"e  tlit,'  fever.  The  salicylates  or  antipyriti  may  he  tried  for 
the  j)aiiis,  which  usually,  however,  require  opium.  During  convalescenee 
ioilide  of  potassium  is  recommended  for  the  arthritic  pains,  and  tonics 
are  indicated. 


XIV.  CEREBRO-SPINAL  MENINGITIS. 

Definition. — A  specific  infectious  disease,  ocourring  sporadically  and 
in  ei)ideniics,  characterised  hy  inllamniation  of  the  cerehro-spinal  menin- 
ges and  a  clinical  course  of  great  irregularity. 

The  affection  is  kiu)wn  by  the  names  of  malignant  purpuric  fever, 
petechial  fever,  ajid  spotted  fever. 

Etiology. — Since  its  recognition  in  fJencva  in  the  early  part  of  tliis 
century,  nunu'rous  epidemics  have  been  described.  Stille's  monograph 
(18<^i7),  and  the  elaborate  section  (pj).  409-553)  in  Volume  I  of  Joseph 
Jones's  works,  give  full  details  of  the  American  epidemics.  In  Europe  it 
is  renuirkable  with  what  frctpiency  the  disease  has  occurred  in  garrisons. 
In  this  country  the  disease  was  first  seen  in  Massachusetts  in  1800,  siiu'o 
which  date  there  have  been  epidemics  in  various  localities  at  irregular  in- 
tervals. 

During  the  civil  war,  according  to  Smart's  report,  comparatively  few 
deaths  were  caused  by  this  disease. 

S{)oradic  cases  occur  from  time  to  time, in  the  larger  cities  and  country 
districts  on  this  continent.  After  the  first  epidemic  in  Montreal  in  18T.'3 
occasional  cases  occurred.  In  Philadelphia,  since  its  ajipearance  in  18(13, 
there  have  been  cases  rej)orted  every  year  in  the  mortality  bills.  AVithout 
autopsy  the  diagnosis  of  maiiy  of  these  cases  is  extremoly  doubtful ;  but 
there  can  be  no  question  that  the  disease,  though  rare,  still  lingers.  Judg- 
ing from  my  own  experience  in  three  of  the  hospitals  of  that  city,  and 
from  the  fact  that  in  five  years  I  saw  only  three  instances,  I  would  regard 
it  as  very  much  less  frequent  than  the  reports  of  the  Health  Office  would 
seem  to  iiulicate. 

The  disease  has  broken  out  simultaneously  in  regions  far  distant  from 
each  other. 

The  epidemics  occur  most  frequently  in  winter  and  spring.  Neither 
soil  nor  locality  has  any  special  influence.  The  concentration  of  indi- 
viduals, as  in  large  barracks,  seems  to  be  specially  favorable. 

Children  are  much  more  susceptible  to  the  disease  than  adults,  though 
the  susceptibility  has  differed  in  different  epidemics.     In  certain  places 


CKIIKHHO-SIMN'AL   MKNINCITIS. 


97 


ulcl 

1 

•om 

<>i 

4 

^ 

her 

% 

idi- 

1 

igli 

i 

fcces 

_^ 

cliiMrcn  aloiio  lmv»'  Ijccii  ufTi'dcd  ;  in  (itlirrs  tlii'  discast,'  lias  Ih'cii  cliii'fly 
ariKiii^'  adults.      It  attacks  inak-s  and  t'cmalrs  alike. 

( 't'Ttaiii  ('|iidci;ii('s  liavi' bt't'ii  must  prcvalt'iit  in  country  districts.  In 
isTM  tlio  (liseasi;  i)rovuiled  along  the  valley  of  tlic  Ottawa,  in  viilagi'S  and 
cuiintrv  ]tlace8,  much  nioro  severely  than  in  the  cities  of  Montreal  and 
Ottawa. 

Over-exertion,  j)rolonged  marching  ii\  the  heat,  depre.'^sing  mental  or 
liddilv  surroundings,  und  the  misery  and  squalor  of  the  large  tciienient- 
lidiises  in  cities  ure  predisposing  causes. 

'i'lie  disease  is  not  directly  contagious;  it  is  probably  iu»t  traiismitted 
i)y  clolhing  or  the  excretions. 

We  are  still  ignorant  of  the  conditions  favoring  the  oeourrenoo  of  epi- 
demics. The  existence  of  the  microco(!cus  laiu'colatus  in  sporadic  as  well 
as  in  epidemic  forms  has  led  to  the  belief  that  the  disease  may  be  due  to 
this  organism,  the  morbid  numifestations  of  which  are  so  varied,  and 
which  is  present  in  so  large  a  percentage  of  all  persons.  Striinipell  has 
suirirested  that  there  may  be  some  connection  with  corvza  and  ei)idemic 
imiiingitis,  the  infection  occurring  directly  from  the  nose.  Flexner  und 
Marker  suggest  that  the  ii»testine  may  be  the  infectif)n-atrium  ;  but  neither 
of  tliese  views  explain  the  rapid  development  of  epidemics,  dependent  ap- 
parently upon  local  conditions. 

Morbid  Anatomy. — In  malignant  cases  there  may  be  no  charac- 
teristic changes,  for  the  patient  may  die  before  exudation  occurs.  In 
well-marked  cases  the  meninges  of  the  brain  and  cord  are  inflamed. 
The  following  abstract  of  one  of  the  Montreal  cases,  in  which  death 
occurred  about  the  fifth  day,  gives  a  good  idea  of  the  condition  in  this 
disease:  The  brain  contained  an  excessive  amount  of  blood.  The  dural 
sinuses  and  all  the  veins  and  artei'ies  were  engorged.  Some  of  the  veins 
of  the  ])ia  were  as  large  as  goose-quills.  On  the  cortex  there  was  much 
lymph  beneath  the  arachnoid  on  either  side  of  the  longitudinal  fissure — 
more  on  the  right  than  on  the  left  hemisphere.  At  the  base  there  was 
a  purulent  exudate  about  tlie  chiasma  and  inner  parts  of  the  Sylvian 
lissuro,  but  none  on  the  pons  or  medulla.  There  was  no  fibrin  in  the 
course  of  the  middle  cerebral  arteries.  The  ventricles  contained  serous 
exudate;  the  walls  were  not  softened.  The  gray  matter  of  the  brain 
was  deeply  congested,  but  presented  neither  hitmorrhages,  spots,  nor 
softouing.  In  the  spinal  cord  the  veins  of  the  pia  were  engorged.  On 
the  posterior  surface,  from  the  cervical  enlargement  to  the  cauda  equina, 
WHS  a  thick  layer  of  grayish-yellow,  lympho-purulent  exudation,  which  in 
places  produced  irregular  bulging  of  the  arachnoid  membrane.  There 
were  no  ch.mges  in  the  thoracic  or  abdominal  viscera.  J'oci  of  hasmor- 
rliage  and  of  encephalitis  occur  in  some  cases.  The  formation  of  abscess 
has  been  occasionally  described.  The  involvement  of  the  ventricles  is  less 
tlmn  in  tuberculous  meningitis.  In  the  cases  which  I  have  seen  the  exu- 
ilation,  as  is  usual  in  the  secondary  meningeal  Inflammations,  was  most 


98 


SPECIFIC   INKKCTIOUS  DISEASES. 


'n  ■  *i, 


f  :    ^ 


uhuiulimt  un  the  cortex.  The  exudation  may  i-xtond  along  tlie  lymph- 
Hhcathri  of  the  cranial  nerves,  jiarticiiiarly  the  auditory  and  optic.  In 
long-rttanding  cases  the  inllainniatory  (irocesses  appear  more  chronic 
There  are  thicliening  and  adhesion  of  tiie  menihrancs,  areas  of  cortical 
softening  or  of  utropliy,  and,  in  some  insUmces,  hydrocei)halus.  The 
changes  in  the  other  organs  are  those  associated  with  fever.  In  the  ma- 
lignant cases  there  may  be  luemorrhagcs  int(»  the  skin  and  on  the  serous 
membranes.  I'lieumo'iia,  pleurisy,  endocarditis,  dysentery  and  nephritis 
have  been  described.  The  s])leen  varies  in  size  according  to  the  jieriod 
of  the  disease  at  which  death  has  occurred.  When  the  fever  has  been 
intense  it  is  enlarged- 

Symptoms. — Cases  differ  remarkably  in  their  characters.  Many 
different  forms  have  been  described.  These  are  perhaps  best  grouped  into 
three  classes : 

1.  Malignant  Form. — This  fulminant  or  apoplectic  type  occurs  with 
variable  frequency  in  epidemics.  It  may  occur  sporadically.  The  onset 
is  sudden,  usually  with  violent  chills,  heailaelie,  somnolence,  spasms  in  the 
muscles,  great  depression,  moderate  elevation  of  tem]ierature,  and  feeble 
pulse,  which  may  fall  to  fifty  or  sixty  in  the  minute.  Usually  a  purpuric 
rash  develops.  In  a  Philadelphia  case  in  IHHH  a  young  girl,  apparently 
quite  well,  ilied  within  twenty  hours  of  this  form.  There  are  cases  on 
record  in  which  death  has  occurred  within  a  shorter  time.  Stille  tells  of 
a  child  (jf  live  years,  in  whom  death  occnrred  after  an  illness  of  ten  hours; 
and  refers  to  a  case  reported  by  Gordon,  in  which  the  entire  duration  of 
the  illness  was  only  five  hours. 

2.  Ordinary  Form. — The  stage  of  incubation  is  not  known.  The  dis- 
ease usually  sets  in  suddenly.  There  may  be  premonitory  symptoms : 
headache,  pains  in  the  back,  and  loss  of  .appetite.  More  commoidy,  the 
onset  is  with  headache,  severe  chill,  and  vomiting.  The  temperature  rises 
to  101°  or  102°.  The  pulse  is  full  and  strong.  An  early  and  important 
symptom  is  a  painful  stiffness  of  the  mnsdes  of  the  neck.  The  headache 
increases,  and  there  are  [ihotophobia  and  great  sensitiveness  to  noises. 
Children  become  very  irritable  and  restless.  In  severe  cases  the  contrac- 
tion of  the  muscles  of  the  neck  sets  in  early,  the  head  is  drawn  back,  and, 
when  the  muscles  of  the  back  are  also  involved,  there  is  orthotonos,  which 
is  more  common  than  opisthotonos.  The  pains  in  the  back  and  in  the 
limbs  may  be  very  severe.  The  motor  symptoms  are  most  characteristic. 
Tremor  of  the  muscles  may  be  present,  with  tonic  or  clonic  spasms  in  the 
arms  or  legs.  Rigidity  of  the  muscles  of  the  back  or  neck  is  very  com- 
mon, and  the  patient  lies  with  the  body  stiff  and  the  head  drawn  so  far 
back  that  the  occiput  may  be  between  the  shoulder-blades.  Except  in 
early  childhood  convulsions  are  not  common.  Strabismus  is  a  frequent 
and  imi)ortant  symptom.  Spasm  of  the  n. ..soles  of  the  face  may  also 
occur.  Cases  have  been  described  in  which  the  general  rigidity  and  stiff- 
ness was  such  that  the  body  could  be  moved  like  a  btatue.    Paralysis  of 


CKUKIlUo-SIMNAL   MIIMXGITIS. 


99 


tlio  trunk  muscles  is  niii;,  l)ut  piinilyais  of  tliu  inuBcles  of  tlio  eye  and  tho 
fare  is  not  unooinmon. 

Of  sensory  symptoms,  headiiclie  is  tlie  most  dominant  and  persists 
fniiu  the  outset.  It  is  cliietly  in  tlie  Itiiek  of  the  head,  and  (lie  pain  ex- 
ti'iids  into  tiie  neck  and  hack.  There  may  he  f,'reat  .sensitiveness  ah)ng 
the  spine,  and  in  many  cases  tiiere  is  marked  liypera'sthesia. 

Tiio  psychical  symptoms  are  marked.  I)elirium  occurs  at  the  onset, 
oceasioiudly  of  a  furious  and  maniacal  kind.  'I'iie  i>atient  may  display  at 
the  start  marked  orotic  symjitoms.  'I'he  delirium  j^ives  place  in  a  few  days 
to  stupor,  which,  as  the  effusion  increa.ses,  deepens  to  coma. 

Tlie  temperature  is  irre<j;idar  and  vuriablo.  Itemissions  occur  fre- 
quently, and  there  is  no  uniform  or  ty])ical  curve  during  tho  di.sea.se.  In 
.some  instances  there  has  been  little  or  no  fever.  In  other  cases  the  tem- 
perature may  reach  10.*)°  or  lufj",  or,  hefoie  death,  108".  The  pidse  nuiy 
1)0  very  rapid  in  children ;  in  adults  it  is  at  first  usually  full  and  strong. 
In  some  eases  it  is  remarkably  slow,  and  nuiy  not  bo  more  than  fifty  or 
sixty  in  tho  minute.  Sighing  respirations  and  C'heync-Stokes  breathing 
are  met  with  in  some  instances.  Tnli'ss  there  is  pneumonia  the  respira- 
tiuiis  are  not  often  increased  in  frecpioncy. 

The  cutaneous  .symptoms  of  the  di.seaso  are  important.  Herpes  occurs 
with  even  greater  frequency  than  in  pneumonia  or  in  intermittent  fever. 
The  petechial  rash,  which  has  given  tho  name  spotted  fever  to  the  disea.so, 
is  very  variable.  Stille  states  that  of  ninety  eight  ca.ses  in  tho  IMiiladid- 
pliia  Hospital,  no  eruption  was  observed  in  thirty-seven.  In  tho  Montreal 
eases  ])etechiai  and  pnr})le  spots  wore  common.  They  appear  to  have  been 
more  frequent  in  the  epidemics  on  this  continent  than  in  Europe.  The 
potechiio  may  be  numerous  and  cover  tho  entire  skin.  Ai\  erythema  or 
dusky  mottling  may  be  present.  In  some  instances  there  have  been  rose- 
colored  hypera?mic  spots  like  the  typhoid  rash.  Urticaria  or  erythema  no- 
dosum, ecthyma,  pemphigus  and  in  rare  instances  gangrene  of  the  skin 
have  boon  noted. 

There  is  a  loucocytosis,  a  point  which  may  help  in  the  diagnosis  from 
typhoid  fever. 

As  already  stated,  vomiting  may  be  a  special  feature  at  tho  onset;  but, 
as  a  rule,  it  gradually  subsides.  In  some  instances,  however,  it  persists 
and  becomes  tho  most  serious  and  distressijig  of  the  symptoms.  Diarrluea 
is  not  common.  The  bowels  are  usually  confined.  The  abdomen  is  not 
tender.    In  acute  cases  the  s[)leen  is  usually  enlarged. 

The  urine  is  sometimes  albuminous  and  the  quantity  may  bo  increased. 
Glycosuria  has  been  noted  in  some  instances,  and  in  tho  malignant  forms 
hivmaturia. 

The  course  of  the  disease  is  extremely  variable.  Ilirsch  rightly  states 
that  it  may  range  between  a  few  hours  and  several  months.  More  than 
half  of  the  deaths  occur  within  the  first  five  days.  In  favorable  cases, 
after  the  symptoms  have  persisted  for  five  or  six  days,  improvement  is  in- 


hi 


100 


SrECIFlC   INFECTIOUS  DISEASES, 


diciited  by  a  lessoning  of  the  spasm,  reduction  of  the  fever,  and  a  return 
of  the  intelligence.  Sudden  fall  in  the  temperature  is  of  bad  omen.  Con- 
valescence is  extremely  tedious,  and  may  be  interrupted  by  complications 
and  secpiehT  to  be  noted. 

3.  Anomalous  Forms. 

(a)  Aliorlit'c  Tijpv. — The  attack  sets  in  with  great  severity,  but  in  a 
day  or  two  tlie  sym[)torus  subside  and  convalescence  is  raj)i(l.  Striimpell 
would  distinguish  between  this  abortive  variety,  which  sets  in  with  such 
intensity,  and  tlie  mild  ambulant  cases  described  by  certain  writers.  He 
re])orts  a  case  in  which  the  nuniingeal  symptoms  set  in  witi\  the  greatest 
intensity  and  persisted  for  four  days,  the  temperature  rising  to  40*9°  C. 
On  the  liflh  day  the  patient  entered  upon  a  rapid  and  satisfi;ctory  con- 
valescence. In  the  mild  cases,  as  distinguished  from  the  abortive,  the  pa- 
tients complain  of  headache,  nausea,  sensations  in  the  back  and  limbs,  and 
stitfness  in  the  neck.  There  is  little  or  no  fever,  aiul  only  moderate 
vomiting.  These  eases  could  be  recognized  oidy  during  the  prevalence 
of  an  epidemic. 

(Z>)  An  Jiitcrmittent  7^y/^<!  has  been  observed  in  many  c])idemics,  and  is 
recognized  by  von  Ziemssen  and  Stille.  It  is  characterized  by  exacerba- 
tions of  fever,  which  may  recur  daily  or  every  second  day,  or  follow  u  curve 
of  an  intermitteiit  or  remittent  character.  Tlie  pyrexia  resembles  that  of 
pyaemia  rather  than  nudaria. 

{(')  C/iroin'r  Form. — Ileubner  states  that  this  is  a  relatively  frequent 
form,  though  it  does  not  seem  to  be  recogiuzed  by  nuiiiy  writers  on  the 
subject.  An  a,ttack  may  be  protracted  for  from  two  to  live  or  even  six 
montlis,  and  nuiy  cause  the  most  intense  marasmus.  The  attack  consists 
of  a  series  of  recurrejices  of  the  fever,  and  may  present  the  most  complex 
symptomatology.  It  is  not  improbable  that  these  protracted  cases  de})end 
upon  chrojiic  hydrocephalus  or  abscesses  of  the  bruin.  This  form  differs 
distinctly  from  the  intermittent  type.  A  very  remarkable  instance  of  it  is 
described  by  Worthingtoii,  in  which  the  disease  lasted  iov  fourteen  weeks. 

Complications. — Pleurisy  and  ])ericarditis  and  parotitis  are  not 
uncommon. 

Pneumonia  is  described  as  freipient  in  certain  ejiidemics.  Immer 
mann  found,  during  the  Kriangen  epidemic,  many  instances  of  the  com- 
bimition  of  })neumonia  witii  meningitis,  but  it  does  not  seem  jiossiblo  to 
determine  whether,  in  such  instances,  pneumonia  is  the  primary  disea.se 
and  the  meningitis  secondary,  or  vice  verm.  The  frequency  with  which 
inllammation  of  the  meninges  of  the  brain  complicates  pneumonia  has 
already  been  mentioned.  It  is  not  itnpossible  that  the  pneumococcus  is 
responsible  for  both  alTections.  Arthritis  has  been  the  nu)st  frequent 
complication  in  certain  epidemics.  Many  joints  are  affected  simulta- 
neously, and  there  are  swelling,  pain,  and  exudation,  sometimes  serous, 
sometimes  purulent.  'I'liis  was  first  observed  by  James  Jackson,  Sr.,  in 
the  epidemic  which  he  described.     Erteritis  has  been  observed. 


CEREBRO-SPINAL  MENINGITIS. 


101 


Aiiioii<^  tlio  imporliuit  sequeltu  are  those  ulToctiiig  tlie  special  senses. 
l^liiidiK'ss  may  result  from  optic  iieiiritis  with  atrophy.  Keratitis  with 
ulceration  may  develop.  This  may  also  occur  in  the  meniuffitis  follow- 
iiiK  piu'iinionia.     Ileitis  is  less  common. 

Still  more  serious  are  the  ear  symptoms,  particularly  in  children. 
Deafness  very  often  follows  inllammation  of  the  labyrintii;  the  result,  no 
(l()id)t,  of  tlie  direct  extension  of  the  inllammation  along  the  auditory 
nerve.  In  children  this  not  infrequently  leads  to  deaf-mutism.  Von 
ZicMissen  states  that  in  the  deaf  and  dumb  institutions  of  Bamberg  and 
Nui'eml)erg,  in  1874,  a  nuijority  of  the  pupils  had  become  deaf  from  epi- 
demic eerebro-s{)inal  meningitis. 

Headache  may  persist  for  months  or  years  after  an  attack.  Chronic 
livdroceplialus  develops  in  certain  instances  in  children.  The  symptoms 
(if  tills  are  "  i)aro.\ysms  of  severe  headache,  i)ains  in  the  lux'k  and  ex- 
treiuitieSj  vomiting,  loss  of  consciousness,  convulsion.^,  ami  involuntary 
di:<eharges  of  faeces  and  urine"  (von  Ziemssen).  \'on  Ziemssen  regards 
•  ■hroiiic  hydroco2)halus  as  by  no  means  a  rare  sequela.  Mental  feebleness 
and  aphasia  have  occasionally  been  noted. 

Paralysis  of  iiulividual  cranial  nerves  or  of  the  lower  extremities  may 
persist  for  some  time.  In  some  of  tliese  cases  laupiestionably  there  may 
be  peripheral  neuritis,  as  Mills  suggested. 

Diagnosis. — There  are  several  atlections  with  which  cerebro-spinal 
nieuiunitis  is  likely  to  be  confounded  : 

{a)  TubiTciilous  MciiiiKjitiS. — In  sporadic  cases  it  is  sometimes  inipos- 
sil)le  to  determine  the  nature  of  a  case  in  the  absence  of  local  tuberculous 
disea,se.  Iictracticn  of  the  neck  and  spasms  of  the  muscles  of  the  arms 
and  legs  are  not  nearly  .so  nuirked  aiul  ])rominent  in  tuberculous  menin- 
jfitis.  Herpes  also  is  rare,  and  tlie  jiulse  is  more  irregular.  There  is  rarely 
[leteeliial  eruption.  "\Vhen  the  disease  is  prevailing  epidemically  this  fac- 
tor is  of  the  greatest  help  in  the  diagnosis. 

{b)  Puck  ma  ma. — Tlie  meningeal  complication  of  this  disease  is  most 
f'omnionly  confined  to  the  cerebrum.  As  the  cortex  is  chiefly  involved, 
there  nuiy  be  a  good  deai  of  motor  sj)asm  and  tremor,  but  rarely  is  there 
retraction  of  the  muscles  of  the  neck  or  opisthotonos.  In  sjioradic  cases, 
as  has  been  said,  it  nuiy  be  quite  impossible  to  decide  whether  the  pneu- 
monia has  complicated  the  nu-ningitis  or  the  meningitis  the  i)ulm()nary 
iiireetion.  The  bacteriological  examination  gives  no  clue,  as  the  jmeumo- 
coccus  is  fouiul  in  both  situations. 

('■)  ]y>lli  olhiv  AchIc  hifecfums  Disciues. — Both  typhus  and  typhoid 
present  symptoms  which  closely  simulate  cerebro-spinal  meningitis.  On 
several  occasions  at  the  Montreal  tieneral  Hospital  eases  have  been  sent 
'Ml  the  ward  with  the  diagieisis  of  cerebro-spinal  fever.  These  ca.ses 
show  jd  high  fever,  delirium,  retraction  of  the  neck,  spasm,  and  tremor  of 
tlie  muscles,  and  had  not  the  post-nmrtem  examination  revealed  typhoid 
lesions  and  only  cerebro-spinal  congestion  the  diagnosis  would  not  have 


102 


SPECIFIC  INFECTIOUS   DISEASES. 


m 


i  ■  :   1 

■""ii-- 


l 

■ 

■'■ 

been  corrected.    I  am  sure  that  many  of  the  cases  sent  into  the  health  offices 
as  cerebro-s])iiial  fever  are  instances  of  the  cerebral  form  of  typhoid. 

I  have  already  referred  to  the  fact  that  the  malignant  form  of  small- 
pox may  be  mistaken  for  cerebro-spinal  meningitis. 

It  could  scarcely  be  possible  to  confonnd  tetanus  with  this  disease. 

Prognosis. — llirs(^li  states  that  the  mortality  has  ranged  in  various 
epidemics  from  20  to  75  per  cent.  In  children  the  death-rate  is  much 
lr'<lher  than  in  adults.  Cases  with  deep  conui,  rei)eated  convulsions,  and 
high  fever  rarely  recover.  The  outlook  in  the  protracted  cases  is  not 
good,  though  Ileubner  gives  an  instance  of  a  lad  of  seven,  who  was  ill 
from  the  end  of  February  until  the  end  of  June,  with  repeated  recur- 
rences, was  worn  to  a  skeleton,  and  yet  completely  recovered. 

Treatment. — The  high  rate  of  mortality  which  has  existed  in  most 
epidemics  indicates  the  futility  of  the  various  therapeutical  agents  which 
have  been  recommended.  When  we  consider  the  nature  of  the  local  dis- 
ease and  the  fact  that,  so  far  as  we  know,  simple  or  tuberculous  cerebro- 
spinal meningitis  is  invariably  fatal,  we  may  wonder  rather  that  recovery 
follows  in  any  well-developed  case. 

In  strong  robust  ])atients  the  local  abstraction  of  blood  by  wet  cups 
on  the  nape  of  the  neck  relieves  the  pain.  General  bloodletting  is  rarely 
indicated.  Cold  to  the  head  and  spine,  which  was  used  in  the  first  epi- 
demics by  Xew  England  physicians,  is  of  great  service.  A  bladder  of  ice 
to  the  head,  or  an  ice-cap,  and  the  spinal  ice-bag  may  be  continuously  cm- 
ployed.  The  latter  is  very  beneficial.  Judging  from  the  beneficial  eifects 
of  the  general  bath  in  typhoid  with  pronounced  cerebro-spinal  symptoms, 
hydrotherapy  should  be  systematically  employed  if  the  temperature  is 
above  102^°.  In  j)rivate  practice  the  cold-pack  or  sponging  may  be  sub- 
stituted. If  any  counter-irritation  is  thought  necessary,  the  skin  of  the 
back  of  the  neck  may  be  lightly  touched  with  the  Paquelin  thermo- 
cautery. Blisters,  which  have  been  used  so  much,  are  of  doubtful  benefit 
and  should  not  be  employed.  Of  internal  remedies  opium  may  be  given 
freely,  best  as  morphia  hypodermically.  Stille  recommends  either  a  grain 
of  opium  every  hour  in  severe  cases  or  every  two  hours  in  cases  of  mod- 
erate severity ;  von  Ziemssen  advises  the  hypodermic  of  morphia,  from 
one  third  to  one  half  grain  in  adults.  Mercury  has  no  special  influence 
on  nu'ningeal  inflammation.  Iodide  of  potassium  is  warndy  recom- 
mended by  some  writers.  Quinine  in  large  doses,  ergot,  belladonna 
and  Calabar  bean  have  had  advocates.  Bromide  of  potassium  may  bo 
employed  in  the  milder  cases,  but  it  is  not  so  useful  as  morphia  to  control 
the  spasms. 

The  diet  should  bo  nutritious,  consisting  of  milk  and  strong  broths 
while  the  fever  i)ersists.  Many  cases  are  very  difficult  to  feed,  and  Ileul)- 
ner  recommends  forced  alimentation  M'ith  the  stomach-tube.  These  cases 
seem  to  bear  stimulants  well,  and  whisky  or  brandy  may  be  given  freely 
when  there  are  signs  of  a  failing  heart. 


? 


DIPHTHERIA. 


103 


XV.    DIPHTHERIA. 

Definition. — A  specific  infectious  disoiiso,  clmr.icterized  by  a  local 
fibrinous  exudate,  usually  upon  a  mucous  membrane,  and  by  constitu- 
tidiKil  symptoms  due  to  toxins  produced  at  the  site  of  the  lesion.  The 
ii;  -vnceof  the  Kk^V)s-Loeffler  bacillus  is  the  etiolo^'ical  criterion  by  which 
true  diphtlieria  is  distinguished  from  other  forms  of  membranous  iullam- 
imition. 

The  clinical  and  bacteriological  conceptions  of  di})htheria  are  at  pres- 
ent not  in  full  accord.  On  the  one  hajid,  there  are  cases  of  simple  sore 
throat  which  the  bacteriologists,  linding  the  Klebs-Loefller  bacillus,  call 
true  di]ilitheria.  On  the  other  hand,  cases  of  membranous,  sloughing 
angina,  diagnosed  by  the  physician  as  diphtheria,  are  called  by  the  bac- 
ti'riologists,  in  the  absence  of  tlie  Klebs-Loelller  bacillus,  pseudo-diph- 
theria or  diphtlieroid  angina. 

The  term  dipltlhcruid  may  be  used  for  the  present  to  designate  those 
forms  in  which  the  Klebs-Loeffler  bacillus  is  not  present.  Though  usu- 
ally milder,  severe  constitutional  disturbance,  and  even  paralysis,  may  fol- 
luw  these  so-called  pseudo-diphtheritic  processes. 

Historical  Note. — 'J'he  disease  was  known  to  Areta^us  and  to 
(ialen.  Epidemics  occurred  throughout  the  middle  ages.  It  appeared 
early  among  the  settlers  of  New  England,  and  accounts  are  extant  of 
epidemics  in  this  country  in  the  seventeenth  and  eighteenth  centuries. 
Huxham  and  Fothergill  gave  excellent  descriptions  of  the  disease.  An 
admirable  account  was  given  by  Samuel  liard,*  of  Xew  York,  whose  essay 
is  one  of  the  most  solid  contributions  made  to  medicine  in  America.  It 
was  reserved  for  Pierre  Bretonneau,  of  Tours,  to  grasp  the  fact  that 
(UKjiua  siiforafiva,  "  cynanche  maligna^'"'  the  "  putrid,"  and  other  forms 
of  nadiguant  sore  throat,  were  one  and  the  same  disease,  to  which  he  gavo' 
the  name  '•'■  diph  flic  rite." 

Etiology. — The  disease  is  endemic  in  the  larger  centres  of  popula- 
tion, and  becomes  epidemic  at  certain  seasons  of  the  year.  While  other 
contagious  diseases  have  dimitiished  within  the  past  decrde,  diphtheria 
h;i<  increased,  particularly  in  cities.  It  has  prevailed  also  with  great 
>tv(.'rity  in  country  districts,  in  which  indeed  the  alTcction  seems  to  be 
specially  virulent.  A  close  relation  between  imperfect  drainage  or  a  pol- 
luted water  supply  and  diphtheria  has  not  been  determined. 

J  diphtheria  is  a  highly  contagious  disease,  readily  communicated  from 
person  to  person.  The  bacilli  may  be  received,  "(1)  from  the  mem- 
branous exudate  or  discharges  from  diphtheria  patients ;  {'2)  from  the 
secretions  of  the  nose  and  throat  of  convalescent  cases  of  dii»htheria  in 
^vlM(•ll  the  virulent  bacilli  persist;  (JJ)  from  the  throats  of  healthy  indi- 
viduals who  have  acquired  the  bacilli  from  being  in  contact  with  others 


*  Tnmsactions  of  the  American  Pl;ilosophical  Society,  vol.  i,  Philadelf.hia,  1770. 
8 


M'U' 


104 

SPECIFIC   INFECTIOUS   DISEASES. 

having  virulent 

germs 

on 

their 

person 

or  clotliing : 

in  s 

uch 

cases 

the 

biUiilli  may  some 

times 

live 

and 

k'veloj) 

for  (lays  or  weeks 

in 

the  throu! 

without  causing 

any  h 

■siou"  (I' 

ariv  aiu] 

Heebe).      In 

the 

tenement 

dis- 

tricts  of  New  York   tiieso  i 

uitliors  recjog 

\ized   two  varieties  of 

local 

epi- 

■  ■k 


demies.  In  one,  the  cases  were  evidently  from  neighborhood  infection  ; 
while  in  the  other,  the  infection  was  derived  from  schools,  since  a  whole 
district  would  suddenly  become  the  seat  of  scattered  eases.  "At  times  in 
a  certain  area  of  tiie  city,  from  whi(di  several  schools  drew  their  scholars, 
all  the  cases  of  dii)htheria  would  occur  (as  investigation  showed)  in  fami- 
lies whose  children  attended  one  school,  the  children  of  the  other  schools 
being  for  th.e  time  exempt." 

iS'o  disease  of  temperate  regions  proves  more  fatal  to  physicians  and 
nurses.  There  seems  to  be  particular  danger  in  the  examination  and 
swabbing  of  the  throat,  for  in  the  gagging,  coughing,  and  spluttering 
efforts  the  patient  may  cough  mucus  and  flakes  of  membrane  into  the 
physician's  face.  The  virus  attaches  itself  to  the  clothing,  the  bedding, 
and  the  room  in  which  the  patient  has  lived,  and  has  m  many  instances 
displayed  great  tenacity.  It  has  been  found  to  live  on  blood  serum  for 
one  hundred  and  fifty-five  days,  in  gelatin  for  eighteen  months,  dried  on 
silk  threads  for  one  liuiulred  and  seventy-two  days,  on  a  child's  plaything 
whicii  had  been  kept  in  a  dark  place  for  live  months,  in  bits  of  dried 
membrane  for  from  fourteen  to  twenty  weeks.  They  have  been  found, 
too,  in  the  dust  of  a  diphtheria  pavillion,  and  in  the  iuiir  and  clothing  of 
the  mirses  in  attendance  upon  iliphtheria  babies  (Wriglit  and  Emerson). 

The  disease  may  be  transmitted  by  inoculation. 

Calves,  cats,  aiul  fowls  are  subject  to  contagious  membranous  diseases, 
whicli  are,  however,  not  identical  with  diphtheria  in  man  and  are  not 
communicable  to  him. 

As  in  other  infectious  disorders,  individual  susceptibility  plays  an  im- 
portant role.  Not  only  do  very  numy  of  those  exposed  escape,  but  even  of 
those  in  whose  throats  the  bacilli  lodge  and  grow. 

Of  predisposing  causes  age  is  one  of  the  most  iinportant.  Very  young 
children  are  rarely  attacked,  but  .. acobi  states  that  he  has  seen  three 
instances  of  the  disease  in  the  newl;  born.  Between  the  second  and  the 
fifteenth  year  a  large  majority  of  tno  cases  occur.  In  this  period  the  great- 
est nuinl)er  of  deaths  is  between  the  second  and  the  fifth  years.  Girls  are 
attacked  in  larger  numbers  than  boys,  probably  because  they  are  brought 
into  closer  contact  with  the  sick.  Adults  are  frequently  affected.  Tiie 
disease  is  most  prevalent  in  the  cold  autumn  weather.  The  secondary 
pseudo-membranous  inflammations,  caused  usually  by  the  streptococcus, 
attack  debilitated  persons,  the  subjects  of  fevers,  particularly  of  scark't 
fever,  tyi^hoid,  and  measles. 

Caille  regards  as  special  predisposing  elements  in  children  enlarged 
tonsils,  chronic  naso-pharyngeal  catarrh,  carious  teeth,  and  an  unhealthy 
condition  of  the  mucous  membrane  of  the  mouth  and  throat. 


st 


DIPHTHERIA. 


105 


Kiiidoiiiips  vary  in  intensity.  Wliilo  in  some  the  alTeotion  is  mild  and 
raivlv  fatal,  in  others  it  is  characterized  by  wide  extension  of  the  mem- 
brane, and  shows  a  special  tenden(>y  to  attack  the  larynx. 

The  Klebs-Loeffler  bacillus  occurs  in  a  larije  percentage  of  all 
suspected  eases.  It  is  found  chielly  in  the  false  membrane,  and  does  not 
extend  into  the  snbjac^ent  mucosa.  In  the  majority  of  instances  the  atfec- 
tien  is  local,  and  only  a  few  organisms  jienetrate  into  the  interior.  In 
exceptional  instances  the  bacilli  are  fonnd  in  the  blood  and  in  the  internal 
nrirans.  It  may  bo  the  predominating  organism  in  the  broncho-pneu- 
iiKiiiia  so  common  in  the  disease.  iJcsides  the  throat,  the  common  site 
of  its  morbid  action,  the  Klebs-Loeftler  bacillns  has  been  found  in  diph- 
theritic conjunctivitis,  in  otitis  media,  sometimes  in  wound  diphtheria, 
in  fibrinous  rhinitis,  and  by   Howard  in  a  case  of  ulcerative  endocar- 

Morphological  Characters. — The  bacillus  is  non-motile,  varies  from 
'i%}  ti) ;}  /x  in  length,  and  from  0-5  to  0-8  ft  [n  thickness.  It  appears  as  a 
straight  or  slightly  bent  rod  with  rounded  ends;  irregular,  bizarre  forms, 
such  as  rods  with  one  or  both  ends  swollen,  are  not  uncommon.  The 
baeilhis  stains  in  sections  or  on  the  cover-glass  by  the  (iram  method. 

It  grows  best  upon  a  mixture  of  glucose  bouillon  and  blood  serum 
(lioetllor),  forming  large,  elevated,  grayish-white  colonies  with  oparpie  cen- 
tres. It  grows  also  upon  all  the  ordinary  culture  media.  The  growth 
usually  ceases  at  temperatures  below  ^0°  C. 

The  bacillus  is  very  resistant,  and  cultures  have  been  made  from  a  bit 
of  membrane  preserved  for  five  months  in  a  dry  cloth. 

Variation  in  Virulence. — For  testing  the  virulence  the  guinea-pig  is 
used,  l)eing  most  susceptible  to  the  poison.  An  amount  of  a  forty-eight  hour 
bouillon  culture  equalizing  one  half  per  cent  of  the  weight  of  the  animal 
is  injected  subcutaneously.  "  A  fully  virulent  culture  is  one  which  causes 
the  death  of  a  guinea-pig  within  tiiree  days  or  less;  a  culture  of  medium 
virulence  one  which  causes  the  death  of  the  animal  in  from  three  to  five 
days.  Cultures  which  only  produce  local  necrosis  and  ulceration  or  death 
after  a  greater  number  of  days  nuiy  be  considered  as  of  slight  virulence  " 
(.1.  II.  Wright).  At  the  seat  of  the  inoculation  there  is  local  necrosis  with 
tibriiu)ns  cxiulate  which  contains  the  bacilli,  and  there  is  also  a  more  or 
loss  extensive  a'dema  of  the  subcutaneous  tissue.  The  Klebs-Loeffler 
baeilliis  evidently  has  very  varying  grades  of  virulence  down  even  to  com- 
plete absence  of  pathogenic  effects.  The  name  pseudo-bacillus  of  diph- 
theria should  not  be  given  to  this  organism. 

The  Presence  of  the  Klebs-Loeffler  Bacillus  in  Non-membranous  Angina 
andin  Healthy  Throats. — The  bacillus  has  been  isolated  from  cases  which 
show  nothing  more  than  a  simple  catarrhal  iingina,  of  a  mild  type  without 
any  membrane,  with  diffuse  redness,  and  perhaps  huskiness  and  signs  of 
eatarrhul  laryngitis.  lu  other  cases  the  anatomical  picture  may  be  that  of 
a  lacunar  tonsillitis. 


!      i  J 


106 


SPECIFIC   INPPICTTOUS  DISEASES. 


■^ 


During  the  prevalence  of  an  epidemic!  the  organisms  may  be  met  with 
in  perfectly  healthy  throats,  particularly  in  persons  in  the  same  house,  or 
the  ward  attendants  and  nurses  in  fever  hospitals. 

F()lh)wing  an  attack  of  diplitlieria  the  l)acilli  may  persist  in  tlie  throat 
after  all  the  menihrane  has  di8a])pcarcd  for  weeks  or  months.  Schiifcr 
notes  a  case  in  wliich  they  were  present  six  months  after  the  attack,  and 
in  a  nurse  in  my  ward  the  bacilli  jiersistod  for  eighty-four  days. 

Toxine  of  the  Klebs-Loeffler  Bacillus.— Koux  and  Yersin  showed  that 
a  fatal  result  following  the  inoculation  with  the  bacillus  was  not  caused 
by  any  extension  of  the  micro-organisms  within  the  body ;  and  they  "were 
enabled  in  bouillon  cultures  to  separate  the  bacilli  from  the  poison.  The 
toxine  so  separated  killed  with  very  much  the  same  effects  as  those  caused 
bv  the  inoculation  of  the  bacilli.  These  results  were  confirmed  by  many 
observers,  particularly  l)y  Sidney  Martin,  who  separated  a  toxic  albumose. 
The  precise  composition  of  the  body  is  still  doubtful. 

Production  of  Immunity. — Susceptible  animals  may  be  rendered  im- 
mune from  diphtheria  by  injection  of  the  dij)htheria  toxine,  at  first  weak- 
ened by  chemical  agents,  and  then  given  in  full  strength  in  gradually 
increasing  doses.  In  this  way  an  animal  may  become  insusceptible  to 
many  times  the  lethal  dose  of  the  toxine.  This  form  of  immunity  is 
called  antitoxic  immunity,  as  the  V)lood  and  other  fluids  of  the  immuni- 
fied  animal  have  acquired  the  property  of  neutralizing  the  effects  of  the 
toxine. 

The  Bacteria  associated  with  the  Diphtheria  Bacillus.— The  most 
common  is  the  streptococcus  pyogenes.  Others,  in  addition  to  the  organ- 
isms constantly  found  in  the  mouth,  are  the  micrococcus  lanceolatus,  the 
bacillus  coli  communis,  and  the  staphylococcus  albns  and  aureus.  Of 
these,  probably  the  streptococcus  pyogenes  is  the  most  imj)ortant,  as  cases 
of  general  infection  with  this  organism  have  been  found  in  diphtheriii. 
The  suppuration  in  the  lymph-glands  and  the  broncho-pneumotiia  are  usu- 
ally (though  not  always)  caused  by  this  organism. 

Pseudo-Diphtheria  Bacillus.— As  mentioned  above,  the  Klebs-Loefflor 
bacillus  varies  very  much  in  its  virulence,  and  it  exists  in  a  form  entirely 
devoid  of  pathogenic  properties.  This  organism  should  not  be  designated 
the  pseudo-diphtheria  bacillus.  The  name  "should  be  confined  to  bacilli 
which,  though  resembling  the  diphtheria  bacillus,  differ  from  it  not  only 
by  absence  of  virulence,  but  also  by  cultural  peculiarities,  the  most  iui- 
j)ortant  of  the  latter  being  greater  luxuriance  of  growth  on  agar,  and  the 
preservation  of  the  alkaline  reaction  of  the  bouillon  cultures"  (Welch). 

Diphtheroid  Inflammations. — Under  the  term  diphtheroid  niiiy 
be  grouped  those  membranous  inflammations  which  are  not  associated  with 
the  Klebs-Loeffler  bacillus.  It  is  perhaps  a  more  suitable  designation 
than  pseudo-diphtheria  or  secondary  diphtheria.  As  in  a  great  majority 
of  cases  the  streptococcus  pyogenes  is  the  active  organism,  the  term  "  strep- 
tococcus diphtheritis  "  is  often  used.     The  name  "diphtheritis"  is  best 


DIPIlTriERIA. 


107 


used  in  an  aniitoniiciil  sense  to  (l(vsig[niite  an  inflammation  of  a  mucous 
iiiciiil)raiie  or  integumentary  surfaee  clianicterized  by  necrosis  aiul  u  fibrin- 
ous I  xiidate,  whereas  the  term  "diphtiu'ria"  should  be  limited  to  the  dis- 
cii.-c  ciiiised  by  the  Klebs-Loeffler  bacillus.  'I'he  jjroportiou  of  eases  of 
(liijhllicroid  inflammation  varies  greatly  in  the  dilTorent  statistics.  Of  the 
l;u'i:('  luiniber  of  observations  made  by  l*ark  and  Heebe  (5,011)  in  New 
York,  40  per  cent  were  diphtheroid.  Figures  from  other  sources  do  not 
show  so  high  a  percentage. 

It  is  not  to  be  inferred  from  these  statistics  that  any  considerable 
iiiiiiitx'r  of  the  cases  which  present  the  appearances  of  typical  and  char- 
iictcristic  primary  (iiphtheria  are  due  to  other  micro-organisms  than  the 
Klchs-Loclfler  bacillus.  Nearly  all  such  cases,  when  carefully  examined 
1)V  a  conipotent  bacteriologist,  are  found  to  be  due  to  the  diphtheria  bacil- 
lus. It  is  the  less  characteristic  cases,  with  uiore  or  less  suspicion  of  diph- 
tlicriii,  whi(;h  are  nujst  likely  to  be  caused  by  other  bacteria  than  the 
Klflis-Locincr  l)acillus.  It  is  also  to  be  vemembered  that  in  the  routine 
examination  of  a  large  number  of  cases  for  boards  of  health  and  diph- 
theria wards  of  hospitals,  some  cases  of  genuine  diphtheria  nuiy  escape 
recognition  by  lack  of  such  re]H'ated  and  thorough  ba(!teriologi(;al  tests 
as  are  sometimes  rerpiired  for  the  detection  of  cases  ])resenling  unusual 
dilliculties. 

('()ii(/ifion!<  tinder  v/iich  the  Diphtheroid  Affevtion  occurs. — Of  450 
eases  (I'ark  and  Heol)t')7  300  occurred  in  the  autumn  months  and  150 
ill  the  sjiring;  108  of  the  eases  occurred  in  children  from  the  first  to  the 
seventh  year.  In  a  large  proportion  of  all  the  cases  the  disease  de- 
velops in  children,  and  can  oidy  bo  differentiated  from  dii)htheria  proper 
by  the  bacteriological  e.\aminatioi\.  In  many  of  the  cases  it  is  simply  an 
acute  catarrhal  angina  with  lacunar  tonsillitis. 

The  diphtheroid  inflammations  are  particularly  prone  to  develop  in 
connection  with  the  acute  fevers. 

{it)  Scarlet  Fever. — In  a  large  proportion  of  the  cases  of  angina  in 
sciiilct  fever  the  Klebs-Loeffler  bacillus  is  not  present.  Booker  has  re- 
ported 11  cases  complicating  scarlet  fever,  in  all  of  which  the  strepto- 
cocci were  the  predominant  organisms.  Of  the  450  cases  of  Park  and 
Hi'cbe,  42  comj)licated  scarlet  fever.  The  angitui  of  this  disease  is  not 
always,  however,  due  to  the  streptococcus.  Where  diphtheria  is  prevalent 
and  ojiportunities  are  favorable  for  exposure,  a  large  proportion  of  the 
casi's  of  meinbra!ious  throats  in  scarlet  fever  may  be  genuine  diphtheria, 
as  is  shown  by  the  statistics  of  Williams  and  Morse  in  the  Boston  City 
Hospital.  Here,  of  97  cases  of  scarlet  fever,  membranous  angina  was 
pivstnt  in  35;  in  13  with  the  Klebs-LocfT^ler  bacillus,  and  in  23  other 
organisms.  Morse  reports  91)  cases  of  angina  in  scarlet  fever  in  which  70 
were  diiihtlieroid.  This  large  proportion  of  cases  in  which  scarlet  fever 
was  associated  with  true  diphtheria  is  attrib'.i',ed  to  local  conditions  in  the 
hospital. 


108 


SPHriFIC    INI'^HCTIOUS   DISKASMS. 


mi 


{!))  ^fen!<lps. — Moinhnuious  aiifjiiiii  is  much  less  common  in  this  di^^- 
case.  It  occurrt'd  in  0  of  tlio  4r»()  diplillioroid  casco  in  Mow  York.  Of  1 
(•uses  witii  s(^vi'ro  mcnihranoiis  anj^ina  at  tlio  Boston  City  Hospital,  oiir 
only  presented  tlio  Klclts-LoctlU'r  l>acillns. 

(r)  \\'/to()pi)if/-con(//i  may  also  bo  complicated  with  membranous  an- 
jrina.  'i'he  bactoriolotric^al  examinations  liave  not  been  very  numerous. 
Eseherieh  gives  four  eases,  in  all  of  whieh  the  Klebs-IiOelHer  bacillus 
was  found. 

{(/)  'l)iph(ti(l  Fci'cr. — Membranous  inflammations  in  this  disease  aiv 
not  very  infrefpient,  and  they  nuiy  occur  in  the  throat,  the  pelvis  of  tlir 
kidney,  the  bladder,  or  the  intestines.  The  coni])lieation  jnay  be  caused 
by  the  Klel)s-Loeffler  bacillus,  which  was  present  in  four  cases  descrilxd 
by  Morse.     It  is  frequently,  however,  a  stre])tococcus  infection. 

Ernst  Wagner  has  remarked  upon  the  greater  frequency  of  these 
membranous   inllammations   in    ty])iioid    fever  when  diphtlieria  is   ])rc- 


-■^: 


Cliincal  Fcitt lives  of  thv  Diphtlicniid  Affection. — The  ctases,  as  a  rule, 
are  milder,  and  the  mortality  is  low,  only  ^'o  per  cent  in  the  4r)()  cases  of 
Park  and  lieebe.  'IMie  diphtheroid  inllammations  complicating  the  spe- 
cific fevers  are,  however,  often  very  fatal,  aiul  a  general  stre])tocoecMs 
infection  is  by  no  means  infrequent.  As  in  the  Klebs-LoefHer  angin:i, 
there  may  be  oidy  a  sinqile  catarrhal  process.  In  other  instances  the 
tonsils  are  covered  with  a  creamy,  pultaceous  exudate,  without  any  actual 
membrane.  An  important  group  may  begin  as  a  simple  lacunar  tonsilli- 
tis, while  i)i  others  the  whole  fauces  and  tonsils  are  covered  by  a  continu- 
ous membrane,  and  there  is  a  foul  sloughing  angina  with  intense  consii- 
tutional  disturbaiufo. 

Are  the  di})htheroid  cases  infectious?  General  clinical  experieuee 
warrants  the  statenuMit  that  the  menibranous  angina  associated  with 
the  fevers  is  rarely  communicated  to  other  patients.  The  health  depart- 
ment of  New  York  does  not  keep  the  diphtheroid  cases  under  super- 
vision. Their  investigation  of  the  450  diphtheroid  cases  seems  to  jus- 
tify tliife  coiudusion.  Park  and  Beel)e  say  that  "  it  did  not  seem  thai 
the  secondary  cases  were  any  less  liable  to  occur  wliere  the  primary  case 
was  isolated  than  when  it  was  not." 

Sequelw  of  the  Diplitlievuitt  Ani/ina. — The  milder  type  is  in  part,  no 
doubt,  due  to  the  less  frequent  systemic  invasion.  Some  of  the  worst 
forms  of  general  streptococcus  infection  are,  however,  seen  in  this  dis- 
ease. There  are  no  peculiarities,  local  or  general,  which  can  be  in  any 
way  regarded  as  distinctive;  and  if  the  observation  of  Bourges  should  lie 
corroborated,  even  the  most  extensive  paralysis  may  follow  an  angina 
caused  by  it. 

Morbid  Anatomy.— A  majority  of  the  cases  die  of  the  faucia!  "r 
of  the  laryngeal  disease.  The  exudation  may  occur  in  the  mouth  antl 
cover  the  inner  surfaces  of  the  clieeks;  it  may  even  extend  beyond  tlie 


DiPirriiEiiiA. 


lU!) 


liiis  on  to  tlio  skill.  This  was  met  oiico  in  tliirty  iiutopsics  at  tlio  Mont- 
rciil  (u'luM'ul  Hospital.  Tiic  aiiionntof  oxiulatioii  varirs  in  dilTiTiiiit  cases. 
I'-ii.illv  tlie  tonsils  and  the  pillars  of  the  funees  are  swollen  and  eovered 
with  the  I'iilse  meinhraiie.  More  eoniiiiotily,  in  the  fatal  cases,  the  e.xiida- 
timi  is  verv  extensive,  involving  tin;  ii villa,  the  soft  ]»alati',  the  jjosterior 
ii.ires,  and  the  latenil  and  posterior  walls  of  tl'c  pharviix.  These  parts  are 
ciivered  with  a  dense  pseiido-inetiihranc,  in  places  firmly  adherent,  in 
111  hers  heiriiniin,ij;  to  separate.  In  extreme  cases  the  necrosis  is  advaiuicd 
ami  there  is  a  gangrenous  condition  of  tlic  parts.  The  niomhrano  is  6f  a 
(hrlv  greenish  or  gray  color,  and  thi;  tonsils  and  palate  may  he  in  a  state 
of  iiecrt)tic  sloughing.  The  erosion  may  he  deep  enough  in  the  tonsils  to 
(i)H'ii  the  carotid  artery,  or  a  false  aneurism  may  he  pro(liiced  in  the  deep 
tissues  of  the  neck.  The  nose  may  lie  completely  hlocked  hy  the  false 
iiu'iiihrane,  which  may  also  extend  into  the  conjunctiva'  and  through  the 
Ktistacdiian  tuhes  into  the  middle  ear.  In  cases  of  laryngeal  di[)litlieria 
the  exudate  in  the  jiharynx  may  he  extensive.  In  many  cases,  however,  it 
is  slight  upon  the  tonsils  and  fauces  and  ahundant  upon  the  epiglottis  and 
the  larynx,  which  may  be  completely  occluded  hy  false  membrane.  In 
i^evcre  cases  the  exudate  extends  into  the  trachea  and  to  the  bronchi  of 
tlic  third  or  fourth  dimension.  This  occurred  in  nearly  half  of  my  thirty 
Montreal  autojisies. 

In  all  these  situations  the  membrane  varies  very  much  in  consistency, 
(Icpendiug  greatly  upon  the  stage  at  which  death  happens.  If  death  has 
occurred  early,  it  is  firm  and  closely  adherent ;  if  late,  il  is  soft,  shreddy, 
and  readily  detacdied.  When  firmly  adherent  it  is  torn  off  with  difliculty 
iiiid  leaves  an  abraded  mucosa.  In  the  most  extreme  cases,  in  which  there 
is  extensive  necrosis,  the  parts  look  gangrenous.  In  fatal  cases  the  lym- 
{iliatic  glands  of  the  neck  are  enlarged,  and  there  is  a  general  infiltration 
of  the  tissues  with  serum;  the  salivary  glands,  too,  maybe  swollen.  In 
rare  instances  the  membrane  extends  to  the  gullet  and  stomach. 

On  inspection  of  the  larynx  of  a  child  dead  of  membranous  croup,  the 
riiiKi  is  seen  filled  with  mucus  or  with  a  shreddy  material  which,  when 
wiishod  off  carefully,  leaves  the  mucosa  covered  by  a  thin  grayish-yellow 
iin'inhrane,  which  may  be  unif<n'in  or  in  patches.  It  covers  the  ary-epi- 
dottic  folds  and  the  true  cords,  and  may  be  continued  into  the  ventricles 
<ir(\('n  into  the  trachea.  Above,  it  may  involve  the  epiglottis.  It  varies 
nuK'h  in  consistency.  I  have  seen  fatal  cases  in  which  the  exudation  was 
Hot  actually  nieml)ranous,  but  rather  friable  and  granular.  It  nmy  form 
a  thick,  even  stratified  membrane,  which  fills  the  entire  glottis.  The  ex- 
iiihitidii  may  extend  down  the  trachea  and  into  the  bronchi,  and  may  pass 
hi'voiiil  the  e[>iglottis  to  the  fauces.  Usually  it  can  be  readily  stripped  off 
tidin  the  mucous  membrane  of  the  larynx  and  leaves  exjiosed  the  swollen 
anil  injected  mucosa.  On  examination  it  is  seen  that  the  fibrinous  mate- 
rial lias  involved  chiefly  the  epithelial  lining  and  has  not  greatly  infiltrated 
the  subjacent  tissues. 


110 


SPECIFIC  IXFKCTIOUS   DISEASES. 


[^Mi 


Jlislolof/ii'dl  C/i(in(/cs. — Wc  owe  largely  to  the  Itiiiors  of  Wu^riior,  Woi- 
gert,  and  more  particularly  to  the  splendid  work  of  Oertel,  our  knowledge 
of  the  niiiiute  changes  which  dike  place  in  diphtlu'ria.  The  following  is 
u  brief  abstract  of  the  views  of  the  last-named  author: 

The  diphtheritic  poison  induces  lirst  a  necrosis  or  death  of  cells  with 
which  it  conies  in  contact,  ])articularly  the  superficial  epithelium  and  the 
leucocytes.  The  deeper  cells  of  the  mucosa  und  of  the  other  parts  reaciied 
by  the  poison  may  also  l)e  alfected.  The  second  change  is  hyaline  trans- 
forniiilion  of  the  dead  cells,  or,  as  Weigert  terms  it,  the  production  of  co- 
agulation-necrosis. Tiic  bacilli  excite  inllanunation  with  the  migration  of 
leucocytes,  which  are  destroyed  by  the  poison  and  undergo  the  hyaline 
change.  The  superficial  e])ithelial  layers  undergo  a  sinular  alteration,  and 
whul  we  know  as  the  false  nuMubrane  rej)resents  in  large  part  an  aggrega- 
tion of  dead  cells,  most  of  which  have  umlergone  the  transformation  into 
hyaline  mateiial,  and  have  become  nuu^h  distorted  in  shape.  Genuine 
fibrinous  exudate  is,  however,  associated  with  this  coagulation-necrosis  of 
cells.  This  is  in  all  probability  a  conservative  process  by  which,  in  a  meas- 
ure, the  poison  is  localized  and  jjrevented  from  reaching  the  deeper  struc- 
tures. The  laminated  condition  of  the  exudate  is  probably  i)roduced  by 
the  inflamnuition  of  ditterent  layers.  Tiie  formation  of  these  foci  of 
necroI)i()sis,  starting  from  the  oj)ithelium  and  proceeding  inward,  is,  ac- 
cording to  Oertel,  the  distinguishing  characteristic  of  diphtheria.  The 
action  of  the  i)oi8on  is  by  no  means  conlined  to  the  superficial  mucosa 
on  which  the  bacilli  grow.  Although  they  do  not  themselves  pene- 
trate deeply,  the  contiguoua  bronchial  glands  show  extensive  foci  of 
necrosis.  In  severe  cases  these  necrotic  areas  are  found  in  the  internal 
organs,  in  the  solitary  glands  of  the  intestines,  und  in  the  mesenteric 
glands. 

The  blood-vessels  may  themselves  be  much  altered  and  the  capillaries 
may  show  extensive  hyaline  degeneration.  Every  one  of  the  histological 
changes  described  by  Oertel  in  luinum  diphtheria  nniy  be  paralleled  in  the 
exijcrimental  disease  induced  by  the  Kleb.s-Loeffler  l^acillus.  Welch  and 
Flexner  have  shown  that  similar  foci  of  necrosis  with  nuclear  fragmenta- 
tion in  lymphatic  glands,  the  liver,  spleen,  intestinal  mucosa,  and  other 
parts,  occur  in  the  experimental  diphtheria  of  guinea-pigs,  and  they  have 
demonstrated  that  these  necroses  are  due  to  the  so-called  tox-albumin  of 
the  diphtheria  bacillus.  The  local  exudate  is  caused  by  the  bacilli  them- 
selves and  cannot  be  produced  by  the  tox-albumin  alone. 

The  changes  in  the  other  orcjans  are  variable.  When  death  has  oc- 
curred from  asphyxia  there  is  general  congestion  of  the  viscera. 

Cajiillary  bronchitis,  areas  of  collapse,  and  pat(;he>  of  broncho-pneu- 
monia are  almost  constantly  found  in  fatal  cases.  The  broncho-pneumo- 
nia complicating  diphtheria  often  contains  the  Klebs-Loeffler  bacillus,  but 
usually  in  combination  with  the  streptococcus  pyogenes  or  the  diplococcus 
pneumoniae.     These  latter  organisms,  particularly  the  strei^tococcus,  are 


111   V( 


DllMITIlKUIA. 


Ill 


tlio  niH-t  froqiioiit  cimso  of  tlic  piiliMoiiJiry  rnniplicatidiis  of  (li[ilitlic'riii. 
In  v('r\  malii^Miaiit  cases  tlic  Idoixl  may  he  lliiid.  Kibriiioiis  (toagiila  may 
l)f  fiiiiiiil  ill  the  heart,  but  the  widc-sjircud  idea  that  tlicy  may  cause  siid- 
ilfii  death  is  erroneous.  Myocardial  chuiif^es  arc  not  infrequent,  anil  in 
ccilaiii  eases  .sudden  di'uth  is  due  to  heart-failure  in  consequence  of  de^'eii- 
cruiiiiii  of  tiie  mu.sclc-lihi'cs.  Endocarditis  is  extremely  rare.  It  was  not 
iiicseiit  in  one  of  my  thirty  autoj)sies.  'i"he  serous  membranes  often  show 
ei'cliviiioses.  The  kidneys  ])resent  parenchymiitous  clian<^('s,  such  us  are 
assdcialed  with  acute  febrile  alTcctioiis.  'riiero  may,  however,  be  acute 
ne|»luilis.  'J'he  si'leen  and  liver  show  the  usual  febrile  changes.  Tho 
siilcen  is  not  always  enlarged.  Cicneral  streptococcus  se])tica'mia  or 
Itsioiis  of  internal  organs  due  to  localizati(»iis  of  the  streptococcus  pyo- 
ireiits  are  common  and  most  dangerous  com])lieations  of  diphtheria.  The 
KK'lis-Loelller  bacillus  niay  be  found  at  uuto})sy  iu  the  blood  and  internal 
(iri,'ans.  liiit  usually  only  in  small  numher. 

Symptoms. — The  period  of  incubation  is  "from  two  to  seven  days, 
ofteiiest  two.'' 

The  initial  symptoms  arc  those  of  an  ordinary  febrile  attack — slight 
chilHiiess,  fever,  and  a(diing  jjiiins  in  the  back  and  limbs.  In  mild  cases 
tliese  symptoms  arc  trilling,  and  the  child  may  not  feci  ill  enough  to  go 
to  Iji'd.  Usually  the  temperature  rises  within  the  first  twenty-four  hours 
to  in'*-5°  or  103° ;  in  severe  cases  to  1()-1°.  In  young  children  there  may 
be  convulsions  at  the  outset. 

Pharyngeal  Diphtheria. — In  a  tyjucal  ease  there  is  at  first  redness  of 
the  fauces,  and  the  child  complains  of  slight  diniculty  in  swallowing. 
The  membrane  first  appears  upon  the  tonsils,  and  it  may  be  a  little  ditli- 
citlt  to  distinguish  a  patchy  diphtheritii.'  pellicle  from  the  exudate  of  the 
tonsillar  crypts.  The  pharyngeal  mucous  mcnd^rane  is  reddened,  and 
the  tonsils  themselves  are  swollen.  By  the  third  day  the  nuMubrane  has 
covered  the  tonsils,  the  pillars  of  the  fauces,  and  perha])s  the  uvula,  which 
is  thickened  and  (edematous,  and  may  fill  completely  the  space  between 
the  swollen  tonsils.  The  membrane  may  extend  to  the  posterior  wall  of 
the  pliarynx.  At  first  grayish-white  in  color,  it  changes  to  a  dirty  gray, 
often  to  a  ycdlow  white.  It  is  firmly  adherent,  and  when  removed  leaves 
a  bleeding,  slightly  eroded  surface,  which  is  soon  covered  by  fresh  exudate. 
The  glands  in  the  neck  are  swollen,  and  may  be  tender.  The  general 
condition  of  a  patient  in  a  case  of  moderate  severity  is  usc.ally  good;  the 
teni|u'nitiire  not  very  high  iu  the  absence  of  complications  ranging  from 
10:2'  to  l(i;r.  The  pulse  range  is  from  100  to  IvM).  The  local  condition 
of  the  tliroat  is  not  of  great  severity,  and  the  constitutional  depression  is 
slight.  The  symptoms  gradually  abate,  the  swelling  of  the  neck  dimin- 
ishes, tlie  membranes  separate,  and  from  the  seventh  to  the  tenth  day  the 
throat  becomes  clear  and  convalescence  sets  in. 

Clinically  atypical  forms  are  extremely  common,  and  I  follow  here 
Koplik's  division : 


"If 


■ 


f  ; 


illli 


I: 


112 


SIMICIKM;  IM-'KCTIOrs  diskasks. 


(it)  'riicrc  luiiy  he  no  Incjil  iimiiifi'Htiifioii  of  mcnihrimo.  Vmt  n  sitnpic 
ciitarili.il  aniriim  associiitfd  soiiicliiiics  with  a  croiiiiy  joii^rli.  'I'lu'  dt'tt'c- 
ti(»ii  ill  these  eases  of  the  Kh'lis- Loetller  liaeilliis  (.'an  alone  detci'iiiino  the 
(iia;;iiu.>in.  Siieh  eases  are  of  j,'n'at  nioiiii'til,  iiiasnuieh  im  lliey  inay  coiii- 
iniiiiieaU!  tho  sevorer  diseaMe  to  otiier  ehildroji. 

(//)  'I'heie  are  eases  in  whieh  tlie  tonsils  are  eovert'(l  by  ii  pultuceoiis 
exudate,  not  a  eonsisleiit  nieiiihrane. 

(r)  Cases  presenting,'  a  punctate  form  of  nieinhrane,  isolated,  ami 
usually  on  the  siirfaee  of  the  tonsils. 

(i/)  Cases  which  he^dti  and  often  run  their  entire  eourwe  wifli  the  local 
I)icture  of  a  typical  lacunar  aniyifdalitis.  Tlu^y  may  he  mild,  and  the 
lor-al  exudate  jnay  not  extend,  hut  in  other  eases  tlu-n?  are  rapid  develop- 
ment of  memhraiie,  and  extension  of  the  disease  to  the  iiharynx  and  the 
uo.se,  with  wevere  septic  and  eonstitutional  .symptomH. 

(r)  ruder  the  term  ''latent  diphtheria"  Heiihrier  lia.s  described  cases, 
usually  .seeoiidarv,  oc<',urrin<;  ehielly  in  hospital  practice,  in  yoiinj^  per.soii> 
the  siihject  of  wastiiii,'  aiTi'ctions.  such  as  rickets  and  tiihereulosis.  'I'lierc 
are  fever,  naso-pliaryn<real  catarrh,  and  irastro-intestinal  distnrljanees. 
Diphtheria  may  not  he  suspe<'ted  until  .severe  laryngeal  complications 
develop,  or  the  condition  may  not  he  determined  until  post  mortem. 

Systemic  Infection. — The  constitutional  distiirbaiu^e  in  mild  dijjhtheria 
is  very  slight.  There  are  instances,  too,  of  extensive  local  disease  without 
grave  systemic  symptoms.  As  a  rule,  the  general  features  of  ii  case  bear 
a  delinite  relation  to  the  severity  of  the  local  disease.  There  arc  rare 
instances  in  which  from  tho  outset  the  constitutional  prostration  is  ex- 
treme, the  pulse  friMpient  and  small,  the  fever  high,  and  tin;  nervous 
phenomi'iia  pronoinuicd  ;  the  patient  may  sink  in  two  or  three  days 
overwhelmed  by  the  intensity  of  the  toxa-mia.  'J'here  are  cases  of  this 
sort  in  which  the  exudation  of  the  tliroat  nuiy  be  sliglit,  but  usually  the 
nasal  symptoms  are  pronounced.  The  temperature  may  be  very  slightly 
raised  or  even  subnormal.  More  commonly  the  .severe  .systemic  symii- 
toms  appear  at  a  later  date  when  the  pharyngeal  lesion  is  at  its  height. 
They  are  constantly  present  in  extensive  di.sea.se,  and  when  there  is  a 
sloughing,  fietid  condition.  'J'he  lympliatic  glands  })ecome  greatly  en- 
larged ;  the  pallor  is  extreme;  the  face  has  ini  ashen-gray  hue;  the  pulso 
is  rapid  and  feeble,  aiul  the  temperature  si^iks  below  normal.  In  tho 
most  aggravated  forms  there  are  gangrenoi.s  ])roce.s.ses  in  the  throat,  and 
in  rare  instances,  when  life  is  prolong(id,  extensive  sloughing  of  the  tis- 
sues of  the  neck. 

Escherich  accounts  for  tho  discro2>ancy  sometimes  observed  between 
the  severity  of  the  constitutional  disturbance  and  the  intensity  of  the 
local  process,  by  assuming  varying  degrees  of  susceptibility  to  the  dij)!!- 
tlieria  bacillus  on  tbe  one  hand,  and  to  its  poison  on  the  other  hand. 
With  high  local  susceptibility  of  a  part  to  tho  .action  of  the  bacillus,  with 
little  general  susceptibility  to  the  toxine,  there  is  extensive  local  exudate 


IHrilTIIKUIA. 


113 


will)  iiiiM  constitiitioniil  syiiijttiim.-!.  or  rirr  n'rsri.  sovcro  systpiuic  distiirl)- 
iiiii'i'  uilh  liiiiiU'il  Idciil  iiilliiiniiiiilioii. 

A  ltiif(((!yt()sis  Im  [trcsciit  in  iliplilliciiii.  Morse  dues  tint  thiiiU  iti>f  iiny 
iirnu'iiiistio  value,  siiicf  it  is  |ireseiit  .-iiid  iiiiiy  lie  proiutimeed  in  mild  eascrt. 

Niisal  Diphtheria.- -Ill  cases  of  iiliarvnirfal  di|tlitlieria  tlie  Klehs-I.oef- 
llri'  liiii'ilhis  is  round  on  llie  niiieous  nieinltrane  of  {\\v  )ios(>  and  in  tin; 
seen'tioiis,  oven  when  no  ineniltraiie  is  present,  hut  it  may  apparently 
liidiliice  luo  alTeetions  .similar  eiiou<fh  loeully  hut  widely  dill'erin^  in 
their  general  features. 

In  niemhraiioiis  or  lihrinoiis  rhinitis,  a  very  reinarkahle  alfeetioii  noon 
iisnally  in  children,  the  iiares  are  occupied  by  tliicdx  ineinliranes,  hut  theiv 
is  an  entire  ahseiice  of  any  constitutional  distiirhaiujo.  The  condition 
has  lii'cii  studied  very  carefidly  hy  Park.  Alihott,  (ierher  and  l'o(la(d\, 
jind  others.  I{avenel  has  collected  seventy-seven  cast's  {.Medical  News, 
1S!I."),  1),  in  forty-one  of  whiidi  a  lia>'teriolo^ical  exaniination  was  made, 
and  ill  thirty-throe  the  Klehs-Iioelller  bacillus  was  pi'e.scnt.  ,\11  the  eases 
rah  a  heni;L,ni  course,  iind  in  all  hut  a  few  the  membrane  was  limited  to 
the  no.so,  and  the  constitutional  symj)toins  were  either  absent  or  very 
sliirht.  IJemarkable  and  puzzling  features  are  that  the  diseas(>  runs  a 
luiiiun  coiii'se,  and  that  infection  of  other  children  in  the  family  is  e.\- 
trcniely  rare. 

Ou  the  other  band,  nasal  diphtheria  i.s  apt  to  present  a  most  nnilignant 
type  of  the  di.^ease.  '^I'lie  infection  may  be  ])rimary  in  tlu'  nose,  and  in  a 
ease  recently  in  my  wards  there  was  otitis  media,  and  the  Klebs-i.oetlU'r 
liacilhus  was  separated  from  the  discharge  before  the  condition  of  na.sal 
diphtheria  was  suspeet(!d.  While  sonu'  (^ases  are  of  mild  chara(^ter,  others 
are  very  intense,  and  the  constitutional  symjttoms  most  profound.  'I'he 
"glandular  inllainniiition  is  usually  very  intense,  due,  as  Jacobi  points  out, 
to  the  great  richness  of  the  nasal  mucosa  in  lymphatics.  l''rom  the  nose 
the  iMllainnuition  may  extend  through  the  tear-ducts  to  the  conjunctiva 
and  into  the  antra. 

Laryngeal  Diphtheria. --.l^'/«/;/vN/«/^s■  Craiip. — With  a  very  large  pro- 
jioitioii  of  all  the  cases  of  membranous  laryngitis  the  Klebs-l.,oelHer 
bacillus  is  associated  ;  in  a  much  smaller  number  other  organisms,  jiarticu- 
larly  the  streptococcns,  are  found.  Membranous  croup,  then,  may  be  said 
to  he  either  genuine  di})litheria  or  diphtheroid  in  cbaracter.  Of  :^S(;  cases 
in  which  the  disease  was  contined  to  the  laryn.x  or  broiudu,  in  'i'X^.)  the 
Klehs-LoelTler  bacilli  were  found.  In  T)?  they  were  not  present,  but  17 
of  those  cultures  were  unsatisfactory  (I'ark  and  Beebe).  The  strepto- 
eocciis  cases  are  more  likely  to  bo  secondary  to  other  acute  diseases. 

Sijniptojnfi. — Xaturally,  the  clinical  symptoms  are  almost  identical  iu 
the  non-specific  ami  sjiecitic  forms  of  membranous  laryngitis. 

'I'ho  affection  begins  like  an  acute  laryngitis  with  slight  hoarseness  and 
rough  cough,  to  which  the  term  croupy  has  been  applied.  After  these 
symptoms  have  lasted  for  a  day  or  two  with  varying  intensity,  the  child 


I  ■-.'  (. 


114 


SPECIFIC   INFECTIOUS   DISEASES. 


\'--  h, 


sufldenly  becomes  worse,  usuiilly  at  niiflit,  iiiid  there  are  signs  of  impeded 
respiration.  At  (irst  tlie  diniculty  in  broatliing  is  paroxysnml,  due  proba- 
bly to  mure  or  less  spasm  of  the  niusfles  of  the  glottis.  Soon  (Ir  dyspnu'u 
becomes  coiitiiiiious,  insj)iration  and  e.xpiration  become  dilllcndt,  particularly 
the  latter,  and  with  the  ins[tiratory  movements  tlie  epigastrium  and  lower 
intercostal  spaces  are  retracted.  'JMie  voice  is  husky  and  may  be  reduced 
to  a  whisper.  The  color  gradually  changes  and  the  imperfect  aeration  of 
the  blood  is  shown  in  the  lividity  of  the  lips  and  finger-tijjs.  Kestlessness 
comes  on  and  the  child  tosses  from  side  to  side,  vainly  trying  to  get  breath. 
Occasionally,  in  a  severer  paro  :ysm,  portions  of  membrane  are  coughed  out. 
The  fever  in  membraiunis  laryngitis  is  rarely  very  h.igh  and  the  condition 
of  the  child  is  usually  very  good  at  the  time  of  the  onset.  The  pulse  is 
always  increased  in  frequency  and  if  cyanosis  be  present  is  sniiill.  In  fav- 
orable cases  the  dyspiuea  is  not  very  urgent,  the  color  of  the  face  renuuns 
good,  and  after  one  or  two  paroxysms  the  child  goes  to  sleep  and  wakes  in 
the  morning,  perhaps  without  fever  and  feeling  comfortable.  The  attack 
may  recur  the  following  night  with  greater  severity.  In  unfavorable  cases 
the  dyspmea  becomes  more  and  more  urgent,  the  cyanosis  deepens,  the 
cliild,  after  a  jieriod  of  intense  restlessness,  sinks  into  a  semi-comatose 
state,  and  death  finally  occurs  from  poisoning  of  the  nerve  centres  by  car- 
bon dio.dde.  In  other  cases  the  onset  is  less  sudden  and  is  })recetled  by  a 
longer  pericxl  of  indisposition.  As  a  rule,  there  are  pharyngeal  symptoms. 
The  constitutional  disturbance  nuiy  be  more  severe,  the  fever  higher,  and 
there  may  be  swelling  of  the  glands  of  the  neck.  Inspection  of  the  fauces 
may  show  the  presence  of  false  membranes  on  the  i)illars  or  on  the  tonsils. 
Bacteriological  examination  can  al()iu>  determine  whether  these  are  due  to 
the  Klebs-Loetller  bacillus  or  to  the  streptococcus.  Fagge  held  that,  non- 
contagious membranous  croup  nniy  spread  upward  from  the  larynx  just  as 
diphtheritic  inllammation  is  in  the  habit  of  spreading  downward  from  the 
fauces.  Ware,  of  Boston,  whose  essay  on  croup  is  perhaps  the  most  solid 
contribution  to  the  subject  made  in  this  country,  re[)orted  the  presence  of 
exudate  in  the  fauces  in  T-i  out  of  75  cases  of  croup.  These  observations 
were  made  prior  to  184(1,  during  ])eriods  in  which  diphtheria  was  not 
epidemic  to  any  extent  in  Boston.  In  protracted  cases  pulmonary  symp- 
toms may  develoj),  which  are  sometimes  due  to  the  difficulty  in  expelling 
the  mueo-pus  from  the  tubes;  in  others,  the  false  membrane  exteiuls  into 
the  trachea  and  even  into  the  bronchial  tubes,  huring  the  paroxysm  the 
vesicular  mui'niur  is  scarcely  audible,  but  the  laryngeal  stridor  nuiy  be 
loudly  commuincated  along  the  bronchial  tubes. 

Diphtheria  of  Other  Parts. — Primary  dii)htheria  occurs  occasionally 
in  the  coiij/uic/ii'd.  It  follows  in  some  instances  the  affection  of  the 
nasal  mucous  membrane.  Some  of  the  cases  are  severe  and  serious,  but 
it  has  been  shown  l)y  C.  Frjinkel  and  others  that  the  diphtheria  bacilli 
may  be  present  in  a  conjunctivitis  catarrhal  in  character,  or  associated 
with  only  slight  croupous  deposits. 


DIPHTHERIA. 


115 


IlliUlV 

tll'r 

l>\lt 

licilli 

lutrtl 


Diphflioria  of  tlie  oxtoniaJ  cDidiforji  virah(s  is  soon  in  raro  instancos 
;•;  wliicli  tliore  aro  diplitlioritic  otitis  niodia  and  oxtonsion  tlirougli  tlio 
-vnipiinic  niotnbrano. 

niplitheria  of  the  ,'^kin  is  most  frequontly  scon  in  tlio  sovoror  forms  of 
pliJirvufroal  diplitlioria,  in  wliich  the  membrane  extends  to  the  mouth  and 
lips,  and  invades  tlie  adjacent  ])ortions  of  tlie  skin  of  the  faee.  The  skin 
alioiit  thi'  anus  and  t^eiiitals  may  also  he  attacked.  Pseiido-mend)ranons 
iiitlaiiiination  is  not  uncommon  on  ulcerated  surfaces  and  wounds.  In 
vrrv  many  of  tiiese  cases  it  is  a  streptococcus  infection,  but  in  a  majority, 
pcrliapH.  in  which  tlie  patient  is  sutTerinti^  witli  diplitluM'ia,  the  Klobs-Loof- 
tlcr  bacillus  will  be  found  in  the  fibrinous  exudate.  As  proposed  by  Welch, 
the  term  "wound  diphtheria"  should  be  limited  to  infection  of  a  wound 
by  tlie  Klebs-Loelller  bacillus.  This  "may  manifest  itself  as  a  simple 
iiillainmation,  or  inllammation  with  superficial  necrosis  or  inflammation 
with  more  or  less  adherent  pseudo-membrane.  The  conditions  as  regards 
varying  intensity  and  character  of  the  infection,  association  with  other 
l),ii't('ria,  particularly  streptococci,  and  the  necessity  of  a  bacteriological 
examination  to  establish  the  diagnosis,  aro  in  no  way  dilTerent  in  the 
(liplitlieria  of  wounds  from  those  in  diphtheria  of  niiicous  membranes. 
Wound  diphtheria  may  occur  without  deiiioiistrai)lc  connection  with  cases 
of  diphtheria  and  without  affection  of  the  throat  in  the  individual  at- 
tacked, but  such  occurrences  are  rare  "  (Wehdi).  Paralysis  may  follow 
wound  dijditlieria.  Pseudo-membranous  inllamniations  of  wounds  are 
••aiised  more  frequently  by  other  micro-organisms,  particulai'ly  the  strop- 
tdcocci  jiyogenes,  than  by  the  Klelis-Loi'fllcr  bacillus.  The  librinous 
iiicmbrane  so  common  in  the  neighborhood  of  the  tracheotomy  wound  in 
(liplitlieria  is  rarely  associated  with  tlu'  Klebs-Loeffler  bacillus. 

Complications  and  Sequelae. —Of  local  complications,  ha^mor- 
rliagc  fruiii  tlie  nose  or  throat  may  occur  in  the  severe  ulcerative  eases. 
Skin  rashes  are  not  infrerpient,  jiarticularly  the  dilViise  erythema.  Occa- 
sidiiiilly  there  is  urticaria  and  in  the  severe  cases  purpura.  The  jnilmonary 
I'liiiipliciitions  are  extremely  important.  Fatal  cases  almost  invariably  show 
('iipiihiry  bronchitis  with  broncho-jineumonia  and  large  patches  of  collapse. 
Ill  viTV  bad  (!ases,  with  extensive  sloughing,  the  septic  particles  may  reach 
the  bronchi  and  excite  gangrenous  processes  which  may  lead  to  severe  and 
fatal  ha-morrhage. 

Heiial  com))lications  are  common.  Alhuminvrin  is  present  in  all 
.severe  cases.  It  may  cause  with  tlu'  usual  tests  only  a  slight  turbidity  of 
tlip  urine,  the  ordinary  febrile  albuminuria.  In  others  ttiere  is  a  large 
luiKuint  of  albumin,  curdy  in  character.  It  is  only  when  the  albumin  is  in 
poiisidorable  quantity  and  associated  with  epithelial  or  blood  casts  that  the 
i''iti(litioii  indicates  parenchymatous  nephritis  and  is  alarming.  The 
iit'phrilis  may  be  quite  early  in  the  disease.  It  sets  in  occasionally  with 
I'umpk'te  suppression  of  the  urine.  In  comparison  with  scarlet  fever  the 
I'oual  changes  lead  less  frequently  to  general  dropsy.     Mention  has  already 


111 


J 


IIG 


SPECIFIC   INFKCTIOLIS   DISEASES. 


f  s  ■ 


1)0011  rniido  of  tlio  froquency  and  gravity  of  septica^miii  and  local  infection 
of  iiitoriiiil  i)arta  due  to  invasion  of  the  streptococcus  i)yogenes,  which  is 
nearly  a  constant  attendant  of  tho  Klehs-Loonicr  bacillus  in  the  huniuu 
body. 

Of  the  seqnehT  of  diphtheria,  pdrah/Kifi  is  by  far  the  most  important. 
Tills  can  be  experimentally  produced  in  animals,  as  already  noted,  l)y  the 
inoculation  of  tlie  toxic;  niiiterial  producetl  by  tin;  bacilli.  Tiu^  paralysis 
occurs  in  a  varialile  jtroportion  of  the  cases,  ranging  from  10  to  15  and 
even  to  20  per  cent.  It  is  strictly  a  sequel  of  tiie  disease,  coming  on  usu- 
ally in  the  second  or  third  week  of  convalescence.  Occasionally  it  comes 
as  early  as  the  seventh  or  eighth  day  of  the  disease.  It  may  follow  very 
mild  cases;  indeed,  the  local  disease  may  be  so  trilling  that  the  onset  of 
tlie  paralysis  alone  calls  attention  to  tlie  true  nature  of  the  trouble.  It  is 
proportionately  less  frequent  in  children  than  in  adults. 

The  disease  is  a  toxic  neuritis,  due  to  the  absorj)tion  of  the  poison, 
and,  like  other  forms  of  multiple  neuritis,  has  an  extremely  complex  symp- 
tomatology, accoi'ding  to  the  nerves  which  are  alTcctod.  The  paralysis 
may  be  local  or  genond. 

Of  the  local  paralyses  the  most  common  is  that  which  affects  the  i)al- 
ate.  Tills  gives  a  nasal  character  to  the  voice,  and,  owing  to  a  return  of 
liquids  through  the  nose,  causes  a  dilliculty  in  swallowing.  Those  may  bu 
the  only  symptoms.  The  palate  is  seen  to  1)0  relaxod  and  motionless,  and 
the  sensation  in  it  i.s  also  much  impaired.  The  affection  may  extend  to 
the  constrictors  of  the  pharynx^  and  deglutition  become  embarrassod. 
Within  two  or  three  weeks  or  even  a  slu)rter  time  the  paralysis  disappears. 
In  many  cases  the  affection  of  the  palate  is  only  part  of  a  general  neuritis. 
Of  other  local  forms  perhaps  the  most  common  are  paralysis  of  the  eye- 
muscles,  intrinsic  and  extrinsic.  There  may  be  strabismus,  ptosis,  and  loss 
of  power  of  accomniodatif»n.  Facial  paralysis  may  develop.  The  neuritis 
nuiy  be  confined  to  the  nerves  of  one  limb,  though  more  commonly  the 
legs  or  the  arms  are  alfected  together.  Very  often  with  the  palatal  pariil- 
ysis  is  associated  a  weakness  of  the  legs  without  definite  p^aLsy  but  with  loss 
of  the  knee-jerk. 

Heart  symptoms  are  not  uncommon.  There  maybe  great  retardation, 
even  to  thirty  beats  in  the  minute.  Bradycardia  and  tachycardia  luiiy 
alternate  in  the  same  jiatieiit.  Iloart-failuro  and  fatal  syncope  may  occur 
at  the  height  of  the  disease  or  during  convalescence.  If  they  occur  du riui^ 
the  fever,  the  child,  perhaps  after  an  exaggeration  of  symptoms,  presents  an 
un...,iial  pallor.  The  pul.se  becomes  weak  and  rapid,  but  may  fall  to  fifty, 
forty,  or  even  lower.  The  extremities  are  cold,  the  temperature  sinks,  and 
death  takes  place,  with  all  the  features  of  collapse,  within  a  few  hours. 
More  frequently  the  fatal  collapse  comes  during  convalescence,  even  iis 
late  as  the  sixth  or  seventh  week  after  apparent  recovery.  The  attack 
may  set  in  abruptly,  perhaps  following  a  sudden  exertion.  More  co'u- 
monly  there  have  been  symptoms  pointing  to  disturbed  cardiac  rhythm, 


DlPriTIIKIUA. 


ii: 


or  I'vcii  faiiUinfj-spolls.  In  some  instiinees  vomiting  lias  propeded  tlio 
seriou.s  canliiic  attack.  Tiiero  may  bu  no  ])hy.sical  siguri  other  than  sligiit 
increase  in  the  cardiac  diilness  und  a  gallo])-rhythni  indicating  dilatation. 
Tlicsi'  syinj)tonis  were  formerly  ascribed  to  cardiac  thrombosis  or  to  endo- 
cariliiis.  Possibly  in  some  of  the  cases  the  result  is  due,  as  pointed  out 
bv  .Miisler  and  Ijcyden,  to  an  infectious  myocarditis,  but  in  a  majority 
of  the  cases  the  symptoms  are  ])robably  duo  to  a  neuritis  of  the  cardiac 
nerves. 

The  niuliiple  form  of  diphtheritic  neuritis  is  not  uncommon.  It  may 
befriii  with  the  palatal  aireclion,  or  with  losr.  of  })ower  of  accommodation 
ami  li'ss  of  the  tendon  rellexes.  Tiiis  last  is  an  important  sign,  whicli,  as 
Bernhardt,  IJuzzard,  ami  II.  L.  IMucDonnell  have  shown,  nuiy  occur  early, 
hut  is  luit  necessarily  followed  by  other  symptoms  of  neuritis.  There  is 
])arai)K'gia,  which  may  be  complete  or  involve  only  the  extensors  of  the 
fuet.  The  paralysis  nuiy  extend  und  involve  the  arms  and  face  and  render 
the  patient  entirely  helpless.  The  muscles  of  respi;-ation  nuiy  be  spared. 
The  chief  danger  in  these  severer  forms  comes  from  the  involvement  of 
the  heart  and  of  the  muscles  of  respiration ;  but  the  outlook  is  in  numy 
cases  not  so  bad  as  the  patient's  coiuliti(jn  would  imlieate.     Of  thirteen 

I J  collected  by  Cadet  de  Gassicourt  six  died.  The  sphincters  may  be 
uivolved,  though  they  are  often  spared. 

Diagnosis. — The  presence  of  the  Klebs-LoelTlcr  bacillus  is  regarded 
iiy  bacteiiologists  as  the  sole  criterion  of  true  diphtheria,  and  as  this  or- 
L'anisni  nuiy  be  associated  with  all  grades  of  throat  ailections,  from  a 
,«iiniili'  catarrh  to  a  sloughing,  gangrenous  j)rocess,  it  is  evident  that  in 
many  iustaiu'cs  there  will  be  a  striking  discrepancy  between  the  clinical 
und  the  bacteriological  diagnosis.  One  inestiuuiblc  value  of  the  recent 
stmhes  has  been  the  determination  of  the  di[>l<therial  charac^tcr  of  many 
of  the  nuhler  forms  of  tonsillitis  and  pharyngitis. 

The  bacteriological  diagnosis  is  simple.  The  ])lan  adopted  by  the 
New  York  Health  Department  is  a  Tuodel  which  nuiy  be  followed  with 
advantage  in  other  cities.  Outfits  for  making  cultures,  consisting  of  a 
box  eonf  ,iiiii,g  u  tube  of  blood-serum  ami  a  sterilized  swab  in  a  test-tube, 
are  disi  ''  ;v'd  to  about  forty  sta,tions  at  convenient  points  in  the  city. 
A  list  >  ■  !:t..v:>  !  i),ces  is  published,  ami  a  physician  can  ol)tain  the  outfit 
free  of  cost.  J  ro  directions  are  as  follows:  "  T1k>  patient  should  be 
jilaeed  in  a  good  light,  and,  if  a  child,  i)roperly  held.  In  cases  where  it  is 
JH)"-  'hie  to  get  a  good  view  of  the  throat,  depress  the  tongue  a!id  rub  the 
cotton  swab  gently  'nit  freely  against  any  visible  exiulate.  In  other 
ca.ses,  iiu'luding  those  in  which  the  exudate  is  confined  to  the  larynx, 
avoiiliiig  the  tongue,  pass  the  swab  far  back  and  rub  it  freely  against  the 
iiiueoiis  membrane  of  the  pharynx  and  tonsils.  Without  laying  the  swab 
dowi'  .  ithdraw  the  cotton  plug  from  the  culture- tube,  insert  the  swab, 
am)  ,.ij  ^hat  portion  of  it  which  has  touched  the  exudate  gently  but 
tlioroi:;  I  ._  ,\'.    over  the  surface  of  the  blood-serum.     Do  not  push  the 


^# 


118 


SPECIFIC  INFECTIOUS  DISEASES. 


i   ■■: 


•      ]■' 


m 


swab  into  the  blood-serum,  nor  l)reiik  the  surfiiee  in  any  way.  Then  rc- 
{)]ace  the  swab  in  its  own  tube,  plug  both  tubes,  put  tlieni  in  tlie  box,  and 
return  the  culture  outiit  at  once  to  the  station  from  which  it  was  oh- 
taiiiod."  Tlie  eulture-tubes  wliicli  have  been  inoculated  are  kept  in  an 
incubator  at  37°  0.  for  twelve  hours  and  are  then  ready  for  examination. 
8ome  prefer  a  method  by  which  the  material  from  the  tliroat  collected  on 
a  sterile  swab,  or,  as  recommended  by  von  Esnnirch,  on  small  pieces  of 
sterilized  sponge,  is  sent  to  the  laboratory  where  the  cultures  and  micro- 
scopical examination  are  made  by  a  bacteriologist. 

An  immediate  diagnosis  without  tlie  use  of  cultures  is  often  possible 
by  making  a  smear  preparation  of  the  exudate  from  the  throat.  The 
Klebs-Tioelller  bacdlli  may  be  present  in  suthcient  numbers,  and  may  bo 
quite  chara(!teristic  to  an  expert.  In  this  connection  may  be  given  the 
following  statement  by  Park,  who  has  had  such  an  exceptional  experi- 
ence :  "  The  examination  by  a  competent  bacteriologist  of  the  bacterial 
growth  in  a  blood-serum  tube  which  has  been  properly  inoculated  and 
kept  for  fourteen  hoi.;  it  the  body  temperature  can  be  thoroughly  relied 
w\)oi\  in  eases  wliere  iL  ;  sible  membrane  in  tlie  throat,  if  the  culture 

is  made  during  the  pent..  i  which  the  membrane  is  forming,  and  no 
antiseptic,  especially  no  mercurial  solution,  has  lately  been  applied.  In 
cases  in  which  the  disease  is  contbied  to  the  larynx  or  bronchi,  surpris- 
ingly accurate  results  can  be  obtained  from  cultures,  but  in  a  certain  pro- 
portion of  cases  no  diphtheria  bacilli  will  be  found  in  the  first  culture, 
and  yet  will  be  abundantly  present  in  later  cultures.  We  believe,  there- 
fore, that  absolute  reliance  for  a  diagnosis  cannot  be  placed  upon  a  single 
culture  from  the  pharynx  in  purely  laryngeal  cases." 

W//e>r  a  bitrtcviologiral  cx(nni)iatio)i  cfuinot  he  mruh,  the  practitioner 
mvxt  regard  as  suspicious  all  forms  of  throat  aJfectio)/s  in  children,  and 
earn/  out  measures  of  isolation  and  dixinfeetion.  In  this  way  alone  can 
serious  errors  be  avoided.  It  is  not,  of  course,  in  the  severer  forms  of 
membranous  angina  that  mistake  is  likely  to  occur,  but  in  the  various 
lighter  forms,  many  of  which  are  in  reality  due  to  the  Klebs-Loefller 
bacillus. 

A  largo  proportion  of  the  cases  of  diphtheroid  inflammation  of  the 
throat  are  due  to  the  streptococcus  pyogenes.  They  are  usually  milder, 
and  the  liability  to  general  infection  is  less  intense ;  still,  in  scarlet  fever 
and  other  specific  fevers  some  of  the  most  virulent  cases  of  throat  disease 
which  we  see,  with  intense  systemic  infection,  are  caused  by  iliis  micro- 
organism. These  streptococcus  cases  are  probably  much  less  numerous 
than  the  figures  which  I  have  given  would  indicate.  The  more  carefnl 
examimitions  in  the  diphtheria  pavilions  of  hospitals,  particularly  in 
Europe,  have  shown  that  in  the  large  majority  of  cases  admitted  the 
Klebs-Iioetfler  bacillus  is  present.  I  liave  already  referred,  under  the  sec- 
tion on  scarlet  fever,  to  the  question  of  the  diagnosis  between  scarlet  fever 
with  severe  angina  and  diphtheria. 


f' 


DlPriTIlEKlA. 


119 


Prognosis. — In  hospitiil  pmctipo  the  disease  is  very  fatal,  the  por- 
ccMla^e  (if  iloatlis  ranging  from  tliirty  to  fifty.  Tliis  is  due  in  great  part 
to  the  admission  only  of  the  severer  forms.  In  eountry  places  the  disease 
luav  display  an  apjialling  virulence.  In  eases  of  ordinary  severity  the  out- 
look is  usually  good.  Death  results  from  involvemejit  of  the  larynx,  seji- 
tio  infection,  sudden  heart-failure,  dijditheritic  i)aralysis,  occasionally 
from  ura'Uiia,  and  sometimes  from  broncho-pneumonia  developing  during 
convalescence. 

Prophylaxis. — Isolation  of  the  sick,  disinfection  of  tlie  clothing 
and  of  everything  that  has  conu^  in  contact  with  the  patient,  careful  scru- 
tiny of  the  milder  case  ■=  of  throat  disorder,  and  more  stringent  surveillance 
in  the  period  of  convalescence  are  the  essential  measures  to  prevent  the 
spread  of  the  disease.  Suspected  cases  in  families  or  schools  should  be  at 
onee  isolated  or  removed  to  a  hospital  for  infectious  disorders.  When  a 
death  has  occurred  from  diphtheria,  the  body  should  be  wrapped  in  a 
sheet  wliicli  has  been  soaked  in  a  cornisive-sublimate  solution  (1  to 
3,()on),  and  placed  in  a  closely  sealed  coffin.  The  funeral  should  always 
be  private. 

In  eases  of  well-marked  diphtheria  these  precautions  arc  usually  car- 
ried out,  but  the  chief  danger  is  from  the  milder  cases,  particularly  the 
ainl)idatory  form,  in  which  the  disease  has  perhaps  not  been  susjiected. 
Mixing  with  susceptible  children  the  disease  is  thus  conveyed.  The 
healthy  children  in  a  fanuly  in  which  diphtheria  exists  nuiy  carry  the  dis- 
ease to  their  school-fellows.  A  striking  illustration  of  the  way  in  which 
diphtheria  is  spread  is  given  by  Park  and  Beebe :  "  The  child  of  a  man 
who  kept  a  candy  store  developed  diphtheria;  there  were  four  other  chil- 
dren in  the  family,  and  these  were  in  no  way  isolated  from  the  sick,  yet 
jioiie  of  them  developed  diphtheria;  but  children  who  bought  candy  at 
the  store,  and  other  children  coming  in  contact  with  these  in  school, 
developed  diphtheria.  The  secondary  cases  ceased  to  develop  so  soon  as 
the  candy  store  had  been  closed." 

A  very  important  matter  in  the  prophylaxis  relates  to  tlie  period  of 
convuiesceuce.  It  has  been  shown  by  inimeroiis  observations  that,  after  all 
tlu'  nieml)rane  has  cleared  away,  virulent  bacilli  may  persist  in  the  throat 
from  periods  ranging  from  six  weeks  to  six  months,  or  even  longer. 
There  is  ov-idence  to  show  that  the  disease  may  be  communicated  by  such 
oiisos,  so  thiit  isolation  should  be  continued  in  any  given  case  until  the 
bacteriological  examination  shows  that  the  throat  is  free. 

It  cannot  be  too  strongly  emphasized  that  the  important  elements 
ill  the  prophylaxis  of  diphtheria  are  the  rigid  scrutiny  of  the  milder 
types  of  throat  affection,  and  the  thorough  isolation  and  disinfection  of 
the  iiulividuid  patients. 

f'areful  attention  should  be  given  to  the  throats  and  mouths  of  chil- 
<ireii.  pin-ticidarly  to  the  teeth  and  tonsils,  as  Caille  has  urged.  Swollen 
and  eidurged  tonsils  should  be  removed.     In  persons  exposed,  the  anti- 


•j' 


II 

Hi  J'." 


120 


SPECIFIC    INFECTIOUS   DISEASES. 


septic  moiitli  washes,  sr.oli  us  corrosive  subliniute  (I  to  10,000),  chloriiio 
wiiter  (1  to  1,100),  or  swubbiiig  the  throat  with  a  diluted  Loeiller's  sohi- 
tioii,  siioiihl  be  eiii])h)ycd. 

Treatment.— I  lie  im[)ortaiit  points  are  h3'gieiii('  measures  to  pre- 
vent the  spread  of  the  malady,  local  treatment  of  the  throat  to  destroy 
the  bacilli,  medication,  general  or  six'cilic,  to  counteract  the  effects  of  the 
toxines,  and,  lastly,  to  treat  the  complications  and  se(piehe. 

{(i)  Hygienic  Measures. — The  patient  should  be  in  a  room  from  which 
the  carpets,  curtains,  and  superlluous  furniture  have  been  removed.  'I'lu' 
temperature  should  be  about  (J8°,  aiul  thorough  ventilation  should  Ih> 
secured.  The  air  may  be  kept  moist  by  a  kettle  or  a  steam-atomizer.  If 
possible,  only  the  nurse,  the  cliild's  mother,  and  the  doctor  should  come 
in  contact  with  the  patient.  During  the  visit  the  physician  should  wear 
a  linen  overall,  and  on  leaving  the  room  he  should  thoroughly  wash  his 
hands  and  face  in  a  corrosive-sublimate  solution.  The  strictest  quaran- 
tine shoidd  be  employed  against  other  members  in  the  house. 

(b)  Local  Treatment. — In  mild  cases  the  throat  symptoms  are  alone 
prominent.  Vigorous  hxtal  treatment  from  the  outset  should  be  carrit'il 
out,  taking  especial  care  in  all  instances  to  avoid  mechanical  injury  to 
the  tissues.  A  very  large  number  of  solutions  have  been  recommended. 
They  are  best  employed  with  a  swab  of  cotton-wool  or  a  soft  sponge, 
or  irrigation  may  be  employed  with  hot  antiseptic  solutions.  The  direct 
application  with  a  swab  of  cotton -wool  or  sponge  is,  as  a  rule,  effect- 
ive. In  many  young  children  it  is  really  a  most  trying  procedure  to 
carry  out  the  treatment,  and  .■sometimes  one  is  compelled  to  desist. 
The  nurse  should  hold  the  child  on  her  knee.s,  well  wrapped  in  a  shawl, 
with  its  head  resting  on  her  shoulder.  'IMie  no.se  is  then  held,  and  so 
.soon  as  the  child  opens  its  mouth  a  cork  should  be  placed  between  the 
molar  teeth.  The  local  application  caii  then  be  made,  or  thorough  irri- 
gation carried  out.  In  i;.faiits  the  disinfecting  fluids  are  sometinio.s 
better  ap|)lied  through  the  nostrils.  The  following  solutions  may  bo 
employed  : 

Loeffler's  solution  :  Menthol,  10  grammes  dissolved  in  toluol  to  30 
c.  c.     Liq.  Ferri  sescpiichlorati,  4  c.  c.  ;  alcohol  absol.,  00  c.  c. 

Corrosive  sublimate,  1  to  1,000,  either  alone  or  with  tartaric  acid,  five 
grammes  to  the  litre. 

Carbolic  acid,  3  per  cent  in  30  per  cent  alcohol  solution,  is  much 
employed  ;  some  prefer  to  touch  the  siiuill  sj)ots  of  exudate  with  pure 
carbolic  acid. 

Other  solution  is:  The  tincture  of  the  perehloride  of  iron,  a  drachm 
and  a  half,  in  glycerine,  one  ounce,  water  one  ounce,  with  from  15  to  till 
minims  of  carbolic  acid.  Chlorine  water,  boric  acid,  peroxide  of  hydro- 
gen, iodoform,  lactic  acid,  trypsin,  aiul  papain  are  also  recomnumded. 

Loeffler's  solution,  which  has  recently  been  given  a  very  thorongli 
trial,  is  perhaps  the  most  satisfactory. 


DIPHTHERIA. 


121 


Nasal  iliplitliPi'ia  roquiros  pron.i)t  and  tliorongli  disiiifcctioii  of  tlu- 
iias-iiL'o"-  -liii'obi  rccomnu'iids  cldoridii  of  sodium,  satiirati'd  boric  acid, 
or  one  [Mrt  <>f  biddoridu  of  inorciiry,  thirty-live  of  chlorido  of  sodium, 
jiiid  diH'  lliiuisaud  of  water,  or  the  oue-iier-ceiit  solution  of  carbolic  acid. 
!>(icl11t'r's  sohitioii  may  bo  used.  >i.t  nuiy  bu  applied  with  a  syringe  or  a 
sitniy.  'I'll  be  efTocitual  the  injection  must  be  i)ro])erly  given.  The  inirso 
should  lie  instructed  to  pass  the  nozzle  of  the  syringe  horizontally,  not 
vcM'tically;  otherwise  the  fluid  will  return  through  the  same  nostril. 

When  the  larynx  becomes  involved,  a  steam  tent  may  be  arranged 
upon  tli(!  bed,  so  that  the  child  may  l)reathe  an  atmosphere  saturated 
with  ivKiistiire.  If  the  dysj)n(ea  bec(»mes  urgent,  an  emetic  of  sulphide  of 
zinc  or  ipecacuaidia  nuiy  be  given.  When  the  signs  of  ol)struction  are 
niiu-krd  there  should  be  no  delay  in  the  performance  of  intubation  or 
tniclK'ot(»iiiy. 

Hot  ii|i|)Hcations  to  the  neck  are  usually  very  grateful,  particularly  to 
yiiuiig  cliihh'cn,  though  in  the  case  of  older  children  and  adults  the  ice 
j)onltic('s  are  to  he  preferred. 

(r)  General  Measures.— The  food  shouM  be  li(|uid— milk,  beef  juices, 
Imrky  water,  an)umen  water,  and  soups.  The  (diild  should  be  encouraged 
to  (h'iiik  water  freely.  When  the  pharyngeal  involvement  is  very  great 
anil  swallowing  painful,  nutritive  enemata  siiould  be  used.  In  ca.ses  with 
si'vcrc  constitutional  symptoms  stimulants  should  be  given  early. 

Medicines  given  internally  are  of  very  little  avail  in  the  disease. 
Their  is  still  a  wide-spread  belief  in  the  profession  that  forms  of  mercury 
arc  l)eiielicial.  The  tincture  of  the  perchlorideof  iron  is  also  very  warndy 
irrniniuendcd.  We  are  still,  however,  without  remedies  which  can  directly 
CDUiiteract  the  tox-albuniins  of  this  disease,  and  we  must  rely  on  general 
nu'usures  of  feeding  ami  stimulants  to  support  the  strength. 

Till'  convalescence  of  the  disease  is  not  v/itliout  its  dangers,  and  ])a- 
tifuts  should  be  very  carefully  watched,  particularly  if  there  are  signs  of 
hoart  weakness. 

The  diplitheritic  paralysis  requires  rest  in  bed,  and  in  those  cases  in 

hviiieh  the  heart  rhythm  is  disturbed  the  avoidance  of  sudden  exertion. 

In  the  chronic  forms  with  wasting,  mas.sage,  electricity,  and  stryi-hnine 

arc  invahiahle  aids.     If  swallowing  becomes  very  dillicult,   the    patient 

iiiii.<t  be  fed  with  the  stomach-tube,  which  is  very  much   preferable  to 

Ifcciliiijr  jirr  irrfinn. 

('/)  Antitoxine  Treatment. — As  above  mentioned,  aiuuuds  nuiy  be  ren- 
Ncivd  iniiniiiie  against  di|ditheria,  and  the  blood  of  an  aninnd  so  treated 
When  introduced  into  another  animal  protects  it  from  infection  with  the 
jbacilli  of  the  disease.  The  observations  of  Behring,  Roux,  and  others 
jiiavc  shown  that  the  use  of  the  blood-serum  of  animals  rendered  arti- 
jflcially  iiiiinuue  against  diphtheria  has  an  important  healing  inlluence 
jtiliiiii  liiplitheria  spontaneously  acquired  in  num.  In  preparing  the  blood- 
jscnini  it  is  very  desirable,  of  course,  to  have  a  uniform  standard  of  strength. 


122 


SPEC'IFU;   INFKCTIOUS  DISEASES. 


One  tentli  of  one  cnbio  centimetre  of  what  Hohring  calls  his  normal  sernm 
will  counteract  ten  times  the  minimum  of  diphtiieria  poison  fatal  I'm' a 
•ruiiica-piff  W('i<fliin(f  1500  j^rammcs.  One  (Uibic  ccntimein!  of  tliis  normal 
!>ernm  lie  calls  an  antitoxine  unit.  The  serum  j)rej)are<l  hy  his  metliuil 
comes  labelled  in  three  strenf,'ths :  No.  I^is  sixty  times  the  strength  of  the 
normal  serum  ;  No.  3  is  one  hundred  times  as  strong;  and  No.  3  is  oiiu 
hundred  and  forty  times  as  strong.  As  a  rule,  in  ordinary  cases  a  flask  (jf 
the  Xo.  1  serum  of  Jiehring,  containing  sixty  antitoxine  units,  is  lirst  used. 
The  injection  may  b(i  made  into  the  skin  of  the  side  of  the  buttock  or 
flank.  On  the  following  day,  if  the  condition  has  not  improved,  a  flask  of 
the  No.  2  serum  should  be  used.  If  tlie  case  is  very  severe  or  not  seen 
until  late,  it  is  best  to  use  tlie  stronger  No.  ;5  solution  at  once. 

A  large  number  of  preparations  are  now  on  the  nuirket,  and  .some 
caution  has  to  be  exercised  by  the  practitioner  as  to  the  serum  which  he 
employs. 

In  favorable  cases  tlio  effects  of  the  serum  are  seen  in  a  marked  amel- 
ioration of  both  the  local  and  general  symptoms.  Within  twenty-four 
hours  the  swelling  of  the  fauces  subsides  and  the  membrane  begins  to  dis- 
appear. At  the  same  time  the  temperature  falls,  the  pulse  becomes  slower, 
and  the  general  condition  of  the  patient  improves  in  every  way.  In  cases 
of  moderate  severity,  when  the  injections  are  employed  early,  the  imjjrovc- 
nieiit  in  both  the  throat  and  constitutional  symptoms  is  certainly  very 
striking.  The  earlier  the  cases  come  nnder  treatment  the  better  are  the 
results.  There  are  cases,  however,  of  great  severity,  in  which  the  anti- 
toxine has  been  employed  early  and  yet  has  not  saved  life. 

Among  the  untoward  effects  of  the  treatment  may  be  the  development 
of  a  local  abscess,  wiiich,  however,  is  rare,  diffuse  erythema  and  urticariti, 
and  albuminuria.  None  of  these  are  serious,  and  the  evidence  is  not  con- 
clusive that  the  incidence  of  albuminuria  is  greater  in  the  cases  treated 
with  antitoxine. 

The  beneficial  effects  of  the  tresitment  are  seen  in  the  great  reduction 
of  the  mortality  from  the  disease.  The  following  figures  may  be  quoted 
in  illustration:  The  mortality  in  Berlin  during  1894  was  '39  per  cent: 
after  the  introduction  of  the  antitoxine  treatment,  in  1,.390  cases  the  nmr- 
tality  was  only  '^1  per  cent. 

The  figures  from  Baginsky's  clinic  in  Berlin  are  still  miore  confirma- 
tive.    In  the  four  years  preceding  the  introduction  of  the  antitoxine  treat-  < 
inent  the  average  mortality  had  been  41*1  per  cent.     In  535  cases  corre- 
sponding to  the  period  duritig  which  the  antitoxine  was  employed  tlie 
mortality  was  only  15-81  per  cent. 

The  figures  given  at  the  Congress  for  Internal  Medicine  at  Mnnicli  in 
1895  were  on  the  whole  very  favorable. 

At  the  Boston  City  Hospital  305  cases  were  treated  Avith  seventy-nine 
deaths — a  mortality  of  35-9  per  cent.  The  mortality  for  the  same  period 
last  year  was  44o  per  cent. 


ERYSIPELAS. 


128 


A  vcrv  much  larger  number  of  eases  mvist  be  treated  over  a  l()iij» 
i,->i'iii(l  bcl'orc!  (iiial  jii(li,'nieiit  cuii  be  reacbi'd  ;  nieamvliik*  tbe  treatintiiit 
slioiiM  be  adopted  in  tbe  eases  of  true  di])btbena. 

Till  question  of  inirnunizing  those  exposed  to  the  disease  is  a  very 
pnictiral  one.  It  has  been  earried  out  on  a  hirgc  scale  in  some  institu- 
tions with  satisfactory  results.  An  injection  of  the  No.  ]  lU'liring  is 
(riven,  and  if  thought  proper  re[)eated  in  a  few  days.  The  immunity  ap- 
pi'iU's  to  be  transient,  only  j)ersisting  for  a  few  weeks. 


luction 
luotcil 
cent ; 
|o  u\oi"- 

[ifiniui- 
trciit- . 
eorre- 

led  tlio 

liich  ill 

tv-iiino 
I  peiioJ 


XVI.    ERYSIPELAS. 

Definition. — An  aeute,  conUigious  disease,  ehanvcterized  by  a  special 
iiilbiniiiiation  of  the  skin  caused  by  streptococci. 

Etiology. — Erysipelas  is  a  wide-spread  afTeetion,  endemic  in  most 
conirmniities,  and  at  certain  seasons  epidemic.  We  are  as  yet  ignorant  of 
tiio  atmospheric  or  telluric  influences  which  favor  the  dilTusion  of  the 
|ioison. 

It  is  particularly  prevalent  in  the  spring  of  the  year.  Of  "ifiM  cases 
pnlloctod  by  Anders,  1,214  occurred  during  the  tirst  five  months  of  the 
year.  April  had  the  largest  number  of  cases.  The  alfeetion  prcivails 
extensively  in  old,  ill-ventilated  hospitals  and  institutions  in  which  the 
sanitary  conditions  are  defective.  With  the  improved  sanitation,  of  late 
years  the  number  of  cases  has  materially  diminished.  It  has  been  ob- 
*rve(l,  however,  to  break  out  in  new  institutions  under  the  most 'favorable 
hygieniv;  circumstances.  Erysipelas  is  both  contagious  and  inocidable ; 
but,  except  under  special  conditions,  the  poi-son  is  not  very  virulent  and 
does  not  seem  to  act  ac  any  great  distance.  It  can  be  conveyed  by  a  third 
person.  The  poison  certainly  attaches  itself  to  the  furniture,  bedding,  and 
ivalls  oC  room.s  in  which  patients  have  been  confined. 

Tlie  disposition  to  the  disease  is  wide-,spread,  but  the  susceptibility  is 
specially  marked  in  the  case  of  individuals  with  wounds  or  abrasions  of 
any  sort.  Recently  delivered  women  and  persons  who  have  been  the  sub- 
ject of  surgical  operations  are  particularly  prone  to  it.  A  wound,  how- 
ever, is  not  necessary,  and  in  the  so-called  idiopathic  form,  although  it 
may  be  difficult  to  say  that  there  was  not  a  slight  abrasion  about  the  nose 
[or  lips,  in  very  many  cases  there  certainly  is  no  observable  external  lesion. 

(!hronic  alcoholism,  debility,  and  Bright's  disease  are  predisposing 
agents.  Certain  persons  siiow  a  special  susceptibility  to  the  disease,  and 
it  may  recur  in  them  repeatedly.  There  are  instances,  too,  of  a  family 
predisposition  to  the  disease. 

The  specific  agent  of  the  disease  is  the  streptococctts  pj/ngeties,  with 
which  the  streptococctis  erysipelatos  appears  to  be  identical.  The  fever 
and  constitutional  symptoms  are  due  in  great  part  to  the  toxins;  the  more 
serious  visceral  complications  are  the  result  of  secondary  infection. 


f 


ilHi 


Wi 


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]     i 


124 


SPEClKir;    INFKCTIOUS   DISKASHS. 


■*M 


Morbid  Anatomy.- Miysipolas  is  a  simplo  iiiflarnniiition.  In  its 
iiii('i)iii|/li('aU'(l  forms  iIutc  is  >ccii,  pdst  ir.ortciii,  little  else  tliaii  iiillamnia- 
torv  (i'(U'iiia.  1 11  vest  illations  have  stiowii  that  \\w  cm-fi  an'  found  (tliiflly 
ill  the  lyiiipli-spaccs  ami  most  al)iiii(lantly  in  llu'  /one  of  sprcadinj^  inllain- 
niatioii.  In  the  iininvolvcd  tissiio  beyond  tlio  iiillaiiuMJ  niarj^dn  tlio  iiii- 
crococri  arc  to  he  f(tiind  in  tlni  lympli-vcsscls,  and  it  is  here,  acconiiiif,'  tn 
MctschnikolT  and  otlicrs,  tliat  an  iiclivo  warfare  ;^o((s  on  l)etwe(Mi  the  lenco- 
eytes  ami  the  cocci  (phajjfoeytosis).  In  more  extensive  and  virulent  forms 
of  the  disease  there  is  iisiiiilly  8iip])iirati()n.  It  is  stated  that  the  iiiilain- 
matioii  may  pass  inward  from  tlu'  scalj)  tlir()ii<;li  the  slviili  to  the  meniiiircs. 
This  I  have  ni'ver  seen,  but  in  oiio  case  I  traced  the  extension  from  the 
face  uloiij,'  the  fifth  nerve  to  the  meninges,  wlioro  an  aoute  tneningitis  ainl 
thrombosis  of  the  hiteral  sinus  were  excited. 

'I'he  visceral  coiiH)lieations  of  erysipelas  are  numerous  and  importiint. 
The  majority  of  them  an;  of  a  septic  nature.  Infarcts  occur  in  tin;  luiiirs 
spleen,  and  kidneys,  and  there  may  be  tlie  general  evidences  of  pyu'inic 
infection. 

Some  of  the  worst  eases  of  malignant  endocarditis  are  secondary  to 
erysipehis;  thus,  of  tw<'iity-tliree  cases,  three  occurred  in  connection  with 
this  disease.     Scptii;  |)ericarditis  and  jileuritis  also  ociciir. 

As  just  mentioned,  the  disease  may  in  rare  cases  extend  and  involvi' 
the  meninges.      I'lic'imoiiia  is  not  a  vcy  common  complication. 

.Acute  iiepliritis  is  also  metv, itli;  it  is  often  ingrafted  upon  an  old 
chronic  trouble. 

Symptoms. — The  follo'.ving  descri[.tion  applies  specially  to  erysipehis 
of  the  face  and  head,  the  form  of  the  disease  which  the  physician  is  most 
commonly  'ailed  upon  to  treat. 

The  iiic.bdiiini  is  variable,  probably  from  three  to  seven  days. 

The  stage  of  iniuisiox  is  often  marked  by  a  rigor,  and  followed  by  u 
rai)id  rise  in  the  temperature  and  all  the  characters  of  an  acMite  fever. 
When  there  is  a  local  abrasion,  the  spot  is  slightly  reddened  ;  but  if  i'  is 
idioj)alliic,  there  is  seen  within  a  few  hours  slight  redness  over  the  bridiro 
of  the  nose  and  on  the  cheeks,  'i'he  swelling  and  tension  of  the  skin 
increase  and  within  twenty-four  hours  the  external  symptoms  arc  wt'll 
marked.  The  skin  is  smooth,  tense,  and  UKlomatous.  It  looks  red,  feels 
hot,  and  the  superficial  layers  of  the  e})idermis  may  be  lifted  as  small 
blebs.  The  patient  complains  of  an  unpleasant  feeling  of  tension  in  tho 
skin;  the  swelling  rapidly  increases;  and  during  the  second  day  the  eyes 
are  usually  closed.  The  lirst-aflFccted  parts  gradually  become  pale  and 
less  swollen  as  the  disease  extends  at  the  periphery.  When  it  reaches  the 
forehead  it  progresses  as  an  advancing  ridge,  perfectly  well  defined  and 
raised  ;  and  often,  on  palpation,  hardened  extensions  can  be  felt  beneath 
the  skin  which  is  not  yet  reddened.  Even  in  a  case  of  moderate  severity, 
the  face  is  enormously  swollen,  the  eyes  are  closed,  the  lids  greatly 
oedematous,  the  ears  thickened,  the  scalp  is  swollen,  and  the  patieiit'f 


ERVSIPRLAS. 


125 


fcrttiiros  nro  (|iiit('  tmrocofjrnizuldo.  'I'lic  formatidii  of  hk'hs  is  oominon  on 
the  I  \.  lids,  ('ill's,  ami  t'orclicail.  'Tlic  cervical  lyiiipli-^laiids  arc  swollen, 
!(iit  lire  usually  masked  in  the  (cdcina  of  tlie  neck.  'I'lie  teni|ieraliire  keeps 
hi^'li  without  marked  remissions  for  four  or  live  days  and  then  deferves- 
cence tiikes  place  by  crisis.  Leiicocytosis  is  jnvsent.  The  c;('iu'nil  eomli- 
lidii  (if  the  patient  varies  luucli  with  his  previous  condition  of  hcaltii.  In 
eld  Miiil  deliilitaled  persons,  particidarly  in  thoso  luldicted  to  alcohol,  tlio 
(■iiii-litulional  depression  from  the  outset  may  ho  very  fir(>at.  Delirium 
is  present,  the  t.on^^ue  heconu's  drv,  the  pulse  feel)le,  and  there  is  marked 
tciulciicv  to  death  from  toxa-niia.  In  the  majority  of  cases,  however,  cvou 
witii  extensive  disease,  the  constitutional  disturl)aiiee,  considi'rinj^  the 
liei,i,dit  of  the  fever  rani^^e,  is  sli.Lrht.  'I'he  mucous  mcmhrane  of  the  mouth 
ami  throat  may  l)e  swollen  iind  reddened.  The  erysipelatous  iiillamnuition 
iiiav  extend  to  the  larynx,  hut  the  severe  (r'dema  of  this  part  occasiojially 
met  with  is  eommoidy  duo  to  the  extension  of  the  inllamrnution  from 
witlidiit  inward. 

There  are  eases  in  which  the  inllammation  extends  from  tlio  facu;  to 
the  neck,  anil  over  the  chest,  and  may  gradually  mi<,n'ato  or  >..indorovor 
the  irreater  part  of  the  hody  [K.  iiii(/r<iiis). 

The  close  relation  hetwoon  the  erysipelas  coccus  and  the  pus  or<ianisms 
is  shown  by  the  freipiency  with  which  suppuration  occurs  in  facial  ery- 
sipelas. Small  cutaneous  absces.ses  are  common  al)out  the  cheeks  and 
forehead  and  neck,  iind  beneath  the  seal])  larjje  collections  of  pus  may 
iiceiiiuiilate.  Suppuration  seems  to  occur  more  frequently  in  some  opi- 
(Iciiiics  than  in  others,  and  at  the  Philadelphia  Hospital  one  year  nea/iy 
nil  the  cases  in  the  erysipelas  wards  jiresenteil  local  abscesses. 

Complications. —  .Menin<jjitis  is  rare.  The  cases  in  which  death 
(icciirs  with  marked  brain  symptoms  do  not  usually  show,  post  mortem, 
ineiiiiiijeal  afTection.  The  delirium  and  coma  are  {\ui-  to  the  fever,  or  to 
toxa'inia. 

Piieiunonia  is  an  occiasional  complication.  ITcerativo  endocarditis 
autl  soptica'mia  are  more  common.  Albuminuria  is  almost  constant, 
particularly  in  persons  over  fifty.  True  nephritis  is  occasiomilly  .seen. 
Da  Costa  has  called  attention  to  curious  irregular  returns  of  the  fever 
which  occur  during  convalescence  without  any  atrgravation  of  the  local 
cuuditioii. 

The  diagnosis  rarely  presents  any  dillicidty.  The  mode  of  onset,  the 
rapid  rise  in  fever,  and  the  characters  of  the  local  disease  are  quite  dis- 
tinctive. Acute  necrosis  of  bone  may  sometimes  be  regarded  as  erysij)elas, 
a  mistake  wliich  I  once  saw  made  in  connection  with  the  lower  end  of  the 
fi'iinir. 

Prognosis. — Healthy  adults  rarely  die.  The  general  mortality  in 
hospitals  is  about  7  per  cent,  in  private  practice  about  4  per  cent 
(Anders).  In  tlie  new-born,  when  the  disease  attacks  the  navel,  it  is 
almost  always  fatal.     In  drunkards  and  in  the  aged  erysipelas  is  a  seri- 


al' 


12«; 


SPECIFIC   INFKCTIOUS   DISKASKS. 


ourt  iidcrlioti,  ami  di'ii'li  iiiuy  result  citlicr  fiorn  the  itit(M)Hity  of  th»!  fovcr 
ur,  tiioiv  cDiiiiiioiily,  from  to\a>iiiiii.  'I'iic  wauilcrin;^'  or  atiiltiilutoiv 
crysijiflas,  which  has  a  more  iirolractcd  course,  may  cause  death  frum 
exhaust  ion. 

Treatir ent. -  IsohUion  shouhl  he  strictly  carried  out,  j)arti<*ularly  in 
hospitals.  A  praclitioiier  in  atteiidaiici!  upon  a  case  of  erysipelas  shouM 
nut  attend  cases  of  confinement. 

The  disease  is  self-limited  and  a  Uirvrc  majority  f)f  the  eases  jjet  well 
without  any  inlei'nal  medication.  I  can  speak  detinitely  on  this  point, 
having,  at  the  I'hiladelphia  Hospital,  treated  nuiny  ca.-es  in  this  way. 
The  <liet  should  be  nutritious  and  li^dit.  Stimulants  are  not  required 
except  in  the  old  ami  feehle.  For  the  restlessness,  delirium,  and  insoniniii, 
(diloral  or  the  bromides  may  lu'  ^'iveii  ;  (jr,  if  these  fail,  opium.  When 
fever  is  hi^di  the  jjatient  imiy  he  bathed  or  spon<;ed,  or,  in  private  2>raclice, 
if  there  is  an  objection  to  thi.s,  antipyrin  or  antifel)rin  may  be  given. 

Of  internal  remedies  i)elieved  to  inllucnco  the  disea.se,  the  tincture  of 
the  pereldoride  of  iron  has  l)een  hijjfhiy  reconinieiidcd.  At  tin;  .Montreal 
(Jeneral  Hospital  this  was  the  routine  treatment,  and  do.ses  of  half  u 
drachm  to  a  drachm  were  given  every  three  or  four  hours.  I  am  by  no 
means  convinced  that  it  has  any  special  action  ;  nor,  so  far  as  I  know,  has 
any  medicine,  given  internally,  a  definite  control  over  the  course  of  the 
disease. 

Of  local  treatment,  the  injection  of  antiseptic  solutions  at  the  nnirgin 
of  the  spreading  areas  has  been  much  praciti.sed.  Two-per-cent  solutions 
of  carbolic  aciil,  the  corrosive  sublimate  and  the  biniodide  of  mercury 
have  been  much  used,  'i'he  injection  should  be  made  not  into  but  just 
a  little  beyond  the  liorder  of  the  inflamed  j)atch.  V.  V.  Jlenry  has  treated 
a  large  nmnber  of  cases  at  the  IMiiladclphia  Hospital  with  the  latter  drug, 
and  this  mode  of  j)ractice  is  certainly  most  rational. 

Of  local  a]»j)lications,  ichthyol  is  at  present  much  used.  'I'he  inflamed 
region  may  be  coveri^d  with  salicylate  of  starch.  Perhaps  as  good  an  a])- 
plication  as  any  is  cold  water,  which  was  highly  recommended  by  lli))- 
pocrates. 


XVM.    SEPTICiCMIA    AND    PYAEMIA. 


In  these  days  of  asepsis  jihysiciana  see  many  more  cases  of  8eptica;niia 
and  pyoimia  than  do  the  surgeons.  For  one  case  in  the  post-mort(>in 
room  with  the  anatomical  diagnosis  of  sepliccemia  which  comes  from  tlio 
surgical  or  gynaicological  departments  of  the  Johns  Hopkins  Hospital,  at 
least  fifteeji  or  twenty  come  from  my  medical  wards.  Certain  terms  must 
first  be  defined. 

An  infection  is  tlie  morbid  process  induced  by  the  invasion  and  growth 
in  the  body  of  pathogenic  micro-organisms.  An  infection  may  be  local, 
as  in  a  boil,  or  general,  as  in  some  casea  of  anthrax. 


SKI'TKM'IMIA    AND   PVMOMIA. 


127 


An  t)ilo,vir(tfi(i)i  is  the  morbid  coiiditiftii  caiiscd  \)\  the  iibsorptioii  of 
tiic  tnvihcs,  ill  lur;j;('  part  (KM'ivcd  from  tJu'  i>iitlio;;('iiic  cirj^iiiusms.  Tlio 
term  .^ii/uviiiiti  is  tiio  iM|iiiviiloiit  of  septic  intuxiciitiori. 

A  liiii'd-iiiid-fiist  liiK!  cutuiot  l)t'  dniwii  ln'twciMi  an  infection  iind  iin 
intoxicalion,  hnl  ai^cntf!  of  infection  alone  are  eapalilc  of  rcjtroduction, 
wlii'iiiis  tiiose  of  intoxication  are  chemical  poisons  [iroilnced  liv  the  a;:cncy 
(if  liiirlcria,  or  by  vegetable  and  animal  cells.  Infi'ctions  diseases  which 
arc  cniMtnunioated  directly  from  one  ju-rson  to  another  are  termed  con- 
la;,'iiiMs,  and  the  infectinj;  agent  is  sometimes  spoken  of  as  a  eontaginm. 
"  Wlicllier  or  not  an  infections  disease;  is  contagions  in  the  ordinary  sense 
(]t'|)(  lids  upon  the  natnre  of  the  infections  agent,  and  especially  npuii  the 
manner  of  its  elimination  from  and  reception  l)y  the  body.  Most  i)nt  not 
all  rontagious  diseases  are  infectious.  S(uibies  is  a  contagious  disease,  but 
it  is  not  infectious"  (Welch). 

There  are  three  chief  clinical  types  of  infection. 


hiii^:! 


Ilfjl';;,; 


1.   boCAIi  INFKCTIO.NS   WITH   TIIK    DFA'KI.OF'.MKN'T  OV  TOXINKS. 

This  is  tho  common  mndo  of  invasion  of  many  of  the  diseases  vvhicli 
wo  have  already  considered.  Erysipelas,  diphtheria,  pneumonia,  tetanus, 
typhoid  fever,  and  anthrax  arc  diseases  which  have  sites  of  local  infection 
in  wliich  the  pathogenic  organisms  di'Velop ;  but  the  constitutional  effecls 
are  cMUsed  by  the  absorption  of  the  jioisonous  products.  'J'Ip  diphtheria 
tnxine  produces  all  the  general  symjjtoms,  the  tetanus  toxineevery  feature, 
of  the  disease  without  tho  presence  of  their  respective  bacilli.  Certain  of 
'0  sym])toms  following  the  absorption  of  the  toxines  are  general  to  all ; 
others  are  special  and  ])eculiar,  acicording  to  the  organism  which  produces 
them.  A  chill,  fever,  general  malaise,  prostration,  rai)id  ])ulse,  restless- 
ness, and  headache  arc  the  most  fre(picnt.  With  but  few  exceptions  the 
febrile  disturbance  is  the  most  common  feature.  'I'he  most  serious  effects 
are  seen  upon  the  nervous  system  and  upon  the  heart,  and  the  gravity  of 
the  symptoms  on  the  part  of  these  organs  is  to  some  extent  a  measure  of 
die  intensity  of  the  intoxication.  The  organisms  of  certain  local  infec- 
tions produce  poisons  which  have  special  actions;  thus  the  diphtheria 
toxiiie,  besides  having  the  effects  already  referred  to,  is  especially  prone  to 
attack  the  nervous  system  and  to  cause  jieripheral  neuritis.  The  tetanus 
toxiuc  has  u  specific  action  on  the  motor  neurons. 


f' 
BP 


f> 


2.  SEPTIOJ^.MIA. 

Formerly,  and  in  a  surgical  sense,  the  term  "septicaemia"  was  used  to 
flesignate  the  invasion  of  the  blood  and  tissues  of  the  body  bv  the  organ- 
isms  of  suppuration,  but  in  the  medical  sense  the  term  nwiy  be  a])plied 
to  any  condition  in  which,  with  or  without  a  local  site  of  infection,  there 
is  niierobic  invasion  of  the  blood  and  tissues,  but  in  which  there  are  no 
foci  of  suppuration. 


w 


%■■'. 


128 


SPECIFIC   INFECTIOUS   DISEASES. 


•  I 


I  m 


W'M 


{(t)  Progressive  Septicemia  from  Local  Infection.— Tlio  common  strep- 
tooocciis  luul  stiiphvl.)cocciis  infection  is  iis  ii  I'l.k:  llrst  locul,  iind  the 
toxinos  alonu  pass  into  the  blood.  In  otluT  iiistunros  the  cocci  appciir  in 
the  bh)0(l  and  tliroughout  tlic  tissues,  causing  a  wijle-spread  si^ptica'mia 
whicli  intensiiies  i^ioatly  tlie  severity  of  tiie  case.  Oilier  infections  in 
which  tiio  bacterial  invasion,  local  at  first,  may  become  general  are  pneu- 
monia, typhoid  fever,  antlirax,  gonorrlupa,  and  puerperal  fever. 

The  clinical  features  of  this  form  are  well  seen  in  the  cases  of  puerpe- 
ral septicaMuia  or  in  dissection  wounds,  in  wliich  the  course  of  tlie  infec- 
tion may  be  traced  along  the  lymphatics.  'I'lio  symptoms  usually  set  in 
within  twenty-four  liours,  and  rarely  later  than  tlie  third  or  fourtii  day. 
There  is  a  cliill  or  chdliiiess,  with  moderate  fever  at  first,  which  gradually 
rises  and  is  marked  by  daily  remissions  and  even  intermissions.  The 
pulse  is  small  and  compressible,  and  may  reach  120  or  higher,  (iastro- 
intestiual  disturliances  are  common,  the  tongue  is  red  at  the  margin,  and 
the  dorsum  is  dry  ami  dark.  There  may  be  early  delirium  or  marked 
mental  prostration  and  apatiiy.  As  the  disease  progresses  there  may  be 
pallor  of  the  face  or  a  yellowish  tint.  Capillary  luemorrhages  are  not 
uncommon. 

Tl'.e  outlook  is  serious  in  streptococcus  cases.  Death  may  occur  within 
twenty-four  hours,  and  in  fatal  ca.ses  life  is  rarely  prolonged  for  more  than 
seven  or  eight  days.  On  post-mortem  examination  there  may  be  no  focal 
lesions  in  the  viscera,  and  the  seat  of  infection  may  present  only  slight 
changes.     The  s|)leen  is  enlarged  and  soft,  the  blood  may  be  extremely 


(iari<  ill  color. 


and   liaMiiorrhages  are  conimou,  particularly  on  the  ser 


Oll.- 


surfaces.     Neither  thrombi  nor  emboli  are  found. 

Many  instances  of  septicaMuia  are  combined  infections;  thus  in  diph- 
theria streptococcus  .scptica'inia  is  a  common,  and  the  most  serious,  event. 
The  local  disea.se  and  (he  symptoms  produced  by  ab.sorjition  of  the  tox- 
inci,  hiininate  the  clinical  picture;  but  the  features  are  usually  much 
aggravMted  by  the  systemic  invasion.  A  similar  infection  may  d.'vclop  in 
typhoid  fever  and  in  tuberculosis,  and  may  obscure  the  typical  picture, 
leading  to  .serious  errors  in  diagnosis.  The  septictemia  is  not  always  due 
to  the  streptococcus. 

{f})  General  Septicseraia  without  Recognizable  Local  Infection.— 07//^ 
fof/f'iir/ir  Srjil i:-(t>iinit. — Tills  is  a  group  of  very  great  interest  to  the 
physician,  the  full  imiiortance  of  which  we  are  only  now  beginning  to 
recognize. 

The  subjects  when  attacked  may  be  in  perfect  health  ;  more  com- 
monly they  are  already  weakened  by  acute  or  chronic  illness.  The  patho- 
genic organisms  are  varied.  'I'he  streptococcus  pyogenes  is  the  most  com- 
mon ;  the  forms  of  staphylococcus  more  rare.  Others  cajiable  of  inducing 
it  are  the  micrococcus  lanceolatu.s  (pneumococcus),  the  protens,  and  the 
bacillus  pyocyaneus.  lietween  May  1,  18',>!i,  and  June  1,  1S9.'5,  tliere 
were  sent  to  the  post-mortem  room  from  my  wards  "l\  cases  of  general 


SEPTICEMIA   AND  PY.EMIA. 


129 


infection,  of  which  13  wore  dne  to  the  stroptoooceiis  pyogenes,  2  to  the 
stanlivliK'oecus  pyoi^ciies,  and  (i  to  the  jmeuiiiococeiis.  In  11)  of  lliese 
cases  tln'  patients  were  already  tlie  sul)jects  of  some  otiie:  malady,  which 
was  air^iavated,  or  in  most  instances  terminated,  by  the  general  septieaimia. 
The  sviiiptoms  vary  somewhat  with  the  charactc'  of  tlio  micro-organisms. 
In  tlie  streptococcus  cases  there  may  be  chilis  with  higli,  irregnlar  fever, 
and  a  more  cliaracteristic  Avy;//V'  state  than  in  the  pneuinocoeous  infeetioi 

.Mdst  of  these  cases  come  correctly  nnder  the  term  "cryptogenetic  septi- 
ca'niia"  as  employed  by  Lenbe,  iTiasn.uv'ii  as  the  local  focus  of  infection  is 
iidt  evident  during  life,  and  may  not  be  found  after  death.  It  is  well  to 
bear  in  nund  that  there  are  instances  of  this  type  of  affection  connng  on 
in  apparently  healthy  persons.  The  fever  may  be  extremely  ii'regnlai', 
eiiarai'teristically  se])tic,  and  persist  for  many  weeks.  Foci  of  suppuration 
may  nut  develop,  and  may  not  be  found  even  at  autopsy.  1  have  on  sev- 
eral occasions  met  with  cases  of  an  intermittent  pyrexia  jjorsisting  for 
weeks,  in  wiiich  it  seemed  impossible  to  give  any  explanation  of  the  {)he- 
noineini,  and  cases  which  ultimately  rec-overed,  and  in  which  tuberculosis 
and  malaria  could  be  almost  positively  ex(duded.  These  cases  require  to 
lie  carefully  studied  bacteriologically.  Dreschfeld  has  described  them  as 
idiopathic  intermittent  fever  of  pya'Uiic  character.  Local  symptoms  may 
be  absent,  tiiough  in  three  of  his  ca-;es  there  was  eidargement  of  the  liver, 
and  in  two  the  condition  was  a  dilfnse  sup})urativi'  iiepatitis. 


;  i 


3.   SKI'TICO-I'VyEMIA. 

The  pathogei.ic  micro-organisms  which  invade  the  blood  and  tissues 
may  settle  in  ct  tain  foci  and  there  cause  suppuration.  When  juul- 
tiple  abscesses  are  thus  produced  in  connection  with  a  general  infection, 
the  condition  is  known  as  jjya'mia  or,  perhaps  better,  septico-pyiunua. 
There  are  no  s{)ecitic  organisms  of  suppuration,  ami  the  condition  of 
pvivnua  may  be  produced  by  organisms  other  than  the  streptococci  and 
staphylococci,  though  these  are  the  most  common.  Other  forms  '.vhich 
may  invade  the  system  and  cause  foci  of  suppuration  are  the  nucrococcus 
lanceolatus,  the  gonococcus,  the  bacillus  coli  communis,  the  bacilli  typhi 
abdominalis,  the  j)roteus,  and  the  bacillus  pyocyaneus.  and  very  probably 
the  liacillus  ivrogenes  capsulatus.  In  a  large  proportion  of  all  c.nses  of 
pya'inia  there  is  a  focus  of  infection,  either  a  suppurating  external  wound, 
an  osteo-myelitis,  a  gonorrha'a,  an  otitis  media,  an  emi)y;vmi;  an  area  of 
snppuratior  in  a  lyinph-gland  or  about  the  appendix.  In  a  large  majority 
of  all  thes'  cases  the  common  pus  cocci  are  present. 

in  a  s  i]){)urating  wound,  for  examjjle,  the  pus  organisms  induce  coagn- 
lation-nr  Tosis  in  the  smaller  vessels  with  the  production  of  thrombi  and 
punilen  phlebitis.  The  entrance  of  pus  organisms  in  small  numbers 
intii  the  blood  does  not  necessarily  produce  pya>mia.  Commonly  the 
transmission  to  various  parts  from  the  lo(^al  focus  takes  place  by  the  frag- 
ments of  thrombi  which  pass  as  emboli  to  ditl'erent  parts,  where,  if  the 


I  At 


130 


SPECIFIC   INFECTIOUS  DISEASES. 


m       (   !, 


Mi 


conditions  are  favorable,  the  pus  organisms  excite  suppuration.  A  tlirom- 
bus  which  is  not  septic  or  contaminated,  when  dislodged  and  impacted  in 
a  distant  vessel,  produces  only  a  simple  infarction ;  but,  coming  from  an 
infected  source  and  containing  pus  microbes,  an  independent  centre  ni 
infection  is  establisliod  wlierever  the  embolus  may  lodge.  These  inde- 
pendent suppurative  centres  in  pya-mia,  known  as  embolic  or  mclanlulir 
abscesses^  have  the  following  distribution  : 

{(t)  In  external  wounds,  in  osteo-myelitis,  and  in  acute  phlegmon  of 
the  skin,  the  enibolic  particles  very  frequently  excite  suppuration  in  tlic 
lungs,  producing  the  well-known  wedge-shaped  pyitniic  infarcts;  but  in 
some  cases  the  infected  particles  pass  through  the  lungs,  and  there  are 
foci  of  inilammation  in  the  heart  and  kidneys. 

(/;)  Suppurative  foci  in  the  territory  of  the  jjortal  system,  particularly 
in  the  intestines,  prodiu;e  metastatic  abscesses  in  the  liver  with  or  without 
suppurative  pyle-phlebitis. 

Endocarditis  is  an  event  which  is  very  liable  to  occur  in  all  forms  of 
septicemia,  and  modifies  materially  the  character  of  the  clinical  features. 
Streptococci  and  staphylococci  arc  the  most  common  organisms  present 
in  the  vegetations,  but  tlie  pneumococei,  gonococoi,  tubercle  bacilli,  ty- 
phoid bacilli,  anthrax  bacilli,  and  other  forms  have  been  isolated.  The 
vegetations  which  develop  at  the  site  of  the  valve  lesion  become  covered 
with  throml}i,  particles  of  which  may  be  dislodged  and  carried  as  emboli 
to  diiferent  parts  of  tlie  body,  causing"  multiple  .ibscrsses  or  infarcts. 

Symptoms  of  Septico-pysemia.— In  a  ease  of  wound  infection, 
prior  to  tlie  onset  of  the  characteristic  symptoms,  there  may  be  signs  of 
local  trouble,  and,  if  a  discharging  wound,  bh.e  pus  may  change  in  charac- 
ter. The  onset  of  the  disease  is  marked  by  a  severe  rigor,  during  which 
the  temperature  rises  to  1013"  or  1()4°  and  is  followed  by  a  profuse  sweat. 
These  chills  are  repeated  at  intervals,  either  daily  or  every  other  day. 
In  the  intervals  there  may  be  slight  pyrexia.  The  constitutional  disturb- 
ance is  marked  and  there  are  loss  of  appetite,  nausea,  and  vomiting,  and, 
as  the  disease  progresses,  rapid  emaciation.  Transient  erythema  is  not 
uncommon.  Local  symptoms  usually  develop.  If  the  lungs  become  in- 
volved there  are  dyspncea  and  cough.  The  physical  signs  may  be  slight. 
Involvement  of  '^'c  pleura  and  pericardium  is  common.  The  tint  of  the 
skin  is  changed ;  at  first  pale  and  white,  it  subsequently  becomes  bile- 
tinged.  The  spleen  is  enlarged,  and  there  may  be  intense  pain  in  the 
side,  pointing  to  perisplenitis  from  embolism.  Usually  in  the  rapid  cases 
a  typhoid  state  grailually  develops,  and  the  patient  dies  comatose. 

In  the  chronic  cases  the  disease  maybe  prolonged  for  months ;  the 
chills  recur  at  long  intervals,  the  temperature  is  irregular,  and  the  condi- 
tion of  the  patient  varies  from  month  to  month.  The  course  is  usually 
slow  and  progressively  downward. 

Diagnosis. — Pyaemia  is  a  disease  frequently  overlooked  and  often 
mistaken  for  other  affections. 


SEPTICAEMIA   AND   PY.T:MIA. 


131 


^1 


Cases  following  a  wound,  an  operation,  or  parturition  :iro  roiulily  roc- 
oisuhoi].  On  the  other  hand,  the  following  conditions  may  bo  over- 
Ion  kwl  : 

Oslro-myelitis. — TIero  the  lesion  may  be  limited,  (lie  constitutional 
svmiitdins  severe,  and  the  course  of  the  disease  very  rapid.  Tiie  cause  of 
tlio  (rouble  may  be  discovered  only  post  mortem. 

So,  too,  acute  septico-pyiemia  may  follow  fjovorrhxen  or  a  prostatic 
nbxfcxx. 

Cases  are  sometimes  confounded  with  ti/p/ioid  fevtr,  particularly  the 
nioro  chronic  instances,  in  which  there  are  diarrhiea,  great  jjrostration, 
delirium,  and  irregular  fever.  The  spleen,  too,  may  be  enlarged.  The 
niiirked  leiu;ocytosis  is  an  im})()rtatit  differential  point. 

Ill  some  of  the  instancies  of  ulcrralive  einhairditix  the  diagnosis  is 
very  didlcult,  particularly  in  what  is  known  as  the  typhoid,  in  contradis- 
tinction to  the  septic,  type  of  this  disease.  In  acute  miliary  tuberculosis 
the  symptoms  occasionally  resemble  those  of  septicoiniia,  more  commonly 
tliosu  of  typhoid  fever. 

The  post-febrile  arfhrifitles,  such  as  occur  after  .''carlet  fever  and  gon- 
orrlid'a,  are  really  instances  of  mild  septic  infection.  The  joints  may 
.soniediiies  proceed  to  suppuration  and  pyivmia  develop.  So,  also,  in  fuber- 
riilosis  of  t/ie  kidneys  and  arlcnlous  pyelitis  recurring  rigors  iiud  sweats 
(hie  to  septic  infection  are  common.  In  this  ladtude  .sep(ic  and  py;vmic 
processes  are  too  often  confounded  with  malaria.  In  early  tuberculosis, 
or  even  when  signs  of  excavation  are  present  in  the  lungs,  and  in  cases  of 
sujipiiration  in  various  j)arts,  particularly  empyema  and  abscess  of  the 
liver,  till!  diagnosis  of  malaria  is  made.  The  pracdtioncr  may  take  it  as  a 
siifc  rule,  to  which  he  will  find  very  few  exceptions,  that  an  inti  rinittent 
frcr  which  resists  quinine  is  not  malaria. 

Odier  conditions  associated  with  chills  which  may  1  ^nistaken  for 
pvii'iiiia  are  profound  anaimia,  certain  cases  of  Ilodgkin  .-  diM'.ise,  tin 
lirpati(!  intermittent  fever  associated  with  the  lodgment  of  gall-s(one  at 
(he  orifice  of  the  common  duct,  rare  cases  of  essential  fever  in  ner\i)us 
woiiieii,  and  the  intermittent  fever  sometimes  seen  in  ra[)idly  developing 
eaiieer. 

Treatment. — The  treatment  of  .septica'inia  and  ])ya'niia  is  largely  a 
surgical  problem.  The  cases  which  come  under  the  notice  of  the  physi- 
cian usually  have  visceral  abscesses  or  ulcerative  endocanlids,  conditions 
wiiich  are  irremediable.  We  have  no  remedy  which  controls  the  fever. 
Quinine  .ind  the  new  antipyretics  may  be  tried,  but  (bey  ar(>  of  little  serv- 
ice. Quinine  is  probably  better  than  antipyrin  and  an(ifel)rin,  which 
lower  the  tempciiatiire  for  a  time,  but  when  a  careful  two-hourly  twenty- 
fiiur-hoiir  (diart  is  taken,  it  is  often  found  that  the  depression  under  the 
iiilliieiKw  of  the  drug  is  made  up  at  some  other  period  of  the  day ;  a  morn- 
ing may  be  substituted  for  an  afternoon  fever. 

riie  brilliant  and  remarkable  results  which  follow  complete  evacuation 


'  mt 


132 


SPECIFIC   INFECTIOUS  DISEASES, 


of  the  [)iis  with  thorough  clrMiuiii^o  give  tho  indication  for  the  only  suc- 
cessful treutnient  of  this  condition. 

Unfortunately,  in  too  numy  cases  wliicli  tlic  physician  is  called  upon 
to  treat,  the  region  of  suppuration  is  iKtt  accessible,  and  we  have  to  be 
content  with  the  eniployinent  of  general  measures  for  the  support  of 
the  patient's  strength. 

TKUMIXAL    INFIXTIONS. 

It  may  seem  paradoxical,  hut  there  is  truth  in  the  statement  that  per- 
sons rarely  die  of  the  disease  with  which  they  suffer.  Secondary  infec- 
tions, or,  as  we  are  a})t  to  call  them  in  hospital  work,  terminal  infections, 
carry  off  many  of  the  incurable  cases  in  the  wards. 

These  may  be  local  or  general.  The  former  are  extremely  common, 
and  are  found  in  a  large  ()roportiou  of  all  cases  of  Hright's  disease,  arterio- 
sclerosis, heart  disease,  cirrhosis  of  the  liver,  and  other  chronic  disorders. 
Affections  of  the  serous  membranes  (acute  ])leurisy,  acute  pericarditis, 
or  peritonitis),  meningitis,  and  endocarditis  are  tlie  most  frequent  lesions. 
It  is  perhaps  safe  to  say  tiuit  the  nuijority  of  cases  of  advanced  arterio- 
sclerosis and  of  Hright's  disease  succumb  to  these  intercurrent  infections. 
Tl'  >  infective  agents  aic  very  varied.  Tiic  streptococcus  pyogenes  is  ])er- 
haps  the  most  common,  but  the  bacillus  dij)htheriiB,  the  pneumoeoccus, 
the  proteus,  and  the  bacillus  pyocyaneus  are  also  met  with. 

Particular  mention  may  be  here  made  of  the  terminal  form  of  acute 
miliary  tuberculosis.  It  is  surprising  in  liow  many  instances  of  arterio- 
sclerosis, of  ciironic  heart  disease,  of  Hriglit's  disease,  ami  more  ])articu- 
larly  of  cirrhosis  of  the  liver,  the  fatal  event  is  determined  by  an  acute 
tuberculosis  of  the  peritoiuxnim  or  jdeura. 

The  geneni!  terminal  infections  are  not  so  common,  but  in  Ilodgkiji's 
disease,  leuka'mia,  Briglit's  disease,  and  tuberculosis  there  may  be  a  ter- 
minal pneumoeoccus  or  streptococcus  septictemia  without  local  lesion,  and 
to  which  the  patients  succumb. 

And,  lastly,  probably  of  the  same  nature  is  the  terminal  entero-colitis 
Eo  frequently  met  with  in  chronic  disorders. 


XVIII.    CHOLERA    ASIATICA. 

Definition. — A  specific,  infectious  disease,  caused  by  the  comma  ba- 
cillus of  Koch,  and  characterized  clinically  by  violent  [uirging  and  rapid 
collapse. 

Historical  Summary. — Cholera  has  been  endemic  in  India  from  a 
remote  })eriod,  but  only  within  the  present  century  has  it  made  inrnads  into 
Europe  and  Ameri<'a.  An  extensive  epidemic  occurred  in  ^S'.i'i,  in  which 
year  it  was  brought  in  imnugrant  ships  from  Great  Britain  to  Quebec.  It 
travelled  along  the  lines  of  trafiio  up  the  Great  Lakes,  and  final  ly  reached 


L.„...ii 


CHOLERA   ASIATICA. 


133 


as  fill'  \\'''~t  as  the  military  posts  of  tlio  upper  ^lississippi.  In  the  same 
year  it  entered  the  United  States  by  way  of  New  Vork.  There  were  re- 
oiirrenct's  of  tlie  disease  in  IH^j-'^ti.  In  1848  it  entered  the  country 
tiirou'^li  New  Orleans,  and  spread  widely  up  the  Mi.ssissi{)])i  Valley  and 
across  the  continent  to  (Ji.lifornia.  In  1849  it  again  appeared.  In  1854 
it  was  introduced  by  immigrnit  ship«  'nto  New  York  and  prevailed  widely 
tlirouglioiit  the  country.  In  18(i(i  and  in  1807  there  were  less  serious  epi- 
demics. In  1873  it  again  appeared  in  the  United  States,  but  did  not  i)re- 
vail  wiiK'ly.  In  1884  there  was  an  outbreak  in  Euro])e,  and  again  in  189:^ 
ami  18!i3.  Although  occasional  cases  have  been  brought  by  ship  to  the 
qiianuitiue  statior.s  in  this  country,  the  disease  has  not  gained  u  foothold 
luTC  since  187;}. 

Etiology. — In  1884  Koch  announced  the  discovery  of  the  s[)ecific 
orgaiiisiii  of  this  disease.  Subserpient  observations  have  confirmed  his 
statciiiont  that  the  comma  bacillus,  as  it  is  termed,  occurs  constantly  in 
the  true  cholera,  and  in  no  other  disease.  It  has  the  forju  of  a  slightly 
bout  rod,  which  is  thicker,  but  not  more  than  about  half  the  length  of  the 
tubcM'ck'  bacillus,  and  sometimes  occurs  in  an  S  form.  It  is  not  a  true 
bacillus,  but  really  a  spiroclnvte.  The  organism  grows  upon  a  great 
variety  of  media  and  displays  distinctive  and  charai'teristic  appearances. 
K(H'h  found  them  in  the  water-tanks  in  India,  ami  also  in  the  water 
(luring  the  Hamburg  epidemic  of  189'^.  During  e})ideinics  virulent 
bacilli  may  be  found  in  the  fa.'';es  of  healthy  persons.  The  bacilli  are 
I'ouiul  ill  the  intestine,  in  the  stools  from  the  earliest  period  of  the  dis- 
ease, and  very  abundantly  in  the  characteristic  rice-water  evacuations,  in 
which  they  may  be  seen  as  an  almost  pure  culture.  'I'hey  very  rarely  occur 
ill  the  vomit.  Post  mortem,  they  are  found  in  enormous  numbers  in  the 
intestine.  In  acutely  fatal  cases  they  do  not  seem  to  invade  the  intestinal 
wall,  Ijut  in  cases  with  a  more  protracted  course  they  are  found  in  the 
tollicles  and  even  in  the  deeper  tissues. 

Modes  of  Infection. — As  in  other  diseases,  individual  peculiarities  count 
for  much,  and  during  epidemics  virulent  cholera  bacilli  have  been  isolated 
from  the  normal  stools  of  healthy  men.  Cholera  cultures  have  also  been 
swallowed  with  im})unity. 

The  disease  is  not  highly  contagious  ;  physicians,  nurses,  and  others  in 
close  contact  with  patients  are  not  often  alTected.  On  the  other  hand, 
washerwomen  and  those  who  are  brought  into  very  close  contact  with  the 
linen  of  the  cholera  patients,  or  with  their  stools,  arc  particularly  prone  to 
eatoli  the  disease.  Tlu're  have  been  several  instances  of  so-callccl  "  labora- 
toiT  cholera,'"  in  which  students  have  been  accidentally  infected  while 
working  at  the  cultures. 

Vegetables  which  have  been  washed  in  the  infected  water,  particularly 
lettuces  and  cresses,  may  convey  the  disease.  Milk  may  also  be  contami- 
ii:iteil.  The  bacilli  live  on  fresh  bread,  butter,  and  meat,  for  from  six  to 
t'ight  days.     In  regions  iu  which  the  disease  prevails  the  possibility  of  the 


a^. 


m 
ii 

m 


^'  .! 


134 


SPECIFIC   INFECTIOUS  DISEASES. 


infection  of  food  by  flics  should  be  borne  in  mind, since  it  has  been  shown 
tiiiit  tlie  l)iicilli  nuiy  live  for  ut  least  three  days  in  their  intestines. 

Infection  throujih  the  air  is  not  to  be  much  drea<led,  since  the  germs 
when  dried  die  rapidly. 

The  disease  is  i)roiiagated  chiefly  by  contaminated  water  used  for 
drinkinjr,  cooking,  and  washing.  The  virulence  of  an  I'pidemic  in  any 
region  is  in  dire(.'t  proportion  to  the  inii)erfection  of  its  water  .suj>|)1y.  In 
India  the  demonstration  of  the  connecition  between  drinking-water  and 
cholera  infection  is  complete.  'I'he  ILuuburg  epidemic  is  a  most  rcnuirk- 
ablc  illustration.  'I'he  unflltered  water  of  the  Kli)e  was  the  chief  supply, 
although  taken  from  the  river  in  such  a  situation  that  it  was  of  necessity 
directly  contaminated  by  sewage.  It  is  not  known  accurately  from  what 
source  the  contagion  came,  wliether  from  Hussia  or  from  France,  but  in 
August,  ISO'^,  there  was  a  sudden  explosive  ei)id<'mic,  and  within  three 
months  nearly  18,000  persons  were  attacked,  with  a  inortaiity  of  i2'',i 
per  cent.  The  neighboring  city  of  Altona,  which  also  took  its  water  from 
the  Elbe,  but  which  had  a  thoroughly  well-equipped  modern  (iltration 
system,  had  oidy  in  the  same  period  51  fl  cases. 

Two  maip.  tyjtes  of  ejjidemics  of  cholera  are  recognized  :  the  flrst,  in 
whit'h  many  individuals  are  attacked  simultaiu'ously,  as  in  tlie  Hamburg 
outbreak,  and  in  which  no  direct  coiniection  can  be  traced  between  the 
individual  cases.  In  this  type  there  is  wide-spread  contamination  of  the 
drinking-water.  In  the  other  type  the  cases  occur  in  groups,  so-called 
cholera  lU'sts ;  individuals  are  not  attacdvcd  simultaneously  but  success- 
ively. A  direct  connection  between  the  cases  may  be  very  diflicidt  to 
trace.  Again.  ])oth  these  types  may  be  combined,  and  in  an  epidenuo 
which  has  started  in  a  wide-spread  infection  through  water,  there  may  be 
other  outbreaks,  which  are  examples  of  the  second  or  chain-like  type. 

Pettenkofcr,  on  the  other  hand,  denies  the  truth  of  this  driidving- 
water  theory,  and  maintains  that  the  conditions  of  the  soil  are  of  the 
greatest  importance;  particularly  a  certain  porosity,  combined  with  moist- 
ure and  contanunation  with  organic  matter,  such  as  sewage.  He  holds 
that  germs  dcveloi)  in  the  subsoil  nu)isture  during  the  warm  month.s,  and 
that  they  rise  into  the  atmosphere  as  a  miasm. 

The  disease  is  always  spread  along  the  lines  of  human  travel.  In 
India  it  has,  in  nniny  notable  cases,  been  widely  spread  by  jdlgrims.  It 
is  carried  also  by  caravans  and  in  ships.  It  is  not  conveyed  through  the 
atmosphere. 

PIa(!es  situated  at  the  sea-level  arc  more  prone  to  the  disease  than 
inland  towns.  In  high  altitudes  the  di.sease  does  not  prevail  ,so  exten- 
sively. A  high  temperature  favors  the  developiiumt  of  the  disease,  but 
in  Europe  and  .Vmerica  the  epidemics  have  been  chiefly  in.  the  late  sum- 
mer and  in  the  autumn. 

The  disease  affects  persons  of  all  ages.  It  is  particularly  prone  to 
attack  the  intemperate  and  those  debilitated  by  want  of  food  and  by  bad 


CHOLKRA   ASIATICA. 


185 


i 


siirrountliiiss.  Depressing  einotioiis,  such  as  fear,  nnfloubtedly  liavo  ji 
Diiirkcd  iiilliiciice.  It  is  douhtt'iil  wlietlicr  nil  aftuck  fiirMislie.s  itiumiuity 
airiiinst  ;i  second  one. 

Morbid  Anatomy. — There  are  nocharacteristie  anatomical  cdiaiigcs 
in  cliiikiii  ;  Imt  a  post-niorteni  dia<,'nosis  of  the  nature  of  the  disease 
(iiulil  111-  made  l)y  any  eompcteiit  haeterioloijist,  as  the  niicro-or^anisms 
jii'c  sjici'lllc  and  distinctive.  'I'lic  body  luis  the  appearances  associated 
witii  pidfoiiiid  collapse.  Tlicre  is  often  marked  post-mortem  elevation  of 
tcMipenitine.  The  ri;/(>r  i/iorfis  sets  in  early  and  may  jjroduee  displace- 
iiiciit  (if  iIk'  limbs.  The  lower  jaw  lias  been  seen  to  move  and  the  eyes  to 
riitiitf.  \iirioiis  movements  of  the  arms  and  ]i'<:;s  have  also  been  seen.  'I'lie 
l)l<i(Mi  is  thick  and  dark,  and  there  is  a  remarkable  diminution  in  ]\v 
luiioimt  of  water  and  salts.  The  peritonanini  is  sticky,  and  the  eoils  of 
iiitcstiiirs  are  congested  and  look  thin  and  shrunken.  There  is  nothing 
siurial  in  the  appearance  of  the  stomach.  'I'lie  stnall  intestine  usually 
(■diitaiiis  a  tiu'l)itl  serum,  similar  in  ap(H^arance  to  that  which  was  passed 
ill  the  stnois.  The  mucosa  is,  as  a  rule,  \r,\]v  and  swollen  and  often  con- 
•.'(■sted  about  tlic  I'eyer's  patches.  Post  mortem  tlu'  epithelial  lining  is 
sDiiictinies  denuded,  but  this  is  jirobably  not  a  cliange  which  takes  jjlaee 
(luring  life.  In  the  stools,  liowever,  large  numbers  of  columnar  epithelial 
('I'll-  have  been  described  by  many  observers.  The  bacilli  are  found  in  the 
niiitents  of  the  intestine  and  in  the  mucous  membrane.  The  spleen  is 
ii-nally  .-mall.  The  liver  and  kidneys  show  cloudy  swelling,  and  the  latter 
('\teiisi\e  coagulation-necrosis  and  destruction  of  the  epithelial  cells. 
The  heart  is  llabliy  ;  the  right  ehaml)ers  are  distended  with  blood  and  the 
left  chainbers  are  usually  empty.  'J"he  lungs  are  collapsed,  and  congested 
at  tlu'  bases. 

The  aliove  appearances  are  those  met  with  in  cases  wliich  prove  rapidly 
fatal.  When  the  patient  survives  and  deafh  occurs  during  reaction,  there 
may  he  more  deiinite  inflammatory  appearances  in  the  intestines  and  more 
jiroiKiinieed  changes  in  the  kidneys  and  liver. 

Symptoms. — A  jieriod  of  incubation  of  uncertain  length,  probably 
not  iiKire  than  from  two  to  five  days,  precedes  the  dc-\e!opnieiit  of  the 
syiiiptdiiis. 

Three  stages  may  be  recognized  in  the  attack  :  the  preliminary  diar- 
iliii'ii,  the  (^oUapse  stage,  and  the  period  of  reaction. 

{it)  The  pir/iiin'mirif  diarrhwa  may  set  in  abruptly  without  any  jire- 
vi(tiis  iiidii'alions.  More  commonly  there  are,  for  one  or  two  days,  colicky 
l>iiiii.-i  ill  the  abdomen,  with  looseness  of  the  bowels,  perhaps  vomiting, 
with  headache  and  depression  of  spirits.     There  may  be  no  fever. 

(/')   Cdltapse  Stof/f. — The  diarriuea  increases,  or,  without  any  of  the 

preliminary  symptoms,  sets  in  with  the  greatest  intensity,  and  profuse 

li<|uid  evacuations  succeed  each  other  raiiidly.     There  are  in  some  in- 

stiinc(',<  griping  ])ains  and  tenesmus.     More  commonly  there  is  a  sense 

of  exhaustion  and  collapse.     The  thirst  becomes  extreme,  the  tongue  is 
10 


';  '4. 


1 

I 

1 


136 


SPECIFIC  INFKCTIOUS   niSKASKS. 


t-   ■■  ■  :n 


■.iW 


white  ;  cmnips  of  giTiit  severity  occur  in  tlio  le<];8  and  feet.  Witliiii  a  few 
liours  voniitinfif  sets  in  ami  heconios  incessant.  'The  ])atient  ra]ti(liy  sinks 
into  a  condition  of  collapse,  tlie  features  are  shrunken,  the  »k'u\  of  an  ashy 
gray  hue,  the  eyel)alls  sink  in  the  sockets,  the  nose  is  pinched,  the  check;; 
are  lioUow,  the  voice  becomes  iuisivy,  tiie  extremities  are  cyanosed,  and  tiie 
skin  is  siirivelled,  wrinkk'd,  atid  covered  with  achimmy  pcrs()ir.ition.  The 
temperature  sinks.  In  the  axilla  or  in  the  nu)utli  it  may  be  from  live  to 
ten  dejrrces  below  norniid,  but  in  the  rectum  and  in  the  internal  parts  it 
may  be  lO'A"  or  104".  'I'hc  pulse  becomes  extremely  fecbU;  and  llickcriuir, 
and  the  patient  gradually  passes  into  a  coiulilion  of  eonui,  though  con- 
sciousness is  often  retaiiuul  until  near  the  eml. 

The  fa'ces  are  at  first  yellowish  in  color,  from  the  bile  pigment,  but 
soon  they  become  grayish  white  aiul  look  like  turbid  whey  or  rice-water; 
whence  the  term  ''  rice-water  stools."  There  are  found  in  it  numeroii.s 
snuill  Hakes  of  mucus  and  granular  nuitter,  and  at  times  blood.  Tiic 
reat^tion  is  usually  alkaline.  The  fluid  contains  albumen  and  the  chiit" 
mineral  ingredient  is  chloride  of  sodium.  Microscopically,  mucus  and 
e})ithelial  cells  and  iniiumeral)le  bacteria  are  seen,  the  nuijority  of  the 
latter  l)eing  tlie  comma  bacilli. 

The  coiulition  of  the  patient  is  largely  the  result  of  the  concentratio'i 
of  the  blood  consequent  upon  the  loss  of  serum  in  the  stools.  There  is 
almost  complete  arrest  of  secr(^ti(jn,  particularly  of  the  saliva  and  the 
urine.  On  the  other  hand,  the  sweat-glands  increase  in  activity,  and  in 
nursing  women  it  has  been  stated  that  the  lacteal  flow  is  unafrcctcd. 
This  stage  may  not  last  more  than  two  or  three  hours,  but  more  coni- 
moidy  lasts  from  twelve  to  twenty-four.  There  are  instances  in  which 
the  [)atient  dies  before  purging  begins — the  so-called  chuJcra  xicrn. 

(r)  Reaction  Slane. — When  the  jiatient  survives  the  collapse,  the 
cyanosis  gradually  disai)|)ears,  the  warmth  returns  to  the  skin,  whicli  may 
have  for  a  time  a  mottled  color  or  present  a  definite  erythenuitous  rash. 
The  heart's  action  be(M)mcs  stronger,  the  urine  increases  in  (pumtity,  the 
irritability  of  the  stomach  disappears,  the  stools  are  at  longer  intervals, 
and  there  is  no  alxlominal  pain.  In  the  reaction  the  temperature  may 
not  rise  above  normal.  Not  in'"reqnently  this  favorable  reaction  is  inter- 
rupted by  a  recurrence  of  severe  diarrhu'a  ami  the  patient  is  carried  off  in 
a  relapse.  Other  cases  pass  into  the  condition  of  what  has  been  called 
chokra-tjiphoid,  a  state  in  which  the  patient  is  delirious,  the  j)ulse  rapiil 
and  feeble,  and  the  tongue  dry.  Death  finally  occurs  with  coma.  These 
symi)toms  have  been  attributed  to  urtemia. 

During  ejiidemics  attacks  are  found  of  all  grades  of  severity.  Tlx  re 
are  cases  of  diarrluea  with  grijiing  jjains,  liqiud,  eojiioua  stools,  vomitiriii;, 
and  cramps,  with  slight  colhijise.  The  term  chohrine  has  been  applied  to 
these  cases.  They  resemble  the  milder  cases  of  cholera  nostraK,  At  tiie 
opposite  eml  of  the  series  there  are  the  instances  of  cholera  sicca,  in  whieji 
death  may  occur  in  a  few  hours  after  the  attack,  without  diarrha>a.     There 


CIIOLKILV    ASIATICA. 


137 


arf  iili*"  <"i^<'S  i"  which  th(^  piititMits  arc  overwliclincd  witli  the  poison  and 
die  ciiiiiatiisc,  without  tiic  prcljiiiiiiJiiT  slaijc  of  colhipsc. 

Complications  and  Sequelae. —'I' lie  typhoid  ccmdition  has  al- 
rciiilv  lidii  n'l'crrcd  to.  'i"!ic  consecutive  nephritis  nirely  indnces  dropsy. 
I)i|ilitlniiiic  colitiH  has  heen  (k'scrii)e(h  Thei'e  is  a  special  tendency  to 
iliiilithciitic  iiillaininati(m  of  the  iniieoiis  midnhranes,  piirticiilarly  of  tlie 
tlifiiai  and  jieiiituls.  I'lieiinionia  and  ]»K'nrisy  may  devch)]),  and  destnic- 
livo  alisce.-scs  may  occur  in  dilTerent  parts.  Snppnrative  parotitis  is  not 
verv  mii'omimtn.  In  rare  instances  hical  gan^M'cne  may  devchip.  A 
troiililr-uiiie  symptom  of  convalesecnco  is  cramps  in  the  muscles  of  the 
anus  and  Icf^s. 

Diagnosis.— The  otdy  a  flection  with  wliicli  Asiatic  clndera  conhl  be 
I'onfeuiiilcd  is  the  r/iolcnr  misfnis,  the  severe  choleraic  diarrho'a  which 
(Kriirs  (hiiiii;?  the  summer  months  in  temjierate  clinnitos.  "^riie  clinical 
jiicinn'  of  the  two  afTec^tions  is  identical.  The  extreme  collapse,  vomitinf?, 
and  rice-water  stools,  tiie  cramps,  the  cyanosed  appearance,  are  all  seen  in 
the  worst  forms  of  cholera  nostras.  In  enfeeliled  persons  death  may  occur 
within  twelve  hours.  It  is  of  course  extremely  important  to  be  able  to 
iHairniise  l)etween  the  two  atTections.  This  can  otdy  be  done  by  one  thor- 
(lUirhly  versed  in  bacterioloijical  methods,  and  conversant  with  the  diversified 
flora  of  the  intestines.  The  comma  bacillus  is  present  in  the  dejections  of 
a  great  iiuijority  of  tlie  cases  and  can  be  seen  on  eover-irlass  preparations. 
TlioM^h  the  eye  of  the  expert  may  be  able  to  differentiate  between  the 
liarilhis  of  true  cholera  and  that  whicdi  occurs  in  cholera  nostras,  cultures 
slionlil  he  made,  from  which  alone  positive  results  can  be  obtained. 

Attacks  vei'y  similar  to  Asiatic  cholera  are  produced  in  jioisonins;  by 
arsonic,  corrosive  sublimate,  and  certain  fungi;  but  a  difficulty  in  diag- 
nosis could  scarcely  arise. 

T\w  proi/iiosifi  is  always  uncertain,  as  the  mortality  ranges  in  different 
fpideniif's  from  .'}0  to  80  per  cent.  Intemperance,  debility,  and  old  age 
aiv  iinfavoraljle  conditions.  The  more  raj)idly  the  collapse  sets  in,  the 
;.nvater  is  the  danger,  and  as  Andral  truly  says  of  the  nndignant  form, 
"It  liegins  where  other  diseases  end — in  death."  C.'ases  with  marked 
rvanosis  and  very  low  temperature  rarely  recover. 

Prophylaxis. — Preventive  measures  are  all-important,  and  isolation 
of  the  sick  and  thorough  disinfection  have  effectually  i)revented  the  dis- 
tast' entering  England  or  the  United  States  siiwe  18?I3.  On  several  occa- 
sions since  that  date  cholera  has  been  brought  to  various  ports  in  Amer- 
ica, hilt  has  been  checked  at  quarantine.  During  epidemics  the  greatest 
earo  should  be  exercised  in  the  disinfection  of  the  stools  ami  linen  of  the 
patients.  When  an  epidemic  prevails,  persons  shoidd  be  warned  not  to 
drink  water  unless  previously  boiled.  Eriors  in  diet  should  be  avoided. 
As  the  disease  is  not  more  contagious  than  typhoid  fever,  the  chance  of  a 
]»c'rsoii  passing  safely  through  an  epidemic  depends  very  much  upon  how 
far  he  is  able  to  curry  out  thoroughly  prophylactic  measures.     Digestive 


i  '■ 


VW 


SIM-:('IF1(;   IN'FKCTIOUS   niSEASKS, 


II 


■i,; 


.-*«,  ■' 


fl*' 

jHit' 

(lisliirbiuioos  are  to  l)o  treated  proiiiptly,  ami  particularly  tlio  diarrlid'!!, 
which  so  ol'tcii  is  a  prcliniiiiarv  syiuptoiii.  For  this,  opiuiii  and  acotato  of 
load  and  larjrt!  doses  of  hisimith  should  hi'  j^ivou. 

llatTkiiii'  has  ohtainod  a  protective  virus  which  has  heou  used  on  a 
larirc  scale  in  India.  Diirinj;  1S!).'{  and  1H!)4  al)out  .'{•<i,()()()  people  wcic 
inoculated,  'i'lii!  results  on  the  whole  are  encoura<;inf,',  as  the  jterceiit- 
a<,'e  attat'ked  of  the  inoculated  was  very  consicUirably  smaller  than  in 
unprotected  individuals. 

Medicinal  Treatment.  — Dnr in jr  the  initial  stajre,  when  the  diar- 
rluea  is  not  excessive  hut  the  ahdoininal  pain  is  marked,  opium  is  tlic 
most  ellicient  rcnicily,  and  it  should  be  given  hypodermically  as  morphia. 
It  is  advisable  to  give  at  once  a  full  dose,  which  may  be  repeated  on  the 
return  of  the  pain.  It  is  best  not  to  attempt  to  give  remedies  by  the 
mouth,  as  they  disturb  the  stomach,  lee  should  he  given,  and  brandy  or 
hot  cotVee.  In  the  collapse  stage,  writers  speak  strongly  against  the  use 
of  o])ium.  Undoubtedly  it  must  be  given  with  caution,  but,  judging  from 
its  effects  in  cholera  nostras,  I  should  say  that  (tollapso  per  ft'  was  not  u 
contra-indication.  The  jjatient  imiy  be  allowed  to  drink  freely.  For  tlio 
vomiting,  which  is  very  dillicult  to  chei^k,  cocaine  may  be  ti'icd,  and  lav- 
age with  hot  water.  Creasote,  hydrocyanic  acid,  and  creolin  have  been 
found  useless.     l{umpf  advises  calomel  (gr.  jf)  every  two  hours. 

Kxternal  applications  of  heat  should  be  made  and  a  hot  bath  may  ho 
tric(l.  Warm  a|ipli(!ations  to  the  abdomen  are  very  grateful.  Hypoder- 
mic injections  of  ether  will  be  found  serviceable. 

Irrigation  of  the  bowel — enteroclysis — with  warm  water  and  soap,  or 
tannic  acid  {'Z  per  cent),  should  be  used.  With  a  long,  soft-rubber  tube, 
as  much  as  three  or  four  litres  may  be  slowly  injected.  Not  only  is  the 
colon  cleansed,  but  the  small  bowel  may  also  be  reached,  as  shown  by  the 
fact  that  the  tanuic-acid  solutions  have  been  vomited. 

Owing  to  the  ])rofuse  serous  discharges  the  blood  becomes  concen- 
trated, and  ai)sorj)tion  takes  place  rapidly  from  the  lymph-spaces.  To 
meet  this,  intravenous  injections  have  been  jiractised.  My  preceptor, 
liovell,  lirst  practiscMl  the  intravenous  injections  of  milk  in  Toronto,  in 
the  epidemic  of  18.54.  A  litre  of  salt  solution  at  107°  may  be  injecteii, 
and  repeated  in  a  few  hours  if  no  reaction  follows.  Less  risky  and  equally 
etlicacions  is  the  subcutaneous  injection  of  a  sidine  solution.  For  this, 
common  salt  should  be  used  in  the  proportion  of  about  four  grammes  to 
the  litre.  With  rubber  tubing,  a  cannula  from  an  aspirator,  or  even  with 
a  hypodermic  needle,  the  warm  solution  may  be  allowed  to  run  by  pres- 
Bure  beuejith  the  skin.  It  is  rajjidly  absorbed,  and  the  process  n)ay  l>e 
continued  until  the  pulse  shows  some  sign  of  improvement.  This  is 
really  a  valuable  method,  thoroughly  physiological,  and  should  be  tiled 
in  all  severe  cjises. 

In  the  stage  of  reaction  special  pains  should  be  taken  to  regulate  llic 
diet  and  to  guard  against  recurrences  of  the  severe  diarrhwa. 


YKIiliOW    KKVHR. 


139 


XIX.  YELLOW    FEVER. 


Definition. — An  iUMitc  fcljiilc  disciisc  of  trnpiral  and  siil)tro|)i('iil 
ciiiiiili  II  "^,  cliiinicterizi'd  hy  juuiidice  uiid  lui'iiiorriiUf^i'S,  and  due  to  the 
;utii>ii  (if  a  spc'cillc  virus,  tliK  nature  of  which  is  yot  unknown. 

Etiology. — The  disease  prevails  cndeniifally  in  tlie  West  Indies  and 
in  ccitaiii  sections  of  tlie  Sjianish  Main,  l-'roin  these  reifions  it  occa-iionally 
(.xlriMls;md,un(h'rsuital)le  conditions,  prevailsepidetnically  in  the  Southern 
Sliiti's.  Now  and  then  it  is  brought  t()  the  hir<re  seaports  of  tlie  Athmtic 
coast.  ForiMcrly  it  occurred  extensively  in  the  I'nited  States.  In  the 
hitter  part  of  the  last  century  and  the  beginninf^j  of  this,  friglitful  epi- 
liciiiirs  jirevailed  in  I'hiladelphia  and  other  North(>''n  cities.  The  epidemic 
of  !"'.•:!,  so  graphically  des(;ribed  by  Matthew  Carey,  was  the  inost  serious 
that  has  ever  prevailed  in  any  city  of  the  Middle  States.  The  mortality, 
as  Lrivcii  l>v  ("arey,  during  the  months  of  August,  September,  October,  and 
NdVi'iiiher,  was  4,041,  of  whom  ;{,4;5r)  died  in  the  months  of  September  and 
Octelicr.  'J'he  population  of  the  city  at  the  time  was  only  4(1,000.  Kpidein- 
i(s  (KTiirreil  in  the  United  States  in  lT!)r,  ITli-S,  1H)!»,  and  in  lSO-.>,  when 
tlic  iliscasc  prevailed  slightly  in  lioston  and  extensively  in  Haltiniore.  In 
18():i  and  IHOo  it  again  appeared  ;  then  for  many  years  the  outbreaks  were 
slii'ht  and  localized.  In  18");}  the  disease  raged  throughout  the  Southern 
Slates.  In  \ew  Orleans  alone  tlnnv  was  a  mortality  of  nearly  eight  thou- 
siiiid.  In  IStiT  and  1873  there  were  nu)derately  severe  epidemics.  In 
18TH  the  last  extensive  epidemic  occurred,  chiefly  in  Louisiana,  Alabama, 
mill  ^lississipj)!.  The  total  mortality  was  nearly  sixteen  thou.sand.  In 
Eiirojio  it  has  occasionally  gained  a  foothold,  but  there  have  been  no 
wiijc'-spread  e{)idemics  except  in  the  Spanish  ports.  The  disease  exists  on 
the  west  coast  of  Africa.  It  is  sometimes  carried  to  ports  in  Great  Britain 
and  France,  but  it  has  never  extended  into  those  countries.  The  history 
of  the  disease  and  its  general  symptomatology  are  exhaustively  treated  in 
tlio  classical  work  of  Kene  La  Koche. 

(luiteras  recognizes  three  areas  of  infection  :  (1)  The  focal  zone  in 
whifh  the  disease  is  never  absent,  inciluding  llavaiui,  \'era  Cruz,  Ilio,  and 
othor  Spanish- American  ports,  {'i)  Perifocal  zone  or  regions  of  periodic 
C|ii(l('iiiii's,  including  the  ports  of  the  tropical  Atlantic  in  America  and 
Africa.  ('.])  'i'he  zoiu!  of  accideiital  epidemics,  between  the  parallels  of 
4')"  north  and  35°  south  latitude. 

The  e})idemics  are  invariably  due  to  the  introduction  of  the  poison 
cithor  iiy  patients  atTected  with  the  disease  or  through  infected  artit'le.s. 
I'liijiicstioniddy  the  jioison  may  be  conveyed  by  fomites.  Lidividuals  of 
nil  ages  and  races  are  attacked.  The  negro  is  much  less  susceptible  than 
'lir  white,  but  he  does  not  enjoy  an  immunity.  Kesidents  in  southern 
i'iiiuitri(>s,  in  which  the  disea.se  is  prevalent,  are  not  so  susceptible  as  stran- 
gers and  temporary  residents.  Males  arc"  m,.re  fre(piently  affected  and  the 
mortality  is  greater  among  them,  owing  probably  to  greater  exposure. 


I!    I 

f .     :£ 
!;.  i! 


i,.y 


}r:l 


m 


4   '^ 


140 


SPKCIFIC    INI'KCTIOUS   DISKASKS. 


Very  youii^  childrtM  iiHUiilly  I'sciipc ;  l)iit  in  tlic  ('|ii<]<'iiiics  of  lar^'c 
cities  tile  iiiiiiilter  uiKJer  live  ill  liukcii  is  liir;,^',  siiice  tliey  (•(»iisliliite  ii  eon- 
Hiiienilile  in-uportioii  oi'  tln'  |Hi|)iil:iii(iii  uii|irotcetr(|  \t\  |ii'evi((iiH  uttack. 
(iiiilriiis  stales  tliuL  llic  "  I'ni  i  cil'  fiidciiiieity  of  yelli»w  fever  are  esseiitiallv 
iiiaiiilaiiit'd  l)y  tiiu  ereojc  ini'aiit  |i<)|iulali()ii."  liniiiiniily  is  atquirt'd  iiy 
])assiii^  liu'oiij^di  ail  at  lack  or  by  itr(d()iij,H'(i  ri'sidnice  in  ii  locality  in  wluch 
it  is  eiideiiiie.  'I'lu'  stateiiieiil  so  oficii  made  tliat  the  (;reoles  an'  exempt 
Iroiii  yellow  fever  lias  lu'iii  abundantly  disproved.  'I'liey  eertainly  are  not 
so  susceptible,  bill  in  severe  epidetiiics  tliey  die  in  niiinberH.  The  evidence 
in  favor  of  inlierilcd  ininiiinity  is  not  conclusive. 

('iiiuliliinis  j'tirnrniii  tlif  lli'cchiihiniil  a/  /Jjiitfrinics.  —  Yellow  fever  is 
u  diseaso  of  the  .H'U-cotist,  and  rarely  prevails  in  re;;ions  with  an  eleva- 
tion above  one  thousand  I'eet.  Its  nivayes  are  most  wrioiis  in  eities,  par- 
ticularly when  the  sanitary  conditions  are  uii favorable.  It  is  always  uidsl 
severe  in  the  badly  drained,  unhealthy  jxtrtioiis  <d'  a  city,  where  the  popii- 
lalion  is  crowded  togi'ther  in  ill-ventilated,  badly  drained  houses.  'I'lic 
disease  prevails  during  the  liot  season.  Jn  Uavanu  the  death-rate  is  great- 
est iluring  the  months  of  Juiu',  July,  and  August.  'J'he  epitleiiiies  in  I  he 
Uniteil  .States  have  always  been  in  the  sunmier  and  autumn  months. 

The  specilie  germ  of  the  disease  has  not  yet  In-en  discovered.  Stern- 
berg, ill  his  last  report  to  the  United  States  (Joveriimcnt,  coneludes  that 
the  spooillc  cause  of  yellow  fever  has  not  yet  been  demonstrated.  With 
thia  statement Coriiil  and  Habes*  agree, and  they  do  not  accept  the  organ- 
isms descriltcd  liy  Kreire,  Carmona,  and  (libier. 

Morbid  Anatomy.—  Tlu;  skin  is  more  or  less  jaundiced.  C'utane- 
ons  luemorrhages  may  be  ])resent.  No  specific  or  distinctive  internal 
lesion.'f  have  been  found.  The  blo(  d-serum  contains  ha'nioglol)in,  owing 
to  destruction  of  the  red  cells,  just  as  in  jiornicious  malaria.  'I'lie  lieiirt 
sometimes,  not  invarialdy,  shows  fatty  change;  the  stomach  presents  nuMC 
or  less  hypera'inia  of  the  mucosa  Avilh  catarrhal  swelling.  It  contains  the 
material  which,  ejecte<l  during  life,  is  known  as  the  /j/arL-  vomit.  The 
es.sential  ingredient  in  this  is  transforn;ed  blood-pigment.  In  the  two 
specimens  which  I  have  had  an  o])portuiiity  of  examining  it  dilTered  in  no 
respect  from  the  material  found  in  other  alTections  associated  with  luenia 
temcsis.  There  is  no  proof  that  this  black  material  depends  upon  the 
growth  of  a  micro-organism.  The  liver  is  usually  of  a  pale  yellow  or 
brownish-yellow  color,  and  tlie  cells  are  in  various  stages  of  fatty  defzcn- 
eration.  From  the  date  of  Louis's  observations  at  (iibraltar  in  is-^'hi,  the 
ap])earances  of  this  organ  have  been  very  carefully  studied,  and  some  have 
thought  the  changes  in  it  to  be  characteristic.  Councilman  has  described 
remarkable  ap])earanccs  in  the  liver-cells  which  he  believes  are  distinctive 
and  ju'culiar.  Fatty  degeneration  and  regions  of  necrosis  are  present  in 
all  cases.     The  kidneys  often  show  traces  of  dilfuse  nephritis.     The  epi- 


*  Les  Bact6ries,  1890. 


YKMiOW   KKVKll. 


141 


tlu'Iiii'ii  of  tho  convoluti'd  tubules  is  swollen  nnd  very  primular;  tliero 
niiiviil-"  1)0  uecrolic  eliuu^res.  In  both  liver  and  kidneys  Im-iteriii  of  viiri- 
ou.s  -ills  have  lieeii  described. 

Symptoms.— 'I'be  in(Ml)atiou  is  usiudly  lliree  or  fi'ur  days,  i)ut  it 
nmv  I'l'  less  lliiiii  twenty-l'our  Imiirs  and  prolonp'd  to  seven  days,  'i'lio 
onset  is  sudden;  as  a  rule,  without  preliminary  symptoms.  An  initial 
.'hill  i-i  eoiniuon,  and  with  it  are  usually  assoeiate(l  headache  and  pains  in 
till' li;ii  k  ant.  limi>s.  The  fever  rises  rajiidly  ami  .he  skin  feels  very  hot 
nil. 1  dry.  The  fuee  is  [lushe<l  ;  the  ton<?ue  fiu'red,  but  moist;  the  throat 
s(irt'.  Nans'M  and  vondtinj;  are  present,  and  become  more  intense  on 
the  second  or  third  day.  The  bowels  are  usually  .  oiistip.ited.  The 
urine  is  re(luced  in  amount  and  may  be  all)uminous  from  the  out.set. 
The  |>nlse,  at  lirst,  has  lh(>  usual  febrile  chai'acters,  but  (pdekly  becomes 
fi'clilc  and,  as  the  jaundiee  develop.s,  nniy  become  slow.  This  sta^e  of 
invn-iiin,  or  the  jHrilf  ■s/ai/t;  lasts  from  u  few  hours  to  two  or  three 
(lavs.  It  is  succeciled  by  a  remission,  or,  as  it  has  sometinu'S  been  called, 
tilt!  x/(i(/r  (if  rti/iii,  durin^i,'  whitdi  the  temperuturo  falls  and  the  sever- 
ity of  tlh'  symj)toms  abates.  In  favorable  ca.se.s  the  fever  nt>w  sid)sides 
anil  couvaleseence  sets  in.  In  such  eases  jaundiee  may  not  develop. 
Ill  the  tliirtl  stajfe,  or  that  of  ihv  J'i/>ri/r  rcarli<i)i^  \\w.  temperature  rLses 
aijaiii  and  the  .symptoms  become  ay<;ravated.  The  jaundice  develops 
riipidly,  the  vomititij,'  increa;;e.s,  and,  in  a  considerable  proportion  of  the 
ciisfs,  black  vomit  occurs.  This  consists  of  blood  and  gastric;  mucus 
ultert'd  by  the  acid  juices  of  the  stomach.  Though  usually  regariled  as 
ili.<liiietive  aiitl  tdiaraeteristie  of  the  disea.se,  material  itientical  with  it  is 
liroiii,'lit  up  Milder  other  febrile  conditions  in  which  vomiting  of  blood 
ooeurs.  .UUied  blood-corpuscles,  epithelial  cells,  portions  of  food,  and 
various  fungi  are  found  in  the  tliiitl.  'J'he  vomiting  nuiy  be  accompanied 
liy  great  abdominal  pain,  'i'he  stools  are  often  tarry  from  the  i)resence  of 
altereil  lilooil.  In  mild  ca.ses  the  vomiting  ceases  during  the  first  stage  (»f 
tliu  tlista.se.  Hlack  vomit  is  not  necessarily  a  fatal  symjitom,  tlituigh  it  is 
prt'Sfiit  only  in  the  severer  cjises  of  the  tiisease.  .Jaundice  occurs  in  a 
limited  number  of  the  ca.ses  which  recover,  and  is  present  in  almost  all  the 
fatal  ciises.  From  the  character  of  the  di.sea.se  it  is  probably  luematoge- 
noiis  in  its  origin.  Bleeding  may  occur  from  the  kitlneys  or  from  the  gums, 
and  luvmorrhages  into  the  skin  are  not  uncommon.  As  would  be  expected 
in  a  fever  of  this  nature,  the  urine  is  albuminous;  the  amount  varying  a 
good  tleal  with  the  intensity  of  the  fever,  and  with  the  grade  of  jaundice. 
I'Vlirile  icterus,  from  whatever  cause,  is  almost  invariably  associatetl  with 
alliiiiiiiiiuria  antl  tube-casts,  and  the  eviilences  of  a  dilfuse  nephritis. 

Kelapses  occasiomdly  occur.  Among  the  varieties  td'  the  disease  it  is 
important  to  recognize  tho  mild  cases.  These  are  characterized  by  slight 
fevor,  continuing  for  one  or  two  days,  and  succeeded  l)y  a  ra[)id  convale.s- 
I'enet!.  Such  cases  would  not  be  recognized  as  yellow  fever  in  the  absence 
of  a  prevailing  epidemic.     Cases  of  greater  severity  have  high  fever  and 


i  i  M 


f  M 


i'  I 


142 


SI'KCIFK'   INFPX'TIOUS  DISEASES. 


'i^R« 


i-  ir}K:  ^ti   ivj 


I 


rm 


ft 


tlu-  fciilnroR  of  tli<!  disciiso  urcf  well   iiiiirkcil — vodiitiiicr,  prostnition,  ami 
hii'iiiorrlijijfes.     Aiwl  lastly  tlicrc  aiv  niiilijj^iiimt  ciiscs  in  whicii  the  piitu 


til 


U(i 


is  (ivcrwiiuliiicd  l)y  tlin  intensity  ol"  tlie  ft'Vi.T,  anil  ilcalii  takos  i)lact!  in  l 
or  til  roe  days.* 

In  severe  cases  etshvaleseeticc"  may  he  eotnplicated  hy  the  oeeurrcnce  of 
jtarotitis,  al.scesses  in  various  parts  of  the  i)odv,  and  diarrlnea.  An  altai  k 
coiifvirs  an  iMiniiinity  which  persists,  as  a  rule,  throii,ij;h  life. 

Diagnosis.  —  Mild  eases,  and  even  severe  cases  in  the  early  period  of 
ail  ejiideniie,  are  very  dilHciilt  to  ri'coL;nize.  The  disease  simulates  closelv, 
and  may  he  mistaken  for  ordinary  malarial  remittent  fever.  It  is  not  uii- 
commoii  for  i)hysieians,  in  reirions  in  which  yellow  fever  is  occasionallv 
epidemic,  (o  call  the  milder  cases  malarial  fever,  reservii'"-  tlu;  name  ot 
yellow  fi'ver  for  llu'  severer  forms  with  jaun<lice  and  l)lack  vomit.  'I'lie 
only  disease  with  whi<'h  these  eases  could  1k>  confounded  is  malaria  in 
its  remittent  ami  pernicious  torn.  But  yellow  fever  can  now  l)e  iKli- 
nitely  aiul  at  once  se)»arated  hy  the  examination  of  the  blood.  The 
clinicjil  picture  in  certain  eases  of  malaiial  remittent  and  yellow  fevi'r 
may  he  almost  identical.  The  })resenee  of  alljumen  in  the  urine,  upon 
which  some  writers  lay  such  stress  as  a  dislin<fiiisliini^  feature  in  yellow 
fevir,  is  far  too  common  a  symptom  in  all  forms  of  malaria,  to  l»e  worlli 
much  as  a  irnidt..  (Juiicras  states  that  there  may  he  dilUcidty  for  a  time 
in  ree()<«:nizin^f  the  dilferviiee  itetwei'n  mild  cases  of  thermic  fever  and 
yelhtw  fever. 

Prognosis. — lu  its  graver  forms,  yellow  fever  is  one*  of  the  most 
fatal  of  epidemic  diseases.  The  mortality  has  rani^i'd,  in  various  epidein- 
ies,  from  l."*  to  H'>  per  <'ent.  In  Sieavy  drinkei's  and  those  who  have  hem 
exposed  to  hardships  the  death-rate  is  much  hii^du'r  than  amoiif;,  the  hit- 
ter classes.  In  the  epidemic  of  ISlS,  in  New;  Orleans,  while  the  mortality 
in  h(»spitals  was  over  od  per  cent  of  the  white  and  'i\  per  cent  of  the  <■■  1- 
ored  patients,  m  private  practice  the  nvrtalitv  was  not  more  than  10  per 
cent  .itncmg  the  white  patients.  l"'avoraltle  symjitoms  are  a  low  i^ra  le  of 
fever,  sliirhl  jauiu^ice,  ahseiice  of  ha'morrhaires,  anil  a  frei;  secretion  of 
urine.  If  the  ti'm|ii'rature  rises  above  1(»:>"  or  lO-I"  diirin<f  the  lir,t  two 
ilays,  the  outlook  is  serious.  Black  vomit  is  not  an  invarial)ly  fatal  riymji- 
tom.     Cases  with  suppression  (>f  urine,  delirium,  (toma,  and  convulsions 

•1 


rarelv  recover. 


Prophylaxis. — The  measures  to  be  taken  are — 

{(i)  "  lv\clnsi<in  of  the  exotic  i^c  'm  of  i'>.e  disi'ase  by  the  sa( 


ii.arv  super- 


vision, at  the  port  of  departure,  of  ^hips  sailinj;  fro?'-,  infc'^teil  ports,  ami 
thoroMjjh  disinfection  at  the  port  of  arrival,  when  there  is  evidence  or  rea- 
sonuble  suspicion  that  they  are  infected;  {/>)  isolation  of  the  sicic  on  ship- 


•  For  a  full  discussion  of  llit^  mi>rl)i<l  iiimtoniy  and  symplonmtolojry  of  the  ilisciv 
thi'  sliidciil  is  referred  to  the  works  of  .losepli  .loiies.  of  New  Orleans,  ami  lu  liis  reci  !it 
piifiers  ill  I  lie  ■    >innal  of  the  Ainerieaii  .Medical  .\s.s()i'iut4oii,  Ibit"),  I. 


Miii 


YEIiLOW  FKVER. 


143 


boiiiil.i'  i|nariuitine  stations,  aiul,  so  far  ivi  practitablc,  in  recently  infected 
plan  ~ :  ('■)  disinfection  of  excreta,  and  of  Liie  clotliin<jj  and  bedding  used 
by  till'  sick,  and  of  l(n'ulilies  into  wliicli  cases  li;ive  been  introduced,  or 
wlui'li  have  become  infected  in  any  way;  {i/}  ilci»oi)ulatit)n  of  infected 
iiliicr-  i.  e.,  the  removal  of  all  susceplible  persons  whose  ])resence  is  not 
iu'i'i',";ir\  for  the  care  of  the  sick"  (Sternlterj::).  iMirin^'  an  e[)idemic, 
iiiilividiialrf  wl»o  must  remain  in  the  locality  should  avoid  the  regions  in 
which  iheilisease  prevails  most;  they  should  live  ti'inperately, avoiding  all 
t'xccssis,  and  shoidd  \h'.  (jai'cfid  not  to  get  overheated,  either  in  the  sun  or 
l)v  cxeiM-'ise.  It  is  very  doulitful  whetlier  the  preventive  iiuiculations  in- 
troiliieed  by  Freire  in  Brazil  and  ('armona  in  Mexico  are  (d'  any  value. 

Treatment. —Careful  nursing  and  a  symptomatic  phin  of  treat nu'iit 
proliaiiU  give  tlui  liest  ri'sults.  Bleeding  has  long  siiK'c  lieen  abandoiu'd. 
Ihiuiniieh  i)atients  will  stand  in  this  disease  is  illustrated  by  Rush's  prac- 
tirc,  uhii'h  w.is  of  the  most  heroic  character.  He  says:  "  i-'roui  a  newly 
arrivi'il  KuglisluniMi  I  took  Ml  ounces,  at  twelve  bleedings,  in  six  days; 
foiu'  were  in  twenty-four  hours.  I  gave  within  the  course  of  the  sanu'  six 
iliiys  ucai'ly  l.'»l»  grains  of  calomel,  with  the  usual  [)i"oportions  of  jala[)  and 
ffaiiilxige  "  *  With  tiu!  courage  of  iiis  convieti(jns  this  mo<h'rn  Sangrado 
liinisclf  siil)mitted  to  two  bleedings  in  one  day,  and  ha<l  his  infant  of  six 
wi'rks'ild  bled  twi(H\  Neither  emetics  nor  puigalives  are  imw  employed, 
(ir  si);ri;d  remedies  (piinine  is  warndy  reiMtuuiu'uded,  and,  v.lu'U  luemor- 
liiiii^e  sets  in,  tin;  perchloritle  of  iron.  Digitalis,  aconite,  and  jaborandi 
li;ivf  been  em[)Ioyed.  Sternberg  iidvises  the  following  unvlure:  Bicar- 
bonate of  sod;;,  l.jO  gndns ;  bichloride  of  nu'rcury,  ^  grain;  pure  water, 
I  (jiiart.  'I'hree  tablespoonfuls  to  be  given  every  hour.  'I'his  is  given  on 
t)n' view  that  the  specilic  ain'iit  is  in  the  intestine,aud  that  its  growth  nuiy 
pussiblv  be  restrained  by  this  anta(;iil  and  antiso[iti(!  mixtur-.  The  fever 
is  liest  treateij  by  hydrotherapy.  'I'here  are  several  rep"''fs  of  the  good 
I'lTei'ts  of  (old  l)aths,  s[ionging,  and  tin;  application  of  ice-cold  water  to 
du'  head  and  the  extremities  in  this  disease.  N'omiling  is  a  very  diilicult 
sym|iloiii  to  control.  Morphia  hypodi'rmically  and  ice  in  small  i|uautities 
arr  [iriiliil  ly  tlu;  best  rcnieilies.  Medicines  given  liy  the  nu>ulh  for  this 
[)up   se  are  said  to  be  rarely  eiru-acious. 

We  liave  no  relial)le  medicine  which  can  be  dep(miled  upon  to  check 
till'  Iia'iiiorriiages.  Krgot  and  acetate  of  lead  aiui  opium  are  rec(unmended. 
Tliti  ma'iuic  symptoms  are  best  treated  by  tjic  hot  bath.  Stimulants  shotdd 
be  i;iveii  freely  dnririg  the  secoiul  stage,  .,  Iicn  the  heart's  action  becomes 
fivlib' and  there  is  a  teiulcncy  to  collnpse.  The  patient  sliou' 1  be  carefidly 
fi'il;  hill  when  the  vomiting  is  incessant  it  is  i)est  iu)t  to  irr.iate  the  stoui- 
aoii,  but  to  give  nutritive  enemata  until  the  gastric;  irritation  is  aMayed. 


te'l  ;.':-.-.:  <.4*^ 


*  Manuscript  letter  to  lledinau  Cexi'. 


w 


144 


SPECIFIC  INFECTIOUS  DISEASES. 


n"' 


•  \- 


'J<     M 


v!(. 


XX.    THE    BUBONIC    PLAGUE. 

A  spcoiflp,  conta<fi(>us   (liscaso,  chiiracterizcd    by  fever,  innanunat 


orv 


swclliiijf  (»f  the  lytiiiiliatic  glands,  and  liaMiiorrliaifcs. 

Tliis  ti'rril)lt'  malady,  known  also  a.s  the  hlark-doath,  or  tlio  Orieiiiiil 
]iIaj:iio,  has  gradually  (lisai)i)car('d  from  Europe,  but  is  still  met  with  in 
parts  of  Asia.  A  short  i)ut  severe  epidemic  in  May,  lS!t4,  ut  llonjr  Kong, 
M'as  rendered  memorahle  by  the  (lis(!Overy  of  the  bacillus. 

In  severe  e])idemics  the  disease  may  kill  within  a  few  hours.  As  a  riilo 
it  comes  on  suddenly  after  an  in-'ubation  j)eiiod  of  from  two  to  ilve  days. 
There  is  usually  intolerable  headache  aiul  excessively  severe  pain  in  tlio 
back  aii<l  limbs.  'I'lu're  is  early  delirium,  ami  the  temperature  rises.  In 
two  or  three  days  l)ubocs  appear,  forming  the  most  characteristic  symptitiii 
of  tiie  disease,     in  about  seventy-live  per  cent  of  the  cases  the  injiuiiii;! 


ghii 


ids  enlar'fe. 


Involvement  of  the  (;ervical  and   axillarv  ulauds  i,- 


Kill. 


inli^. 
lilill 


i're«pient.     iiesolution   may  occur,  or  the  glands  pass  on  to  supj)urat 
In   the  very  severe  cases   the  alTccted   glands   nuiy   liccomc  gangrei 
('ar!)un('lcs  also  occur  on  the  skin.     Ha'iuoi'ihages  are  common  in  cci 
e]tidemics,  and  gave  to  the  disease  the  name  of  "black-death." 

The  bai'illus  discovered  by  Kitasato  is  a  short  rod  with  rouiuled  cud.-. 
reseml)ling  the  bacillus  of  (diiitken-choleru.     It  grows  in  a  perfectly  cliar- 
Mcteri.'>tic  manner.     The  conclusions  ap])ended  to  Kitasatu's  re])ort  on  ih 
Ilong-Kong  epidemic  are  as  follows: 

1.  "  In  the  plague,  bacilli  are  found  in  the  blood,  glands  and  viscera. 


Til 


is  ))articular  l)acil]us  is  not  iound  in  any  other  <li.sease. 


',].  "Obtained  in  pure  culture  it  is  capable  of  j)ro(lucing  in  inocid; 


itrd 


aiui'ual 


tl 
It 


ic 


ame  < 


ITcct 


s  as  in  huniau  bciii'^s 


liiiins  entrance  into  the  bodv  thron<rh 


(.0  tl 
{//)  e.vc()ria*^ioiis  of  the  surface,  (r)  tlu!  digestive  tract. 


le  res])iratory  tr; 


Tl 


le   <I1S(-, 


)revaiU  esjiecially  under  faulty  hygienic  couditioi 


IS  ■  r 


is  therefore  urired  that  general  hvgicnic  measures  Ite  carried  out.      I*n 
recepta<'ics  for  sewage  should  be  )»rovided  ;  a  pure  water  su])ply  alTon 


llitT 


houses  and  streams  art'  to  be  cican.scd  ;  al 


■rsons  sick  of  the  disease 


lated  ;  the  furniture  of  the  sick-room  washed  with  a  two-per-ceiit  carhdlic 
solution  in  milk  of  lime;  oM  clothes  and  bedding  are  to  be  steanicil  :i! 
1(10''  ('.  for  at  least  one  luuir,  or  I'xposed  for  a  few  hours  to  sunlight,  ll 
feasi])le,  all  infccttd  articles  should  he  burned.  'IMie  evacuations  of  ilif 
sick  arc  to  be  mixed  with  milk  of  lime;  and  those  who  die  of  the  di.-i;iM 
are  to  l)e  i)uricd  at  a  depth  of  three  nu-tres,  or,  preferably,  cremati'il. 
After  recovery  the  jmtient  is  to  l»e  kejtt  in  isolation  at  least  one  month. 
All  conta<'t  with  the  sick  is  to  be  avoided,  and  great  care  is  to  be  cmt- 
cised  with  reference  lu  food  and  drink." 


DYSENTEIIY. 


145 


XXI.    DYSENTERY. 


Definition. — Under  tliis  cliiiical  tcnn  sevonil  (lifTcrcnt  forma  of  in- 
t,'>ti!i;il  llux  iiro  di'scrihi'd,  whicli  iiiv  flmnioterized  by  frequent  stools,  and 
in  li!!' acute  stiigo  iiro  iU'('()ni])anieil  In*  tormina  and  tenesmus.  Auatonii- 
Oiillv  I  here  are  iiiflammation  and  usually  ulceration  of  tli(>  lar<,'e  howel. 

Etiology. — Dysentery  is  one  of  the  four  ici't'iit  epidemic  diseases  of 
tlic  unild.  In  the  tropics  it  destroys  more  lives  than  cholera,  and  it  has 
bt  cii  ninn!  fatal  to  armies  than  powder  iiiul  shot. 

While  especially  severe  in  the  tropics,  sporadic  cases  constantly  occur 
ill  iiinri.'  lem|)erate  climates,  and  tiiuler  favorinj;  circumstances  epidemics 
iiif  i'diind  even  in  the  more  northern  countries,  siu'h  as  Canada  and  \<»r- 
w.iy.  It  has  become  less  frequent  t>\'  late  years,  owing  to  imjjroveil  sani- 
tary I'onditions.  The  statistics  of  the  Montreal  (lencral  Hospital,  for  the 
twenty  }ears  endini;  May  1,  1SS9,  show  a  renuirkal)le  decrease  in  tlu'  dis- 
oasc.  In  the  decade  ending  May,  iST'.),  1,"")()  cases  were  admitted  ;  whereas 
ill  ihc  last  ten  years  there  have  been  oidy  151  cases  admitted.  There  has 
Ixcii  a  similar  decrease  at  the  Pennsylvania  lfos})ital. 

In  the  Southern  cities  of  this  country  dysentery  is  more  prevalent;  even 
when  not  epidemic,  sporadic  cases  are  common.  In  IVdtimore  it  prevails 
L'Nciy  Slimmer,  and  has  on  several  occasions  l)een  epidemic. 

Kpidemics  of  dysentery  have  occurred  in  tl>  •  United  States  f<(r  more 
tluiii  a  century,  and  Woodwai'd  has  collected  the  data  which  show  the 
various  outlireaks.  Perhaps  the  most  serious  was  that  which  prevailed  in 
various  localities  from  1S]|  to  1S.")(!.  During  the  war  of  .'^ecessioii  the  di.s- 
tasc  existed  to  an  alarming  extent  in  both  armies.  According  to  Wood- 
ward's report,*  there  were  in  the  Federal  service  in  all  v*.")'.i.(iTl  cases  of 
ai  iito  and  "28,451  eases  of  chronic  dysentery.  Pntbably  a  considerable  pro- 
]inrti(in  of  the  18"-2,.j,S<!  cases  of  chronic  diarrhd'a  should  also  come  in  this 
catigory.  The  decennial  census  reports  since  1S.")(I  show  a  progressive  de- 
civase  in  the  total  number  of  deaths  from  this  disease.  It  jirevails  most 
I'Meiisively  in  the  summer  ami  antumn.  Sudden  ciianges  of  temperature 
Mlipear  more  harmful  than  variations  in  jiioisture.  The  ellhivia  from  de- 
I'liiiiposiiig  animal  matter  have  been  thought  by  some  to  ])redispose  to  or 
even  to  cause  the  disease.  That  dysenteric  alTections  are  more  fre(pient 
ill  iiiiilarial  localities  has  long  been  known,  and  is  prot)abIy  connected  with 
cxtenial  conditions  favoring  their  development.  With  reference  to  the 
iiitlio  'CO  of  drinking-water.  Woodward  is  doul)tIess  correct  in  stating  that 
.1.'  etl'ects  of  dissolved  nuneral  matters  have  been  greatly  exaggeiated. 
'Ml  ti. '  other  hand,  from  th(>  days  of  the  old  (Jreek  physicians,  it  has  been 
liiil   thai   the   ijnpurities  in   the   slagmint  water  of  marshy  districts  and 


*  .Mt'<U(')il  nnd  Siirpical  History  of  tlip  Wi.r  ef  tli(>  Ki'liclliiin.  Mi'dical.  vel.  ii ;  the 
mnst  cxtmiisiivt'  treatise  extntit  on  iiitesl'iiiil  tiuxt's — iii>  cmhn'Uig  iiioiiiiiia'iil  to  the  iu- 
lii^Uy  tiiul  uliility  of  the  luitlior. 


w 


ii  \ 


!:■;  J!: 


uo 


spkcifk;  iNFi<:cTiors  diseases. 


ponds  may  j?ive  rise  to  diurrlupa  and  dysentery,  lloro,  howovor,  it  is  prob- 
ably  not  tbe  vcffctablo  ini])uriti('s  wliicb  are  directly  causative,  but  the  or- 
ganic Miatlcr  renders  tiie  water  a  more  favorable  medium  for  the  develop- 
nient  of  organisms  which  may  cause  disease. 

Dysjjeptic  conditions,  particularly  those  caused  by  the  ingestion  of  bud 
food  and  nnrii)e  fruit,  seem  to  |)redispose  to  the  disease.  (Jrcat  stress  lias 
been  laid  by  (Jerman  authorities  on  the  importance  of  constipation  as  u 
causal  factor  in  dysenterv. 

Dysentery  occurs  at  all  ages.  There  is  no  race  immunity.  The  con- 
tagiousness of  the  disease  is  doul)tful.  The  experience  of  tlie  civil  war 
is  decidedly  against  it,  but  the  possibility,  as  with  typhoid  fever,  must  he 
acknowledged. 

Clinical  Forms.— (rO  Acute  Catarrhal  Dysentery.— This  may  occur 
•sporadically  or  endemically,  aiul  is  the  variety  most  fretpiently  found  in 
teni[)erate  clinuitcs. 

Mor/jid  Aini/oiiii/. — The  lesions  are  confined  to  tlie  large  bowel,  ami 
sonnUimes  the  ileum  also  is  involved.  The  mucous  membrane  is  injectcil, 
.swollen,  and  often  covered  with  tenacious  })lood-staiiied  mucus.  The 
most  striking  feature  is  the  enlargement  of  llu^  solitary  follicles,  which 
stand  out  j)romineutIy  from  the  mucous  membrane.  In  very  acn'e 
forms,  as  in  children,  the  picture  is  that  of  an  acute  follicular  colitis.  In 
more  protracted  cases  the  follicles  suj)|)urate  or  are  capped  with  an  area 
of  necrotic  ti.ssue.  In  other  instances  the  sloughs  have  separated  ami  the 
entire  colon  presents  numerous  ulcers,  most  of  wliicii  have  developed  frimi 
the  follicles,  ami  others  have  resulted  from  nei'rosis  and  sloughing  of  the 
intervening  tissue. 

SiiniplDiiis. — Ther(^  nuiy  be  prelimin;iry  dyspepsia  or  slight  pains  in  the 
abdomen.  Chills  are  rare.  Diarrlnea  is  tlu'  most  constant  initial  symp- 
tom, and  at  lirst  is  not  painful.  Usually  within  thirty-six  hours  the  char- 
actei-istic  features  of  tiie  disease  dcvel()[) — abdominal  pain  of  a  colicky, 
griping  character,  freipient  stools,  which  are  jiassed  with  straining  ami 
tenesmus;  the  constitutional  disturbance;  is  variable,  and  in  mild  cases 
may  be  slight.  'I'lie  temju'rature  range  is  not  high,  but  at  the  outset  the 
fever  may  rise  to  l()"i"  or  l(>IJ°.  The  tongui;  is  furred  and  moist,  ami  a.s 
the  disease  j)rogresses  beconu's  red  and  glazed.  Nausea  and  vomiting  may 
be  present,  but  as  a  rule  the  ]iaticnt  retains  nourishment.  The  con.-taiil 
desire  to  go  to  stool  and  tbe  straining  or  tenesmus  are  the  most  distressini.' 
symptoms.  The  alxhutu-n  may  be  flat  and  hard.  The  thirst  is  often  execs- 
•sive.  The  stools  in  this  vai'ietyof  dysentery  have  tbe  following  characters: 
During  the  lirst  twenty-four  or  forty-eight  hours  they  consist  of  more  oi 
less  clear  mucus  and  blood  mixed  with  small  faral  scybala.  After  this  they 
become  purely  gelatinous  aiul  bloody,  and  are  simdl  and  frcfpient,  from 
fiftei'ii  to  tw;)  bumlred  in  twi'iity-four  Inuirs,  according  to  the  severity  of 
the  case.  About  the  end  of  the  tirst  week  tbe  mtu'iis  becomes  opa({ue,  the 
proportion  of  blood  diminishes,  and  grayish  or  brownish  shretldy  material 


DYSENTERY. 


U) 


jiiitiears  in  the  stools,  whicli  lu'coiiic  gradually  reduced  iu  fre(|nency. 
Siiim' <if  '1'*^'  stools  at  this  time  may  l)e  wholly  composi'd  of  a  jirccnisli  pul- 
tacc'iiiis  material  and  mueus.  As  the  disease  subsides,  fa'eal  matter  ajrain 
appears  in  the  stools,  inereasiii^^  in  amount  until  fully  formed  fa-ees  are 
na.-Hfil<  ('i>iitainin<r  no  mueus  or  hlood.  Mid'oscopieal  examimitioii  of  the 
irlairv  iiloody  stools  shows  red  blood-eoriiuseles,  few  or  many  leucocytes, 
anil  constantly  large,  swollen,  round  or  oval  e()ithelioid  cells,  containing 
fat-ilrop:-  and  vacuoles.  IJaeteria  are  scarce  ;  occasionally  the  ccrciniiiinas 
iittvMiiiiilis  is  seen  in  large  numliers. 

Caiirsf  of  //it'  Piscasi'. — Tlie  milder  cases  run  a  course,  as  Flint  has 
fliown,  III'  about  eight  <lays;  severer  ones  rarely  terminate  within  four 
weeks.  The  alTection  occasionally  becomes  chronic.  I'l'ritonitis  and  liver 
abscess  are  extrenudy  rai'c. 

(b)  Tropical  Dysentery— AmoBbic  Dysentery.— This  foi-m  of  intestimil 
iliix  is  I  liiiractcrized  by  irregular  diarrho'a  and  the  constant  preseiu-ein  the 
stools  of  the  itiineba  roll  (Los(di),  i(iii<c/ta  (/i/seii/t<ri(e  (("ouncilnum  and  La- 
lli'iu').  It  is  this  variety  whiidi  prevails  extensively  in  the  tropical  and  sul>- 
iri)|ii('iil  regions,  and  which  ]>roves  so  fatal  in  epidemic  form.  Tiie  ainu'ba 
is  a  iniii'clhdar,  protoplasmic,  motile  organism,  from  fifteen  to  thirty  mi- 
cnitiiiliinietres  in  diameter,  consisting  of  a  clear  outer  zoiu^  eelosarc,  and 
airnuiiilar  inner  zone,  eiuiosarc,  containing  a  nucleus  and  one  or  more 
vaeiiolcs.  It  was  first  described  by  Iiainl)l  in  IS.Mt,  ami  subsef|uently  by 
hiisrli,  wiio  considered  it  the  caus(!  of  the  discasi'.  In  the  eiulemie  dysen- 
tti'v  (if  Kgypt,  Kartulis,  in  IHS.'},  found  the.se  amtebic  constantly  in  the 
stools,  in  the  intestines,  ami  in  the  liver  ab.'icesse.s.  lie  was  afterward 
I'liiibled  to  cultivate  them  in  straw  infusion,  and  to  produce  the  di.sease 
iirtiliiially  in  cats  and  dogs.  In  18(10  1  reported  a  case  of  dysentery 
with  al)sce.ss  of  the  liver  originating  in  I'anama,  in  whi(di  the  anuel)a' 
wi'iv  found  in  the  stools  and  in  the  pus  from  tlu>  abscess;  and  Council- 
iimii  and  liUlleur*  have  described  the  idinical  features  and  amitomical 
k'sioiis  in  a  series  of  cases  of  this  form  of  tlysentery  in  my  wards.  Dock 
h;is  (leinonstrated  their  ])resence  in  a  numlKT  of  ca.ses  in  (Jalveston,  and 
Miisser  has  found  them  in  IMiiladelphia.  Amccba'  arc  occasiomilly  fouiul 
ill  the  stools  of  healthy  men.  Quincke  and  Kooh  recogniz(!  three  forms  of 
imiasiiic  ama'bu',  two  of  whiidi  are  pathogenic.  'I'he  di.s(!uso  is  very  com- 
imm  in  tropical  ami  subti'opical  countries.  It  is,  however,  found  more  or 
ll■^>  widely  distributed  throughout  Kurope  and  North  America.  The 
-"iiiccs  nf  infection  are  not  known,  but  it  seems  probable  that  one  of  them 
i-ilriiiking-water. 

Mi>rl)i(l  AiKifi/Dii/. — The  lesions  are  found  in  the  large  intestine,  somo- 
iiiiies  in  the  lower  portion  of  the  ileum.  Abscess  of  the  liver  is  ii  common 
■ii|iiei  ■('.     I'erfonUion  into  the  right  lung  is  not  infretpient. 

Iii/csh'nes. — The  lesions  consist  of  ulceration,  produced  by  preceding 


im 


liy;  • 


r  •II 


t.      '  ?<H 
1    I    t 


si    1 


*  Jolms  Hopkins  Hospital  Uei.orls,  vol.  ii. 


I 


::fa 


li-.'i        s 


I   f 


148 


SPECIFIC   INFECTIOUS   DISEASES. 


infiltration,  goncrul  or  local,  of  the  submucosa,  the  general  infiltration 
being  duo  to  au  oideinatous  condition,  the  local  to  inultiplicatioii  of  the 
fixed  ci'lls  of  the  tissue.  In  the  earliest  stage  these  local  inliltratinu^ 
aj)l)ear  as  lieniisplu'rieal  elevations  above  the  general  level  of  the  niucd.si 
The  uuK'ous  iueinl)rane  over  these  soon  beconies  lU'crotic  and  is  east  dlT, 
exposing  the  infiltrated  submucous  tissue  as  a  grayish-yellow  gelaliiiou; 
mass,  \vlii(di  at  first  forms  the  lloor  of  the  ulcer,  but  is  subsequently  east 
oil  as  a  slough. 

Tlu!  individual  nlcers  are  round,  oval,  or  irregular,  with  infiltrated, 
undermined  edges.  The  visible  apertunt  is  often  small  com2>are(l  to  the 
loss  of  tissue  beneath  it,  the  nlcers  undermining  the  mucosa,  coalescing, 
and  forming  sinuous  tracts  bridged  over  by  a])parently  nornud  mucous 
niend)rane.  According  to  the  stage  at  which  the  lesions  are  observed,  the 
floor  of  the  ulcer  may  be  formed  by  the  submucous,  the  muscular,  or  the 
senms  coat  of  the  intestine.  The  ulceration  may  altect  the  wluile  or  some 
portion  only  of  the  large  intestine,  particidarly  the  ca.'cum,  the  hepatic 
and  sigmoid  llexures,  and  the  rectum.  Tn  severe  cases  the  whole  of  tlie 
intestine  is  much  tliickeiu'd  and  riddled  with  ulcers,  with  only  here  and 
there  islands  of  intact  mucous  membrane. 

The  disease  advances  by  progressive  infiltration  of  the  connective-tissue 
layers  of  the  intestine,  which  i)roduces  necrosis  of  the  overlying  structures. 
Thus,  in  severe  cases  there  may  be  in  dilTcrent  parts  of  the  bowel  slou^'li- 
ing  ('II  iiiftx.'<r  of  the  mucosa  or  of  the  muscidaris,  and  the  same  process  is 
observed,  Init  not  so  conspicuously,  in  the  less  severe  forms. 

In  some  cases  a  secondary  diphtheritic  infiammation  complicates  the 
original  lesions. 

Healing  takes  place  by  the  gradual  formation  of  fibrous  tissue  in  flie 
floor  and  at  the  edges  of  the  ulcers,  which- may  ultimately  result  in  partial 
and  irregular  stri(!tures  of  the  bowel. 

Microscopical  examiiuition  shows  a  notable  absence  of  the  products  of 
])uruleiit  infiaTumation.  In  tlie  inliltrated  tissiu^s  jtolynuclear  leucocytes 
are  sehlom  found,  and  never  constitute  purulent  collections.  On  the 
other  hand,  there  is  proliferati<ui  of  the  fixed  connective-tissue  cells, 
Ama4)iP  are  found  mon;  or  less  abundantly  in  the  tissues  at  the  base  et 
and  aroutid  the  ulcers,  in  the  lymphatic  sjiaces,  and  occasiomdly  in  the 
blood-vessels. 

The  lesions  in  the  Jirrr  are  of  two  kimls :  firstly,  local  necroses  of  the 
parenchynui,  scattered  throughout  the  liver  and  possibly  due  to  the  notion 
of  chemical  jiroducts  of  the  amo'b.T;  and,  secondly,  abscesses.  These  may 
be  single  or  nuiltiple.  When  single  they  are  geiuu-ally  in  the  right  hdie, 
either  toward  the  convex  surface  near  its  diaphragmatic  attachment,  or  on 
the  concave  surface  in  proximity  to  the  bowel.  >rnltiple  abscesses  are 
small  and  getu>rally  superficial.  In  an  early  stage  the  al)scesses  are  grayish- 
yellow,  with  sharply  (lefine<l  contours,  and  c(uitain  a  spongy  necrotic  ma- 
terial, with  more  or  less  fluid  in  its  interstices.     The  larger  abscesses  have 


DYSENTERY. 


149 


i 
k 

(•Hot     [ 
(M'VtrS     { 

II  t!io  ■ 
vv\k  i 
iscot  \ 

III  llic  , 

if  tlic 

Mi'iinn 

;('  iii;iy 

Idlie, 

or  oil 

lire 

■avish- 

ic    IlKl- 

IS  luive 


^ 


fiiiiri'l  necrotic  walls,  and  contain  a  more  or  less  vi.-ciil,  pfroonisli-yollow 
or  rc(l(li.-li-ycllo\v  purulent  material  mixed  with  blood  and  shreds  of  liver- 
ti.-siie.  The  older  abscesses  have  libroiis  walls  of  a  dense,  almost  earti- 
lairiiiKiis  toughness.  A  section  of  the  abscess  wall  shows  an  inner  necrotic 
/line,  a  middle  zone  in  which  there  is  great  proliferation  of  the  cotinective- 
ti-siie  ceils  and  compression  and  atrophy  of  the  liver-cells,  and  an  outer 
zone  of  iiii'Mise  hypera'Uiia.  'I'here  is  the  same  al)seiice  of  purulent  iiillam- 
inatinn  as  in  the  intestine,  except  in  those  cases  in  whiidi  a  secon<Iary  in- 
fection with  jiyngciiic  orLranisms  has  taken  jtlaee.  1'he  material  from  the 
abscess  cavity  shows  chielly  fatty  and  granular  detritus,  few  cellular  ele- 
nu'uts,  and  nu»re  or  less  inimerous  amu'ba-.  Amcrbu'  are  also  found  in  the 
abscess  walls,  chielly  in  the  inner  necrotic  zone.  Cultures  arc  usually 
sterile.  liCsions  in  the  lungs  are  seen  when  an  al*scess  of  the  liver — as  so 
frei|iiently  ha])peiis — [loints  toward  tlie  diajdiragm  and  extends  by  conti- 
nuity tliroiigl;  t  into  the  lower  lobe  of  tlu(  right  lung.  The  gross  and 
microscopical  apju-arances  are  similar  to  those  of  the  liver. 

Si/)iij)/(iin.<<. — The  onset  may  be  sudden,  as  in  catarrhal  dysentery,  or 
gradual,  beginning  as  a  trilling  and  perhaps  transient  diarrluea.  In  severe 
gangrenous  cases  the  abrupt  onset  is  more  common.  The  subscfpu'ut 
course  is  a  very  irregular  diarrluea,  marked  by  exacerbations  and  inter- 
inissioiis,  and  progressive  l(»ss  of  strength  and  llesh.  There  is  moderate 
fever  as  a  rule,  but  many  cases  aiH*  afel)rilc  throughout  the  greater  part  of 
their  course.  Al)domiiud  ])ain  ami  teiu'smus  are  frcfiuently  present  at  the 
onset,  especially  in  severe  cases,  but  may  be  entirely  absent,  and  vomiting 
and  nausea  are  only  occasionally  observed.  The  stools  vary  very  mucii  in 
fre(|iieiicy  and  appearance  in  dilTerent  cases  and  at  dilferent  periods  in  the 
,«aiiie  cases,  'i'hcy  may  be  very  fre<|ueiit,  bloody,  and  mucoid  at  the  out- 
set, as  in  catarrhal  dysentery;  but  their  main  characteristii',  when  the 
disease  is  well  established,  is  Ihiidity.  From  six  to  twelve  yellowish-gray 
lii|iiid  stools,  containing  mucus  and  occasionally  blood  in  varying  propor- 
tions, are  passed  daily  for  weeks.  Actively  moving  atiueba3  are  found  in 
tliese  stools,  more  a1)un(lantly  during  exacerbations  of  the  diarrhu'a,  and 
diaiqipear  gradually  as  the  stools  become  formed. 

Aliscess  of  tlie  liver,  and  especially  of  the  liver  and  lung,  is  a  frequent 
ail']  fiiruiidable  complication.  In  India  it  occurs  once  in  every  four  or 
liv','  cases. 

Tile  iliiralion  of  the  disease  in  uncomj)licated  cases  varies  from  six  to 
twelve  weeks.  Recovery  is  tedious,  owing  to  ana'inia  and  muscular  weak- 
lU'ss,  often  (hdayed  by  relapses,  and  then!  is  in  all  cases  a  constant  teiul- 
eiK y  to  chronicity.  The  mortality  is  much  Iiigher  than  in  catarrhal 
(Ivseiitery.  A  fatal  issue  is  due  either  to  the  initiid  gravity  of  the  intes- 
tuial  lesions,  to  exhaustion  in  prolonged  cases,  or  to  involvement  of  the 
livor. 

('  i  Diphtheritic  Dysentery. — .V  form  of  colitis  or  entero-colitis  in 
wliich  areas  of  necrosis  occur  iu  the  mucous  membranes,  which  on  sepa- 


m 


r  J, 


150 


SPECIFIC   IXFKCTIOUS  DISRASES. 


3     ' 


'"    1 

IS 

■l 

,]l 

1 

II 

\W  j 

,1 

1 

'-■'i 

'  "  ) 

^^^^B^^H 

1 

ration  loavo  nloor.s.  Tliia  ocmirs  :  {it)  An  a  priiiuiry  disoaso  coiiiin;,'  n\\ 
aciiloly  and  sonictiines  jtnjving  fatal.  In  its  niildiT  grades  the  tofis  df 
tli(!  folils  of  tli(!  colon  aiT  capped  with  a  tliin,  yellow  exudate.  In  se- 
verer Torms  tlio  colon  is  ciionnoiisily  enlar<ied,  the  walls  are  tliickeiicil, 
still',  and  iiililt rated,  and  tlio  nmirosa,  from  the  ileo-ca'cal  valve  to  ilic 
rectum,  represented  by  a  tough,  yellowish  material,  in  which  on  sectidii 
no  trace  of  the  glandular  elements  can  bo  seen.  It  is  an  extensive 
necrosis  of  the  mucosa.  Tlierc  are  cases  in  which  this  necrosis  is  sii- 
perlicial,  iuvniviiig  ouly  tlie  upper  layers  of  the  mucous  meml)raiie;  Imt 
in  the  nu>st  advunci'd  foruis  it  may  i>e,  as  in  the  description  by  K'oki- 
tansky,  "a  black,  rotten,  friabl;',  charred  mass."  'I'he  areas  of  iu'ci'o>is 
nniy  be  more  localized,  aiul  large  sloughs  an.'  formed  which  may  lir  a 
lialf  to  three  fourths  of  an  iiu-h  in  thickness  and  extend  to  the  serosa. 
There  are  instances  in  which  this  condition  is  confined  to  the  lower  jmr- 
tion  of  tile  largo  bowel.  A  sailor  from  the  Mediterranean  was  adndtlcil 
to  the  Montreal  <Jencral  Hospital  under  my  (;are  with  syuiploms  resem- 
bling typhoiil  I'ever.  The  autcjisy  showed  enormous  sloughs  in  the  n'ctum 
and  in  the  sigmoid  ilcxure,  but  scarcely  any  disease  in  the  transverse  or 
ascemling  colon.  In  cases  which  last  for  many  weeks  the  sloughs  separate 
and  may  be  thrown  olT,  sometimes  in  large  tiil)ular  ])iccos. 

{!))  Sraiiiiiiirif  Piji/if/nrifir  /\i/si>ii/rri/. — This  occurs  as  a  terminal 
event  in  many  acute  and  chronic  diseases.  It  is  not  infre(|uent  incbrnni' 
lieart  alfectioiis,  in  Urighl's  disease,  and  in  cachectic  states  generally.  In 
acute  diseases  it  is,  as  [)ointed  out  by  Bristowe,  most  frecpiently  associated 
with  piu'umoiua.  Anatomically  there  maybe  only  a  thin,sui)erlicial  iiilii- 
tration  of  the  upper  layer  of  tlu;  mucosa  in  localize*!  regions,  jtartieularlv 
along  the  ridges  and  folds  of  the  colon,  often  extending  inio  the  ileum. 
In  severer  forms  the  entire  mucosa  may  be  involved  and  necrotic,  soiuo- 
times  having  a  rough,  gramdar  ai)pearance.  In  the  .secondary  colitis  of 
pneumonia  the  exudatioi»  may  be  pseudo-membranous  and  form  a  tiriii, 
thin,  white  pellicle  which  seems  to  lie  upon,  not  within,  the  mucous  niciii- 
brane. 

Si/inpioins. — The  clinical  features  of  dij)htlieritic  dy.sontery  are  very 
varied.  In  the  acuto  jyriman/  cases  the  patient  from  the  outset  is  often 
extremely  ill,  with  high  fever,  great  prostration,  pain  in  the  abdomen,  and 
frequent  discharges.  Delirium  nuiy  be  early  ami  the  clinical  features  may 
closely  resend)le  severe  typhoid.  I  have,  on  more  than  one  occa.«ien, 
known  this  mistake  to  bo  made.  The  abdomen  is  distended  and  often 
tender.  The  discharges  are  frequent  and  diarrlucal  in  character,  and 
tenesmus  may  not  bo  a  striking  symptom.  Blood  and  mucus  may  bo 
found  early,,  but  are  not  such  constant  features  as  in  the  follicular  disease. 
This  primary  form  is  very  fatal,  but  the  sloughs  may  separate  and  the 
condition  become  chroiuc.  In  the  sccondarji  form  there  may  have  lieen 
no  symptoms  to  attract  attention  to  the  large  bowel.  In  a  majority  of  tlu' 
cases  the  patient  has  a  diarrha-a — three,  four,  or  more  movements  in  llic 


DYSENTERY. 


1..1 


,l;iv.  ttlik'li  lire  often  profiisi'  and  Wfiikciiiii;^.  A  littK'  blood  and  mucus 
iiiiiv  !k'  pii.-scd  at  first,  but  tliey  are  not  specially  (diaractcriitie  ilonients 
in  tilt'  stools. 

Ill  nil  forms  of  dyscntorv  doatli  usually  results  from  asthenia.  The 
niii.c  inn )i lies  weaki'r  and  more  rapid,  the  ton<,aie  dry,  the  face  pinehed, 
the  .-kill  i"i'l  iiud  covered  with  sweat,  and  the  patient  falls  into  a  drowsy, 
toiiijil  condition.  Conseiousness  nniy  be  retained  until  the  bust,  but  in 
till' pn>lrii<'led  eases  there  is  a  low  delirium  deepening  into  collajiso. 

(d)  Chronic  Dysentery. — Tbis  usually  suecei'ds  an  acute  attack,  though 
the  aiiKjI'i''  form  nuiy  be  subacute  fi'om  t  be  outset  and  not  presi'iit  an  acute 
l„.|'i(i(l.  Anatomical  changes  in  tbe  large  intestine  in  cbntiiic  dysentery 
;iir  viiriable.  'I'here  may  be  m)  ulceration,  and  the  entire  mucosa  presents 
a  r(iiij.'li,  irregular  puckered  appearanci',  in  places  slate-gray  or  blackish  in 
idldf.  The  siibniuco.si  is  ibickened  and  the  muscular  cdats  an;  byper- 
triiiiliinl.  There  may  be  cystic  degeneration  of  tbe  glandular  elements, 
;b  i>  bciiiilirully  llgured  in  Woodward's  volume. 

rict  IS  are  usually  present,  oftfu  extensive  and  deeply  pigmeiitel,  in 
jiliU'cs  iifi'haps  healing.  Tbe  submucous  and  muscular  coats  aie  lliick- 
i'IumI  iiiid  the  calibre  of  tlu'  bowel  nuiy  be  reduced.  Stricture,  however,  is 
viTV  I'iire. 

Tile  siinijihHiis  of  chronic  dysentery  are  by  no  means  dciinite,  and  it  is 
uiil  always  po.ssUjle  to  separate  the  cases  from  those  of  chronic  diarrluea. 
Many  of  the  characteristic  synii)toms  of  the  acute  disease  are  absent. 
TciK'Siiiiis  and  severe  grijung  pains  rarely  occur  e.\ce})t  in  acute  exacerba- 
tiiiiis.  Tiic  character  of  the  stools  varies  very  much.  Jilood  and  lU'crotic 
aliri'ddy  tissue  are  not  often  found.  Mucus  is  passeil  in  variable  amounts. 
i)ii  11  mixed  diet  the  faeces  are  thin,  often  frothy,  and  contain  particles 
nf  f()(i(l.  Tbe  motions  vary  from  four  or  live  to  twelve  or  more  in  tbe 
tweiuy-four  hours.  There  are  cases  in  which  nuirked  constipation  alter- 
nate's with  attacks  of  diarrluea,  and  scybala  nuiy  be  i)assed  with  much 
'i.iuus.  Ill  many  cases  the  faeces  have  a  senu-lUud  consisteiu-y,  and  a  yel- 
\»\\\A\  or  lirown  (.-olor  dej)ending  on  tbe  amount  of  bile.  Fragments  of 
iiiidinestcd  food  inay  bo  found,  and  tlu"  discbarges  have  the  character  of 
what  is  termed  a  lienteric  diarrluea.  Indeed,  variations  in  tiie  bile  and 
ill  till' food  give  at  once  corrospomling  variations  in  tbe  character  of  the 
viiiils.  In  chronic  dysentery  recurrences  are  common  in  which  blood  and 
iiiiuiis  again  appear  in  the  stools,  accompanied  })erhai>s  by  pus.  Flatu- 
liiiic  is  in  some  cases  distressing,  and  there  is  always  more  or  less  ten- 
'liiiii'ss  along  the  course  of  tbe  colon,  'i'he  aj)petite  is  capricious,  the 
iliircsliou  disordered,  and  uidess  the  patient  is  on  a  strictly  regulated  diet 
ilic  iuiml)er  of  stools  is  greatly  increased.  'I'he  tongue  is  not  often  furred  ; 
it  is  more  conunonly  red,  glazed,  and  beefy,  and  becomes  dry  and  I'rav'ked 
tottiii'd  the  end  in  protracted  cases.  There  is  always  amvmia  ami  the 
fniariuiidu  may  be  extreme;  with  the  exception  of  gastric  cancer,  we 
rurily  see  such  ghastly  faces  as  in  patients  with  prolonged  dysentery. 
11 


::M 


w 


ii-  • 


* 


152 


SPKCIFIC   INh'HCTIOlJS   DISKASES. 


Tho  coniplicatioii.s  iiro  thoso  jvlrcudy  rcfiTred  to  in  tho  acute  form.  The 
grciitiT  dfl)ility  rrii(k'rs  tho  jKitii'iit  more  liiihlu  to  tlus  inttTcnrroiit  af. 
feclioiis,  Kiirli  as  |iiu'iiiiioiiiii  111x1  tulH'rculo.sis.  ricerutiou  of  tho  ooriicn 
wiiH  rriMjiiciitly  noted  diiriiiL,'  tho  civU  war. 

Complications  and  Sequelae.— A  local  peritoidtis  may  urisc  by 
cxtoiisioii,  or  a  dilTuso  iullammutioii  may  follow  |icrl'oratioii,  whicli  u 
usimlly  fatal.  When  this  occurs  about  tho  ca-cal  region,  perityphlitis;  iv- 
suits:  when  low  down  in  the  rectum,  jtoriproclitis.  In  one  hundred  ;ini| 
eight  autopsies  eollciicd  hy  Woodward  perforation  occnrred  in  eleven.  \\\ 
far  the  most  serious  complication  is  ahsoess  of  the  liver,  which  occurs  fre- 
quently in  the  tropics  ami  is  not  very  uncommon  in  this  country,  it  w;i< 
not,  however,  a  fre(|ii(nt  complication  in  dyseiitory  during  the  civil  war. 
In  this  latiludi' it  is  certaiidy  iiot  uncommon,  as  wo  have  had  live  cases, 
within  two  y«'ars,  in  tho  .lolins  Hopkins  Hospital,  it  usually  comes  on 
insidiously  'i'ho  sym])toms  will  ho  discussed  in  eonneclion  with  hejiatu' 
abscess. 

It  is  stateil  that  malaria  is  a  complication,  hut  with  oiu'  exception  the 
cases  which  1  have  .seen  with  intermittent  iivrexia  were  invariablv  iissuci- 
ated  with  suppuration,  in  extonsivo  opidomics,  liowever,  Woodward  stalcii 
that  cases  of  ordinary  dysentery  occur  associated  w  ilh  all  tlie  ])hemtiin.'iia 
of  malaria.  With  roforence  to  typhoid  fever,  as  a  comi)lication,  tliis  au- 
thor mentions  that  the  combination  wa-s  excoeilingb  frequent  during  tik' 
civil  war,  and  characteristic  h  sions  of  both  diaea.-^'  coexisted.  In  tiMi 
practice  it  must  bo  extremely  rare 

Sydeidiam  noted  that  dy.sentcry  was  sometimes  a.ssociated  witli  rluii- 
matic  pains,  and  in  certain  epidemics  joint  swellings  have  been  e.speciallv 
ju'cvaleiit.  They  are  jjrobably  not  of  tho  nature!  of  true  rheumatism,  Imt 
are  rather  analogf)Us  to  gom)rrh(eal  arthntis.  In  severe,  ]»rotracted  <'asi< 
there  may  be  pleurisy,  pericarditis,  endocarditis,  and  occasionally  pyainii' 
maiufestations,  among  which  niiiy  be  mentioned  pylephlebitis.  Chrniiii' 
Hright's  disease  is  also  an  occasiojial  sequel.  In  protracted  cases  tlitTf 
may  be  an  ana'iinc  ledoma.  An  interesting  scfpud  of  dysinti'ry  is  paialv- 
sis.  Woodwanl  reports  eight  ca.«es.  "Weir  ^litchell  mentions  it  as  ii"i 
uncommon,  oee.irringcliiotly  in  tho  form  of  paraplegia.  .\s  in  other  aniti' 
fever.s,  this  is  diu-  to  a  neuritis.*  Intestinal  stricture  is  a  rare  sequcinv- 
so  rare  that  no  case  was  rej)orted  at  tho  8urgeon-(ionerars  oiTicc  iliiriiii' 
the  war.  Among  tho  soquehv  of  chronic  dysentery,  in  ])ersons  who  have 
recovered  a  certain  mea.suro  of  lu-alth,  may  be  mentioned  persistent  dys- 
[M'ltsia  and  irrital)ility  of  the  bowels. 

Diagnosis. — 'I'ho  recognition  of  tho  acute  follicular  fofin  is  easy; 
tlu(  frecpiency  of  tho  pa.ssages,  tho  jireseiic*-  of  blood  and  mucus,  ami  the 
lonesmus  forming  a  very  characteristic  i»icture.  Local  affections  of  the 
rectum,  particularly  syphilis  and  opithelionni,  may  produce  tenesmus  uith 


PugilK't,  Revuo  (le  Mudeciiie,  February,  1888. 


DYSKNTKllV. 


ir>;{ 


"hn 

)W 

s   tl 

11 're 

|K.l 

h1\- 

I  ;i^ 

11"' 
'ii'i' 

ICII 

•r— 

tliii'iir.' 

li'i 

IKlM' 

•111 

•lyv 

ii' 

■a^v; 

an 

1  tlio 

'!   (1 

f    tiK' 

III- 

wiih 

the  passu L'O  of  niuroid  ami  Idooily  slodl.j.  'I'lio  a<'iit(*  diiilitlicril  ic  fcrin, 
i.i,iiiiiij^r  .  )  witli  j^Tcat,  iiitciisily  iiml  willi  severe  ('(•iistitiilioiial  tlistiirl- 
iiiuri*,  is  iiwl  iiifre(|iii'iitly  mistaken  for  typlioid  fever,  li»  wliicli  iiideeil  in 
riiaiiv  ca-is  tlio  reseniljlance  is  extremely  elose.  'i'lie  lii<;lier  j^'rade  of 
f,.\rr,  till'  more  pronoiimcil  intest  inal  s\  niptoms,  tlu;  j)reseni'e,  |iarticnlarlv 
in  tlic  early  sta;;e,  of  a  small  amount  of  blood  in  the  stools,  tlie  abseiui'  of 
(■iilarjjiiiii  lit  of  the  spleen  and  the  rose  rush  sliould  lead  to  a  correct  dia^- 
iiilsIs.  Ill  the  am(el)i(!  form  the  diajjnosis  can  readily  he  made  by  ex- 
;iiiiiMatiiiii  of  the  stools.  A  characteristic  feature  of  these  cases  is  their 
iin'L'iilar.  I'hronii!  course.  A  naticnt  may  be  about  and  in  fairly  good 
i„niliii"ii,  with  wcll-formeil  stool.^  and  very  slight  intesiimd  distiirbanco, 
ill  wlio.x  fit'ccs  rile  aiiueba'  may  still  be  discovered,  and  in  whom  the 
(li.^iuse  i:<  at  any  time  likely  to  recur  witli  intensity.  In  some  cases,  corii- 
plirattMl  l»y  abscess  <d"  the  liver  and  lung  discharging  through  a  broiH'hiis, 
till' (liagiiesis  may  rest  on  the  delcclion  of  aiineba'  in  the  sputa,  when  they 
caiiiiot  he  found  ill  tlie  stools  owing  to  the  latency  of  the  intesliiuil  (li.s- 
I'.rliaiice.    Three  such  oases  occurred  in  my  wards  in  18!M).* 

Treatment.  —  Flint  has  shown  that  sporadic  dysentery  is,  in  its 
.«liL'liU'r  grades  at  least,  a  self-limited  disease,  which  runs  its  course  in 
iiirlitor  nine  days.  Heading  a  report  of  his  eas(^s,  one  is  struck,  liowevt-r, 
with  tlicir  comparative  nuldiu'ss. 

The  enormous  surface  involve<l,  amounting  to  many  square  feet,  the  con- 
>ia!ii  |'"esence  of  irritating  particles  of  fo. .d,  and  the  impossil)ility  of  get- 
tiii::  ahsdiiite  rest,  are  conditions  which  render  the  treatment  of  dysenterv 
]iiriiliarly  ditlicult.  Moreover,  in  the  severer  cases,  when  necrosis  of  the 
imicosa  lias  occurred,  ulceration  necessarily  follows,  and  cannot  in  anyway 
lie  obviated.  When  a  case  is  seen  early,  iiarticularly  if  there  has  been  con- 
stipatiini,  a  saline  purge  should  be  given.  TIk!  free  watery  evacuations 
pniiliic'cd  liy  a  dose  <»f  s:ilts  cleanse  tin;  large  bowel  with  the  leasi  possible 
iiiitation,  and  if  necessary,  in  the  course  of  the  disease,  particularly  if 
M\l»ala  are  present,  the  dose  may  be  repeate(i.  Purgatives  arc,  as  a  rule, 
iiiijirtidiiable,  and  the  profession  has  largely  given  up  their  use.  (*f  metii- 
liiu's  given  by  the  mouth  which  are  supposed  to  have  a  diri'ct  eiTect  upon 
till'  disease,  ipecacuanha  still  maintains  its  rc[mtation  in  the  tropics.  It 
iliil  not,  however,  prove  satisfactory  during  the  civil  war;  nor  can  I  say 
tliiit  in  eases  of  sporadic  dysentery  I  have  ever  seen  the  marked  elTect 
liiwribod  by  the  .\nglo-Indian  surgeons.  The  usual  method  of  adminis- 
tration is  jo  give  a  jireliminary  dose  of  opium,  in  the  form  of  laudanum  or 
iimrpliia,  and  half  an  hour  after  from  twenty  to  sixty  grains  of  ipecacuanha. 
lfrijV('te(l  by  vomiting,  the  dose  is  repeated  in  a  few  hours. 

Miiiiiie  doses  of  corrosive  sublimate,  one  hiindredth  of  a  grain  every 

[twii  hoiiis,  ;ire  warmly  recommended  by  Hiiiger.     iiarge  doses  of  bismuth, 

liiilf  a  drachm  to  a  drachm  every  two  hours,  .so  that  the  patient  miiy  Tiilie 


i « 1 


*  For  details  see  monograph  of  Councilman  and  Laflpur. 


w- 


164 


Hl'KClKlr   INI'KCTIOL'S   DISKASKS. 


'•I  P' 

I  < 


Hi:-* 


frotn  twelve  to  fifteen  (Irjielmis  in  u  day,  Imvc  in  inimy  enseg  had  ii  Ix  no- 
licial  fllcct.  To  do  irooil  it  must  he  ;.qv('ii  in  liir^re  do-cs,  as  recomineii'lcii 
i)y  Moniieri't,  wlio  },'iive  as  lii^di  as  seventy  ^Maninies  a  day.  ll  ceituinly  is 
liionMiHefiil  in  tli(>  elironiu  than  the  ueutu  eusoH.  It  ix  boHt  j^ivcn  ainiip. 
Opium  is  ail  iiivahiahle  retnedy  for  tlie  relief  of  the  pain  and  to  f|uic't  tiic 
Iterifitalsis.  ll  shoidd  he  ^'iven  as  nior|ihia,  liyi)odfrnii«'ully,  acuordin;,'  to 
the  net'dfi  of  llie  juitiont. 

The  treatment  of  dysenteiy  l)y  topieal  a|)plieiitionrt  Ih  by  far  the  tii(p>i 
rational  plan.  .\  serious  obstacle,  liowever,  in  the  aeute  cu.xch,  is  the  t'.x- 
treme  irritability  of  the  rectum  and  the  teiiesmii.<<  which  follows  any 
iittempt  to  iri'i;;ale  the  (tolon.  A  (ireliminary  cocaine  suppository  or  the 
injection  of  a  small  (pianlity  of  the  four-per-<'cnt  .solution  will  sometiiihs 
relieve  this  and  then  with  a  loni^  tiilic  tlu'  solution  can  i»c  allowed  to  tlnw 
in  slowly.  The  patient  slioidd  he  in  tint  dor.<al  ponition  with  a  pillcm 
under  the  hips,  so  as  to  j;et  the  ell'ect  <if  <,n'a\  itaticpu.  Water  at  the  tciii 
peratun.'  of  100°  is  \\>v\  tjootliin<f,  but  the  irfilabilily  of  the  bowel  is  .Midi 
that  larjre  quantities  can  rarely  b(>  retaineil  for  any  time.  When  the  acute 
symptoms  subside,  the  inject ion.s  ari'  better  home.  Various  astrinj^eiits 
may  bo  iised — tdum,  aceUite  of  lead,  sulphate  of  zinc  and  copper,  uml 
nitrate  of  silver.  Of  these  renu'(liert  the  nitrate  of  .silver  is  the  lie,-t, 
though  1  think  not  in  very  acute  cases.  In  the  chronic  form  it  i:  ptr- 
haps  the  most  satisfactory  method  of  treatment  which  wt;  have,  li  h 
usek'S.s  to  give  it  in  the  small  injections  of  iwo  or  three  ounces  with  mi' 
to  two  grains  of  the  salt  to  the  ounce.  It  iiiii.-t  be  a  large  irrigating  in- 
jection, which  will  reach  all  j)arts  of  the  colon.  This  plan  was  introdiiipil 
by  Hare,  of  Ivlinbiirgh,  and  is  highly  recommended  by  Stephen  .M;ii- 
Kcnzie  and  II.  ('.  Wood.  The  solution  must  be  fairly  strong,  twenty 
to  thirty  grains  to  the  pint,  and  if  possible  from  three  to  si.\  pints  di 
tliiid  must  be  injected.  To  begin  with  it  is  well  to  use  not  more  than  ;i 
drachm  to  tlu-  two  jiints  or  two  and  a  half  pints,  and  to  let  the  warm  lliml 
run  In  slowly  through  a  tube  passed  far  into  the  bowel.  It  is  ut  times 
intensely  jiainful  and  is  rejeiited  at  onci'.  In  the  ca.ses  of  aino'bic  dy»'ii- 
tcry  we  have  bei-n  using  at  the  Johns  Hopkins  Hospital  with  great  binclii 
warm  injections  of  (piinitu'  in  strength  of  1  to  r),0oo,  1  u>  '■1,'>(H),  and  1  i" 
1,000.  The  amu'ba'  are  rapidly  destroyed  by  it.  These  largo  inject i'iii> 
are  not  without  a  certain  degree  of  danger.  IJrayton  Hall  reports  ihc 
cii.«e  of  a  child  in  whom  general  ju'ritonilis  followed  the  injections.  1 
have  nevci  seen  any  ill  elTectS;  even  with  the  very  large?  amount.*.  Wluii 
Uierc  is  not  much  ten<'siniis,  a  small  injection  of  thin  .stari'li  with  half  ;i 
liiachm  to  a  drachm  of  laudanum  gives  great  relief,  but  for  tho  torniina 
and  tenesmus,  the  two  most  distressing  symptoms,  u  hypodermi'  "t 
morphia  is  the  oidy  .satisfactory  remedy.  Local  applications  to  the 
;d)domen,  in  the  form  of  light  poultices  or  turpentine  stupes,  are  very 
grateful. 

The  diet  in  acute  cases  must  be  restricted  to  milk,  whey,  and  bnilis, 


MAIiARIAL  FKVKH. 


mr. 


mill  iluriMjj  ontivalcsccnco  Iho  frn-atest  mrc  miiHt  ln'  taken  to  provide  only 
tilt'  111"-'  ilijj<'stil)k'  artii'lcs  of  fdml.  In  clironir  (IvHt'iitcrv,  dii'i  is  pcihapn 
the  iiin-i  iiii|inrintit  ('IctMciit  in  llic  treatment.  'I'lie  niinil)ei- of  htools  (lan 
frii|iii  iiily  1)0  re(lnci'(l  fruni  ten  or  twelve  in  the  day  In  t wo  or  tlifee,  by 
hhiciii'-'  the  patient  in  bed  and  restricting  the  (lict.  Many  cases  do  well 
III)  iiiill^  alone,  lull  the  stools  should  he  eareftilly  watched  and  the  anuaint 
IjiiiitiMl  to  that  which  can  be  <li>;est(Mi.  If  curds  appear,  or  if  iniich  oily 
iimtiii'  i;*  »"'en  on  microscopical  cNaniinatioii.  it  is  itcsl  to  reduce  the 
uiiKiiiiii  of  milk  and  to  sin)plcmcnt  it  with  licci'-juicc  or,  lietter  still,  efjj;- 
ulbiinirii  The  lar;.'!'  <loses  of  bismuth  seem  specially  suitable  in  the 
clinunc  cases,  ami  the  injeiMious  of  nitrate  of  silver,  in  the  way  already 
mt'ijli(iiie(l,  should  always  be  given  a  trial. 


r.   im. 


XXII.    MALARIAL    FEVER. 


Definition.  —  An  infectious  disease  characterized  by  :  {it)  paroxysms  of 
iiittriiiillcnt  t'l'Vci' (d'  (piotidian,  tertian,  or  (piartan  ty|ie;  (/>)  a  continued 
fever  with  nuirked  remissions;  (<■)  certain  pendcioiis,  rapitlly  fatal  forms; 
iiml  (il)  a  chruidc  cachexia,  with  ameniia  and  an  eidarged  spleen. 

With  tlu'  disiase  are  invariably  associated  the  luvnuitozoa  described  by 
Lavcniii. 

Etiology.— (1)  Geographical  Distribution.— In  Kurope,  southern  Uu.s- 
siii  uiid  certain  parts  of  Italy  tire  now  the  chief  scats  of  the  disea.se.  It 
is  not  wid(dy  prevalent  in  (iermany,  !•' ranee,  or  Kn^^dand,  and  t lie  foci  of 
t|ii(li'nii('s  arc;  beconiin;f  yearly  more  restricted.  In  .\nu'rica  it  is  now 
rare  on  the  vVtlantic  coast  above  the  latitude  of  Philadelphia.  I'^rom  New 
Kiii;laiid,  where  it  once  prevailed  extensively,  it  has  graihially  disai)j»eared, 
liiit  there  iiaa  of  late  years  been  a  sli<fht  return  in  sonte  places.  In  the  city 
(if  New  York  jfcnuino  malaria  is  rare  except  as  an  imported  disease.  In 
I'iiihiilelphia  and  alonjf  the  valleys  of  the  Delaware  and  Schuylkill  Kivers, 
formerly  hot-beds  of  malaria,  the  disease  has  become  much  ivstricted. 
Kxci'pt  in  the  low-lyiuf?  .southern  portions  of  the  city  it  rarely  devel- 
I'lis,  and  the  majority  of  cases  admitted  into  hospital  are  of  the  poorer 
iliiss,  who  have  returned  from  pickinj;  craiil)erries  and  ])eaches  in  Dela- 
ware and  New  Jersey  In  Baltimore  a  few  <'ases  develop  in  the  autumn, 
iiiil  a  majority  of  the  patients  seekinjf  relief  are  from  the  outlyin*,'  dis- 
iiiets  and  one  or  two  of  the  iidets  of  (.'hesapeake  Hay.  'rhouf:fh  prevalent 
ill  certain  rejfions  on  this  bay,  the  disea.se  is  yearly  becotnin<f  less  wide- 
s'ln'ead  and  less  severe.  In  the  Southern  Stales  there  are  on  th(!  seaboai'd 
many  isolated  regions  in  which  malaria  prevails;  but  here,  too,  there  has 
eveiywhere  been  a  marked  diminution  in  the  prevalence  and  intensity  of 
the  disease.  W.  W.  Johnston  states  that  in  the  (U\li  district  there  arc 
places  in  which  the  disease  is  increasing  The  percentage  of  cjuses  admit- 
ted to  the  Marine  Hospital   Service  in   187G  was  18-4,  ana  5J3-4  in  1887. 


:.li 


1; 


SPKCIKIC   INFKCTIOUS   DISEASES. 


!i- 


I?iit  tliis  may  he  diic  to  tho  (Icvclopiiicdt  of  tlio  sliippitiff  tnuK'  and  i.,  the 
grcatiT  iiiiiiiIkt  of  sailiM's  who  carrv  the  inl'r'ciioii  rrdiii  tlit-  Wi'sl  liidiaii 
ports,  iiixl  tliosc  ("if  Mexico  and  ('ciitral  America. 

Ill  llic  iiilerioi- o|"  Louisiana,  Mississippi,  Arkansas,  and  Texas  iiialiiii;i 
JH  endemic,  and  tjie  severe  tvpt's  are  not  inrreipieiit.  At  irre<fiilar  jn  ri(M|> 
epidemics  of  the  most  severe  forms  occur. 

In  tlu'  .Norliiwestcrti  .States  malaria  is  almost  unknown.  It  i>  liin 
on  tile  I'acilic  coast.     In   the  reifion  of  llieiJreat   iiakes  malaria  priviiil< 


onlv  ill   the   Lake    Krie  and    Lake  St.  (lair  re<ncns.     It    ha 


s  pra('!ii';ili\ 


disappeared  from  i-ake  Ontario,  whereas  in  the  upper  Huron  and  hik>' 
Superior  l)a.<ins  it  is  unknown.  The  St.  Lawrence  liiver  rejjion  reiiiaiii< 
free  from  the  disease,  in  Moiiireal  a  patient  with  malaria  i.s  invariablv 
(|UC'stioned  as  to  his  latest  residence. 

(".')  Telluric  Conditions. — Tlie  importance!  of  the  .stale  of  tho  soil  iutlio 


eti 


oioLfy  ol    malaria   is   umversallv  reeoiriu/et 


1.     Il 


is  seen   particularly  v.i 


low,  marshy  re;,non.s  which  have  an  al)iindant  vejii'lahle  {growth.  K.-tii- 
arie.s,  hadly  drained,  lowlyin<^  districts,  the  course  of  old  river-heds,  tnids 
of  land  whiidi  are  rich  in  vcLTi'taltle  matter,  and  particularly  district.^  siuii 
as  the  Ikoman  t'ampajxna.  which  have  been  allowed  to  fall  out  of  ciiltiiit- 
tioii,  ar(>  favorite  localities  for  the  development  of  the  malarial  pdi.-nn. 
These  comiilioiis  are  most  fre(piently  found,  of  course,  in  tropical  iii;, 
siiiitropical  regions,  hut  nothiii;,' can  he  truer  than  the  fact  that  reekm.' 
marshes  of  the  most  pestilent  appearaiu'i^  may  he  entirely  devoid  nf  ii, 
pois<in,  and  the  disa|ipearance  of  the  disease  from  a  locality  is  not  iicci-- 
sarily  a>sociated  with  any  material  improvement  in  the  condition  of  ili' 
marshes  or  of  tho  soil.  Thus,  in  .New  Lnj^daiid  and  in  parts  of  wi-i'ii 
Canaila.  in  wliich  malaria  formerly  was  very  prevalent,  the  increased  .-ul ; 
brity  is  usually  attriinitcd  to  the  cleariiiff  of  the  forests  uiul  tho  boliir 
draiiiap' (d'  the  ijniiiiid  ;  iaiL  these  improvements  alone  can  scarcely  ex- 
plain the  disappearance,  since  in  many  tlistricis  t'icre  are  marshy  tnir- 
and  low-lyin;f  lands  in  every  res()ect  like  those  iu  which,  even  at  the  sin. 
latitude,  the  disease  still  prevails.  Compare,  for  examj)lo,  a  swampv  tri' 
on  the  northern  shore  of  Lake  Krie  and  a  similar  tract  on  tlio  .soutlid:, 
shore  id'  Lake  Ontario ;  the  llora  ami  fauna  of  the  two  districts  are  |ii;i- 
tically  identical,  but,  in  the  former  the  conditions  under  which  the  iikiIi- 
rial  virus  develops  .still  exist,  whereas  in  the  latter  thiy  have  ^'railii;i:  ■ 
disappeared.  In  short,  it  is  impossible  to  ascertain  from  the  natiiiv  "i 
tho  soil  and  climate  in  any  ^nvn  place  whether  it  is  malarial  or  not.  Iii 
tho  ab.seiice  of  ac<'iirate  kmtwledire  as  to  the  habitat  of  the  ha-mato/Ha. lii'' 

nici'  hi 


only  means  of  d»'cidin<^  this  point  is  by  noticing  tho  olTect  of  rosid 
.siudi  11  place  on  the  human  subject,  preferably  ono  (d'  the  ('aucasian 

(;>)  Season.  -Lven  in  the  tropics,  where  malaria  constantly  piwaii 
there  arc  minimal  ami  maximal  jieriods;  the  former  corresponding:  intli 
Slimmer  and  winter,  tho  latli-r  to  the  s[)iinir  and  autumn  month-.  I 
tem])orato  regiona,  like  tho  central  Atlantic  States,  thore  aro  only  a  fi 


raiT. 


m. 


WALAUIAL   FEVKU. 


167 


i  ill  ilic  Fjirini:,  usiiiilly  in  tlio  nioiidi  of  ^fay,  ami  a  larpo  Diiriibr.- of 
,  ill  Si'ptonibt'r  jiinl  Oi'IuIkt,  ami  .soincliiiK'S  in   Novciiilxr.     In  tlio 


tropirs,  t' 


ti'o  cast's  arc  most,  iiunu  ron.s  in  llu>  aiitiinin  niontlb 


(1)  Meteorological  Conditions.— (r^)  JlaL  —  X  tulerahly  lii.i^li  Icnipcra- 


tiirc  ISnlK 


if   tlio  c.-isenlial  comliUons  f<ir  the  (I('V(l(i]inifnl  uf  the  \ii 


us. 


It  is  iii'iii  iircvalciit  after  jiroiongcd  hot  siininicrs. 

(//)  Mci-i/iirr. — In  tlic  tro()i('S  the  inahirial  fevers  aro  most  jirevalent  in 
lilt' r;iin\  x'asoiis.      In    the   temperate  eliniales   the   relation   between  the 


mil 

liiy 

ef"l! 


ifall  111 


il  malaria  is  not  so  clear,  .iml  eases  art;  more  iiunierons  after  a 


siiininer;  Imt  if  eillier  heal  or  moi.-liire  is  excessive,  the  cluvelopnieiit 


ilS 


is  checked  for  a  time 


[(■)    W  ni(/.'<. — Many  facts  an;  on  reeord  whieli  seem  to  indieato  tliat  tl 


10 


jioi 


am  iiiav  oe  can 


■ied  t 


,o  some 


dist: 


;inc(i  1)V  wind 


he  plain  m:,'  ol   trees 


liiis  hciii  held  to  iiilerfeiv  with  the  traiismis.-ion  liy  prevailini,'  winds. 
I'ossililv,  however,  the  «pii(d\lygrowinif  trees  siieh  as  the  Ijtcuhjjilns  (jhihii- 
//,'N,  have  aeied  more  heiielicially  hy  drying-  the  soil. 

(."i)  Specific  Gravity. — 'I'hat  (lie  distrihntion  of  (he  iioisui  of  malaria 
iV  iiiiliieihid  hy  Lrra\ity  has  loii^  been  conceded.  Persons  dwelling  in  the 
ii|)|)i'r -t'nies,  or  in  buildings  elevated  some  distanee  above  tho  groniid, 
aiv  fxeiiipl  ill  a  mafked  degree. 

The  Specific  Germ.— As  Ilirseh  correctly  remarks,  (he  late  J.  K.  Mitcli- 
iir<t   to  ap|)roach   in    a  seieiitilii' spirit  the  nature  of  infec- 


'  wa-;   tlie 


MM'   ill- 


>east^  antl   particularly   in   malarial   fev 


er, 


M; 


iiiy   attempts   were 


iiiinli'  to  discover  a  constant  and  characteristic  organism.  Klebs  and 
Tiiii>::.,isi-('riideli  in  isil)  annoiiiieed  the  discovery  of  a  IhkiUks  iiitihiria', 
liiil  tlieir  observations  have  not  been  coiilirmed.  In  JStSO  liaveran,  a 
I'i'ciicli  army  surgeon,  now  jirofessor  at  tho  Mcilieal  Hchool  at  \'a!  (h' 
liruiT,  jiiiiioiiiH'ed  tliedisco\  'IT  of  a  para-ite  in  :'>el)iood  id"  palieiilsat- 
ii'kid  hv  malarial  fever.  During  tiie  iu\l  three  yi  ars  he  published  nine 
aiitliiimial  communieatioiis,  but  fo;  a  time  these  oliservatioiis  attracted 
liitlu  iilieiition.  The  Italian  observers  Marchiafava,  Celli,  and  (lolgi 
nirmhurated  Laveran's  statements.  Councilman  carefully  studied  tho 
i|iU'stiiMi  ill  this  country,  and  JiUVeran's  .-laleiiieiits  were  coiilirmed  liy  niy- 
•ilf  ill  I'hiladelphia,  by  Walter  James  in  \ew  York,  and  nioro  I'oceiitly 
1)V  Pock  in  (lalvest on,  Koplik  in  Now  York.  The  whole  question  has 
I'li'ii  considered  recently  in  an  extensive  tnoiiogiaph  liy  my  assistants, 
Tliayn'and  llowctson,  in  Hal  imore.*  In  India,  \'andyke  ('art"r  has  piib- 
ii>!u'ii  an  elaborate  monograph  on  the  parasites.  In  Franco,  (lermany, 
1  Kiiuland,  owing  in  great  part  t(j  tho  absence  of  cases  of  malari.i,  the 
Value  ef  Laveran's  ob.servations  was  at  lirst  overlooked,  but  recently  tho 
"Millniiiition  has  boon  jmblishod  from  many  of  the  (ierman  clinics,  while 


aiK 


ahialile  ob.sorvatious  have  reoon 


tly  bt 


son  mat 


le  in  Southorii   Kiissia.     So 


-ir  a<  1  know,  not  a  sin<do  observer,  who  lias  had  tho  noces.sarv  trainiiiir 


\   ■'» 


'ti 


♦  The  Miiliirittl  Fevcfh  of  Ualtimtiri',  J.  11.  II,  Jiiporln,  vol.  v. 


158 


SPECIFK;   INFRCTTOrS  DISKASKS. 


and  tlie  materiiil  at  liis  command,  has  failed  to  demojustratc  the  oxistciicf. 
of  tlu'se  parasites. 

The  Ixidit's  wliicli  have  liccn  found  invariably  assopiatcc]  with  all  fnrni- 
of  malarial  fevers  heloni;  to  the  protozoa  and  to  a  _£rroM|i  of  or^Miii>iii> 
known  as  tiie  li(nn(itin"ii.  the  precise  afVmitics  of  which  iiave  not.  yet  liren 
definitely  detenniiied.  Parasites  of  the  reel  Mood-corpnscles  have  liccii 
met  with  aliunilantly  in  the  blood  of  fish,  tnrtles,  and  many  specii~  nf 
birds.  One  of  the  best  and  most  readily  studied  examples  is  the  />/'/,</• 
niitiinn  rdiKinnii,  a  common  parasite  in  liie  red  blood-corpuscles  of  iln 
frog.* 

These  organisms  are  generally  placed  among  the  snorozoa ;  their  furtlur 
cla.ssifioation  is  still  a  matter  of  dispute.  The  parasites  an-  true  ha'miu'y 
tozoa.  existing  a!id  pursuing  their  cyide  of  exi^^('nc(■  within  the  red  blodii. 


cor 


pu 


;cles  of  tlu!  infi-cfed  individual.     'I'he  voungcst  forms, small,  hval 


nil. 


anueboid  bodies,  enter  the  ri'd  blood-corpuscles  and  develop,  accuniidatii 
thev  increase  in  size,  line  jrranules  of  dark  pigment,  whicdi  is  fonutd 


as 


the  expense  of  the  luemoglobin  of  the  including  corpuscle.  When  ;lii 
organisms  have  reached  their  fidl  develoinnent  and  destroyed  their  lie<i., 
the  ))igmet\t  granules  gather  into  a  central  cluni])  or  block,  and  the  p;ir,i- 
sites  l)ri'ak  up  into  a  iniml)er  of  small  rouiul  or  ovoid  hyaline  bodies,  carl; 


one 


of  which  represents  a  fresh  young  organism  ready  to  attack  a  ne 


pu.scio  ami  negiii  again  a  cyi 


■le  of 


existence, 


Sevei'al  varieties  of   the  parasite  have  been  se]iarated,  eacli  of  wl 


il'il  I- 


i;ir: 


associated  with  a  eharacteristic  ty|)e  of  fever,  '["hese  varietie.s  are:  (li 
The  parasite  of  tertian  fever;  ('J)  the  parasite  cd"  ipun'tan  fiver;  ('■>)  \\w 
parasite  associated  with  the  more  irregular  fevers  occuriing  in  tempiiiii' 
climates,  in  the  later  sujnnu'r  and  autumn — t!ie  "  a'stivo-autumnal  fcMi " 
of  tile  Italians,  (iolgi  lirst  pointed  out  the  remarkable  fact  that  the  |i:ir;i- 
sites  of  the  regularly  internntteiit  fevers — -the  tertian  an<I  ipiartaii 
sites — exist  in  the  blood  in  great  groups,  all  the  niemliers  of  which  arc  an- 
proximately  at  the  same  stagi^  of  development.  Thus  an  entire  grouji  i>: 
myriads  of  parasites  undergoes  sporul.alion  within  a  period  of  .■^cvcni 
hours.  7'//r  sjiiiriildliiiii  uf  sncli  a  i/roii/)  of  'Kinrsifi's  />■  ahriii/,s  fitllturnl  lui 
till'  iiiithtridl  f>in-n.nis)ti,  whi(di  very  possibly  depend.s  upon  some  toxic  <iil' 
stance  which  is  developed  at  the  tiuu^  of  spornlation.  The  tertian  piira 
site  reipdres  al)out  forty-eight  hours  to  aecoiuplisli  its  cycle  of  devln' 
ment  iuid  undergo  sitorulation.  Thus  with  infections  with  a  single  i::  ■ 
of  tci'tiaii  parasites,  spornlation  occurs  every  othei  day,  resulting,  as  nii;'lr 
be  expei'ted,  in  tertian  paroxysms.  More  often,  however,  infections  wiili 
two  groups  of  tertian  parasites  are  seen  -groups  reaching  maturiiy  m; 
alternati'  days,  and  causing  cpiotidian  ))aroxysms.  \'ery  rarely  inferiidn- 
with  multiple  groups  of  the  parasite  may  be  seen. 

♦  Kiir  Mil  (xccilciit  acceiint  of  thl'^<o  ha'miitozoa  and  tlu'ir  (Icvulopniunt,  son  (W/i,  ii. 
Koitschrilli'  ilcr  .Meihciii,  1HI»1. 


MALARIAL   FP:VI';R. 


150 


Till  rvc'Ie  of  oxistonoe  of  the  qnartjui  piini^itc  lasts  iiboiit  scventy-twr) 
hours,  ;m<l  if  '"'t  o'"'  j^i'oiip  of  ori^raiiisms  he  pivsi'iit,  ty|»i('al  (|uartai'  fever 
iv;iilts.  Till'  prosciieo  of  two  (groups — (loiihlr  (|iiartaii  iiifcrtioii — is  asso- 
liiitiil  uitli  paroxysms  on  two  siuM-cssivc  days,  follownl  \t\  a  day  of  iiiler- 
,iiis<ioii ;  the  ijrcscnco  of  three  <i;nnij)s  <iives  rise  to  (piotidiaii  ]iar(>xystiis. 
Vcrv  rarely  more  thati  three  groups  may  ho  present. 

Till'  parasite  of  the  autumnal  type  possesses  a  cycle  of  (h'vei<)|>nient  tlio 
cxiict  iluration  of  which  is  still  a  subject  i»f  dis[)iite ;  il  is  pi'uliahly  vari- 
iihjc.  lii.Ming  from  tweiity-t'oiir  Imnrs  or  less  to  forty-eiirht  hours  or  even 
iiion',  ilie  variations  depending  upon  conditions  not  wholly  known.* 
While  111  the  liegiiining  of  the  infection  the  arrangement  of  the  parasiti-s 
111  gi'iiii|is  may  he  made  out,  this  regular  arranirement  often  disa|ipears, 
anil  or;.:.iiiisms  at  dilTereiit  stages  of  develoiimeiit  may  lie  found  at  the 
sitiic  time. 

Segiiieiitiilion  may  thus  oecip-  at  irregidar  intervals,  sometimes  almost 
idiitiiuiouslv.     The  resnltiiiL''  fever  mav  t)e  rcL^nlarlv  intcrmitttMit,  hut  is 


iftcii  irregular  a 


nd 


oim  times  almost  continuous 


77/'  jiiirasih'  iif  frr/ittji  fi  nr  begins  its  cycle  of  development  as  ii 
-timll.  lisaline,  amo'lxiid  body.  This  rapidly  accumulates  tine  brown  pig- 
iiiciit  granules  which  are  thrown   into  active  motion;  the  including  cor- 

piwlc  Ik mes  expanded  and  decolorized  as  the  pai'asiie  grows.    The  fidl- 

irrnwii  tertian  organism  is  about  the  size  of  a  norniid  red  corpuscle.     In 
.•jMtnihiiioii  the  segments  niimlier  from    liftecii  to  twciitv,  or  even  more. 

77('-  /»,/.  'v//''  (i/ ijiiar/diiO'i'i-r  is  very  similar  in   its  appearance  to  the 
tertian   organism.     The  amo'lioid   movements  are,   however,  slower,  and 
tho  pigment  granules  are  coar.ser,  daiker,  and  in  less  active  motion, 
fiiliv  (levelopeil  parasite  i 


'i' 


IS  sma 


.Mill 
tiTti 


ler,  while  the  corpuscle  in  whi(di  the  or- 
siu  develops,  instead  of  beconiing  expamled  and  decolorized,  as  in  the 
111  infections,  rather  shrinks  about  tlu'  parasite  and  assumes  a  deeper, 
iiisiT,  somewhat  brassy  color,  in  sponilation  the  segments  are  ''ewer, 
fiiiiii  live  to  ten  in  nunilier.  'I'hey  are  arranged  with  great  regularity 
liiiinl  the  central  pigment  elnmp  or  block,  forniing  the  most  iieautifid 
•Ti.sftte.s." 

T/ir  })ii)'iisiff>  of  thr  nufiinninf  niiilnn''//  t'rrc  \<  consiib^rably  smaller 
iiaii  the  other  varieties;  at  full  <levelopmenl  it  is  often  less  than  one  half 
ihr  size  of  a  red  iilood-corpii.<!cIe.  The  pigment  is  miicli  scantier,  oft<'n 
I'liisisting  of  a  few  minute  granules. f  Only  the  earlier  staL'e-'  of  devel- 
"piiH'tit,  small,  hyaline  Iwidies.  .siometiiiies  with  one  or  two  pigment  g'-ni- 
'ili'S  are  to  be  found  in  the  peripheral  circulation  ;  the  later  stages  are 
"''linarily  only  to  be  seen   in   the  l)lood  of  certain   intertuil   organs,  the 


\  % 


I 


TfM   "f"**'-'    '■ 


ilA. 


*  M.inliiiifavH  and  Hijjnumi  (listiuijiiish  twn  vari'Micsof  flio  n'stivo-aiitiiinnnl  |iHni- 
'  .il  i|ii(iliiban   and  a  tcrlini'.     TlifH*  oltscrvationM  we  have  not  as  yet  lo-cri  atilc  to 
■  iifirni. 

f  Sigmontiiig  liodics  havi-  Itfcti  deaerihod  whicli  wurc  nintc  frof  frciin  pignieiil. 


,1 


100 


SPKCnnc   IXFl-TTIOUS   DISKASES. 


spleen  and  lioiie  marrow  particularly.  Tlie  corjniscles  ('(intaininfi  the 
parasites  heroine  iint  int'rei|iiently  siirnnken,  cretiattd,  ami  hnissvrdl- 
ored.  After  tlu'  process  has  existed  for  ahoiit  a  week,  larj^MT,  refi'ac  live, 
crescentie,  ovoid,  and  ronml  hodies,  with  central  dumps  of  coarse  pij;- 
nuMit  uranules.  he;,Mn  to  appear.  'I'l 
d  f( 


lese  hudies  are  cliaracti'ristic  ot  a'slivc 


autumiud  fever,     'i'heir  si^Miilieaneo  is  a  matter  of  dispute. 

l''rom  the  full-irrown  tertian  and  (piartaii  ])arasites,  and  from  the  I'ounii 
bodies  with  cejitral  pi;.,Miient  clumps  in  astivo-autumnal  infections,  liini;, 
actively  nmvinjij  tla::ella  may  develop;  these  may  at  times  hreak  luesc 
and  move  aliout  free  aMH)ni3'  tlie  corj)nscles.  Tlair  siyniiicance  ha.s  nut 
heeii  wholly  di'termined. 

The  <fenei'al  symptoms  and  morhid  anatomy  of  nuilaria  are  in  Imr- 
niony  with  the  changes  whicli  these  parasites  induci'.  The  remarkiiMc 
])erio(licity  of  the  manifestations  of  paluilism  are  well  explaiiu'd  when  wv 
consider  the  ridations  whi(di  these  manifestations  hear  to  the  life  histdi'v 
of  the  p;irasite.  'I'he  destrudidn  of  the  red  hlood -corpuscles  hy  the  ori^iui- 
ism  can  he  traced  in  all  stages.     'Vho  /irc.sr/ice  ofjtiijninif  in  the  blood  uihI 


viscera  so  cli 


iiracteristie  of  malaria  results  from  the  transformation 


the 


luL'mojxIoliiu  hy  the  parasites.  'I'he  aua'inia  is  a  direct  conse(jiience  of  tin 
wide-spread  destnietioii  of  the  corpusidcs  themselves.  The  severe  cciv 
bra!  symptoms  in  pernicious  casi's,  as  well  as  the  occasional '  ease  ■;  of  (Iml 
eriform  malaria,  have  been  shown  to  be  associated  with  the  special  Iim'hI 
ization  of  thi'  parasiti's  in  capillaries  o 
inemlirane  of  the  gastro-intestiaal  tract. 


f    the   brain,  or   in   the   miic<iii> 


der 
f 


ron 


There  are,  however,  many  ;,M(ts  in  our  knowledge.  While  by  liy[iii- 
mlc  or  intravenous  inoculation  nitilarial  infection  may  he  transfirrtii 
1  one  indivi<lual  to  aiutther,  the  same  ty|»e  always  appearing  in  the 
inoculated  individual,  yet  we  are  i|uile  ignorant  of  the  form  in  which  tin 
})arasite  e.\ists  outside  of  the  human  bddy,  .Ml  experiments  at  cultiva- 
tion of  the  parasit<'s  have  faileil.  W'e  are  tlu'refore  also  ignorant  fis  t«i  tin 
manner  of  infection.     'I'he  evidence  appears  to  suggest    that   this 


occurs 

generally  through  the  respiratory  tiaet,  though  the  proof  of  this  suii|'().«i- 
tion  is  wanting.  Thaf  infection  T;uiy  occur  hyjiodermically  is  proved  In 
the  inocidation  experiments.  I\epcatcd  attempts  to  bring  about  iiifectiim 
through  the  gust ro-intestinal  tract  have  ill  failed. 

Meantime,  awaiting  further  knowledge,  advantage  maybe  taken  of  tin 
constant  presence  of  the  parasite  in  malaria,  'i'his  alone,  without  nfiT- 
onoo  to  the  true   naturi'  of  the   oruanism,  is  a  fact  of  tlie  liighost  iiiiiHir- 


tUlU'C 


o  he  ahle,  evervwiiere  and  umlcr 


circumstances,  to  dilTeniiti- 


ute  between  imdaria  and  other  forms  of  fever  is  one  of  the  most  imi)ortiiiit 


P 
advam-es  whiidi  has  been   made  of   late  yetu's  in  practical  meditdni 

whi(di  will  revidutionize  the  study  of   fevers   in    tropical   titid  subtro| 

countries,  and  should  within  a  short   time   bring  some  ordt'r  out  nt 

chaos  whiidi  ut  present  exists  regarding  the  ililTerent  forms  which  tl 

prevail. 


one 
)ical 


llTl' 


MALARIAL   FKVKR. 


i»;i 


Morbid  Anatomy. — 'I'lic  cliiin^ft's  result  from  tlic  (iisintcuiatioii  of 
tlir  I.,]  lilddd-cdipiisclcs,  jiccuimilatiou  of  tlio  |»i.irim'iit  tluToln' formed,  and 
|)(i.-iiii\  the  iiilliienee  of  toxic  iiiiiteiiids  |iroduei'd  \t\  the  piirasite.  Cases 
(,f  .-iiii|ili'  malarial  infeetion,  the  a^^iie,  are  rarely  fatal,  and  our  kimwledi^e 
(if  ihf  iiioi'liitl  auatomv  of  tiu'  disease  is  drawn  from  ihe  iicruicinUh  mata- 
liiMii' llie  elironie  eaelu'xia.  IiUptui'e  d'"  the  enlai';,''t'd  spleen  mav  nccur 
siieiitaiiconsly,  iait  nu)re  eDmnmnly  fnun  traunui.  A  ease  (if  the  kind 
was  iidniitied  under  my  e(»l  league,  llalsted,  in  .lune,  1  SSI),  and  lUnk  lias 
recrlitiv  i'c|iiprti'(l  two  ease.s. 

(1)  Pernicious  Malaria -'I'lie  hldod  is  hydra'tnie  and  the  serum  may 
evfli  lie  liiiilfd  with  lia'UioiLjhihin.  The  ret)  hhiod-eorpuseles  ])n'sent  tiu' 
(■iiilii::l'ihular  fiirnis  of  the  ])arasite  and  are  in  all  stages  nf  dc-lruetion. 
The  splefn  is  enlarged,  often  oidy  moderately;  thus,  nf  iwo  fat.'d  eases 
iccciiily  in  my  wards  the  sjjleens  measured  I.'i  X  S  elm.  and  11  XS 
(till,  respectively.  If  a  fresii  infeetion,  the  spleen  is  usually  very  sdfl.and 
the  |inl|i  lake-colored  and  tiirhid.  In  Cj.ses  of  intense  reiiifectidii  the 
^|lleell  may  hi'  enlarged  and  tirni.  The  aiiKiiint  (if  [ligment  in  'he 
.<ilileeii  elements  is  greatly  increased.  The  pulp  cuntains  large  niim- 
hers  (if  red  corpuscles  eoiitainiiig  jtarasites.  J'jiormoii.-'  nuiiihers  df 
|iliag(ieytt>s,  large  and  snuill,  are  to  be  .«eeii,  some  of  the  lai/er  heing  ne- 
enitie.  The  liver  is  swollen  and  turhid.  In  very  acute  cases  there  is  nut 
iieecs.-^arily  any  niaeroscopie  jiigmontation,  though  mierosco[)ically  the 
eiiliillaries  may  ho  stuired  with  pliagocytes,  which  may  almost  occlude 
the  vessels.  Parasites  may  he  present  in  considerahle  numhers,  usually 
within  the  red  cdrpiiscl".  Areas  of  (lis,seminated  jiecrosis  (ddf-ely  similar 
t(i  thdse  iihserved  in  ty])hoid  fever,  diplitlieria,  and  other  acute  infectidus 
(iiseases,  have  heen  deserihed  hy  (iuarnit''re,  !>igiiami,  and  Parker.*  In 
assiieiatinii  with  tliese  areas,  Parker  describes  capillary  thrombosis.  Peri- 
vaseiilar  (portal)  inlillration  has  been  found  in  a  very  acute  case  in  a 
vdiing  man  (Ooek).  'i'iie  i)rain  usually  .shows  in;erestiiijr  changes.  In 
.M'V(  re  eases  of  some  duration  the  tissue  is  stained,  sonu'times  ehoeolate- 
(•(ildi'eil.  Ill  uiild  eases  the  discobn'ation  'is  present,  l)ut  less  markeil. 
The  lilddd-vessels,  especially  the  arterioles  and  capillaries,  contain  larg( 
iiiiinhers  df  parasites,  with  j)artial  or  total  destruction  of  re(l  Idodd-cor- 
|iusele-.  and  phagocytes.  Occlusions  of  arterioles  by  means  of  parasites 
lire  often  seen,  together  with  j)erivaseular  infection  and  punctate  liu'iiuir- 
liiages.  In  .soim^  instances  changes  of  this  sort  occurring  in  special  areas 
liavi'  giv(>:;  ri.se  to  I'oeal  symptoms.  Amemia  and  ledeimi  are  commoner 
than  e(iiiL;i'sti  ,,!.     The  kidneys  show  atudogous  condition.s. 

111  Sdui"  acute  ])ernicious  cases  witli  choleraic  symptoms,  the  capillaries 
(if  the  i.!-!  •■o-i-     stinal  mueo.sa  may  be  stulTed  with  parasites. 

'.aiarioi  Cachexia. — A  patient,  the  subject  of  clironie  paludism, 
11^  i.  .  dies  of  aiuemia  or  of  luvmorrliagc  associated  with  it.     The  most 


i'      \   !W 

?'     '■•'■:■■! 


m 


ilo'.i 
f'l 


f  s 


rli 


.ST 


-m 


m « 


*  Morliid  Anatomy  of  Miliaria,  J.  If.  If.  RcportH,  vol.  v. 


■]'  'I- 


1^-4., 


3. 


102 


SPKriFK"   IXKKf'TIOUS   DISKASIX 


clianuitorist'K!  onsos  of  the  kiml  wliicli  Imvc  ("itnc  iiiulcr  niy  obsorviitinn 
Imvo  liccii  ill  the  wnrknit'ii  n'tiiriiin<(  fraiii  llic  I'liiKmia  ( 'aiiiil,  victims  nf 
tlif  S(i-ciill('(l  ( 'liiiirrt's  fever. 

'Pile  imieiiii:!  is  iirol'diiiu],  piirticiiliirly  if  tlie  piifieiit  liiis  dieil  of  fe\ir. 
TIk^  s|)leeii  is  ;:reat,ly  eiilari,'e(l,  and  may  wcii:li  fi'om  seven  to  ten  pounds. 
If  the  disease  lias  persisted  for  any  !en;,rtli  of  time,  it  is  linn  and  resists 
eiittinj^.  The  eapsiiie  is  t iiiid<eiied,  th"  pareiiidiyiiia  lirowiiisii  or  \il- 
lowish-lirouii,  with  areas  of  piL,Miienlation,  or  in  very  pi'otraeted  cases 
it  is  extremely  nielaiiosed,  partimlai'ly  in  the  trabeciila'  and  about  the 
vess(<ls. 

Tho  liver  may  be  ;j:reatly  eiilarired  ;  lnil,  as  a  rule,  the  increase  in  >izc 
is  nidderate  in  proportion  to  that  of  the  spleen.  It  may  present  to  \\\v 
naki'd  eve  a  j^'rayish-brown  or  slate  color  due  to  the  lar^'e  amount  of  pi^r- 


ment. 


in  tile  portal  canals  and  beneath  tlu-  capsule  the  conneciivc 
tissue  is  impreLriiated  with  melanin.  N'aryin;^  with  the  duration  cd'  tlir 
disease,  the  .shade  of  color  (d'  the  liver  ran^rcs  from  a  iijiht  frray  to  a  dicp 
Hhite-;;ray  tint.     The  texture  is  lirm,  but  there  is  not  iieces.sarily  any  trieut 


increase  in  the  connective  tissue. 


Ifistol 


oiTically,  the  piirment  is  .seen  in 


the  Kuplfcr's  cells  and  the  perivascular  tissue 


The  k 


iiliieys  may  lie  enlar^red  and  present  a  grayish  red  color,  or  artus 


of  pij,'mentatioii  may  ite  seen.      1  lu-  pigment  may  lie  ditiii.soly  .seattci 
and    particularly  marked    about    the    blood-vessids    ami    the    Malpi< 


IllMIl 


ixidie.s,  or  it  is  often  abundant  in  the  cells  of  the  (^involuted  and  eoUectiiiL' 
tul)ules.  The  peritoiueum  is  usually  of  a  deep  slat(>-eolor.  The  nuicnu. 
ineinliraiic  of  tlic  stomach  and  intestines  may  have  the  same  hue,  due  [<> 
the  pijiiiieiit  in  and  about  the  blood-vessels.  In  some  cases  this  is conliiifil 
to  the  lymph  nodules  (d'  I'eyer's  pat(dies,  causing  the  shaven-beard  aj^piar- 
ancc. 

(;i)  The  Accidental  and  Late  Lesions  of  Malarial  Fever. 

{it)  Till'  LIrrr. —  Pallidal  hepatitis  jilays  u  very  important  ri'ilc  in  tin 
lii.story  of  malaria,  as  descrilied  by  I'Vemdi  writers.  Kelscdi  and  Kiriiir 
devote  over  sixty  pages  to  a  descri]>tioii  of  the  various  forms,  parencliym- 
iitous  and  interstitial,  de.soriidiig  under  the  latter  uiree  <IilTeront  varie- 
ties. The  perusal  of  this  .section  (d'  their  work  by  no  means  carries  ceii- 
vietion  that  all  the  f<irms  whi(di  thoy  describe  are  associated  deliniicjv 
with  malaria.  .Many  of  the  patients  were  the  subjeets  of  chronic  alcolml- 
ism,  and  the  most  important  diagnostic  point  upon  wliiidi  they  .seem  t" 
have  iilaceii  reliance  was  iiiehuiosis  of  the  s[)leen,  sometimes  with  pi^'- 
mentation  of  (ilisson's  sheath.  Tlie  existence  of  a  cirrhosis  deju'iidciit 
npon  tlw  irritation  of  large  ([Uiintities  of  pigment  in  the  liver  is  uiiMno- 
tioned,  Im',  only  those  ca.^i.^  \\\  which  the  history  of  chronic  nialaii;i  i- 
definite,  and  in  which  the  iiielaiK.ois  of  both  liver  and  spleen  coe\i>t. 
ijlioiild  be  regarded  as  of  pahuiul  origin.  The  afTection  in  this  country  i- 
of  extraorilinary  rarity.  In  the  post-inorteni  room  of  the  IMiiladelpliia 
Hospital    1    have   frequently  Sfen.  in   subjects  in   whom  tlu>  spleen  »:l" 


MALAUIAL   IM'AKIl. 


io;5 


,l,,(,ply  jiliiincntod,  tlie  portui  slicatlis  (-f  the  liver  stained,  ami  u  A'v^hl 
iiiriviisi'  II'  tl't'  t'(iiiii('i'tiv('  tissue;  hut  il  is  iiei.f^iii;^f  tiie  i|nesli()ii  ti>  say 
that  ill  .>ii'li  liiitieiils,  wild  have  almost  cerlaiiily  lieeii  liaititiial  (•(•iismiiers 
iif  li;i(l  wlii^ky,  the  eomlitinii  of  ilie  liver  Was  (liio  to  malaria.  No  instance 
,,f  iiKilaii  il  cirrhosis  has  iieeii  shown  at  the  I'liilaili'lphia  l'atholoi;ieal 
Sofii'tv  .-iiieo  its  roiindation.  Wi'lch  tells  me  lie  knows  of  hiil  one  speci- 
iiM>ii  wlii'li  liiis  been  shown  in  New  York,  and  that  was  from  an  Alt^erian. 

(//I  I'm  iniKiiiia  is  helieved  by  many  authors  to  1k^  common  in  malaria, 
and  cvcii  i'l  depeiiil  directly  ii|ion  the  malarial  poison,  (.cciirriii;^'  either  in 
ill,,  ai'iiir  111'  in  the  chronic  forms  of  tlu'  disetise.  1  have  no  |iersonal 
knmvlcili;!'  of  such  a  special  |meiimonia.  It  certainly  di'cs  nn|  (  ccur  m 
till'  iiiici  iiiittent  or  remittent  fevers  which  prevail  in  I'hiladelphia  and 
lialtiiiiorc.  The  two  diseases  may  lie  conciirreni.  Inllamiiiation  of  ihe 
Imiirs  iiiav  ilcvi'lop  diirinn'  a  siiii[ile  inlei'inilteiil,  and  the  i|iiiiiine  may 
liitrk  the  chills  without  inlliieiicinir  in  any  way  the  pneumonia.  There 
wi'iv  tun  cases  amonjf  the  til'i  analy/e(l  hy  Thayer  and  llewcts(ui. 

(( )  \</i/iri/is. — Acute  inllammalion  of  the  kidneys  is  rai'e  in  the 
liif  iiiililiT  rnriiis.  Alimmin  in  the  urine  is  not  infrc'iiieiit  diiiiii'.''  the  chill, 
aii'l  ill  the  course  of  the  contiiiiU'd  or  reiniltenl  fevers.  Kelsch  and 
KJi'iier  descrilu!  several  forms  of  nephritis.  No  instance  of  chi'onic 
I'liiirlil's  di.soast'  resiiltin;;'  directly  from  palndisin  has  come  uiuler  my 
iii'ticc. 

Clinical  Forms  of  Malarial  Fever.  ( i )  The  Regularly  Inter- 
mittent Fevers.— ('/)  Tertian  ft^ver;  (//)  (|Uarlan  fever.  These  foi'i, is  are 
iiiiaririi/.cd  l)y  recurrinj,'  paroxysms  of  what  arc  known  as  auiie,  in 
uiiii'li.  as  a  rule,  chili,  fever,  and  sweat  follow  each  other  in  ordci'ly 
■  'iiiciice.  The  sta.LTe  of  i iiriiliiilion  is  not  delinilely  known  :  it  probably 
rir-  iiiiirh  accordiiiii'  to  the  amoiiul  of  the  infectious  nuilcrial  absorlied. 
i.\lii'riuieiitally  the  period  of  incMliati(Ui  varies  frcuii  six  to  llftetn  days, 
'iiiiiLT  a  Irille  loii^'cr  in  (piartaii  than  in  tertian  infectious,  .\ttacl\s  have 
■rii  reported  within  a  very  short  time  after  the  ajiparcnt  e\|)osiiri'.  On 
till'  other  hand,  tlu'  ayue  may  be,  as  is  ,siid,  "  in  the  .>ysleni,"  and  the 
patient  may  have  a  paroxysm  months  after  he  has  removed  from  a  mala- 
n;il  re^non,  thoujjfli  I  doubt  if  this  can  ne  theca.se  unless  he  has  hail  the 
ili-rase  when  livini:  there. 

It'sirl/i/liui  (if  Ihi'  /\n'(i.ri/sni. — 'i'lie  patient  jreiierally  knows  he  is 
.''liii;:  to  have  a  chill  a  fc.  hours  before  its  advent  liy  iiupleasaiit  feeliii;;s 
Ml]  iiiuMsy  sensations,  sometimes  by  headache.  The  paroxysm  is  dividdl 
into  three  sta^'(.\s — cold,  heat,  and  sweat in<r. 

Colli  S/{i(/i'. — The  oii.set  is  indicated  by  a  feelini:  of  lassitude  and  a 
lioirc  to  yawn  and  stretch,  by  headache,  uneasy  sen.satious  in  the  epi;.''as- 
'riiiiii,  soiiu'times  by  nausea  ami  voinitiiijf.  Kven  before  Ihe  chill  begins 
the  tlierimimeter  indicates  sli<fht  rise  ii.  temp"rature.  (Iradually  the  pa- 
th ut  licLrins  to  shiver,  (ho  face  looks  cold,  and  in  the  fully  developed  riiror 
!!ii' whiilo  body  shakes,  tho  teeth  chatter,  and  the  inovonicn^".  may  often 


Willi    :.:■■;;>  Y 


li  I;' 


^^«"!5a, 

V..-IJI 
'.  ■■  't'Fk. 


1<!I 


SPECIFIC  INFECTIOUS  DISEASES. 


i:^^ 


• 


MALAIJIAL   FKVKR. 


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lOG 


Sl'KCinc   INKKCTIUUS    DISKASKS. 


lu-  viiilclit  cinii!;,'!!  to  sliiikc  till'  licil.  Not  only  (Iocs  till'  |t;iticiit  look  .(iM 
mitl  i)liu',  but  !i  siirfiicc  tlicriiioinclcr  will  indiciitc  a  ri'ihiction  nf  the  -kin 
tciMiK'nitiirc.  <Mi  till'  oilier  iKimi,  tlir  nxillarv  or  rt'cinl  lrm|Mialiirc  m.iy, 
during'  the  chill,  he  ;,'ri'atl_v  iiicn-asfil,  ami,  as  shown  in  the  rliarl.  iln' 
ffvcr  iiiav  rise  diiriiiL'  thi'  rhill  to  In.'t '  ur  1(1(1'.  Of  syiiiptoniH  associatol 
with  the  chill,  nausea  and  vomiting;  arc  coninioii.  Thert'  may  he  iiilciisc 
headaehe.  The  pulse  is  (|iiiek,  small,  and  hard.  The  urine  is  inereasnl 
in  (|iiaiitity.  'I'he  chill  lusts  for  a  variahle  time,  from  ten  or  twolvc  iiiin- 
litis  to  an  hour,  or  even  hniirer. 

'I'hc  //'//  shKjf  is  iishereil  in  hy  tran.-ieiit  Hushes  of  heat  ;  ^fradiially  the 
coldne.s.s  <d'  the  siirf.ice  disapiiears  and  the  skin  lu'comcs  inteii.scly  li,,i, 
The  contract,  in  the  |ialient's  a|)|iearanec  is  slrikinj; :  the  face  is  iliislu'ij, 
the  hands  arc  coiijfcstcd,  the  skin  reildeiicd,  the  pnlsc  is  full  and  hound- 
in;,',  the  heart's  aetioii  is  foreililc,  and  the  patient  may  complain  of  ;i 
throlihiii;.,'  headaehe.  The  rectal  temperature  may  not  ini'rea>e  niiieh  diir- 
in^  this  staj^e ;  in  fact,  hy  the  terminalinii  df  the  chill  the  fever  may  li;i\t 
reaclii'tl  its  maxiiiiiim.  Tlie  diiratinii  df  the  hot  sta.irc  varies  from  half  iii; 
hour  to  tlirei  or  four  hours.  'I'he  patient  is  intcnsi-lv  thirsty  and  drink- 
eagerly  of  cold  water. 

Si"t'ii/itii/  Sffif/c. — lieads  of  perspiration  appear  upon  the  face  iiii'l 
gradually  (he  entire  iiody  is  hathetl  in  a  ciipious  sweat.  The  iiiicdiiif'ir'- 
ahle  feeling  associatcil  with  the  fever  di.sappeur.s,  the  headache  is  relievni. 
and  within  an  hour  or  two  the  paroxysm  is  ovt-r  and  the  patient  iisii:ill\ 
.sinks  into  a  refreshing:  sleep.  The  sweating'  varies  much.  It  may  li^ 
(IreiiehiiiL:  in  charaeicr  or  ii  may  he  sli;,dit. 

('hail  X  is  a  fiu;  simile  of  a  ward  temperat lire  chart  in  <a  ca-r  nf 
tertian  aL,nic.  'I'lie  duration  of  the  paroxysms  on  l''chriiary  1st,  IM.  iiii'l 
Atli  was  from  twelve  to  si.xteen  hours,  t^iiiiiiiic  in  l\yo-^iain  dose-  wa- 
given  on  the  .")tli  and  was  Millicienf  t<t  prevent  tlu'  on-coiniiii:  paro\\>iii- 
on  the  'ill.  lliniii;|i  the  temperature  ruse  to  KKt-')".  The  small  iloses.  huu- 
ever.  Were  not  (dTcctive,  and  on  ihc  '.Mh  he  had  a  severe  chill. 

The  total  duration  of  tlu-  paroxysm  averaires  from  ten  to  I 
hours,  hut  may  he  sh(trter.  X'ariatioiis  in  the  paroxysm  are  coiiiiiiun 
Thus  the  patient  may,  instead  of  a  chill,  experience  only  a  >IiL:lit  I'n  tin.' 
of  coldness.  The  most  common  viiriatioii  is  the  o(!Curreiu'e  of  a  hot  .--I:!;;' 
alone,  or  wiih  very  sli<,'ht  sweatin^j^.  DiiriiiL,'  the  paroxysm  tln'  sph 
enlarged  and  the  edtje  can  usually  h((  felt  helow  the  costal  margin,  hi 
the  interval  or  intermission  of  the  paro.xysm  the  })atieiit  feels  very  wrIL 


\\v\\r 


Cli    1- 


and,  unless  llie  disease  is  niiiisually  severe,  he  is  ahle  to  he  up 


Urol 


icllll!- 
icllllv 


is  a  commoii   svmploin.      IIer[)es,  usually  laliial,  is  perhaps  us  freip 
.seen  in  a^nie  as  in  pneumonia. 

7'i/f)i's  (if  Ihc  /tc(/iilin/i/  liifcniiitlrnf  /'V/vr.v.  -  .\s  has  been  staii'd  in 
the  description  of  tlu'  parasites,  two  distinct  types  of  the  regnlaily  nitii- 
mitteiit  fevers  have  been  separated.  These  are  ((^)  tertian  fever  ami  (''i 
(piurtun  fever. 


MM,  \  IMA  I,    I'KVKK. 


in 


(i/)  T' I  linn  IVrrr.  'I'liis  t\|M'  of  U'wv  (Ic|)(m1(Is  ii|inii  tin-  pi-cscnrT  in 
ll,,.  MiiimI  nf  tlir  liTtiiiii  |iiinisilt',  111)  or.i:;iiiisiii  wliicli,  as  >tiit(il  iilxivc.  is 
ihiiiillv  iin-ciit  ill  sliarplv  flt'liiu'il  jjnitips,  wlmsc  cycle  of  ilcvcl«i|im('iil 
|.,,t:.  ji|i|iin\im!iti'iy  f'orty-ciirlit  lidiirs,  s|inniliilinii  urciiniiii.'  every  tliii'd 
ii;iv.  Ill  iiirt'cli'iii.-j  with  line  irr(iii|i  of  (lie  tertian  parasite  tlie  panixvsins 
i„-,iir  sviiclii'i'iiDiisly  with  sporiilalinn  al  I'einarkalily  rei,nilar  intervals  uf 
jilioiit  i'eilv-ei;.'lil  lionrs,  e\ery  tliinl  day  lieiice  the  name  ti  rlinn.  N'ei'y 
i(iiiiiii(piil\.  however,  there  may  lie  two  ;:i'uiips  of  para>iles  wliieh  reach 
iiiatiiritv  I'll  alternate  ilays,  ri'siiliiiiLr  Miiis  in  daily  {t/mi/ii/inn)  parowsms 
^ilmilili  lifHini  inf'i'rtiiin.  (Quotidian  fever,  depeiidiiiij  upon  doid)le  ter- 
!i;iii  infection,  is  the  most  frcipient  t\pein  tiie  acute  iiitcriiiitlent  fc\ers 
ill  this  latitude. 

(//)  Uinir/nn  /'rm: — 'I'liis  type  of  fever  depends  upon  infection  witli 
the  i|ii;Mlaii  parasite,  an  oi-L'^iiiiisin  which  oi'curs  in  well-dcliiie(|  ^j-roups, 
\\|iii«c  cycle  of  existence  last s  ahoiil  seventy-two  hours.  In  inl'cction  with 
,,iu' ^.Tniip  of  parusiles  the  paroxysm  oi'dirs  every  fourth  day;  hence  the 
tiriii  7'""'/"".  At  times,  however,  two  irroiips  of  ijie  parasites  inav  lie 
|ircsc'iit ;  uiuler  these  circuinstanees  paroxysms  occur  on  two  successive 
(liivs,  wiili    a  (lav  (»f    intermission    followiii"-.      In    infection   with    three 


:;niiiiis  e 


irasites  there  arc 


dail 


c  (lailv  |iarox\sins. 


Tliiis  a  ipiotidian    intermittent    fever  may   In'   i\u['   to   infection  will 
ritluT  the  ti-rlian  or  (piartan  parasites. 

('ii)irxc  III'  till'  IHsrnsr.-    After  a  few   paroxysms,  or  after   ll 

■  i>led  for  ten  davs  or  two  weeks,  the   patient  iiiav  'jet  well  witiioiii, 


le    disease 


IMT 


,IIlV 


spi'iial   ineilication.      In  ca.-"es   in  wIThdi  we    ha\i'   iiecn    -tiidyiiiL''   thi 
iiiiiiatdzoa    I  have    repeatedly   known    the    chills   to  stop  spontaneously, 


Siii'li  cases,  however,  ai'c   verv    lialile   t 


o   rcciirreiice 


•rsistcliee    of    1 1 


f. 


\rr  leads  to  aiui'inia  and  ha'inatoi'enous  jaundice,  owin^^  to  the  destriii 


Hull    et    the 
II'IIV    1)1 


red    hlooddisks   by  the   parasiies.      riiiinalely  the  condition 


ii'coiiK'  eiironie,   and    will    he  descrihcd    under    malaiial    caeliexia. 
Tile  ivirularly   intermittent    fevers   \ield    promptly  and    iiiimediately  to 
ii'iitiiiiiii  hy  cpiinine. 
r.M  The  more  Irregular,  Remittent,  or  Continued  Fevers.    iEstivo- 

ailttimiial  Fever. — Tins  type  of  fever  oci'urs  in  temperate  climates. 
'iiirlly  III  till'  later  summer  and  fall:  hence  the  term  ^i^iveii  to  it  liy 
M;iiv|iia|'ava  and  Celli,  irslirn-inilinnnnl firrr.  The  severer  forms  of  it 
jHvviiil  in  the  Southern  States  and  in  tropical  countries,  where  it  i< 
kiiHAii  v\\\v[\\  w^  hilidiis  ri'iiiillrnl  frnr.  The  entire  i;ioiip  of  cases  iii- 
'lii'li'il  under  the  terms  mnilhiil  I'i'i'it  liiliniis  mniltml,  and  lif/ilio- 
I'liiliin'iil  I'rrrrs  reipiires  to  he  studied  anew. 

This  type  of  fever  is  ussociuted  with  the  presence  in  the  iilood  of  the 
i-tivd-autiunnal  parasite,  an  orjji.nisn.  liie  leii<j;tli  of  the  cycle  of  devtdop- 
iiKii!  of  which  is  proliahly  suhji-t  to  variations,  while  the  existence  of 
'iii'!ii|ile  Lrroiips  of  the  parasite,  or  i!ie  ;ib.-:eiiee  vif  arrangement  into  deti- 
'ii'i';.'roiips,  is  Mot  infre(pienl. 
13 


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Photographic 

Sciences 

Corporation 


33  WEST  MAIN  STREET 

WEBSTER,  NY.  14580 

;71«)  872-4503 


0 


C/.X 


168 


SPECIFIC  INFECTIOUS  DISEASES. 


The  symptomfi  are  therefore,  as  niiglit  ])e  cxjiected,  often  irregular. 
In  some  instances  there  may  be  regular  intermittent  fever  occurring  at 
uncertain  intervals  of  from  twenty-four  to  forty-eiglit  hours,  or  even 
more.  In  the  cases  with  longer  remissions  the  paroxysms  are  longer. 
Some  of  the  (luotidian  intermittent  cases  may  clo.sely  resemble  the  qufitid- 
ian  fever  clei)encling  upon  double  tertian  or  triple  quartan  infection. 
Commonly,  however,  the  paroxysms  show  material  dilferences ;  tlioir 
length  averages  over  twenty  hours,  instead  of  from  ten  or  twelve  ;  the  onset 
occurs  often  without  chills  and  even  without  chilly  sensations.  The  rise 
in  temi)erature  is  frequently  gradual  and  slow,  instead  of  sudden,  wliile 
the  fall  nuiy  occur  by  lysis  instead  of  by  crisis.  Tliere  is  a  marked  tend- 
ency toward  anticipation  in  the  paroxysms,  while  frequently,  from  the 
anticipation  of  one  paroxysm  or  the  retardation  of  another,  more  or  l^■^■; 
continuous  fever  may  result.  Sometimes  th(!re  is  continuous  fever  with- 
out sharp  paroxysms.  In  the.se  cases  of  continuous  and  remittent  fever 
the  j)atient,  seen  fairly  early  in  the  disease,  has  a  flushed  face  and  looks 
ill.  The  tongue  is  furred,  the  pulse  is  full  and  bounding,  but  rarely 
dicrotic.  The  temperature  may  range  from  105i°  to  103°,  or  is  in  suiiie 
instances  higher.  The  general  appearance  of  the  patient  is  strongly  m'^- 
gestive  of  typhoid  fever — a  suggestion  still  further  borne  out  by  the  oxi.-t- 
ence  of  acute  splenic  enlargement  of  moderate  grade.  As  in  intermittent 
fever,  an  initial  bronchitis  may  be  present.  The  course  of  these  cases  is 
variable.  The  fever  may  be  continuous,  with  remissions  more  or  less 
marked ;  definite  paroxysms  with  or  without  chills  may  occur,  m  which 
the  temperature  rises  to  105°  or  100°.  Intestinal  symptoms  are  usually 
absent.  A  slight  ha.>matogenous  jaundice  may  develop  early.  Delirium 
of  a  iuild  type  may  occur.  The  cases  vary  very  greatly  in  severity.  In 
some  the  fever  subsides  at  the  end  of  tlie  week,  and  the  practitioner  is  in 
doubt  whether  he  has  had  to  do  with  a  mild  typhoid  or  a  simple  febric- 
ula.  In  other  instances  the  fever  persists  for  from  ten  days  to  two  weeks; 
there  are  marked  remissions,  perhaps  chills,  with  a  furred  tongue  aiii 
low  delirium.  Jaundice  is  not  infrequent.  These  are  the  cases  to  wliieh 
the  term  bilious  remilte)it  and  typho-mahtrial  fevers  are  applied.  In 
other  instances  the  symptoms  become  grave  iind  assume  a  character  of  the 
pernicious  type.  It  is  in  this  form  of  malarial  fever  that  so  mucii  con- 
fusion still  exists.  The  similarity  of  the  cases  to  typhoid  fever  is  most 
striking,  more  particiUarly  the  appearance  of  the  facies,  and  the  patient 
lookx  very  ill.  The  cases  develop,  too,  in  the  autumn,  at  the  very  tiino 
when  typhoid  fever  occurs.  The  fever  yields,  as  a  rule,  promptly  to  qui- 
nine, though  here  and  there  cases  are  met  with — rarely  indeed  in  my 
experience — in  which  they  are  refractory.  It  is  just  in  this  group  that  tlio 
observations  of  Laveran  will  bo  found  of  the  greatest  value.  Several 
of  the  charts  in  Thayer  and  Ilewetson's  report  show  how  closely,  in  some 
instances,  the  disease  may  simulate  typhoid  fever. 

The  diagnosis  of  malarial  remittent  fever  may  be  definitely  made  by 


MALARIAL  FEVER. 


169 


the  examination  of  the  blood.  The  small,  actively  motile,  hyaline  forms 
of  till'  ii'sti\o-autumniil  parasite  are  to  be  fouiul,  while,  if  the  case  has 
li'..st(.'(l  over  a  week,  the  larger  crescentic  and  ovoid  bodies  are  usually  seen. 
Viiiulvke  Carter,  in  his  monograph,  alludes  to  tlie  value  of  this  metliod  in 
the  fevers  of  India.  In  many  cases  here  we  are  at  first  unable  to  distin- 
iruish  l)itwoen  typhoid  and  continued  malarial  fever  without  a  blood  cx- 
iiniination.  A  more  wide-s})read  use  of  this  means  of  diagnosis  will 
eiiiiblc  lis  to  bring  some  order  out  of  the  confusion  which  exists  in  the 
classifiratiou  of  the  fevers  of  the  South.  At  present  the  following  febrile 
alToctioiis  are  recognized  by  various  physicians  as  occurring  in  the  sub- 
tropical regions  of  this  continent:  (a)  Typhoid  fever;  {b)  typho-malarial 
fever— a  typhoid  modified  by  malarial  infection,  or  the  result  of  a  com- 
bined infection  ;  (c)  the  malarial  remittent  fever ;  and  {d)  continued 
thermic  fever  (Guiteras).  In  these  various  forms,  all  of  which  mjiy  be 
characterized  l»y  a  continued  pyrexia  with  remissions  or  with  chills  and 
sweats  (for  we  nnut  remember  that  chills  and  sweats  in  typhoid  fever  are 
by  no  means  rare),  the  blood  examination  will  enable  us  to  discover  those 
which  de)tend  upon  the  malarial  poison.  In  many  of  these  cases  of  con- 
tinued or  remittent  fever  careful  incpury  will  show  that  at  the  beginning 
the  patient  had  several  intermittent  jiaroxysms.  In  this  latitude  we  have 
not  the  opportunity  of  seeing  many  of  the  protracted  and  severe  cases, 
but  I  am  inclined  to  think  that  future  observations  will  siiow  that,  apart 
from  the  thermic  fever,  there  are  only  two  forms  of  these  continued  fevers 
in  the  South— the  one  due  to  the  fypltoid  and  the  other  to  the  malarial 
infi'etion.  The  typhoid  fever  of  Philadelphia  and  Baltimore  presents  no 
cssfutial  (lifTei'e)ice  from  the  disease  as  it  occurs  in  Montreal,  a  city  prac- 
tically free  from  malaria.  Dock  has  shown  conclusively  tliat  cases  diag- 
iioseil  in  Texas  as  continued  malarial  fever  were  really  true  tj'phoid. 

Pernicious  Malarial  Fever. — This  is  fortunately  rare  in  temperate  cli- 
mates, and  the  number  of  cases  which  now  occur,  for  example,  in  Phila- 
ilclphia  and  Haltimore,  is  very  much  less  than  thirty  or  forty  years  ago. 
Among  the  cases  of  malaria  which  have  been  under  observation  during 
the  past  five  j'ears  there  were  only  three  of  the  jjernicious  form.  Per- 
nicious fever  is  idways  associated  with  the  testivo-autumnal  parasite.  The 
folkiwing  are  the  most  im})ortant  types : 

{(()  Tlie  comatose  form,  in  which  a  patient  is  struck  down  with  symp- 
toms of  the  most  intense  cerebral  disturbance,  either  acute  delirium  or, 
more  frequently,  a  rapidly  developing  coma.  A  cliill  may  or  may  not 
precede  the  attack.  The  fever  is  usually  hij^h,  and  the  skin  hot  and  dry. 
The  unconsciousness  may  persist  for  from  twelve  to  twenty-four  hours,  or 
the  patient  may  sink  and  die.  After  regaining  consciousness  a  second 
attack  may  come  on  and  prove  fatal.  In  these  instances,  as  has  been 
stated,  the  special  localization  of  the  infection  is  iii  the  brain,  where 
iictual  thrombi  of  parasites  with  nuirked  secondary  changes  in  the  sur- 
rounding tissues  have  been  found. 


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SPECIFIC   INFECTIOUS   DISEASES. 


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{//)  Al (I id  Form. — In  tliis,  the  iittfick  sctn  in  usuiilly  witli  gastric  .symji- 
toms  ;  there  are  voniitiiij^,  inti'iise  prostration,  and  fccljU'iicss  out  of  ;i!l 
proportion  to  tho  loi-al  symptoms.  The  put-ii-nt  complains  of  feeling,'  ((jIiI, 
altliough  there  may  be  no  actual  chill,  'i'he  tem])erature  may  be  normal, 
or  oxi'W  subnormal  ;  consciousness  may  lie  retaini'd.  The  pulse  is  IVcbli 
and  snudl,  and  the  respirations  are  increased.  There  may  be  most  seveiv 
diarrlnea,  the  attack  assuming  a  cholcriforni  nature.  The  urine  is  (tftcii 
diminished,  or  even  sup]ircsscd.  This  condition  may  persist  wilh  slii:Ii: 
exacerbations  of  fever  for  several  days  and  the  ])atient  may  die  in  a  coiuli- 
tioti  of  profound  asthenia.  This  is  essentially  the  same  as  descriln'il  ;i~ 
the  asilivnic  or  adi/iiainin  form  of  the  di.'-ease.  In  the  cases  with  voniitiii;' 
and  diarrluea,  Marchiafava  has  shown  that  the  gastro-intestinal  mucn-aj- 
oftsn  the  seat  of  a  special  invasion  by  the  parasites,  actual  thromlxiHs  (.f 
the  small  vessels  with  superficial  ulceration  and  necrosis  occurring.  Simi- 
lar  lesions  were  found  by  Barker  in  the  gastro-intestinal  tract  of  a  casi' 
from  my  wards. 

(r)  Hcemorrliagic  Fonns. — In  all  the  severe  types  of  malarial  iulVr- 
tion,  especially  if  jiersi.-tent,  luemorrhage  may  occur  from  the  niucm;; 
mendiranes.  An  important  form  is  the  malarial  haniuttnria.,  which  in 
some  instances  assumes  a  very  nudignant  type.  Paroxysms  of  ague  iiiav 
precede  the  attack,  but  in  many  cases  called  malarial  luvmatni'ia  tlnivi- 
no  febrile  paroxysm.  The  condition  is  usually  luvmoglobinuria,  \\w\v;\. 
blood-cor])usclcs  are  present  also.  In  severe  cases  there  is  l)leeding  fnni: 
the  mucous  mendjrancs.  Jaundice  is  present,  but  to  a  variable  extcii', 
and  is  htpnuitogenons,  due  to  tlie  destruction  of  the  red  blood-eorpiiscli-. 
Malarial  luematuria  ( ccurs  in  ejudemic  form  in  many  regions  of  tii- 
Southern  States,  and  in  -ome  seasons  jn'o.ves  very  fatal. 

Many  dilTerent  forms  of  periucious  nudarial  fever— diajdioretic,  syiini- 
pal,  iJuennmnic,  jdenr.tic,  choleraic,  cardiac,  gastric,  and  gangrenous— :ii. 
of  whicli  depend  upon  some  special  symptom,  have  been  described. 

Malarial  Cachexia. — The  symptoms  of  chronic  nudarial  poisoniii'r 
are  very  varied.  It  may  follow  the  frecpient  recurrence  (tf  ordinary  iiitti- 
mittent  fever,  a  common  sequence  in  tins  country.  A  patient  has  eliill- 
for  several  weeks,  is  improp(;rly  or  imperfectly  treated,  and  on  exposure 
the  chills  recur.  This  may  be  repeated  for  several  months  nntil  the  pa- 
tient ])resents  the  two  striking  features  of  malarial  cachexia — natndv, 
niKeinia  iiud  an  cnlcrt/cd  ftptcrn.  Cases  developing  without  chills  nr  \vitli- 
out  febrile  paroxysms  are  almost  unknown  in  this  region.  They  may 
occur,  however,  in  intensely  malarial  districts,  but  in  such  cases  tiiti  pa- 
tients have  fever,  though  chills  may  not  supervene.  The  most  pronoiiuwl 
types  of  malarial  cachexia  which  we  meet  with  here  are  in  sailors  from  tli'  | 
West  Inilics  and  Central  America.  There  is  profound  anaemia;  tlic  lili"'' 
count  nniy  be  as  low  as  one  million  per  cubic  millimetre;  the  skin  lia^'l 
salfron-yellow  or  lemon  tint,  not  often  the  light  yellow  tint  of  pernici* 
ana;mia,  but  a  darker,  dirtier  yellow.     The  spleen  is  greatly  ciihirH' 


MALARIAL  FEVEll. 


171 


firm,  amnuird.  It  rarely  roiiclic,'^  the  dimetisions  of  llie  large  hMik»!iiiic 
(.iL'aii,  I'lir  coiiics  next  to  it  ill  size. 

Tln'  i;ciicr:il  syini)toms  are  those  of  ordinary  annetnia— breathlessness  on 
exertion,  irdonia  of  the  uidiles,  lueniorrhages,  partieidarly  into  the  retina, 
;i<  imtcfl  hy  Stephen  ^laekcnzie.  Occ^asionally  the  bleeding  i.s  severe,  and 
I  liavc  twice  known  fatal  hannateniesis  to  occur  in  association  with  the 
eiiliirircil  spli'cn.  The  fever  is  vai'iable.  The  tetnperatnre  may  hv  low  for 
iliivs,  ii"t  rca<^hing  al)ove '.I'.l'o".  In  other  instances  iIkm'c  may  bo  irreg- 
ular fever,  and  the  temperature  rises  gradually  to  10"^  5°  to  in;}°.  The 
cases  ill  fact,  present  a  ^)icture  of  splenic  ameinia. 

With  careful  treatnu!nt  the  outlook  is  good,  and  a  majority  of  cases 
recover,  'i'lie  sjileon  is  gradually  reduced  in  size,  but  it  may  take  several 
iiiontlis  fir,  indeed,  in  some  insta"  >s,  .several  years  before  the  ague-cake 
entirely  (lisapi)ears. 

Among  the  I'arer  symptoms  which  may  develop  as  a  result  of  ma- 
larial inloxication  may  be  mentioned  p(irttj)I<'(ji(i,  cases  of  which  have 
been  ilescrilx'd  l)y  (iibney,  Suckling,  and  others.  Some  of  the  cases  are 
il(iiil)tfiil,;iiid  have  been  attributed  to  malaria  simply  because  the  paralysis 
was  iiitcrinitteiit.  It  is  a  condition  of  extreme  rarity.  So  ease  is  meii- 
lioiu'il  hy  Kelsch  and  Kiener.  Suckling's  case  had  had  scvera.l  attacks  of 
malaria.  I  lie  last  of  which  i)receded  by  about  two  weeks  the  onset  of  the 
nervoi;s  symptoms,  which  were  lieadaehe,  giddiness,  loss  of  speech,  and 
liara|ili'i:ia.  'I'lie  attack  was  transient,  but  he  had  a  subse(juent  attack 
uiiieh  also  followed  an  ague-tit.  The  jiatient  was  an  old  soldier  who  had 
had  syiiliilis,  a  jwint  which  somewhat  complicated  the  case.  OMiifis  has 
lueii  described  as  developing  in  malaria  by  Charvot  in  Algiers  and  Fedeli 

ill   IlOlllC. 

Diagnosis. — The  blood,  as  one  might  expect,  shows  marked  changes 
111  malarial  fever.  In  Uie  regularly  intermittent  fevers  there  is  a  loss  in  red 
(orimsc'los  after  eacdi  paroxysm,  which  may  be  considerable,  but  which  is 
rapidly  cduipen.sated  during  the  intermissions.  In  ivstivo-autumual  fever 
the  losses  are  oftener  greater  and  more  jiermanent.  In  any  case  of  malariii 
^wiieli  has  existed  for  any  length  of  time  there  is  always  considerable 
iiiueiiiia.  The  luvmogloliin,  as  in  all  secondary  anannias,  is  diminished, 
usually  in  greater  proportion  than  the  corpuscles.  The  leucocytes  an^ 
aliiHist  invariably  diminished  in  numlier  in  malarial  fever.  The  reduc- 
tiuii  is  greatest  just  after  the  paroxysms,  the  number  increasing  slightly 
iittlie  beginning  of  the  febrile  })aroxysm.  The  dilferential  count  shows  a 
relative  diminution  in  ])olynuclear  leucocytes,  with  a  relative  increase  in 
tlilar<,'c'  mononuclear  forms,  exactly  the  same  condition  that  is  seen  in 
tyiihoid  fever.  Sometime^  in  fatal  post-malarial  anannia  the  blood  shows 
iill  the  (diaracteristics  of  true  pernicious  anajinia;  in  other  instances  of 
ftital  anaemia,  where  the  blood  during  life  has  shown  an  absence  of  leuco- 
eytosis,  or  of  nucleated  red  corpuscles,  the  marrow  of  the  long  bones  has 
I  wen  fuund  to  bo  perfectly  yellow,  no  evidence  of  regenerative  activity. 


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SPECIFIC  INFECTIOUS  DISEASES. 


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Tho  (liiigiiosis  of  the  viirioiis  forms  of  nmliiriti  is  usually  casv, 
Tlio  oonliiuu'd  rt'iiiiltfut  and  curtiiiu  of  lliu  pernirious  cases  oH'or  dilli- 
culties,  which,  however,  iiro  now  groiitly  lessened  or  entirely  overcdim. 
since  Lavuran's  researches  have  given  us  a  positive  diagnostic  iiidiciitioii. 
Many  forms  of  intermittent  i)yroxia  are  nustaken  for  malarial  fevur, 
particularly  tho  initial  chills  of  tuberculosis  and  of  septic  infection.  In 
these  instances  the  blood  shows  leucocytosis,  which  is  rare  in  maliuia. 
If  tho  practitioner  will  take  to  heart  the  lesson  that  an  intermittent  fever 
which  resists  quinine  is  not  malarial,  ho  will  avoid  many  errors  in  diag- 
nosis. In  the  so-called  nuisked  intermittent  or  dumb  ague,  the  fi'irik^ 
manifestations  are  more  irregular  and  the  syin[>toms  less  }tron()iinced  ;  but 
occasionally  chills  occur,  and  the  therapeutical  test  usually  removes  evuiy 
doubt  in  the  diagnosis. 

Tho  malarial  poison  is  sujiposcd  to  influence  many  affections  in  a  re- 
markable way,  giving  to  them  a  paroxysmal  character.  A  Avhole  seriisuf 
minor  ailments  and  some  more  severe  ones,  sucsh  as  neuralgia,  tire  attrib- 
uted to  certain  occult  effects  of  paludism.  The  more  closely  such  easo^ 
are  investigated  the  less  definite  appears  tho  connection  with  malaria. 
Practitioners  in  districts  entirely  exempt  from  the  disease  have  to  deal 
with  ailments  which  present  the  same  odd  ])eriodicity,  and  which  the  i)by- 
sicians  of  the  Atlantic  coast  attribute  to  a  "  touch  of  malaria." 

Treatment.— We  do  not  know  as  yet  how  the  poison  reaches  the  sys- 
tem. Infection  seems  most  liable  to  occur  at  night.  In  regions  in  wliidi 
the  disease  jirevails  extensively  the  drinking-water  may  be  boiled,  thougluill 
experimenls  tend  to  show  that  the  virus  does  not  enter  through  the  gastro- 
intestinal tract.  Persons  going  to  a  malarial  region  should  take  abmit 
ten  grains  of  quinine  daily,  though  liichard  found  that  two  or  three  grains 
three  times  a  day  was  a  sufficient  protection  against  the  disease.  During' 
the  paroxysm  the  patient  should,  in  the  cold  stage,  be  Avrapjied  in  blanktt- 
aiid  given  hot  drinks.  The  reactionary  fever  is  rarely  dangerous  even  if 
it  reaches  a  high  grade.  The  body  may,  however,  be  sponged.  In  qu'uiiie 
we  possess  a  specific  remedy  against  malarial  infection.  Experiment  ba- 
shown  that  the  {)arasites  are  most  easily  destroyed  by  quinine  at  the  stage 
when  they  are  free  in  the  circulation — that  is,  during  and  just  after  sporii- 
latiou.  While  in  most  instances  the  parasites  of  the  regularly  intermittent 
fevers  may  be  destroyed,  even  in  the  intra-corpuscular  stage,  in  a?stivo-aii- 
tuninal  fever  this  is  much  more  difficult.  It  should,  then,  be  our  object. 
if  we  wish  to  most  effectually  eradicate  the  infection,  to  have  as  mucli 
quinine  in  circulation  at  the  time  of  the  pai'oxysm  and  shortly  before  as  is 
possible,  for  this  is  the  period  at  which  sporulation  occurs.  In  the  regu- 
larly intermittent  fevers  from  ten  to  thirty  grains  in  divided  doses  througli- 
out  tho  day  will  in  many  instances  prevent  any  fresh  paroxysms.  If  thi' 
patient  comes  under  observation  shortly  before  an  ex])ected  paroxysm,  the 
administration  of  a  good  dose  of  quinine  just  before  its  onset  may  be  mi- 
visable  to  obtain  a  maximum  effect  upon  that  group  of  parasites.    Tin' 


MALARIAL  FEVER. 


173 


(luiniiio  \u]l  not  prevent  the  paroxysm,  but  will  destroy  the  greater  part 
i,f  thf  i^iuiip  of  organisms  ami  prevent  its  further  recurrence.  It  is  safer 
toirivoai  least  twenty  to  thirty  grains  daily  for  the  first  three  days,  and 
tlifU  to  I'tiiitinne  the  remedy  in  smaller  doses  for  the  next  two  or  three 
«,rkH.  In  a'stivo-autumnal  fever  larger  doses  may  bo  necessary,  though 
111  relatively  few  instances  is  it  necessary  to  give  more  than  thirty  to  forty 
irniiii.s  ill  the  twenty-four  hours. 

The  quinine  should  be  ordered  in  solution  or  in  capsules.  The  pills 
ami  compressed  tablets  are  more  uncertain,  as  they  may  not  be  dissolved. 

A  qaestion  of  interest  is  the  efhcient  dose  of  quinirc  necessary  to  cure 
the  (li.^easc.  I  have  a  number  of  charts  .showing  that  grain  doses  three 
limes  a  day  will  in  nuuiy  cases  prevent  the  paroxysm,  but  not  always  with 
the  certainty  of  the  larger  doses.  In  cases  of  tvstivo-autumnal  fever  with 
[ifi'nicious  symptoms  it  is  necessary  to  get  the  system  under  the  iniluence 
iif  (jiiiiiine  as  rapidly  as  possible.  In  these  instances  the  drug  should  be 
mliiiiiiistcred  hypodermically  as  the  bisulphate  in  thirty-grain  doses,  with 
live  grains  of  tartaric  acid,  every  two  or  three  hours.  The  muriate  of 
(|iiiiiiiiu  and  urea  is  also  a  good  form  in  which  to  administer  the  drug  hy- 
podermically;  ten,  fifteen,  or  twenty  grain  doses  may  be  necessary.  In 
the  most  severe  i 'stances  some  observers  advise  the  intravenous  adminis- 
tration of  quinine.  For  extreme  restlessness  in  these  cases  opium  is  indi- 
cated, and  cardiac  ,■  imulants,  such  as  alcohol  and  strychnine,  are  neces- 
jiirv.  If  in  the  comatose  form  the  internal  temperature  is  raised,  the 
Kifieiit  should  be  put  in  a  bath  and  doused  with  cold  water.  For  malarial 
;iii;einia,  iron  and  arsenic  are  indicated. 


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XXIII.    ANTHRAX. 

(Maliffnrnit  Piistiih' ;  S/ili'uif  Fever;  Charhnn  :  Wonf-.tnvfir'.i  Di'smse.) 

Definition. — An  nmtv  iulVrtious  (li>(.'ase  caused  by  the  bacillus  an. 
thrarin,  Ic  is  ti  wide-spreml  alTcL'tion  in  aniniiils,  purticularly  in  s1kh'|)iiiu1 
cattle.  In  man  it  occurs  sporadically  or  as  a  result  of  accidental  aijsur].- 
tion  of  the  virus. 

Etiology. — The  infectious  a<,^:'iit  is  a  non-motile,  rod-shaped  ortrnn- 
isni,  the  Oitcillus  diil/irdri.s,  which  has,  by  the  researches  of  Tollender,  I)ii. 
vaine,  Koch,  and  Pasteur,  become  the  best  known  perliaps  of  all  jiatliu- 
genic  microbes,  'riie  bacillus  has  a  length  of  from  two  to  leu  times  tin.' 
diameter  of  a  red  blood-corpuscle  ;  the  rods  are  often  united.  They  uuil- 
tiply  by  lission  with  great  rapidity  and  grow  with  facility  on  various  cult- 
ure media,  extending  into  long  fihunents  Avhich  interlace  and  ])ro(luco;i 
dense  mycelium.  'I'he  spore  foi-nuitiou  is  seen  with  great  readines.s  in 
these  lilaments.  The  bacilli  themselves  are  readily  dt'stroyed,  but  tin,' 
spores  are  very  resistant,  and  survive  after  ]»rolonged  immersion  in  a  tiw- 
per-cent  solution  of  carbolic  acid,  and  resist  for  some  minutes  a  tempera- 
ture of  '21'^''  Fahr.  They  are  oai)ablc  also  of  resisting  gastric  digestion, 
Outside  the  body  the  spores  are  in  all  probability  very  durable. 

Geographically  and  zoiilogically  the  disease  is  the  most  wide-spread  df 
all  infectious  disorders.  It  is  nnich  more  prevalent  in  Europe  and  in  Asia 
than  in  America.  The  ravages  among  the  herds  of  cattle  in  Russia  and 
Siberia,  and  among  i-dieep  in  certain  ])arts  of  Europe,  are  not  equalleil  liy 
any  other  animal  plague.  In  this  country  the  disease  is  rare.  >So  far  us  I 
know  it  has  never  prevailed  on  the  ranches  in  the  Northwest,  but  cases 
were  not  hifrequeut  about  Montreal. 

A  protective  inoculation  with  a  mitigated  virus  has  been  introduced  h\ 
Pasteur,  and  has  been  adopteil  in  certain  anthrax  regions,  llankiu  has 
isolated  from  the  cultures  an  albunioso  which  renders  aninuds  imunuiL' 
against  the  most  intense  virus. 

In  animals  the  disease  is  conveyed  sometimes  by  direct  inoculation,  a? 
by  the  bites  and  stings  of  insects,  by  feeding  on  carcasses  of  animals  wliich 
have  died  of  the  disease,  but  more  commonly  by  feeding  in  pastures  in 
which  the  germs  have  been  preserved.  Pasteur  believes  that  the  earth- 
worm plays  an  important  part  in  bringing  to  the  surface  and  distributiii;,' 
the  bacilli  which  have  been  propagated  in  the  buried  carcass  of  an  in- 
fected animal.  Certain  fields,  or  even  farms,  may  thus  be  infected  for  an 
indefinite  period  of  time.  It  seems  probable,  however,  that  if  the  carcass 
is  not  opened  or  the  blood  spilt,  spores  are  not  formed  in  the  buried 
animal. 

Animals  vary  in  susceptibility :  herbivora  in  the  highest  degree,  llicn 


t.?;** 


ANTHRAX. 


175 


tlip  omnivKin,  uiid  lastly  the  oarnivoni.  Tlio  dLst'iiso  docs  not  occur  spon- 
tiincoii-lv  ill  nuui,  but  jihvfUrf  rcsult.s  from  infection,  cither  through  tho 
4iii  till'  intestines,  or  in  rure  instances  through  the  lungs.  The  disease 
is  t'dUii'i  ill  persons  whose  oceui)atii)ns  bring  thon  into  contact  with  ani- 
iiiaU  or  animal  products,  as  stablemen,  shepherds,  tanners,  butelu'rs,  and 
ihost'  "Im  work  in  wool  and  liiiir. 

ViiriiMis  forms  of  the  disease  have  been  desciJ)ed,and  two  chief  groups 
iiiav  lir  I'ccogni/A'd  :  the  external  anthrax,  or  malignant,  pustule,  and  the 
iiiifinal  anthrax,  of  which  there  are  pulmonary  and  intestinal  forms. 
Symptoms.— (1)  External  Anthrax. 

{(i)  M(ili(jiinnt  I'uxlii/c. — The  inoculation  is  usually  on  an  exposed 
surface— llui  hands,  arms,  or  face.  At  tho  site  of  inoculation  there  arc, 
wiiliiii  .1  few  hours,  itching  and  uneasiness,  (iradually  a  small  pa|)ide 
Joviliips,  which  becomes  vesicular.  Inllammalory  indural ii'U  extends 
around  ilii ',  and  within  thirty-six  lu)urs,  at  the  site  of  inoculation  there 
isailark  brownish  eschar,  at  a  little  distance  from  which  there  may  be  a 
scrius  of  small  vesicles.  Tho  brawny  iiuluratiou  may  be  extreme.  The 
(idc'iua  produces  very  great  swelling  of  the  parts.  The  inllanunation  ex- 
teiuls  along  the  lymphatics,  and  the  neighboring  lymph-glands  are  swollen 
aiiil  sore.  The  temperature  at  first  rises  rapidly,  and  tlie  fe1)rile  jdu'noni- 
iiiaaii'  marked.  Subserpu'iitly  the  fever  falls,  and  in  many  cases  becomes 
-iiiiiHinnal.  Death  may  take  place  in  from  ihvvc  to  five  days.  In  cases 
wiiirli  recover  the  constitutional  symptoms  ari'  slighter,  the  eschar  gradu- 
iiily  sloughs  out,  and  the  wound  heals.  The  eases  vary  much  in  severity. 
In  ilio  mildest  form  there  may  be  only  slight  swt'lling.  At  the  sito  of  in- 
iH  alaiiou  a  papule  is  formed,  which  ra})idly  becomes  vesicular  and  dries 
iiilo  ii  scab,  which  separates  in  the  course  of  a  few  days. 

(//)  Midignnnt  Anthrax  Oedema. — This  form  occurs  in  the  eyelid,  and 
;i!M)in  the  head,  hand,  and  arm,  and  is  characterized  by  tho  absence  of  the 
liap'.ile  and  vesicle  forms,  and  by  the  most  extensive  (edema,  which  may 
follow  rather  than  precede  tho  constitutional  symptoms.  Tho  u'dema 
reaches  such  a  grade  of  intensity  that  gangrene  results,  and  may  involve  a 
considerable  surface.  Tlie  constitutional  symptoms  then  become  extremely 
grave,  and  the  eases  invariably  prove  fatal. 

In  a  recent  case,  in  a  hair-picker,  thei'e  was  most  extensive  enteritis, 
peritonitis,  and  endocarditis,  which  latter  lesion  has  been  described  by 
Hiipiiitfer. 

A  feature  in  both  these  forms  of  malignant  pustule,  to  which  many 
writers  refer,  is  the  absence  of  feeling  of  distress  or  anxiety  on  the  part  of 
till' patient,  whose  mental  condition  may  be  pcfectly  clear.  lie  may  be 
ivitlioiit  any  apprehejision,  even  though  his  condition  is  very  critical. 

Tlie  diagnosis  in  most  instances  is  readily  made  from  the  character  of 
tlie  lesion  and  the  occupation  of  the  patient.  V/hen  in  doubt,  the  exanii- 
iiatiuu  of  the  tiuid  from  the  pustule  may  show  the  presence  of  the  an- 
tlu'ux  bacilli.    Cultures  should  be  made,  or  a  mouse  or  guinea-pig  iuocu- 


m 


'  i'* 


1  r 


%\ 


vm  i 


!         ^ 


iH.  ^^m 


176 


SPECIFIC  INFECTIOUS   DISEASKS. 


luted.     It  is  to  be  rcmoinbcrod  that  the  blood  may  not  show  the  bacilli  in 
nuiiibcrs  until  shortly  before  death. 
{''i)  Internal  Anthrax. 

((/)  liih'sliitdl  Fiirni,  MijfitsiK  iii/cs/i)ntJin. —  III  these  eases  the  iiifw- 
tion  is  tliritii^di  the  stoniaeh  and  intestines,  and  residts  from  eatiii;;  ihc 
ilesii  or  drinking'  the  milk  of  diseased  animals.  "J'he  8ym])toms  are  \hu<c 
of  intense  poisoning.  The  disease  nmy  set  in  with  a  ehill,  followed  bv 
vomiting',  diarrluea,  moderate  fever,  and  pains  in  the  legs  and  baek.  In 
acute  eases  there  are  dyspniea,  eyanosis,  gri'at  anxiety  and  restles.-iu'ss, 
uml  toward  the  end  eonvulsions  or  sjiasms  of  the  muscles,  ira'morrliii;.^ 
may  occur  from  the  mucous  membranes.  Occasionally  there  are  s(ii;i!l 
l)hiegmon(ius  areas  on  the  skin,  or  pi'techia'  develop.  The  S2»leen  is  on- 
larged.  Tlu!  blood  is  dark  and  renuiins  lluid  for  a  long  time  after  ileatli, 
Late  in  the  disease  the  bacilli  nuiy  be  found  in  the  blood. 

This  is  one  of  the  forms  of  acute  poisoning  which  may  affect  many  in- 
dividuals together.  I'lius  lUitler  and  Karl  Ilnber  describe  an  eiiidonijf 
in  which  twenty-five  persons  Avere  attacked  after  eating  the  flesh  df  an 
aniuud  which  liad  had  anthrax.  Six  died  in  from  forty-eight  hours  to 
seven  days. 

(b)  ]V(iohsoricr\'i  Disensc. — This  important  form  of  anthrax  is  fnninl 
in  the  large  establishments  in  which  wool  or  hair  is  sorted  and  cleuiijuil, 
The  hair  ami  avooI  inij)orted  into  Europe  from  Kussia  and  South  Anicrici 
appear  to  have  induced  the  largest  number  of  cases.  Many  of  these  casis 
show  no  external  h^sion.  The  infection  has  been  swallowed  or  iiilialnl 
with  ust.     There  are  rarely  premonitory  symptoms.     The  patient  is 

sei/.i  ..  a  ehill,  becomes  faint  and  prostiated,  has  pains  in  the  lj;iili 

and  legs,  and  tlie  temperature  rises  to  10".*°  to  103°.  The  breatliiiiir  is 
rapid,  ami  he  complains  of  much  pain'  in  the  chest.  Tlu'rc  may  be 
a  cough  and  signs  of  bronchitis.  So  prominent  in  some  instances  are 
these  bronchial  symptoms  that  a  pulmonary  form  of  the  disease  has  buen 
described.  The  pidso  is  feeble  ami  very  rajiid.  There  may  be  voiiiitini', 
and  death  may  occur  within  twenty-four  hours  with  symptoms  of  pro- 
found collapse  ami  prostration.  Other  cases  are  more  protracted,  and 
there  may  be  diarrhroa,  delirium,  and  unconsciousness.  The  cerebral 
symptoms  may  be  most  intense;  in  at  least  four  cases  the  brain  seems tn 
have  been  chiefly  affected,  and  its  capillaries  stuffed  with  bacilli  (Mer- 
kel).  The  recognition  of  wool-sorter's  disease  as  a  form  of  anthrax  is  due 
to  J.  11.  Bell,  of  Bradford,  England. 

In  certain  instances  these  profound  constitutional  symptoms  of  iiitenial 
anthrax  are  associated  with  the  external  lesions  of  malignant  pustule. 

The  r (t(i -picker'' s  disease  has  been  made  the  subject  of  an  exhaustive 
study  by  Eppinger  {Die  Haderukrankhcit,  Jena,  1894),  who  has  sliuwii 
that  it  is  a  local  anthrax  of  the  lungs  and  pleura,  with  general  infection. 

The  diagnosis  of  internal  anthrax  is  by  no  means  easy,  uidiss  the 
history  points  definitely  to  infection  in  the  occupation  of  the  individual 


vinis,  and  e 


iiYDiioriioniA. 


Treiitment.  —  In  malij,Mi(VTit  jmsttilc  the  sito  of  innoulatioii  .slioiil<l  bo 
il(.,iriivi 'i  liy  llu:  ciuuslic  or  hot  iron,  iiiid  {lowdi'i'cd  hicliloriik-  of  nicrciiry 
ni.iv  111'  >iiriiil<lt'<l  over  tho  exposed  siirfiice.  The  h)cal  devehtpiiieiit  of  the 
bacilli  alioiit  the  site  of  inoculation  may  be  iirevetited  Ity  the  siihcuta- 
uoiius  iiijectioiia  of  .solutions  of  carbolio  acid  or  l)i(dil(iride  of  niereiiry. 
Till' iiijt<'t ions  should  be  made  at  various  points  around  the  pustule,  and 
miivbu  rcpeateil  two  or  three  times  a(hiy.  'I"he  internal  treatment  should 
liccunlhu'd  to  the  administration  of  stimulants  and  ]ilenty  of  nutritions 
fijdd,  l)avies-Collcy  advises  ipeoaeuanlm  powder  iu  doses  of  from  five  to 
ti'ii  "mill-  every  three  or  four  hnnrs. 

In  iii;i!i,i:nant  forms,  particularly  the  intestinal  C'a,-.es,  little  can  be  done. 
Activu  purgatives  may  be  given  at  the  out.set,  .so  as  to  remove  tlie  infect- 
ing nuUt^rial.     Quiniiu!  in  largo  dcses  has  been  recommended. 

XXIV.    HYDROPHOBIA. 

(LysHu;  Itabies.) 

Definition. — An  acute  disease  of  animals,  dependent  upon  a  specific 
virus,  anil  comnninicated  by  inoculation  to  man. 

Etiology.  —  In  man  the  disease  is  very  variously  distributed.  In 
IJiissiii  it  is  common.  In  North  Germany  it  is  extremely  rare,  owing  to  the 
wise  |)ni\  ision  that  all  dogs  shall  be  muzzled  ;  in  Kngland  and  France  it  is 
miicli  more  common.  In  this  country  the  disease  is  very  rare.  Dulles  eould 
oollt'ct  only  78  cases  in  the  five  and  a  half  years  ending  Dec.  31,  1893, 

Canines  are  specially  liable  to  the  disease.  It  is  found  most  frequently 
ill  tliedog,  the  wolf,  and  tho  cat.  All  animals  are,  however,  susceptible; 
;iii(l  it  is  communicable  by  inoculation  to  tho  ox,  horse,  or  pig.  The 
iljjoasc'  is  propagated  chiefly  by  tho  dog,  which  seems  specially  susceptible. 
In  the  Western  States  the  skunk  is  said  to  be  very  liable  to  the  disease. 
The  nature  of  the  poison  is  as  yet  unknown.  It  is  contained  chiefly  in 
the  nervous  system  and  is  met  with  in  the  secretions,  particularly  in  the 
saliva. 

A  variable  time  elapses  between  the  introduction  of  the  virus  and  the 
appearance  of  the  symptoms.  Ilorsley  states  that  this  depeiuls  upon  the 
fallowing  factors  :  "  (a)  Age.  The  incubation  is  shorter  in  children  than 
in  adults.  For  obvious  reasons  the  former  are  more  frequently  attacked. 
(//)  Part  infected.  The  rapidity  of  onset  of  the  symptoms  is  greatly  de- 
torniiiied  by  the  part  of  the  body  which  may  ha})pen  to  have  been  bitten. 
^\  ounds  about  the  face  and  head  are  especially  dangerous ;  next  in  order 
in  degrees  of  mortality  con.e  bites  on  the  hands,  then  injuries  on  the 
other  parts  of  the  body.  This  relative  order  is,  no  doubt,  greatly  de- 
pendent upon  tho  fact  that  the  face,  head,  and  hands  are  usually  naked, 
«'hile  the  other  parts  are  clothed,  (c)  The  ext  nt  and  severity  of  the 
wound.  Puncture  wounds  are  the  most  dangerous;  the  lacerations  are 
fatal  in  proportion  to  the  extent  of  the  surface  afforded  for  absorption  of 


h  ^m 


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1  s 


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h       H 

^m 


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ITS 


SPKriPIC   INKEf'TIOUS  DISEASES. 


tiic  virus.  {(I)  'I'lit'  iiniiiial  (•(iiivcyiii;L,f  the  iiil'cclidii.  In  (inliT  of  (Iccnus. 
iiifif  HdVt'rity  couk^:  lirst,  the  unit';  .sfcoiul,  tlic  cat;  tliirii,  llic  do;.';  mihI 
I'oiirlli,  other  aiiiiiiiils."  (>iil\  a  limited  iiiiiiil)er  of  those  liilieii  iiy  i;ilii.| 
(loij.s  Iteeomi!  alVeeted  by  tiie  disease;  aet.'ordiii;;  to  ilorsley,  not  niore  tlmn 
llfliieii  per  cent.  Oil  th((  other  hand,  tliu  deiilh-rati'  of  Ihosc  iier.-diis 
bitten  l)y  wolves  is  hi.uiier,  not  h-ss  than  forty  per  ccnr. 

'I'lio  inculiaiiiiii  period  in  man  is  e\treme!y  vai'ialile.  The  avcrau'c  is 
from  .six  weeks  to  two  inoiitlis.  In  a  few  casos  it  liu.s  hei'n  iinch-r  two 
weeks.  It  may  lie  pi'olonircd  to  tl>i'ee  months.  It  i.s  stated  that  the  iiicii. 
balion  may  be  prolont^^ed  fur  a  year  or  even  two  yeans,  but  tiiis  lias  not 
been  definitely  settled. 

Symptoms. — Three  sta_i,M's  of  the  disoiiso  are  reeoiiiiized  : 

(1)  rrriiiiiiiilnrii  xhiiji',  ill  wbich  there  may  be  irritation  alioul  tlif 
bite,  or  pain  or  numlmess.  'J'lie  patient  is  depressed  and  melaiiehnly; 
uiid  complains  of  headache  and  loss  of  api>etite.  He  is  very  irritable  iind 
sleepless,  and  has  a  constant  sense  of  imjit'iidinu'  ilanirer.  There  is  ul'tcn 
j^reafly  increased  .sensibility.  A  briylit  lij,'ht  or  a  loud  vftice  is  distressing. 
The  larynx  may  \n\  injected  and  the  lii  4  symptoms  of  dilliculty  in  swal- 
lowing' ar((  experienced.  The  voice  also  becomes  husky.  'J'liere  is  a 
slight  rise  in  the  teniperatiii'e  iJi-'  the  pulse. 

{'i)  Sl(((te  of  Kxcitcmeiii. — Tois  is  eliaracterizcd  by  great  excitability 
and  restlessness,  and  an  extrem.'  de<;ree  of  hyperiestliesia.  "Any  allVieiit 
stimulant — i.  e.,  a  sound  or  a  draught  of  air,  or  the  mere  association  ot 
u  verbal  siiggesti',)u — will  cause  a  violent  reflex  S2)asm.  In  man  this  symp- 
tom constitutes  the  most  distressing  feature  of  the  malady.  The  spasm,«, 
which  alT'ect  particularly  the  muscles  of  the  larynx  and  mouth,  are  excord- 
ingly  ))ainfiil  and  are  accompanied  by  an  intense  .sense  of  dyspnica,  oven 
when  the  glottis  is  widely  opened  or  trac'heotomy  has  been  perforiiieil" 
(Ilorsley).  Any  attempt  to  take  water  is  followed  by  an  intensely  painful 
spasm  of  the  muscles  of  the  larynx  and  of  the  elevators  of  the  hyoid 
bone.  It  is  this  whitdi  makes  the  patient  dread  the  very  sight  of  wiitor 
and  gives  the  name  liinlniplmhiK  to  the  disease.  These  spasmodic  attacks 
may  be  associated  with  maniacal  symptoms.  In  the  intervals  between  ihcni 
the  patient  is  quiet  and  the  mind  unclouded.  The  temjieratnre  in  this 
stage  is  usually  elevated  and  may  reatdi  from  100°  to  10,'3°.  In  some  in- 
stances the  disease  is  afebrile.  The  patient  r-^rcly  attempts  to  injure  his 
attemhmts,  and  in  the  intense  spasms  may  be  particularly  anxious  to 
avoid  hurting  any  one,  '^Fhere  are,  however,  occasional  fits  of  furious 
mania,  and  the  patient  may,  in  the  contractions  of  the  muscles  of  tlio 
larynx  and  ])harynx,  give  utterance  to  odd  sounds.  This  stage  lasts  from 
a  day  and  a  half  to  three  days  and  gradually  passes  into  the — 

(3)  Panthjtic  Sfar/c. — In  rodents  the  preliminary  and  furious  stages 
are  absent,  as  a  rule,  and  tlie  paralytic  stage  may  be  marked  from  the  out- 
set— the  so-called  dumb  rabies.  This  stage  rarely  lasts  longer  than  from 
six  to  eighteen  hours.     The  patient  then  becomes  quiet ;  the  spasms  no 


;iiii|  iiKii'Mhi; 


ti 

iiljs'i 


IIYDUOI'IIOIUA. 


ny 


loiiijcr  occur  ;  tliorc  is  fjrailiiiil  imcnnscioiisncHs  ;  (liplicartV  action  ln'comcs 
jiiorc  :inil  iiiorc  cnrccliicil,  ainl  ticatli  (icciir.-*  hy  syiii'npc. 

Morbid  Anatomy.  -Tlic  lesions  arc  in  the  cci'cl»ro-s|iinaI  svslctn. 
The  lilonil-vcsscis  arc  conj^cstcil  ;  tlicic  is  |ici'ivasciilar  exudation  ol'  leiico- 
(•vt(s:aii(i  tlaTc  arc  niinntc  luciuori'liaLjes.  Arcnrdinir  to  fiowcrs.  tlicso 
arc  |i;ii'lieularly  ii, tense  in  tin^  ineilnila.  'Tlic  jiiianiix  is  con^^'cslcd,  tlio 
iiiiiiiJiiN  iiietnl)raiu'  of  the  stomach  is  iiy|ici'a'inie,  and  not  infi'ci(nently 
(.ovcrcil  uiih  a  lihiod-staiiicd  ninciis.  'i'hi'  larynx,  tracliea,  and  iinuKdii 
,^li(i\v  ;iculc  con;i'cslion.  'i'licrc  are  no  special  chanties  in  tlic  ahdoniiiial  or 
llidnicic  \isccra.  'I'lu'  inoculation  experiments  sliow  that  tlic  virus  is  not 
lircsciit  in  tlio  liver,  s]ilccu,  or  kidneys,  but  is  ahundant  in  tlio  spinal  cord 
iiiiil  liriiin. 

Treatment. -  ri'ophylaxi.s  is  of  the  <_n'catest  im[iortancc,  atid  I)y  a 
■ivstciiiiiii''  uiw/./.Wujj;  of  doi^r.s  the  disease  can  be,  as  in  'Icnuany,  [)raclically 
(•i';iili''aU'd. 

The  bites  should  bo  carefully  washed  and  tlioron.<,ddy  cauteri/c(l  with 
can-tic  piitash  or  concentrated  carbolic  acid.  It  is  best  to  keeji  'he  wound 
(Miiistiiiilly  open  for  at  least  ilve  or  six  weeks.  AViien  once  cstiiblislicd  tho 
(li«('a>c  is  hopelessly  incurable.  No  measures  I'lave  l)een  found  of  the 
sliirlitcst  avail,  conscfpu'iitly  the  treatment  must  be  ]i;11i:itivo.  Tlie  pa- 
tient slmidd  be  kept  in  a  darkened  room,  in  cliarL;-e  nf  not  more  tlian  two 
ciirfl'iil  ailcndan:-.  To  allay  the  spasm,  chloroform  may  be  administered 
ami  iii(ir|i'iia  <xiven  liypodermically.  It  is  best  to  Wi^v.  these  jiowei'fid  reine- 
iliis  from  the  outset,  and  not  to  tein[iorize  with  chloral,  bronndi'  of  potas- 
<iiiiii,  anil  other  less  potent  drnifs.  liy  tho  local  application  of  cocaine, 
the  scusiliveness  of  the  throat  maybe  diminished  sufViciently  to  enable 
the  patient  to  take  liquid  nourishment.  Sometimes  he  can  swallow  read- 
ilv.     Nutrient  enemata  shotdd  be  adnunistered. 

Preventive  Inoculation.— Pasteur  has  found  that  the  virtis,  when  propa- 
gated through  a  series  of  rabbits,  increases  ra])idly  in  its  virulence;  so  that 
whereas  sid)dnral  inoculation  fron  the  brain  of  a  mail  don^  takes  from  (if- 
toen  to  twenty  days  to  produce  the  disease,  in  successive  innculatif)ns  in  a 
series  of  ral)bit3  tho  incnbatif)n  period  is  u'radiudly  ri'duced  to  sc^ven  days. 
The  spinal  cord  of  these  rabl)its  contains  the  virus  in  great  intensity,  but 
wlieii  [ircservcd  in  dry  air  tho  virus  gradually  diminishes  in  intensity.  If 
now  (logs  are  inoculated  with  cords  ])reserved  for  from  twelve  to  fifteen 
'hp,  and  then  with  cords  preserved  for  a  shorter  period,  i.  e.,  M'ith  a  pro- 
•.M'essivcly  stronger  virus,  they  gradually  acqiure  immuiuty  against  the  dis- 
ease. A  dog  treated  in  this  way  will  resist  inoculation  Avith  material  from 
:i  perfectly  fresh  cord  from  a  rabid  rabbit,  which  otherwise  would  inevi- 
tably have  proved  fatal.  Relying  upon  these  experiments,  Pasteur  began 
iiKieulations  in  the  human  subject  usijig,  on  successive  days,  material  from 
t'lirils  in  which  the  virus  was  of  varying  degrees  of  intensity. 

Tliere  is  still  much  discussion  as  to  the  full  value  of  this  method, 
hut  if  the  protective  inoculation  can  be  successfully  performed  in  dogs, 


1, 


'••■ti  i 
I 


m^ 


I.  !i 


180 


SPECIFIC  INFECTIOUS  DISEASES. 


<  i. 


I  ,<i 


there  is  no  reason  wliy  the  same  should  not  hold  good  for  man ;  and  tlie 
figures  published  annually  from  the  Pasteur  Institute  show  that  in  }»er- 
sons  bitten  l)y  animals  known  to  have  been  rabid,  the  mortality  after  in- 
oculation is  only  r.oout  0-GO  per  cent. 

Pseudo-hydrophobia  (Lyssophobia). — This  is  a  very  interesting 
affection,  which  may  closely  resemble  hydrophobia,  but  is  really  nothing 
more  than  a  neurotic  or  hysterical  manifestation.  A  nervous  person  bitten 
by  a  dog,  either  rabid  or  supposed  to  be  rabid,  develops  within  a  few  months. 
or  even  later,  symptoms  somewhat  resembling  the  true  disease.  lie  is  irri- 
table and  depressed.  lie  constantly  declares  his  condition  to  be  serions 
and  that  he  will  inevitably  become  mad.  lie  may  have  paroxysms  in  wliioh 
he  says  he  is  nimble  to  drink,  grasjis  at  his  throat,  and  becomes  emotional. 
The  temperature  is  not  elevated  and  the  disease  does  not  progress.  It  lasts 
much  longer  than  the  true  rabies,  and  is  amenable  to  treatment.  It  is  not 
improbable  that  a  majority  of  the  cases  of  alleged  recovery  in  this  disease 
have  been  of  this  hysterical  form.  In,  a  case  which  Burr  reported  from 
my  clinic  a  few  years  ago  the  patient  had  paroxysmal  attacks  in  Avhicli  lio 
could  not  swallow.  He  was  greatly  ext-ilcd  aiul  alarmed  at  the  sight  of 
water  and  was  extremely  emotional.  The  attack  lasted  for  a  couple  of 
weeks  and  yielded  to  treatment  with  powerful  electrical  currents. 


XXV.    TETANUS. 

(Lockjaw.) 

Definition. — An  infectious  malady  characterized  by  tonic  spasms  of 
the  muscles  with  marked  exacerbations.  The  virus  is  produced  by  a 
bacillus  which  occurs  in  earth  and  sometimes  in  putrefying  fluids  and 
manure. 

Etiology. — It  occurs  as  an  idiopathic  affection  or  follows  trauma.  It 
is  frequent  in  some  localities  and  has  prevailed  extensively  in  epidemic 
form  among  new-born  children,  when  it  is  known  as  tetanus  or  trismus 
neonatorum.  It  is  moro  common  in  hot  than  in  temjierate  climates, 
and  in  the  colored  than  in  the  Caucasian  race.  This  is  particuliu'ly 
the  case  with  tetanus  following  confinement  and  in  tetanus  neonato- 
rum. In  certain  of  the  West  India  Islands  more  than  one  half  of  the 
mortality  among  the  negro  children  has  been  due  to  this  cause.  In  a  ma- 
jority of  the  cases  there  is  an  injury  which  may  be  of  the  most  trilling 
character.  It  is  more  common  after  punctured  and  contused  than  after 
incised  wounds,  and  frequently  follows  those  of  the  hands  and  feet.  The 
disease  usually  appears  within  two  weeks  of  the  injury.  In  some  militan 
campaigns  tetanus  has  prevailed  extensively,  but  in  others,  as  in  the  late 
civil  war,  the  cases  have  been  comparatively  few.  Idiopathic  tetanus  is 
rare  in  man,  but  it  has  sometimes  followed  exposure  to  cold  or  after  sleep- 
ing on  the  damp  ground. 


TETANUS, 


181 


The  infectious  nature  of  tetanus  was  suggested  by  its  endemic  occur- 
rence anil  from  the  manner  of  its  behavior  in  certain  institutions.  Vet- 
oriiiiiriiiiKS  luive  long  been  of  this  belief,  as  cases  are  apt  to  occur  together 
in  horses  in  one  stable.  In  the  United  States  attention  was  early  called  to 
this  feature  by  the  prevalence  of  the  disease  in  the  eastern  end  of  Long 

The  Tetanus  Bacillus. — The  observations  of  Rosonbach,  Xicolaier,  and 
Kitusato  liave  demonstrated  that  there  is  in  connection  with  the  disease  a 
fpc'cifii-'  organism  which  can  bo  isolated  and  cultivated.  The  bacillus  forms 
a  slender  rod  with  rounded  ends  and  nuiy  grow  into  long  threads.  It  is 
inetilo,  grows  at  ordimiry  temperatures,  aiul  is  anaerobic.  The  bacilli  de- 
velop at  the  site  of  the  wound  (and  do  not  invade  the  blood  and  organs), 
where  alone  the  toxine  is  manufactured.  With  small  quantities  of  the  cul- 
ture the  disease  may  be  transmitted  to  animals,  which  die  with  symptoms 
of  tetanus.  Tlie  poison  is  a  tox-albumiu  of  extraordinary  potency,  which 
lias  been  separated  by  Brieger  and  Colin  in  a  state  of  tolerable  ]>urity. 
It  is  perhaps  the  most  virulent  poison  known.  Whereas  the  fatal  dose 
of  strychnine  for  a  man  weighing  70  kilos  is  from  30  to  100  milligrammes, 
that  of  the  tetanus  toxine  is  estimated  at  0-"-*:3  milligrammes.  Every  fea- 
ture of  the  disease  can  be  jiroduced  by  it  experimentally  without  the  pres- 
ence of  the  bacilli.  The  symptoms  do  not  develop  immediately,  as  in  the 
ease  of  ordinary  poisons,  but  slowly,  and  it  haj  been  suggested  that  it  acts 
by  producing  a  kind  of  fermentation.  Anoliier  point  of  intoicst  is  the 
fact  that  immunity  can  be  procured  by  inoculating  an  animal  with  the 
blood  of  another  which  has  had  the  disease.  The  organism  has  been 
i'linid  in  the  earth  and  in  putrefying  lluids,  and  Isicolaier  has  caused  the 
disease  liy  inoculating  with  different  sorts  of  surface  soil. 

Morbid  Anatomy. — Xo  characteristic  lesions  have  been  found  in 
the  cord  or  in  the  brain.  Congestions  occur  in  different  parts,  and  peri- 
vascular exudations  and  granular  changes  in  the  nerve-cells  have  been 
found.  The  condition  of  the  wound  is  variable.  The  nerves  ari.'  often 
found  injured,  reddened,  atul  swollen.  In  the  tetanus  neonatorum  the 
umbilicus  may  be  inllamcd. 

Symptoms. — After  an  injury  the  disease  sets  in  usually  within  teti 
'lavs.  In  Vandell's  statistics  in  at  least  two  fifths,  and  in  -ocph  Jones's 
afoiu'  fifths,  the  symptoms  occurred  before  the  fifteenth  day.  The  pa- 
tient complains  at  first,  of  slight  stiffness  in  the  neck,  or  a  feeling  of 
tightness  in  the  jaws,  or  ditRculty  in  mastication.  Occasionally  chilly 
feelings  or  actual  rigo;-;  may  precede  these  symptoms.  (Jradually  a  tonic 
•^pasm  of  the  muscles  of  these  parts  develops,  producing  the  condition 
"f  trismus  or  lockjaw.  The  eyebrows  may  be  raised  and  the  angles  of 
tiie  mouth  drawn  out,  causing  the  so-called  sardonic  grin — risun  .sardoni- 
c'.*.  In  children  the  sjiasm  may  be  confined  to  these  parts.  Sometimes 
ilie  attack  is  associated  with  ])aralysis  of  the  facial  muscles  and  difficulty 
ill  swallowing — the  head  tetanus  of  Rose,  which  has  moat  commonly  fol- 


1  .f^ 


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182 


SPECIFIC  INFFXTIOUS  DISEASES. 


|l; 


■  I- 

1  <  ft     .  k..i 


lowed  injuries  in  the  neighborliood  of  tlie  fiftli  nerve.  Graduall}-  tlie 
process  extends  and  involves  tlio  muscles  of  the  body.  Those  of  tln' 
back  arc  most  affected,  so  that  during  the  spustn  the  unfortunate  vii'tim 
may  rest  upon  tlie  head  and  heels — a  position  known  'dsopist/uilonos.  The 
rectus  ahdoniinalis  muscle  has  been  torn  across  in  the  spasm.  The  en- 
tire trunk  and  limbs  may  be  perfectly  rigid — orlliofoitos.  Flexion  to  oiic 
side  is  less  common — jihuronthotfDios  ;  wliile  spasm  of  the  muscles  of  the 
abdomen  may  cause  the  body  to  be  bent  forward- — ciiijiroKfliotono.s.  h 
very  violent  attacks  the  thorax  is  compressed,  the  respirations  are  nipiil. 
ajid  spasm  of  the  glottis  may  occur,  causing  aspliyxia.  Tho  paroxysms 
last  for  a  variable  jieriod,  but  even  in  tlie  intervals  the  relaxation  is  tint 
complete.  Tho  slightest  irritation  is  sullicieut  to  cause  a  spasm.  Tlio 
paroxysms  are  associated  with  agonizing  pain,  and  the  patient  muy  lie 
lield  as  in  a  vise,  unable  to  utter  a  word,  rsiially  he  is  bathed  in  a  ]in;- 
fuse  sweat.  The  tempei'ature  may  remain  normal  throughout,  or  slinu- 
only  a  slight  elevation  toward  the  close.  In  other  cases  the  pyrexiu  is 
marked  from  the  outset;  the  temperature  reaches  105°  or  l(i'i°,  ami  In- 
fore  death  109°  or  110°.  In  rare  instances  the  temperature  may  reach  n 
still  liigher  point.  Death  either  occurs  during  the  paroxysm  from  licart- 
failure  or  asphyxia,  or  is  due  to  exhaustion. 

The  cephalic  tetanus  {Knpftctainis  of  Rose)  originates  usually  from  a 
wound  on  one  side  of  the  head,  and  is  characterized  by  stiiTness  of  the 
muscles  of  the  jaw  and  paralysis  of  the  facial  muscles  on  tho  same  side  as 
the  wouiul,  with  diflticulty  of  swallowing.  The  prognosis  is  good.  In  the 
chroiuc  cases  only  eight  of  thirty-two  died,  but  in  the  acute  form,  of  forty- 
five  cases,  only  four  recovered  (Willard). 

Diagnosis. — Well-develoj)ed  cases  following  a  trauma  could  not  bo 
mistid^en  for  any  other  disease.  The  s[)nsms  are  not  unlike  those  ef 
strychnia-i)oisoning,  and  in  the  celebrated  Palmer  murder  trial  this  \va> 
the  plea  for  the  defence.  The  jaw-muscles,  however,  are  tu^ver  invulvod 
early,  if  at  all,  and  between  the  paroxysms  in  strychnia-poisoning  tlicre 
is  no  rigidity.  In  tetany  the  disti'ibution  of  tiie  spasm  at  the  extremi- 
ties, the  ])cculiar  position,  the  greater  involvement  of  the  hands,  aini 
the  condition  under  which  it  occurs,  are  sidTieient  to  nud<e  the  dia;:- 
nosis  clear.  In  doubtful  cases  cultures  should  be  made  from  the  pu^^  I'f 
the  wound. 

Profijnosis. — Two  of  the  Ilippocratic  aj^liorisms  express  tersely  tlie 
general  prognosis  even  at  the  present  day  :  "  The  spasin  supervening  'in  :i 
wound  is  fatal,"  and  "  such  persons  as  are  seized  witli  tetanus  die  witliiti 
four  days,  or  if  they  pass  these  they  recover." 

The  mortality  in  the  traumatic  cases  is  not  less  than  eighty  per  cent 
(Conner) ;  in  the  idiopatnic  cases  it  is  under  fifty  per  cent.  Acem'tliiiL' 
to  Yan<lell,  the  mortality  is  greatest  in  children.  Favorable  indications 
are :  late  onset  of  the  attack,  localization  cf  the  spasms  to  the  muscles  of 
the  neck  and  jaW;  and  an  absence  of  fever. 


TETANUS, 


183 


Treatment. — Local  treatment  of  the  wound  is  essential,  as  the  poi- 
coii  is  iiianiil'iictiiroJ  here.  Tizzoni  advises  nitrate  of  silver  as  tlie  best 
(fH'iiiii'itl''  '"'■  the  tetanus  bacillus,  '.riiorougli  excision  and  antiseptic 
tiviitiiii'iit  should  be  carried  out.  The  i)atient  aliould  be  i\ept  in  a  dark- 
^.iied  room,  absolutely  quiet,  and  attended  bv  only  one  jjerson.  All  pos- 
sible sources  of  irritation  should  be  avoided.  Veteriiuirians  appreciate 
tlic  iiniiortance  of  tliis  complete  seclusion,  and  in  \vell-er|ui[)])ed  infirmaries 
there  nmy  be  seen  a  brick  ])added  chamber  in  whicli  the  horses  are 
treated. 

When  tlie  lockjaw  is  extreme  it  may  be  impossible  to  feed  the  patient, 
iiiider  whicli  circumstances  it  is  best  to  use  rectal  injections,  or  to  feed  by 
II  ciitlieter  passed  through  the  nose.  The  spasm  should  be  controlled  by 
(hloi'olunn,  wliicli  may  be  repeatedly  given  at  intervals.  It  is  more  satis- 
fiictory  to  keep  the  patient  tliorougiily  under  the  intluenco  of  morphia 
L'ivi'ii  hypodermically.  Chloral  hydrate,  bromide  of  potassium.  Calabar 
bean,  ciu'ara,  Indian  hemp,  belladonna,  and  other  drugs  have  been  recom- 
mended, and  recovery  occasionally  follows  their  use.  It  is  very  difficult 
to  estimate  the  value  of  the  blood-serum  therapy  in  this  disease.  T'izzoni 
and  C'antani  have  used  an  antitoxine  prepared  from  the  blood-serum  of 
immunized  animals.  Tlie  material,  which  is  now  to  be  obtained  from 
Merck,  is  in  the  dried  state,  and  comes  in  tubes  containing  four  to  five 
<:ramnies.  It  can  be  obtained  in  this  country  from  his  agents.  An  anti- 
toxine serum  is  also  prepared  by  Behring  and  by  Roux.  Of  the  fluid 
>eriun  '^0  to  30  c.  c.  may  be  used  for  the  first  dose  and  15  to  JiO  c.  c.  every 
live  or  ton  hours  after.  Tizzoni  advises  2-'2r)  grammes  of  his  antitoxine 
for  the  iirst  dose  and  O'G  grammes  for  subsequent  doses.  According  to 
Hewlett,  of  fifty  cases  treiited  with  antitoxine,  only  sixteen  died .  Kanthack 
has  made  an  elaborate  auidysis  (Medical  Chronicle,  May,  1805)  of  all  the 
rworded  cases,  fifty-four  in  number,  with  twenty  deaths.  He  concludes 
that  the  method  is  still  on  trial,  and  tliat  no  really  acute  or  otherwise 
hopeles-s  case  has  yet  been  cured  by  it. 


f    1 


rf    r. 


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18 


184 


specific;   INFKCTIOUS  DISEASES. 


:  :iS:  ■ 


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■I'l  i 


1.1 


XXVI.  SYPHILIS. 

Definition. — A  spocille  diseuso  of  slow  evolution,  propagatoi]  bv 
inoculation  (ac(|uii'od  sy{)liilis),  or  by  hereditary  transmission  (oongciiiiul 
syphilis).  In  the  acquired  form  the  site  of  inoculation  becomes  the  seat  of 
a  special  tissue  change — jtrunary  lesion.  After  an  interval  of  two  or  tliroi' 
months  constitutional  symptoms  develop,  with  aifections  of  the  skin  ami 
mucous  tnomi)rancs — scconddrij  Icxions.  And,  liiuiUy,  after  a  period  of 
three,  four,  or  more  years,  granulomatous  growths  develop  iu  the  viscera, 
muscles,  bones,  or  skin — tertiary  lesions. 

I.    CiKN-KllAL    ExiOLOriY    AXD    MOURID    AnATOMY. 

The  nature  of  the  virus  is  still  doubtful.  Lustgarten  found  in  tlic 
hard  chancie  and  in  gummata  a  rod-shaped  bacillus  of  3  or  4  /a  in  lonirtli, 
which  ho  claims  is  specific  and  peculiar  to  the  disease.  This  orgaiiijiii 
closely  resembles  the  smegma  bacillus,  which  is  found  beneatli  the  pn- 
puce,  but  from  its  occarrence  in  gummatous  growths  it  is  hardly  possibk' 
that  they  can  be  identical.  Further  observations  are  required  before  tbi' 
question  can  be  considered  settled. 

Syphilis  is  peculiar  to  man,  and  cannot  be  transmitted  to  the  lower 
animals.     All  are  susceptible  to  the  contagion,  and  it  occurs  at  all  ages. 

Modes  of  Infection. —  (1)  In  a  large  niajority  of  all  cases  the  disea*!^ 
transu^itted  by  sexual  eonr/ress,  but  the  designation  renereal  disease  {lni< 
venerea)  is  not  always  correct,  as  there  are  nuiny  other  modes  of  iuociihi- 
tion. 

(2)  Accidental  Infection. — In  surgical  and  in  midwifery  practice  phy- 
sicians are  not  infrequently  inoculated.  It  is  surprising  that  inlVctimi 
from  these  sources  is  not  more  common.  I  have  known  {)ersonally  of  .>iv 
cases.  ^lidwifery  chancres  are  usually  on  the  lingers,  but  I  have  niii 
with  one  instan(!e  on  the  back  of  the  hand.  The  lip  chancre  is  the  iim-i 
common  of  these  erratic  or  extra-genital  forms,  and  may  be  acqiiiml  in 
many  ways  apart  from  direct  infection.  !Mouth  and  tonsillar  sores  ri'siil: 
as  a  rule  from  improper  practices.  Wet-nurses  are  sonu^times  iiifectcil 
on  the  nipple,  and  it  occasionally  happens  that  relatives  of  the  child  inv 
accidentally  contaminated.  One  of  the  most  lamentable  forms  of  acei- 
d''  'al  infection  is  the  transmission  of  the  disease  in  hunumized  vaociin' 
lymph.  This,  however,  is  extremely  rare.  The  conditions  under  w'licii 
it  occurs  have  been  already  referred  to  (see  Vaccination). 

(3)  Hereditary  Transmission. — This  may  be,  and  is,  most  eemninn 


SYPHILIS. 


185 


from  («)  tl>(^  father,  the  mother  being  liealtliy  (sperm  inlieritance).  It  is, 
iinfortunaicly,  an  every-. 'ay  experience  to  see  cases  of  congenital  syphilis 
^1  wliich  the  infection  is  clearly  ])ateriiiil.  A  syphilitic  father  may,  how- 
ever, bcijct  a  healthy  child,  even  when  tl>e  disease  is  fresh  and  fidl-ljlown. 
On  tlu'  other  liand,  in  very  rare  instances,  a  man  may  h  ive  had  syphilis 
wlicii  yoim,!,',  undergo  treatment,  and  for  years  present  no  signs  of  disease, 
and  yet  liis  lirst-borii  may  show  very  characteristic  lesions.  II;ippily,  in  a 
large  nmjority  of  instances,  when  the  treatment  has  been  thorough,  the 
tillsiiriiig  f-scupe.  'I'lie  closer  tlie  begetting  to  the  ])rim!iry  sore,  the  greater 
till'  chance  of  infection.  A  man  with  tertiary  lesions  may  beget  liealthy 
chililri'ii.  As  a  general  rule  it  may  be  said  that  witli  judicious  treatment 
the  tratistiiissive  ])0wer  rarely  exceeds  three  or  four  years. 

(//)  Maternal  transmission  (germ  inheritance).  It  is  a  reniarka1)le 
ami  iiilorestiug  fact  that  a  woman  who  lias  borne  a  syphilitic  child  is  her- 
scir  iiiiinune,  and  cannot  be  infected,  though  she  may  present  no  signs  of 
the  disease.  This  is  known  as  Colles's  law,  and  was  thus  stated  by  the 
(lisliiiiruislu'd  Dublin  surgeon:  "  1'hat  a  child  born  of  a  mother  who  is 
witiidiit  obvious  venereal  sym2)toms,  and  which,  without  being  exposed  to 
any  infection  subsequent  to  its  birth,  shows  this  disease  when  a  few  weeks 
nliK  this  child  will  infect  the  most  healthy  nurse,  whether  she  suckle  it,  or 
merely  haiuUe  aiul  dress  it ;  and  yet  this  child  is  never  known  to  infect  its 
own  iiiutlier,  even  though  she  suckle  it  wliile  it  has  venereal  ulcers  of  the 
lipii  and  tongue."  In  a  majority  of  these  cases  the  mother  has  received  a 
s(irt  (if  protective  inoculation,  without  having  had  actual  manifestations  of 
the  disease. 

A  woman  with  acquired  syphilis  is  liable  to  bear  infected  children. 
The  father  may  not  be  affected.  In  a  large  number  of  instances  both 
parents  are  diseased,  the  one  having  infected  the  other,  in  wliich  case  the 
ohaneos  of  fo'tal  infection  are  greatly  increased. 

('•)  I'lacental  transmission.  The  mother  may  be  infected  after  con- 
ception, in  which  case  the  child  may  be,  but  is  not  necessarily,  born  syph- 
ilitie. 

Morbid  Anatomy. — The  prmar>/  le.non,  or  chancre,  shows:  (a)  A  dif- 
fuse infiltration  of  the  connective  tissue  with  small,  rouiul  cells,  (b) 
harcrer  epithelioid  cells,  (c)  Ciiant  cells.  {</)  The  Lustgarten  bacilli,  in 
small  ninidjers.  (r)  Changes  in  the  small  arteries,  chiefly  thickening  of 
the  intli.ia,  and  alterations  in  the  nerve-fibres  going  to  the  part  (]?erkeley). 
Tlie  sclerosis  is  due  in  part  to  this  acute  obi  iterative  endarteritis.  Asso- 
ciated with  the  initial  lesions  are  changes  in  the  adjacent  lymph-glands, 
wliieh  niidcrgo  hyperplasia,  and  finally  become  indurated. 

The  scrfDifliiri/  Irsiojis  of  syjiliilis  are  too  varied  for  description  liere. 
They  consist  of  condylomata,  skin  eruptions,  affections  of  the  eye,  etc. 

The  fcrliary  lesions  consist  of  circumscribed  tumors  known  as  gum- 
niata,  and  of  an  arteritis,  whicdi,  however,  is  not  peculiar  to  the  disease. 

Ounuiuda. — Syphilomata  develop  in  the  bones  or  periosteum — here 


'  iii    »| 


186 


SPECIFIC   INFECTIOUS  DISEASES. 


they  arc  called  nodes — in  the  muscles,  skin,  brain,  lung,  liver,  kid iicys, 
heart,  testes,  and  adrenals.  They  vary  in  size  from  small,  almost  micro- 
scopio,  bodies  to  largo,  solid  tumors  from  three  to  live  centimetres  in  (limn- 
eter.  They  are  usually  firm  and  hard,  but  in  the  skin  and  on  the  nuicoiis 
membranes  ihey  tend  to  break  down  ra})idly  and  ulcerate.  On  cro.ss-sei'- 
tion  a  medium-sized  gumma  has  a  grayish-white,  homogeneous  apiicar- 
ance,  presenting  in  the  centre  a  firm,  ca-eous  substance,  and  at  tlie  pi'- 
riphery  a  translucent,  fibrous  tissue.  Often  there  are  groups  of  throe  or 
more  surrounded  by  dense  sclerotic  tissue.  They  are  usually  very  lirm 
and  hard.  Jlistologically,  a  small  gumma  consists  of  a  graindation  tissue 
composed  of  rounded  cells.  Owing  to  insutlicient  blood-su])ply,  coagiihi- 
tion  necrosis  takes  place  in  the  centre  with  the  fornuition  of  a  fibro-casoous 
material,  while  the  growth  extends  at  the  nuirgins  with  the  gradual  pro- 
duction of  fibre-cells.  Ultimately  the  central  caseous  part  may  be  ab- 
sorbed, and  healing  takes  place  witli  the  develo])meiit  of  a  fibrous  .scar. 
The  arteritis  will  be  considered  in  a  separate  section. 

II.    ActiuniKi)  Sy  I'll  I  MS. 

Primary  Stage. — This  extends  from  the  appeai-ance  of  the  initial  sore 
until  the  onset  of  the  constitutional  syinptoms,  and  has  a  variable  dura- 
tion of  from  six  to  twelve  weeks.  The  initial  sore  appears  within  a  nioiitli 
after  inoculation,  and  it  first  shows  itself  as  a  snudl  red  papule,  wiiicli 
gradually  enlarges  aiul  breaks  in  the  centre,  leaving  a  small  ulcer.  Tlu' 
tissue  about  tliis  becomes  indurated  so  that  it  ultimately  has  a  gristly,  car- 
tilaginous consistence — hence  the  name,  hard  or  indurated  chancre.  Tiic 
size  attained  is  variable,  and  when  small  the  sore  may  be  overlooked,  par- 
ticularly if  it  is  just  within  the  urethra.  The  glands  in  the  lymph-district 
of  the  chancre  enlarge  and  become  hard.  'Suppuration  both  in  the  initial 
lesion  and  in  the  glaiuls  may  occur  as  a  secondary  change.  The  goiioral 
condition  of  the  patient  in  this  st;ige  i.;  good.  There  may  be  no  fever 
and  no  impairment  of  health. 

Secondary  Stage. — The  first  constitutional  symptoms  are  usually  muni- 
fested  within  three  months  of  the  appearance  of  the  primary  sore.  Tluv 
rarely  develop  ciirlier  than  the  sixth  or  later  than  the  twelfth  week.  'I'lie 
symptoms  are:  (a)  Fever,  slight  or  intense,  and  very  variable  in  charac- 
ter. A  mild  continuous  ])yrexia  is  not  uncommon,  the  temperature  not 
rising  above  101°.  The  fever  may  have  a  distinctly  remittent  chanietcr; 
but  the  most  remarkable  and  puzzling  type  of  syphilitic  fever  is  the  inter- 
mittent, which  often  leads  to  error  in  diagnosis.  The  fever  may  coiium)ii 
within  a  month  after  exposure  and  rise  to  104°  or  10.')°,  with  oscillation? 
of  five  or  six  degrees  (Yeo)  A  remarkable  case  is  reported  by  Siihu'V 
Phillips,  in  which  pyrexia  persisted  for  months,  with  paroxysms  rosoin- 
bling  in  all  respects  tertian  ague,  and  which  resisted  quinine  and  vickleii 
promptly  to  mercury  ami  potassium  iodide.  Although  usually  a  secoiidarv 
manifestation,  the  fever  of  syphilis  may  occur  late  in  the  disease. 


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SYPHILIS.  Ig7 

« 

(/;)  Anaemia. — In  many  oases  the  sypliilitic  poison  oanses  a  pronounced 
iiiiiiiiniii  \\lii(;li  gives  to  tiic  face  a  TiiiKidy  pallor,  and  there  may  even  be  a 
liirlit-ycliow  tiiigeing  of  the  eonjiuutiva'  or  of  the  skin,  an  ha'iiiato<renou3 
ittfi'iis.  This  syi)hilitic  cachexia  may  in  some  instances  be  extreme.  'I'he 
ml  bliiod-eorpuscles  do  not  sh(  v  any  sjiecial  alterations.  The  blood- 
ooiuit  iiiiiy  fall  to  three  millions  ])er  cubic  millimetre,  or  even  lower,  and 
the  liiiniiiglobin  to  forty  or  fifty  per  cent  (Ilayem).  No  eliaracteristic 
orMiiisnis  have  been  found  iji  the  blood. 

(r)  Cutaneous  Lesionx. — Skin  eruptions  of  all  forms  may  develop. 
The  earliest  and  most  common  is  a  rash — macular  Kt/philide  or  si/philitic 
romilti—wh'n'h  occurs  on  the  abdomen,  the  chest,  and  on  the  front  of  the 
iinii.s.  The  face  is  often  exempt.-  'J'iie  spots,  which  are  reddish-brown 
;iii(l  syiiiTuetrically  arranged,  persist  for  a  week  or  two.  Kext  in  frecpiency 
\>  A  jKip II Icr  si/jihi/ide,  wh'wh  may  form  acne-like  indurations  about  the 
face  and  trunk,  often  arranged  in  groups.  Other  forms  are  the  jninfidar 
riisli,  which  may  so  closely  simulate  variola  that  the  patient  may  be  sent 
to  a  .small-pox  hospital.  A  i^f/namous  ,si/j)/nli(/c  occurs,  not  unlike  ordi-  ' 
nary  psoriasis,  except  that  the  scales  are  less  abundant.  The  rasli  is  more 
copper-colored  and  not  specially  confined  to  the  extensor  surfaces. 

In  the  moist  regions  of  the  skin,  such  as  tlie  periuienm  and  groins,  the 
axilla',  between  the  toes,  and  at  the  angles  of  the  mouth,  the  so-cidled 
w»CT//.s'7w/c7«'.s  develop,  which  are  flat,  warty  outgrowths,  with  well-defined 
margins  and  surfaces  covered  with  a  grayish  secretion.  They  are  among 
the  most  distinctive  lesions  of  syphilis. 

Frecpiently  the  hair  falls  out  (alopecia),  either  in  patches  or  by  a 
general  thinning.  Occasionally  the  nails  become  affected  (syphilitic 
onychia). 

('/)  Mucous  Lesionf. — Witli  the  fever  and  the  roseolous  rash  the  throat 
iiiul  month  become  sore.  The  pharyngeal  mucosa  is  hyperamiic,  the  ton- 
sils are  swollen  and  often  present  small,  kidney-shaped  ulcers  with  gray- 
i>h-\vhite  borders.  Mucous  patches  are  seen  on  the  inner  surfaces  of  the 
uheeks  and  on  the  tongue  and  lips.  Sometimes  on  the  tongue  there  are 
whitish  spots  (leucomata),  which  are  seen  most  frequently  in  smokers,  and 
which  Hutchinson  regards  as  the  Joint  result  of  sy))hilitic  glossitis  and  the 
irritation  of  hot  tobacco-smoke.  Hypertrophy  of  the  papilla:"  in  various 
portions  of  the  mucous  membrane  produces  the  syphilitic  warts  or  condy- 
lomata which  are  most  frequent  about  the  vulva  and  anus. 

{(')  Other  Lesions. — Iritis  is  common,  and  usually  affects  one  eye  be- 
fiire  the  other.  It  develops  in  from  three  to  six  months  after  the  chancre. 
There  may  be  only  sliglit  ciliary  congestion  in  mild  cases,  but  in  severer 
forms  there  is  great  pain,  and  tlie  condition  is  serious  and  demands  care- 
ful maiiiigement.  Choroiditis  and  retinitis  are  rare  secondary  symptoms. 
Ear  affections  are  not  common  in  the  secondary  stage,  but  instances  are 
fomul  in  which  sudden  deafness  develops,  which  may  be  due  to  labyrinth- 
ine disease ;  more  commonly  the  impaired  hearing  is  due  to  the  extension 


188 


SPECIFIC   INFECTIOUS   DISEASES. 


i : 


i 


\ 


of  inlliiminiition  from  the  throat  to  the  middlo  car.  Epididymitis  arui 
parotitis  are  occasional  secondary  li\sioti8. 

Tertiary  Stage. — No  hard  and  fast  line  win  be  drawn  between  the 
lesions  of  llie  secondary  and  tliose  of  the  tertiary  period  ;  and,  indueii,  in 
e.x  optional  cases,  manifestations  wiiicli  usnally  aj)pear  late  may  set  in 
oven  before  the  primary  sore  has  properly  healed.  The  special  alTec lions 
of  this  stajre  are  certain  skin  erui)tions,  gummatous  growths  in  the  viscera, 
and  amyloiil  degenerations. 

(a)  'J'lie  late  siiphiUdi-H  show  a  greater  tendency  to  ulceration  lunl 
destruction  of  the  deeper  layers  of  the  skin,  so  that  in  healing  siais 
are  left.  They  are  also  more  scattered  and  seldom  symmetrical.  Oiic 
of  the  most  cliaracteristic  of  the  tertiary  syphilides  is  rnpia^  tiie  dry 
stratified  crusts  of  which  cover  an  ulcer  which  involves  the  deeper  layurs 
of  the  skin  and  in  healing  leaves  a  scar. 

{b)  Unmmatn. — These  may  develop  in  the  skin,  subcutaneous  tissue, 
muscles,  or  internal  organs.  The  general  character  has  been  alrwuly 
described.  When  they  develop  in  tiie  skin  they  tend  to  break  down  iiiul 
ulcerate,  leaving  ugly  sores  whicih  heal  with  diflicidty.  In  the  solid 
organs  they  undergo  fibroid  transformation  and  produce  puckering  ami 
deformity.  On  the  mucous  membranes  these  tertiary  lesions  lead  tu 
ulceration,  in  the  healing  of  which  cicatrices  are  formed ;  thus,  in  llio 
larynx  great  narrowing  nuiy  residt,  atid  in  the  rectum  ulceration  vitli 
fibroid  thickening  and  retraction  may  lead  to  stricture. 

(c)  Ami/liiid  Dcf/PuemliuH. — Syphilis  plays  a  most  important  role  in 
the  production  of  this  affection.  Of  244  instances  analyzed  by  Faggc, 
76  had  syphilis,  and  of  these  4"i  had  no  bone  lesions.  It  follows  tlie 
acquired  form  and  is  very  common  in  association  with  rectal  syphilis  in 
women.     In  congenital  lues  amyloid  degeneration  is  rare. 

(d)  ParasjiphiUtic  Affections. — Certain  disorders  not  actually  syphi- 
litic, yet  so  closely  connected  that  a  large  proportion  of  the  cases  liiive 
had  tlie  disease,  are  termed  by  Fournier  parasyphilitic  (Les  Ajfirlivus 
Purasi/p/iilitifjues,  liSU4).  These  affections  are  not  exclusively  and  neces- 
sarily caused  by  syphilis,  and  they  are  not  influenced  by  specific  treatment, 
The  chief  of  them  are  locomotor  ataxia,  dementia  paralytica,  certain  lypw 
of  epilepsy,  and,  we  may  add,  arterio-sclerosis. 

III.   Congenital  Syphilis. 

With  the  exception  of  the  primary  sore,  every  feature  of  the  ncquiml 
disease  may  be  seen  in  the  congenital  form. 

The  intra-uterine  conditions  leading  to  the  death  of  the  foetus  do  not 
here  concern  us.  The  child  may  be  born  healthy-looking,  or  witli  well- 
marked  evidences  of  the  disease.  In  the  majority  of  instances  the  former 
is  the  case,  and  within  the  first  month  or  two  the  signs  of  the  diseiu^e 
appear. 

Symptoms. — («)  At  Birth. — When   the  disease  exists  at  birth  the 


SY  Pill  MS. 


189 


cliilil  i.-i  t'lchly  (lovolopo'l  iiiid  \viist(Ml,  iiiid  a  skin  oriiptiou  is  usually 
iiivst'iit,  ((miiiionly  in  the  form  of  bulla'  about  the  wrists  and  ankles,  and 
,111  the  liiiii'ls  and  foct  (pcinphijijjus  ncoiiatonini).  The  cliild  snntlles,  tho 
liii«  are  iilccnitcd,  the  anjjjles  of  Uie  mouth  lissured,  and  there  is  en- 
l.irirciiH'iit  of  the  liver  and  s])leen.  'I'he  Oone  symptoms  nii'.y  be  marked, 
;i!:il  till'  <'|M[)hyses  may  even  be  sejjarated.  In  su(,'h  eases  tho  children 
niroly  survive  lon_if. 

(//)  Fjirlji  M((/iif('sf(ifi<))is. — Wlien  born  healthy  tlie  eliild  thrives,  is 
f;it  and  pliiinp,  iind  shows  no  abnormity  whatever;  then  from  the 
loiirth  to  the  eighth  week,  rarely  later,  a  nasal  eatarrh  develops,  si/jtfiiliHc 
rhinitix,  which  impeiles  respiration,  and  produces  the  characteristic 
sviiiptoin  wiiicli  has  given  the  name  siii/Jflrx  to  tho  disease.  The  dis- 
ili;ir<fe  may  be  scro-purulent  or  bloody.  The  child  nurses  with  great 
(litlic'iilty.  In  severe  cases  xdeeration  takes  ])laee  with  necrosis  of  the 
'line,  lending  to  a  depression  at  the  root  of  tlie  nose  and  a  deformity 
rharacteristic  of  congenital  syphilis.  This  coryza  may  be  mistaken  at 
iir>t  for  an  ordinary  catarrh,  but  the  coexistence  of  other  manifestations 
;;>iially  makes  the  diagnosis  clear.  The  disease  may  extend  into  tho 
liiistai'liian  tubes  and  middle  ears  and  lead  to  deafness. 

The  cii/aneons  lesions  develop  with  or  shortly  after  the  onset  of  the 
-v.ullli.'!!.  The  akin  often  has  a  sallow,  earthy  hue.  The  eruptions  are 
!ir<t  luiticed  about  the  nates.    There  may  be  an  erythema  or  an  eczematous 

iiulitioii,  but  more  commoidy  there  ai'e  irregular  reddish-brown  patches 
Mtli  well-defined  edges.      A  painilar  syphilide   in  this  region  is  by  no 

muns  uncommon.  Fissures  develop  about  the  lips,  either  at  the  ;  iigles 
li!'  the  nioutli  or  in  the  median  line.  These  rlinf/ftdcs,  as  they  are  called, 
111'  very  characteristic.     There  nuiy  l)e  marked  ulceration  of  the  muco- 

utaiieous  surfaces.  The  secretions  from  these  mouth  lesions  are  very 
viriiloiit,  aiul  it  is  from  this  source  that  the  wet-nurse  is  usually  infected. 
Xnt  only  the  nurse,  but  members  of  the  family,  may  be  contaminated. 
Tiure  arc  iiistaiu.es  in  which  other  children  have  been  accidentally  inocu- 
iaiid  from  a  syphilitic  infant.  The  hair  of  the  head  or  of  the  eyebrows 
may  fall  out.  The  syphilitic  mn/rJn'a  is  not  uncommon.  Enlargement  of 
the  glands  is  not  so  frequent  in  the  congenital  as  in  the  acquired  disease. 
When  the  cutaneous  lesions  are  marked,  the  contiguous  glands  can  usually 
ho  felt.  As  pointed  out  by  Gee,  tlie  spleen  is  enlarged  in  many  cases. 
The  condition  may  persist  for  a  long  time.  Enlargement  of  the  liver, 
tlioiigh  often  present,  is  less  significant,  since  in  infants  it  may  be  due  to 
viii'ious  causes.  These  are  among  the  most  constant  symptoms  of  con- 
.'iiiital  syphilis,  and  usually  develop  between  the  third  and  twelfth 
Weeks.  Frequently  they  are  preceded  by  a  period  of  restlessness  and  wake- 
fulness, particularly  at  night.  Some  authors  have  described  a  peculiar 
s,v|ihilitic  cry,  high-pitched  and  harsh.  Among  rai'er  manifestations  are 
haiiiorrhages — the  si/phib's  hwmorrhagica  neonatorum.  The  bleeding 
niiiy  be  subcutaneous,  from  the  mucous  surfaces,  or,  when  early,  from  the 


m 


■i'ih 


190 


SPECIFIC   INFFXrnoUS   DISEASES. 


;  .:  I 


i   :,>  ■'! 


:  ^  ■:;  i  , ^    ''ill 

1*  ii-:-.  M' 


umbilicus.  All  of  such  cases,  however,  are  not  syphilitic,  juxl  the  disease 
must  not  be  confounded  with  the  acute  hfumo^dobinuria  of  new-hom  in. 
fants,  which  Win(;kol  describes  as  occurring  in  epitlemic  form,  and  whiili 
is  probably  iiii  acute  infectious  disorder. 

{(•)  Litlv  MdiiiffKlatiiHis. — (Miildren  with  coti^jfenital  syphilis  rarclv 
thrive.  ITsually  they  present  a  wizened,  wasted  apjiearanci',  and  a  ]ii\'. 
m.aturely  aged  face.  In  the  cases  which  recover,  the  general  nutrition 
may  remain  good  and  the  child  may  show  no  further  manifestations  of 
the  disease;  commonly,  however,  at  the  period  of  .si'cond  dentition  oriit 
pub(M"ty  the  diseasi!  reapj)ears.  Althoui,'!!  the  child  may  have  recovcrod 
from  the  early  lesions,  it  does  not  develo[)  like  other  children.  Growth  is 
slow,  development  tardy,  and  there  are  facial  and  cranial  characteristics 
whicdi  often  render  the  disease  recognizable  at  a  glance.  A  young  iium  of 
nineteen  or  twenty  may  neither  look  older  nor  he  more  developed  tli;iii;i 
boy  of  tenor  twelve.  Fournit'r  describes  tliis  cotidition  w^  infaiiliHsm. 
The  forehead  is  prominent,  the  frontal  eminences  are  marked,  and  ilic 
skull  may  be  very  asymmetrical.  The  bridge  of  the  nose  is  depressed, 
the  tip  rt'froiisse.  The  lips  are  often  prominent,  and  there  are  striati-i 
lines  running  from  the  corners  of  the  mouth  The  /crfh  are  dei'orimil 
and  may  present  appoaranci's  which  Jonathan  Hutchinson  claims  aiv 
specific  and  peculiar.  The  upper  central  incisors  of  the  permanent  set 
are  the  teeth  which  give  information.  The  speciiic  alterations  are— ilic 
teetii  are  peg-sha[K'd,  stunted  in  length  and  breadth,  and  narrower  iit  tin' 
cutting  edge  than  at  the  root.  Ou  the  anterior  surface  the  enaiiicl  is 
well  formed,  and  not  eroded  or  honeycombed.  At  the  cutting  edge  there 
is  a  single  notch,  usually  shallow,  sometimes  deep,  in  which  the  dentine  is 
exposed. 

Among  late  manifestations,  particulaVly  apt  to  appear  about  pubortv, 
is  the  interstitial  kcralitis,  which  usually  begins  as  a  slight  steaniiaessnf 
the  corneiw,  which  ]iresent  a  ground-glass  appearance.  It  affects  both 
eyes,  though  one  is  attacked  before  the  other.  It  may  persist  for  niontlis, 
and  usually  clears  comi)letely,  though  it  may  leave  ojiacities,  which  pre- 
vent clear  vision.  Iritis  may  also  occur.  Of  ear  affi'cUonx,  apart  from 
those  whicli  develop  as  a  sequence  of  the  pliaryngeal  disease,  a  form  occurs 
about  the  time  of  puberty  or  earlier,  in  which  deafness  comes  on  rapi'Hv 
and  persists  in  spite  of  all  treatment.  It  is  unassociated  with  ol)vii)ii> 
lesions,  and  is  probably  labyrinthine  in  character.  Bone  lesions,  occnrriii!: 
oftcTiest  after  the  sixth  year,  are  not  rare  among  the  late  manifestations  of 
hereditary  syphilis.  The  tibiii?  are  most  frequently  attacked.  It  is  rciillv 
a  chronic  giunrratous  periostitis,  which  gradually  leads  to  great  thicken- 
ing of  the  bone.  The  nodes  of  coTigenital  syphilis,  which  are  often  mis- 
taken for  rickets,  are  more  commonly  diffuse  and  alTect  the  bones  of  the 
upper  and  lower  extrennties.  They  are  generally  symmetrical  and  rarely 
painful.     They  may  develop  late,  even  after  the  twenty-first  year. 

Joint  lesions  are  rare.     Glutton  has  described  a  symmetrical  synovitis 


.r% 


SYIIIIF.IS, 


191 


of  th(>  kiiop  in  lioroditiirv  sypliili-*.  Kiiliirironioiit  of  tlio  siOoon,  unnictiriicH 
with  tlif  lviii|ili-.i,Mim(ls,  tiuiy  bo  (»iic  of  tlic  latit  iiiaiiifcstiitioiis,  mid  rimy 
iiiriir  ciilicr  iiUmc  or  in  conncctinn  with  discnso  of  tlio  liver,  At  tlic 
|'nivcisii\  llosiiitul,  IMiiiadclpliia,  I  hail  uii(hT  nhscrvation  for  more  than 
a  vciirii  uii'l  of  thirteen,  small  and  feehly  tU'Velopeil,  witli  a  luetic  facies, 
wiiiisc  siilieii  rea<'hed  as  low  as  the  level  of  the  navel.  The  condition  was 
nut  tlien,i;lit  to  ho  due  to  iidiei'ited  .syphilis  until  she  developed  osseous 
losioiis.     Clironie  eidarf:;eineiit  of  the  saliviiry  {jlands  may  also  occur. 

(IntMMiata  of  the  liver,  brain,  and  kidneys  have  been  found  in  lato 
iiiivilitary  syphilis. 

IV.   Vlsckiial  Sy I'll! lis, 

A,  Syphilis  of  the  Brain  and  Cord. — 'I'he  following'  lesions  occur: 

(1)  litiiniiuild,  forming  delinite  tumors,  ranging  in  size  from  a  pea  to 
aw:ilniit.  They  are  usiudly  multijilcand  attached  to  the  })ia  nuiter,  some- 
Mine,-;  to  the  dura.  Very  rarely  they  are  found  unass(»ciated  with  the 
meninges.  When  small  they  present  a  uniform,  translucent  appearance, 
Imt  uliiii  large  the  centre  undergoes  a  fibro-easeous  change,  while  at  tho 
[Hriplidy  there  is  a  firm,  translucent,  grayish  tissue.  They  nuiy  closely 
resuiiible  large  tuberculous  tumors.  The  growths  are  most  common  in 
the  cereltrum.  They  may  be  multiple  aiul  nuiy  even  attain  a  (tonsid- 
erable  size  without  becoming  caseous.  Occasionally  gummata  undergo 
cystic  degeneration.  In  tho  cord  large  gummatous  growths  are  not  so 
coiiunon.  In  an  instance  recently  rei)orted  by  me  a  tumor,  from  three 
eighths  to  oue  fourth  of  an  inch  in  diameter,  was  (completely  within  the 
cord  oj)posite  the  fourth  cervical  ne/ve,  and  there  were  numerous  gum- 
miita  in  th  -  Cauda  equina. 

('.')  (I'liiiiDKi/oKs  Mn/inf/i/is. — This  constantly  occurs  in  tlie  neighbor- 
iiooil  of  the  larger  growths,  and  there  may  be  local  meningeal  thickening 
si'wnil  ceutiuietres  in  extent,  in  which  the  })ia  is  infiltrated  and  the  ar- 
teries greatly  thickened.  This  by  no  means  uncommon  form  may  run  a 
siibacuto  or  a  chronic  course;. 

(3)  flummntous  A licri'/ist.— Tho  lesions  maybe  confiiuMl  to  the  arteries 
wliicli  present  the  nodular  tumors  to  i)e  described  hereafter. 

(i)  Foci  of  sclerosis,  which  Lanccreanx  holds  may  be  distinguished 
from  non-specific  forms  by  a  much  greater  tendency  of  the  neuroglia  ele- 
monts  to  undergo  fatty  transformation,  aiul  by  the  secondary  alterations, 
as  areas  of  softening,  which  occur  in  the  neighborhood.  Neither  the  dif- 
fuse nor  the  nodular  cerebral  sclerosis,  met  with  particularly  in  children, 
appears  to  have  any  special  relation  to  inherited  syphilis. 

(o)  Whether  a  localized  eiu^e))halitis  or  myelitis  can  result  from  the 
action  of  the  syphilitic  poison  without  involvement  of  the  blood-vessels  is 
•Inubtful.  In  a  case  of  multiple  arterial  gummata  recently  in  my  ward, 
Tliomas  found  in  the  lumbar  region  of  the  cord  foci  of  inflammatory  soft- 
ening. 


it  I 


ii 


!i  I 


'm 


WA 


102 


SI'KCIKK*   IM'M'XTlors   DISKASKS. 


See<md(U'ii  CJndiffr.s. — In  tlin  brain  gunmmtous  artoritin  is  one  of  the 
(M)iiiiiioii  caufit'rt  of  Kortciiiii;,',  wliicli  iiiav  lit'  cxtciisivc,  as  wlicii  tlio  iiiiilillc 
(UTchnil  artery  iri  iuvdlvcd,  or  wlicii  liicrt*  is  ii  lari,'!'  jiatcli  of  sy|pliiliiic 
iiit'iiiiij^iLis.  Ill  siit'ii  iiistaiifcs  tlit-  proci'ss  is  really  a  iiieiiiiiL^o-eiicciiiin. 
litis,  and  the  synniloins  urediu!  to  tlie  seeoiulary  cliaii^^es  in  the  braiii-siili. 
stance,  not  (lire(!tly  to  tiie  f^iiiutna.  In  the  iieiiiiihoriiood  of  a  jiuniiiiMtdiis 
}i;ro\vth  intense  eneephalitis  or  myelitis  may  develop,  and  within  a  few 
(lavs  chanLfe  the  clinical  jiii'lnre.  (luninialous  urlerilis  may  lead  to  utuk- 
iMiinj;  of  the  wall  of  tlio  vessel  and  rnptnre  with  meninjreal  ha'm()rrliii;:c. 

Syphilitic,  diseast^  of  the  nerve-centres  may  occnr  in  the  inheriinl  nr 
aei|nired  form,  most  commonly  in  the  latter.  In  the  coii^'enital  casrs  tli,. 
tumors  usually  develop  early,  hut  may  he  as  late  as  the  twenty-lirst  Near 
(11.  ('.  Wood).  In  tlui  acquired  form  the  nerve  lesions  belong,',  as  a  rule, 
to  the  late  manifestations,  and  patients  may  have  (|uite  forjj;otten  tli('t.'x- 
istence  of  a  itrinuiry  infection,  and  in  very  many  instances  the  secoiidan 
nuinifestalions  have  been  slij^ht.  Heiibner,  to  whom  we  owe  so  much  in 
eonnection  with  this  subject,  has  seen  them  as  late  as  the  thirtieth  ytar. 
On  the  other  hand,  in  exceptional  instances,  they  may  occnr  very  early, ainl 
severe  convulsions  with  hemiplejjfia  have  been  rejiorted  within  throe  months 
of  the  primary  sore.  'I'lie  recent  discussion  at  the  Koyal  Medical  iiinl 
Chirnryical  Society  (/A  .)/. ./.,  IS'.I,"),  vol.  i),  and  Lydston's  paper  (./our.  Am. 
Mnl.  Assoc,  IS'J.j,  vol.  i),  show  that  various  alTi'Ctions  of  the  nervous  sy- 
tom  are  by  no  means  nncommon  durinj;  tlio  secomlary  stage  of  the  disease. 

Sjiinptonis. — The  chief  features  of  cerebral  syphilis  are  tliose  of  tumor, 
which  will  be  considered  subsefpiently  under  that  section.  They  may  In 
classilied  here  as  follows  : 

(1)  I'sycdiii-al  features.  A  sudden  and  violent  onset  of  delirium  may 
be  the  first  symptom.  In  other  instancies  prior  to  the  occurrence  (if 
delirium  there  have  been  headache,  alteration  of  character,  and  loss  of 
menujry.  The  condition  may  be  accompanied  by  convulsions.  I'here  may 
be  no  neuritis,  no  palsy,  and  \w  localizing  synijjtoms. 

{'i)  More  commonly  following  heada(;he,  giddines.s,  or  an  excited  stale 
which  nuiy  amount  to  deliriujn,  the  patient  has  an  epileptic  seizure  or  dt- 
velops  hemi])logia,or  there  is  involvement  of  the  nerves  of  the  base.  Sdtiio 
of  these  cases  display  a  prolongi'd  torpor,  a  special  feature  of  brain  syiilii- 
lis  to  which  both  Buzzard  and  Ileubner  have  referred,  which  may  \w\-A>\ 
for  as  long  as  a  month.  H.  C.  Wooil  describes  with  this  a  state  of  au- 
tomatism occurring  particularly  at  nigV.t,  in  which  the  patient  beluives 
like  "  a  restless  n(jcturnal  automaton  rather  than  a  man." 

(3)  A  clinical  pictnrc  of  general  paralysis — dementia  paralytica.  The 
question  is  still  in  dispnte  Avhether  this  syphilitic  encephalopathy,  wliich 
so  closely  resembles  general  paralysis,  is  a  distinct  and  independent  alTec- 
tion.  Mickle,  who  has  carefully  reviewed  the  subject,  conclndes  that 
syphilis  may  directly  produce  the  inflammatory  changes  in  the  brain,  while 
in  other  instances  it  directly  predisposes  to  this  affection.    It  is  a  isome- 


liiil 


SYFMIIMS. 


193 


wli;it  rciiiarkiiblo  foiitiiro  that  tlic  cilscs  whicli  jirosotit  tlic  (liiiiciil  pictiim 
of  irciii'ial  |iiiivsis  uro  nio.sl  lV('i|iiciitlv  tliowo  whivli  huvf  not,  had  any  hx'ul- 
i/iii(' .xvtii[itoiiis,  aiitl  they  may  imi  have  (■(iiiviil.<ioiis  until  thi'  disease!  is 
well  uihaiirt'd. 

(1)  Many  cases  of  ccTcijral  syj)iiiHs  display  tiic  symiitoiiis  (if  hniiii 
tiiiiior- iicadachc,  ojitin  neuritis,  vomiting',  and  convulsions.  Of  theso 
fiVMi|it(Mns  coiividsions  are  the  most  iniiiortant,  and  holli  T'onrnier  and 
W  ()(j(l  have  laid  threat  stress  en  tiie  value  of  this  syni|tlom  in  persons  ovor 
ihinv.  T!ie  lirst  symjitonis  may,  liowever,  latlier  reseinl)le  those  of  cin- 
iinli«iii  or  llu'oiiihosis ;  thus  there  may  he  sudden  lit'mi])Iegia,  with  or 
iiillmut  loss  of  coiiscioiisnt'SS. 

Till'  sy mploMi.s  of  xpinnl  njipliilis  uro  pxtromely  varied  and  may  bo 
.  aiis'.'il  iiv  lar;(e  ffiimmatons  j^rowths  attai'heil  to  the  nK'nin;,'es,  in  whicli 
,  ;i<c  the  features  are  th(jsc  of  tumor;  hy  gummatous  artci'lUs  with  sccoi\(l- 
a;v  .-ofiriiinm  hy  meiiintjjitis  with  secondary  cord  changes;  or  by  scleroses 
(i(Vilii[iiiig  latu  in  the  disease,  the  relation  of  whicdi  to  syphilis  is  still  ob- 
-r HIT.  A  full  n'sioiu'  by  Micklt!  of  the  recent  progress  in  this  department 
uill  lie  fiiund  in  />nn'/i  of  the  current  year.  Krb's  syphilitic  mycilitis  will 
liL'  considered  under  the  sjjastic  paraplegias. 

Diiiipidsis. — The  history  is  of  the  lirst  importance,  but  it  may  be  cx- 
truiiiely  dillicult  to  get  a  reliable  account.  Careful  examination  slioidd  bo 
iiiaile  for  traces  of  the  i)i'imary  sore,  for  the  cicatrices  of  bubo,  for  scars  of 
ilic  skin  eruption  or  throat  ulcers,  and  for  bone  lesions.  The  character 
.if  the  syiiiptoins  is  often  of  great  assistance.  They  are  multiform,  vari- 
:iMf,  and  often  sucli  as  could  not  be  explained  by  a  .single  lesion ;  thus 
ihfi'o  may  bo  anomalous  spinal  symi)toms  or  involvement  of  the  nerves  of 
ihi'  lii'aiu  on  both  sides.  And  lastly  the  result  of  treatment  has  a  delinito 
iiiuriiiif  (111  the  diagnosis,  as  the  symptoms  may  clear  up  and  disa])peur 
with  the  use  of  antisyidiilitic  remedies. 

I!.  Syphilis  of  the  Lung. 

This  is  a  very  rare  disease.  During  twenty  years  I  have  not  seen  moro 
t'  an  half  a  dozen  specimens  in  which  there  was  no  (piestion  as  to  the 
II  iiiiiv  of  the  tr()ul)le.  Early  in  my  professional  life  I  learned  to  recognize 
tilt'  disease  from  the  tcniching  of  Wilks,  and  became  familiar  with  the  ex- 
illcnt  specimens  })reserved  at  Guy's  llospital.  In  my  ten  years'  work  in 
Miiutrcal  not  a  single  sj)eeimen  was  recognized  at  the  dissections  at  the 
'MiuTal  Hospital.  In  18T8  and  1884  I  saw  several  characteristic  examjiles 
n  hiiiiihiii  and  Gerniany.  During  five  years  in  Philadelphia,  for  the 
■.Tcalor  part  of  which  time  I  was  connected  with  the  Philadelpliia  Ilospi- 
'il-  which  has  perhaps  as  ricli  luetic  material  as  is  to  be  foniul  anywhere, 
Illy  one  or  two  specimens  were  seen.  Three  admirable  illustrations  of 
pulmonary  gumniata  have  occurred  at  the  Johns  Hopkins  Hospital  during 
llie  past  two  years.  I  mention  these  details  because  tho  subject  is  one 
"liit^h  has  always  interested  me,  and  I  have  been  constantly  on  tho  lookout 
for  the  disease.     It  has  been  a  continual  surprise  that  it  should  be  so  com- 


f'M 


194 


SPECIFIC   INFECTIOUS  DISEASES. 


mnn  in  oort.'iin  lociilitios,  but  I  find  that  my  experience  as  to  its  compn'"i. 
tive  rarity  tallies  very  eloscly  with  tliat  of  patholoj^ists  and  hospital  jihvsi. 
eiana  in  tliis  country  and  in  Kurope.  The  literature  of  the  sulijcit  U 
extensive,  but  from  the  clinical  aspect  largely  wortiiless,  as  it  i)rucL'il((l 
Koch's  discovery  of  the  bacillu)^  tiibcrciilo.sis. 

E/i()J(i(/j/  mid  Morbid  Anatomy. — Sy2)hilis  of  the  lung  occurs  luidcr 
the  following  forms : 

(1)  The  H'liite  pnrinuoniK  of  the  fu'tn^t.  This  may  affect  large  iirc;i- 
or  an  entire  lung,  which  then  is  firm,  heavy  and  airless,  even  though  tln' 
child  may  have  been  born  alive.  On  section  it  has  a  grayish-white  aiipcar- 
anoe — the  so-called  white  hepatization  of  Virchow.  The  chief  change  is 
in  the  alveolar  walls,  which  are  greatly  thickened  and  infiltrated,  so  tlint. 
as  Wagner  exi)ressed  it,  the  condition  resembles  a  dilfuse  sy})hiloi)i;i.  Ii. 
the  early  stages,  for  example,  in  a  seven  or  eight  months'  fietus,  there  iriiiv 
be  scattered  miliary  foci  of  this  ijiduration  ehieily  al;out  the  artcriij 
The  air-cells  are  filled  with  desquamated  and  swollen  ei)itheliuin. 

(2)  In  the  forni  of  definite  f/xDinuita,  which  vary  in  size  from  a  pea  t<i 
a  goose-egg.  They  occur  irregularly  scattered  through  the  lung,  l)iit,  a; 
a  rule,  arc  more  numerous  toward  the  root.  They  present  a  grayish-yellnw 
caseous  appearance,  arc  dry  and  usually  imbedded  in  a  translucent,  more 
or  less  firm,  connective  tissue.  In  a  case  from  my  wards  recently  descrili'"! 
by  Councilman,  there  was  oxteusive  involvement  of  the  root  of  the  \n\v:i 
I3ands  of  connective  tissue  passed  inward  from  the  thickened  pleiu'fi  an! 
between  these  strands  and  surnuuiding  the  gummata  there  was  in  ])hv- 
a  mottled  red  pneumonic  consolidation.  In  the  caseous  nodules  there 
is  typical  hyaline  deg.'ueration.  Councilman  describes  as  the  priiiiarv 
lesion,  atrophy  of  the  alveolar  walls  with  hyaline  degeneration  of  the  C'a|iil- 
laries;  iu)t  the  syphilitic  endarteritis,  whicdi  is  well  marked,  and  to  which 
the  lesions  are  attributed.  The  bronchi  are  usually  involved,  and  sur- 
rounding the  gummata  there  may  be  a  diffuse  broncho-i)ncumonia,  which 
does  not  ajipear  to  have  any  peculiar  cdniracters. 

(3)  A  nnijority  of  authors  f>)liow  Virchow  in  recognizing  the  fihrmi- 
interstitial  pneumonia  at  the  root  of  the  lung  and  passing  along  the  hrnii- 
chi  and  vessels  as  probably  syphilitic.  This  mucli  may  V)o  said,  that  in  oer- 
tain  cases  gummata  are  associated  with  these  fibroid  changes.  Again,  tlii- 
condition  alone  is  fouiul  in  persons  witli  well-nnirked  syphilitic  histiirvnr 
with  other  visceral  lesions.  It  seems  in  many  instances  to  be  a  luircl; 
sclerotic  process,  advancing  sometimes  from  the  pleura,  more  coiiininnly 
from  the  root  of  the  lung,  and  invading  the  interlobular  tissue,  grailiially 
producing  a  more  or  less  extensive  fil)roi(l  change.  It  rarely  involve- 
more  than  a  portion  of  a  lobe  or  portions  of  the  lobes  at  the  root  of  the 
lung.     The  bronchi  are  often  dilated. 

Sj/mptoms. — Is  there  a  syphilitic  i)hthisis,  an  ulcerative  and  dostrnc- 
tive  disease,  due  to  lues?  Personally  I  have  no  knowledge  of  siu'h  ar, 
alTcction,  either  clinically  or  anatomically,  and  the  cases  which  I  have  seen 


SYPHILIS. 


195 


0  as  to  its  compn'"'- 
i  and  hospitiil  pliysi- 
re  of  tlio  fiubjirt  is 
iless,  us  it  pivix'ilfil 


lung  occurs  under 


lay  affect  large  areas 
loss,  even  thouLrh  tlio 
rrayisli-wliite  iiiipcar- 
The  chief  changeis 
u\  intiltrated,  so  tlmt, 
ilTuso  syphilom;).    In 
iths'  fu'tus,  there  miiy 
y   ahniit  the  arteriis, 
1  opitheliuni. 
■  in  size  from  a  poa  to 
ugh  tlie  lung,  Imt,  ii' 
•cseiit  a  grayish-yclliAv 
in  a  translucent,  more 
mis  recently  flesoribcil 
the  root  of  the  hms'. 
thickened  pleura  a^! 
ta  there  was  in  place; 
caseous  noduUs  tlim 
rihes  as  the   priinarv 
eneration  of  tlie  oaiiil- 
marked,  and  to  whirli 
lly  involved,  nud  snr- 
ho-pueumonia,  uIimIi 

■cognizing  the  fibmi? 
lassing  along  the  brmi- 
lay  1)0  said,  that  in  cer- 
ehanges.     Agnin,  llii^ 
.(I  syphilitic  history  nr 
Itances  to  be  a  piircl.v 
leura,  more  connnmily 
[hular  tissue,  gni'hisiHy 
ce.     It  rarely  involv(- 
^bes  at  the  root  of  the 

llcerative  and  dostruo- 

niowledgo  of  ?nc\\  an 

lise3  which  I  have  seen 


(loiiioiistrated  do  not  joeni  to  nie  to  have  characters  distinctive  enough  to 
sfiianilo  them  from  ordiiuiry  tuberculous  phthisis.  C'ertaiji  French  writers 
iwK'iiize  not  only  a  clironic  syphilitic  phthisis  but  an  acute  syphilitic 
jiiii'iinioiiia  in  iidults,  simulating  acute  pneunumic  phthisis.  Clinically, 
|iiiliiioii;U'y  syphilis  is  iu)t  of  mucii  importance,  as  the  cases  can  rarely  bo 
liiairMu.SL'il,  and  the  syn)ptoms  which  arise  arc  usually  those  of  bronchi- 
n'ta.sis  or  of  chronic  interstitial  pneumonia.  The  white  imeumonia  is 
usiiallv  found  in  the  still-born. 

Diagnosis. — It  is  to  be  borne  in  mind,  in  the  first  place,  that  hospital 
pli\>iL'i:uis  and  pathologists  the  world  over  bear  witness  to  the  extreme 
nirity  of  hing  syphilis.  In  the  second  place,  the  therapeutic  test  upon 
wliieli  so  much  reliance  is  placed  is  by  no  means  conclusive.  AVith  pul- 
iiiDiiary  tuberculosis  there  should  now  be  no  confusion,  owing  to  tlic  readi- 
ness with  which  the  presence  of  bacilli  is  determined.  Bronchiectasy  in 
till'  lower  lobe  of  a  lung,  dependent  upon  an  interstitial  pneumonia  of 
fivpliilitie  origin,  could  not  be  distinguished  from  any  other  form  of  the 
disease'.  In  persons  with  well-marked  syphilitic  lesions  elsewhere,  when 
oljscure  pulmonary  symptoms  oc(uir,  or  if  there  are  signs  of  chronic  inter- 
siilial  iiHi'iimonia  with  dilated  bronchi,  and  no  tubercle  bacilli  are  present, 
liie  I'Diidiiion  may  possibly  be  due  to  syphilis.  8o  far  as  my  experience 
iroos,  tuberculous  phthisis  occurring  in  a  syphilitic  subject  has  no  sjiecial 
jee'uliiirities.  The  lesions  of  syphilis  aiul  tuberculosis  could  of  course  co- 
exist in  ii  lung.  Since  writing  the  above,  the  recent  paper  of  Satterthwaito 
li;is  appeared,  but  not  oiu'  of  the  cases  upon  whiidi  it  is  based  could  prop- 
erly be  regarded  as  syphilitic  in  the  absence  of  an  examination  for  tulxT- 
ele  bacilli.  Much  more  suggestive  of  true  syphilitic  phthisis  is  Case  I  of 
MeLauc  Titfany's  series,  but  it  too  may  have  been  tuberculous.  It  is  quite 
jiiissiblo  that  a  large  caseous  gumma  nuiy  break  down  aiul  form  a  cavity, 
!mt  the  existence  of  an  extensive  ulcerative  and  destructive  disease  of 
tlie  lungs  (comparable  to  tuberculosis)  due  to  syphilis  has  not  yet  been 
proved. 

e.  Syphilis  of  the  LlA'er. 

This  occurs  in  three  forms  :  (a)  J)ijfiisf>  Siiphililir  llcpalitii<. — This  is 
must  common  in  cases  of  congenital  sy])hilis.  The  liver  preserves  its 
fiMMi,  is  large,  hard,  and  rcsi.stant.  Sometimes  it  has  a  yidlow  look,  com- 
pared by  Trousseau  to  sole-leather,  or  an  aiipearance  not  unlike  the  amy- 
Inid  liver.  Careful  inspection  shows  grayish  or  whitish  points  and  lines 
enrrespoiuling  to  the  interlobular  lU'W  growth.  Microscoi)ically,  great 
iaereasu  in  the  connective  tissue  is  seen,  and  in  many  places  foci  of  sniall- 
(vlled  infiltration.  Rometinuvs  these  nodules  are  visible,  forming  firm 
"''  .T  gnminata  which  in  cic.'idrizing  i)r()duce  more  or  less  deformity. 
Large"  gum mata  may  also  be  })reseiit. 

(//)  (iHinvKiia. — As  a  result  of  congenital  syphilis  these  may  occur  in 
I'liildhood  or  in  adult  life.  In  acquired  syphilis  they  rarely  come  on  bo- 
fre  the  second  year  after  infection.     In  the  early  stage  there  are  pale 


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196 


SPECIFIC   INFECTIOUS   DISEASES. 


grayish  nodules,  varying  in  size  from  a  pea  to  a  marble.  The  larger, 
wliieh  are  usually  limited  toward  tlie  liver  tissue,  present  yellowish  cen- 
tres at  Orst;  but  later  there  is  a  "  ]»ale  yellowish,  cheese-like  nodule  of 
irregular  outline,  surrounded  by  a  fibrous  zone,  the  outer  edge  of  whirli 
loses  itself  in  the  lobular  tissue,  the  loljules  dwindling  gradually  in  its 
grasp.  This  fibrous  zone  is  never  very  broad  ;  the  cheesy  centre  varies  in 
consistence  from  a  gristle-like  toughness  to  a  pulpy  softness;  it  is  sonic. 
times  mortar-like,  from  cretaceous  change"  (Wilks).  When  nunicnius, 
the  most  extensive  deformity  of  the  liver  is  produced  in  the  graduiil  lieiil- 
ing  of  these  gummata.  On  the  surface  there  are  deep,  scar-like  depres- 
sions, and  the  entire  organ  may  be  divided  inl(j  a  cluster  of  irrcirular 
masses,  held  together  i)y  fibrous  tissue.  'J'o  tliis  coTiditicm  the  term  W;/. 
raid  has  beeii  given,  from  its  resendjlance  to  a  l)unch  of  gra{)es.  Asa 
rule,  the  gimimata  gradually  v.ndergo  fibroid  trausfornuition.  They  may, 
however,  soften  and  licpiefy,  and,  according  to  AVilks,  may  form  a  iliietu- 
ating  tumor. 

(c)  Occasionally  the  syphilitic  (;iringes  are  chieny  manifested  in  (His- 
son\'i  .sheaf/i,  in  a  thickening  of  the  capsule,  ])n)ducing  peri-hepatitis,  and 
increase  in  the  connective  tissue  in  the  portal  nDuiIs,  so  that  on  soetioa 
the  organ  presents  a  number  of  branching  fibrous  scars  which  may  eaiise 
considerable  deformity. 

Si/inp/onifi. — The  symptoms  of  sypliilitic  hepatitis  are  very  vari;ilili?. 
In  the  new-born  icterus  is  not  uncommon,  but  tlie  condition  of  tlic  livtr 
can  scarcely  be  recognized.     In  the  adult  there  are  two  groups  of  cases: 

The  patient  presents  a  picture  of  cirrhosis  of  the  liver;  there  are 
digestive  disturbances,  slight  ictterus,  loss  of  weigid,  and  ascites.  If  siiriis 
of  syphilis  are  present  in  other  organs,  the  C(tndition  may  be  suspeeted, 
or  if  after  removal  of  the  fluid  the  liver  Is  felt  to  be  extremely  irrciriilar, 
the  diagnosis  may  be  made  almost  with  certainty.  These  cases,  uiili 
proper  treatment,  may  get  well,  and  they  form  an  important  contingent 
of  the  reputed  recoveries  in  ordinary  cirrhosis  of  the  liver. 

In  a  second  group  of  cases  the  patient  is  anaemic,  passes  large  quan- 
tities of  pale  urine  containing  albumen  and  tube-casts ;  the  liver  is  en- 
larged, perhaps  irregular,  ami  the  spleen  also  is  eidarged.  Dropsical  symp- 
toms may  supervene,  or  the  [latient  may  be  carrie<l  off  by  some  intercurrent 
disease.  Extensive  amyloid  degeneration  of  the  spleen,  the  intestinal  mu- 
cosa, and  of  the  liver,  with  gummata,  are  foutid. 

The  dinf/nosis  of  syphilis  of  the  liv  'r  is  very  important,  since  upon  it 
the  proper  treatment  depends.  If  with  a  history  of  infection  the  liver 
is  enlarged  and  irregular,  and  the  general  health  fairly  good,  tlio  con- 
dition is  probably  syphiloma.  Occasionally  tumors  of  a  definite  form  may 
be  produced  by  the  gumnuita.  For  two  years  I  showed  repeatedly,  at  my 
clinic  at  the  University  IIos|)itaI,  I'hiladelphia,  a  boy  aged  eleven,  who 
had  a  prominent  tumor  in  the  e[iigastrium  connected  with  the  liver,  tlio 
uature  of  which  was  obscure  until  well-nuirked  bone-lesions  develitped. 


SYPHILIS. 


197 


In  aiiotlior  oase,  a  miui,  aged  thirty,  was  sent  to  nic  for  advice  concerning 
till'  iiKikiiiu^  of  an  exploratory  incision  to  determine  tlie  natnre  of  a  firm, 
invi^nilar  tiiinnr  which  occupied  tlie  epiga.stric  region,  and  was  evidently 
coniiec'trd  witli  llie  left  lobe  of  the  liver.  It  had  lasted  for  more  than  a 
vc:ii'  hail  increased  slightly,  and  had  not  impaired,  to  any  marked  degr^o, 
the  ccnorai  health.  This  fact,  together  with  a  well-markeil  history  of 
acquired  svphilis,  led  me  to  place  him  upon  a  rigid  antisyphilitic  treat- 
iiHiit,  wiili  the  result  that  within  six  months  the  entire  tumor  disappeared. 
1),  Syphilis  of  the  Digestive  Tract. 

The  (fsiipluKjus  is  very  rarely  atl'ected.  Stenosis  is  the  usual  result, 
(luiiiiiiata  of  tlie  sion  avk  occur  occasionally.  Sy])hilitic  ulceration  has 
Ihtii  fouiul  ill  the  stomach,  in  the  small  intestine,  and  in  the  ca'cum. 

The  most  common  seat  of  syphilitic  disease  in  this  tract  is  the  rechim. 
The  iilTeetion  is  found  most  c()mnu;)idy  in  women,  and  results  from  the 
'levek)i)iiieiit  of  gunnnata  in  the  submucosa  above  the  internal  sphincter. 
Tlie  process  is  sl'>\v  and  tedious,  and  may  last  for  years  before  it  finally 
mihiees  stricture.  'J'lie  symptoms  are  usually  those  of  narrowing  of  the 
lower  bowel.  The  condition  is  readily  recognized  by  recital  examination. 
The  history  of  gradual  on-(M)ming  stricture,  the  state  of  tlu'  patient,  and 
the  fact  that  there  is  a  hard,  librous  narrowing,  not  an  elevated  crater-like 
ulcer,  usually  reiuh'r  easy  the  diagnosis  from  nudignant  disease.  In  nu'ili- 
cal  practice  these  cases  come  under  observation  for  other  sym])toms,  par- 
liriiliuiy  inuyloid  degeneration ;  and  the  rectal  disease  may  be  entirely 
ovcrlnokeil,  uiul  only  discovered  post  mortem, 
i:.  Circulatory  System. 

Sii/i/i ill's  of  the  Heart. — A  fresh,  warty  endocarditis  due  to  syphilis  is 
nut  recognized,  though  occasionally  in  persons  dead  of  the  disease  this 
I'lim  is  present,  as  is  not  uncommon  in  coiulitions  of  debility.  Outgrowths 
"lithe  valves  in  connection  with  gummata  have  ))cen  reported  by  Janeway 
iinl  (itheis,  and  in  Lang's*  monograph  there  are  thirteen  cases  which  ho 
iciiorts  as  syphilitic  endocarditis,  most  of  them  of  the  fibrous  or  sclerotic 
variety 

Syphilitic  myocai'ditis  apj)ears  cither  in  the  form  of  diffuse  fibroid  in- 
hiratioii  or  as  deiinite  gummata.  Lang  has  collected  many  cases  from  the 
hiciiiture,  a  majority  of  which  were  of  the  former  description.  Gummata, 
however,  occur  not  infrequently  as  definite  and  characteristic  tumors  in 
tiio  luyocanlium.  Kupture  may  take  j)Iace,  as  in  the  cases  reported  by 
Itaiidridge  and  Xalty,  or  sudden  death,  as  in  the  cases  of  Cayley  and  Pearce 
Oould. 

Sjipliih's  of  the  Arteries. — Syphilis  is  believed  to  play  an  important 
ruh'ln  arterio-sclerosis  and  aneurism.  Its  connection  with  these  processes 
^^ill  lie  eonsidei'cd  later;  here  we  shall  refer  only  to  the  syphilitic  arteri- 
tis.   This  occurs  in  two  forms  : 


*i  !'■ 


*  Die  Syphilis  des  Hcrzcns,  Wien,  1889. 


198 


SPECIFIC  INP^ECTIOUS  DISEASES. 


If,', 


J    i 


[a)  An  oMifcrafinf/  eiiflarteriiis^chiirkictcr'ncd  by  a  proliferation  of  tlie 
suheudotlic'liiil  tissue.  'J'iie  new  growth  lies  witliin  the  eliistic  liuuiiiii,  imd 
may  frnidiially  1111  tlie  entire  lumen;  lientje  tlie  term  obliteratinjx.  Tlie 
media  and  adveiititia  are  also  inliltrated  with  small  eells.  This  I'orin  nf 
endarteritis  described  by  lleubner  is  not,  however,  charaeteristio  of  syjilii. 
lis,  and  its  ]>reseiice  alone  in  an  artery  conld  not  .be  considered  jialhoi;- 
nonioiiic.  If,  however,  there  are  f,nimmata  in  other  })ai'ts,  or  if  the  con- 
dition about  to  be  ilesin'ibed  exists  in  atijaeent  arteries,  the  i)roee.<s  iiiav 
bo  regarded  as  syphilitic. 

(b)  GummatouH  Pcri-artcritis. — With  or  without  involvement  of  the 
intima,  nodular  gumniata  may  develop  in  the  adveiititia  of  the  arlfn, 
producing  globular  or  ovoid  swt'Uings,  which  may  attain  ct)nsiderable  size. 
They  are  not  infrecpieiitly  seen  in  the  cerebral  arteries,  which  seem  toU 
specially  prone  to  this  aU'ectiitn.  'i'his  form  is  specilic  and  distinctive 
of  syphilis.  The  disease  usually  alfects  the  smaller  vessels  and  iiiiiy  U 
found  in  the  coronary  arteries,  and  particularly  in  those  of  the  brain. 

F.  Renal  Syphilis. — (Jummata  occasionally  develop  in  the  kidnoys, 
particularly  in  cases  in  which  there  is  extensive  guiiimatous  hepatitis. 
They  are  rarely  numerous,  ami  occasionally  lead  to  scattered  cicatricoj. 
Clinically  the  alTection  is  not  recogiiizalde. 

G.  Syphilitic  Orchitis. — Tliis  alTection  is  of  special  .significance  to  the 
physician,  as  its  detection  frequently  clinches  the  diagnosis  in  obsciir. 
internal  disorders.     Syphilis  occnirs  in  the  testes  in  two  forms: 

(«)  The  (jummatous  ^;v>«'///,  forming  an  indurated  mass  or  grnnpot 
masses  in  the  substance  of  the  organ,  and  sometimes  diilicult  to  distin- 
guish from  tuberculous  disease.  The  area  of  induration  is  harder  ami  it 
atTects  the  body  of  the  testes,  while  tubercle  more  commoiily  involves  tlie 
epididymis.  It  rarely  tends  to  invade  the  skin,  or  to  break  down,  sol'uii, 
and  suppurate,  and  is  usually  jiainless. 

(b)  There  is  an  infers/ ih'al  tirclntix  regarded  as  syphilitic,  Avhidi  k■a^l^ 
to  fibroid  induration  of  the  gland  and  gradually  to  atrophy.  It  is  a  slow, 
progressive  change,  coming  on  without  pain,  usually  involving  one  organ 
more  than  another. 

General  Diagnosis  A  Syphilis. — There  is  seldom  any  donht 

concerning  the  existence  of  syphilitic  lesions.  The  negative  statciiii'iitj 
of  the  patient  must  be  taken  with  extreme  caution,  as  jiersons  will  lie 
deliberately  with  reference  to  primary  infection,  when  it  is  in  their  bi-i 
interest  to  make  a  straightforward  truthful  statement.  It  is  to  be  re- 
membered that  sy})hilis  is  common  in  the  community,  and  there  are  proh- 
ably  more  families  with  a  luetic  than  with  a  tuberculous  taint.  It  is  po.-- 
sible  that  the  primary  sore  may  luive  been  of  trifling  extent,  or  uictlinil 
and  masked  by  a  gonorrlui^a,  and  the  patient  may  not  have  had  seven 
secondary  symptoms,  but  such  instances  are  extremely  rare.  Im|imi(> 
should  be  made  into  the  history  to  ascertain  if  the  jiatient  lias  liiul  ■'kin 
rushes,  sore  throat,  or  if  the  hair  has  fallen  out.    Careful  inspection  shoiilJ 


SYPHILIS. 


19U 


W  iiiiult'  i^f  tlio  throat  and  skin  for  signs  of  old  lesions.  Soars  in  the 
(friiiiiN 'li'' ''''^"'^ '*t'  buboes,  may  be  taken  as  jiositive  evidence  of  infec- 
tinii  (Hiililiiiisoii).  The  cicatriees  on  the  legs  are  often  eojiper-colored, 
ilioiiirh  this  cannot  be  regarded  as  peculiar  to  syidiilis.  1'he  bones  should 
lie txiiiiiiiH'l  for  nodes.  In  doubtful  cases  the  sear  of  the  i)rinuiry  sore 
iiiiiv  be  fdiiiid,  or  there  may  be  signs  of  atrophy  or  of  hardening  of  the 
tc-li's.  In  women,  special  stress  has  been  laid  upon  the  occurrence  of 
frequent  nii.>earriages,  which,  in  connection  with  other  circumstances,  are 
ahviiys  suggestive. 

ill  the  cuiigenital  disease,  the  occurrence  within  the  first  three  months 
of  smilllrs  and  skin  rashes  is  conclusive.  Later,  the  characters  of  the 
fV|)hiliti<'  facies,  already  referred  to,  often  give  a  clew  to  the  nature  of  some 
(ilisiiire  visceral  lesion.  Other  distinctive  features  are  the  symmetrical  de- 
viliipmeiit  "f  nodes  on  the  hones,  and  the  interstitial  keratitis. 

In  doiilitful  cases  much  stress  is  laid  by  some  writers  upon  the  thera- 
peutic tost,  by  placing  the  patient  upon  antisyphilitic  treatment.  In  the 
iiise  (if  iui  obstinate  skin  rash  of  doubtful  character,  which  has  resisted  all 
(itlier  forms  of  medication,  this  has  much  greater  weight  than  in  obscure 
viseefiil  lesions.  I  have  on  several  occasions  known  such  marked  im- 
jiruveiiieiit  to  follow  large  doses  of  iodide  of  potassium  that  the  diagnosis 
iif  ?vpliilitic  lesion  was  greatly  strengthened,  but  the  subsequent  course 
mill  the  post-mortem  have  shown  that  the  disease  was  not  syphilis. 

Prophylaxis. — Irregular  intercourse  has  existed  from  the  begin- 
iiiiij;  of  recorded  history,  and  unless  man's  nature  wholly  changes — 
and  of  this  we  can  have  no  hope — will  continue.  Resisting  all  attempts 
at  siihitioii,  the  social  evil  remains  the  great  blot  upon  our  civilization, 
ami  inextricably  blended  with  it  is  the  ([uestion  of  the  prevention  of  syphi- 
lid. Two  measures  are  available — the  one  personal,  the  other  adminis- 
trative. 

Personal  purity  is  the  prophylaxis  which  we,  as  j^hysicians,  are  espe- 
[  cially  hound  to  advocate.  Continence  may  be  a  hard  condition  (to  some 
jlianler  than  to  others),  but  it  can  be  borne,  and  it  is  our  duty  to  urge  this 
li.vim  upon  young  and  old  who  seek  our  advice  in  matters  sexual.  Cer- 
tainly it  is  better,  as  St.  Paul  says,  to  marry  than  to  burn,  but  if  the  fonuer 
li<  nut  feasible  there  are  other  altars  than  those  of  Venus  upon  whicdi  a 
youiii:  niai)  may  light  fires.  lie  may  practise  at  least  two  of  the  five 
means  hy  which,  as  the  physician  Kondil)ilis  counselled  Panurge,  cariuil 

niipiseence  may  be   cooled  and  quelled — hard  work  of  body  ami  hard 

hvurk of  mind.     Idleness  is  the  mother  of  lechery;  and  a  young  man  will 

fitnl  that  absorption  in  any  pursuit  will  do  much  to  cool  passions  which, 

[tlion^'h  natural  and  proper,  cannot  in  the  exigencies  of  our  civilization 

|ii!«ay-!  oljtain  natural  and  proper  gratification. 

The  secoiul  measure  is  a  rigid  and  systematic  regulation  of  prostitu- 
[tii'ii.  The  state  accepts  the  responsibility  of  guarding  citizens  against 
|fniall-pox  or  cholera,  but  in  dealing  with  syphilis  the  problem  has  been 
14 


.\  m 


•  ii 


200 


SPECIFIC  INFECTIOUS  DISEASPIS. 


-■    -i  : 


!^ 


t    1 


<,    < 


A-  ?! 


S'V.  • 


too  conii)lcx  and  has  hitherto  baffled  sohition.  On  the  one  hand,  inspec- 
tion, segregation,  and  regulation  are  dilliciilt  if  not  ini[)ussible  U)  oam 
out;  on  the  other  hand,  public  sentiment,  in  Anglo-Saxon  eoinniuiiiiitj 
at  least,  is  as  yet  bitterly  opposed  to  this  plan.  While  this  feeling,  ihtmirii 
unreasonable,  as  1  think,  is  entitled  to  consideration,  the  choice  lies  be. 
tween  two  evils — licensing,  even  imperfectly  carried  out,  or  wide-siiread 
disease  and  misery.  If  the  olfeiider  bore  the  cross  alone,  I  would  snv, 
forbear;  but  the  {)hysi('iaii  behind  the  scenes  knows  that  in  countless  in. 
stances  syphilis  has  wrought  havoc  among  innocent  mothers  and  lielplufs 
infants,  often  entailing  life-long  sullering.  It  is  for  them  he  advocate 
protective  measures. 

Treatment. — We  must  admit  that  various  constitutions  react  vcrv 
differently  to  the  poison  of  syphilis.  There  are  indiviiluals  who,  altlioii;:!! 
receiving  brief  and  unsatisfactory  treatment,  display  for  years  no  traces  of 
the  disease.  On  the  other  liaiul,  there  are  persons  thoroughly  and  sys- 
tematically treated  from  the  outset  who  display  from  time  to  tinu'  well- 
marked  indications  of  the  disease.  Certainly  there  are  grounds  fi»r  ihe 
opinion  that  persons  who  have  suffered  very  slightly  from  secoiulaiv 
symptoms  are  more  prone  to  have  the  severer  visceral  lesions  of  the  later 


stage. 


When  we  consider  that  syphilis  is  one  of  the  most  amenable  of  all  dis- 
eases to  treatment,  it  is  lamentable  that  the  later  stages  which  come  iiihIit 
the  charge  of  the  ])hysician  are  so  common.  This  results,  in  great  par;, 
from  carelessness  of  the  patient,  who,  wearied  with  treatment,  cainiot  mi- 
derstand  why  he  should  continue  to  take  medicine  after  all  the  syiiipt(iiii> 
have  disap[)eared ;  but,  in  part,  the  profession  also  is  to  blame  for  not 
insisting  more  urgently  in  every  instance  that  acquired  syphilis  is  not 
cured  in  a  few  months,  but  takes  at  least  two  years,  during  which  time 
the  ])atient  should  be  under  careful  supervision.  The  treatment, of  tlie 
disease  is  now  })ractically  narrowed  to  the  use  of  two  remedies,  justly 
termed  specifics — namely,  mercury  and  iodide  of  potassium.  The  former 
is  of  special  service  in  the  secondary,  the  latter  in  the  tertiary  manifesta- 
tions of  the  disease ;  but  they  are  often  combined  with  advantage. 

Mercury  may  be  given  by  the  mouth  in  the  form  of  gray  powder,  tlie 
hydrargyrum  cum  creta,  which  Hutchinson  recommends  to  be  given  in 
pills,  one-grain  dose  with  a  grain  of  Dover's  powder.  One  pill  from  fmir 
to  six  times  a  day  will  usually  suftice.  I  warmly  endorse  the  excellent 
results  which  are  obtained  by  this  method,  under  which  the  patient  often 
gains  rapidly  in  weight,  and  the  general  health  im])roves  remarkably,  li 
may  be  continued  for  months  without  any  ill  effects.  Other  forms  ,i,nvin 
by  the  mouth  are  the  pilules  of  the  biniodide  (gr.  r^),  or  of  the  protiodide 
(gr.  \),  three  times  a  day. 

Inunction  is  a  still  more  effective  means.  A  drachm  of  the  ordinary 
mercurial  ointment  is  thoroughly  rubbed  into  the  skin  every  evening  fur 
six  days ;  on  the  seventh  a  warm  bath  is  taken,  and  on  the  eighth  the  nier- 


i.'i  i  i.iij'.fi 


ML 


SYPHILIS. 


201 


ciiri;il  oouvse  is  resumed.  At  least  half  an  hour  should  bo  piven  to  each 
imiin'tioii.  It  is  well  to  a])])ly  it  at  dill'erent  ])hi('es  on  suceessive  days. 
Tin'  siiiL'-'  "f  tl'*^  chest  and  abdomen  and  the  inner  surfaces  of  the  arms 
and  tlii.u'li^  '^^'^  tliG  best  positions. 

The  iiHTeury  may  bo  j;iven  by  direct  injection  into  the  museles.  If 
lironiT  pivcautions  are  taken  in  sterilizin<(  the  syringe,  and  if  tlie  injec- 
tions art'  made  into  the  museles,  not  into  tlie  subcutaneous  tissue,  ab- 
scesses rarely  result.  One  tliird  of  a  grain  of  the  bicblorido  in  twenty 
drops  of  water  may  be  injected  once  a  week,  or  from  one  to  two  grains  of 
caloiiH'l  ill  glycerin  (:^0  minims). 

Still  another  method,  greatly  in  vogue  in  certain  parts  of  the  Continent 
anil  ill  institutions,  is  fumigation.  It  may  be  carried  out  etTectively  by 
iiicaiKS  dl'  Lee's  lamp.  Tlie  patient  sits  on  a  chair  Avrapped  in  blankets, 
with  the  head  exposed.  The  calomel  is  volatilized  and  deposited  with 
tlie  vapor  on  the  patient's  skin.  IMie  ])rocess  lasts  about  twenty  minutes, 
ami  the  patient  goes  to  bed  wrapped  in  blankets  without  washing  or  dry- 
in;:  the  skin.  A  patient  under  mercurial  treatment  should  avoid  stimu- 
lants and  live  a  regular  life,  not  necessarily  abstaining  from  business. 
(Iiwn  vegetables  and  fruit  should  not  be  taken.  Salivation  is  to  bo 
avoided.  The  teeth  shoidd  be  cleansed  twice  a  day,  and  if  the  gums  be- 
poine  tender,  the  breath  fetid,  or  the  tongue  swollen  and  indented,  the 
(Iriiir  should  bo  suspended  for  a  week  or  ten  days. 

In  congenital  syphilis  the  treatment  of  cases  born  with  bulla;  and  other 
siiriis  of  the  disease  is  not  satisfactory,  and  the  infants  usually  die  within  a 
fiw  days  or  Aveeks.  The  child  should  bo  nursed  by  the  mother  alone,  or, 
it'tliis  is  not  feasible,  should  be  hand-fed,  but  under  no  circumstances 
should  a.  wet-nurse  be  employed.  The  child  is  most  rapidly  and  thor- 
miL'lily  brought  under  the  inlluence  of  the  drug  ])y  inunction.  Tlie  mer- 
inirial  ointment  may  bo  smeared  on  the  flannel  roller.  This  is  not  a  very 
ili'aiily  method,  and  sometimes  rouses  the  susjiicion  of  the  mother.  It 
is  preferable  to  give  the  drug  by  the  mouth,  in  the  form  of  gray  ppwider, 
lialf  a  grain  three  times  a  day.  In  the  lato  uumifestations  associated 
with  hone  lesions,  the  combination  of  mercury  and  iodide  of  potassium 
is  most  suitable  and  is  well  given  in  the  form  of  (Jilbert's  syrup,  which 
consists  of  the  biniodidc  of  mercury  (gr.  j),  of  potassium  iodide  (  3  ss.), 
and  water  (  3  ij).  Of  this  a  dose  for  a  child  under  three  is  from  five  to 
tin  drops  three  times  a  day,  gradually  increased.  Under  these  measures, 
tlie  cases  of  congenital  syphilis  usually  improve  with  great  rajiidity.  The 
nudication  should  bo  continued  at  intervals  for  many  months,  and  it  is 
«vll  to  watch  these  patients  carefully  during  the  period  of  second  dentition 
and  at  puberty,  and  if  necessary  to  place  them  on  specific  treatment. 

In  the  treatment  of  the  visceral  lesions  of  syphilis,  which  come  more 
distinctly  within  the  province  of  the  physician,  iodide  of  potassium  is  of 
fjiial  or  even  greater  vaUie  than  mercury.  Under  its  use  ulcers  rapidly 
l'»"il,  gummatous  tumors  melt  away,  and  we  have  an  illustration  of  a  spe- 


1  '&* 


>!' 


i.' 


.1.1:   •  • 


i,.       '■ 


.is  1  '4 


111, 


u  ;, 


203 


SPECIFIC  INFECTIOUS  DISEASES. 


I'' 


'P     1 


cific  action  only  eqiialleil  by  that  of  nierciii';-  in  the  secondary  stajros,  liv 
iron  in  certain  forma  of  anaMnia,  mul  l)y  quinine  in  mahiriu.  It  is  as  a 
rule  well  Ijorue  in  an  initial  dose  of  ten  grains,  or  ten  iniiiims  of  the  satii- 
rated  solution  ;  <,aveii  in  milk  the  patient  does  not  notice  the  taste.  It 
should  be  gradually  increased  to  thirty  or  more  grains  three  times  a  dav, 
In  syphilis  of  the  nervous  system  it  may  be  used  in  still  larger  ddscs, 
Seguin,  who  has  specially  insisted  upon  the  advantage  of  this  plan,  uri:oj 
that  the  drug  should  be  pushed,  as  good  elfects  are  not  obtained  willi  tlif 
moderate  doses. 

When  syi)hilitic  hepatitis  is  suspected  the  combination  of  mercury  iiini 
iodide  of  ])otassium  is  most  satisfactory.  If  there  is  ascites,  Addison's  or 
Niemeyer's  pill  (as  it  is  often  called)  of  calomel,  digitalis,  and  squills  will 
be  fouiul  very  useful.  A  patient  of  mine  with  recurring  ascites,  on  wIkiih 
paracentesis  was  repeatedly  j)erformed  and  who  had  an  eidarged  and  iiTtuu- 
lar  liver,  took  this  pill  for  nujre  than  a  year  with  occasional  intermissioiiN 
and  ultimately  there  was  a  complete  disappearance  of  the  drop.sy  ami  an 
extraordinary  reduction  in  the  volume  of  the  liver.  Occasionally  the 
iodide  of  sodium  is  more  satisfactory  than  the  iodide  of  potassium.  It  i,> 
less  depressing  aiul  agrees  better  with  the  stonuich.  Many  patients  \H)m<i 
a  remarkable  idiosyncrasy  to  the  iodide,  but  as  a  rule  it  is  well  \wnw. 
Severe  coryza  with  salivation,  and  o'dema  about  the  eyelids,  are  its  iiiosi 
common  disagreeable  elfects.  Skin  eruptions  also  are  frequent.  I  liaw' 
known  patients  umil)le  to  take  more  than  from  twenty  to  thirty  gniiiis 
without  suffering  from  an  erythenuitous  rash  ;  much  more  common  is  the 
acne  eruption.  Occasionally  an  urticarial  rash  may  develop  with  spots  of 
purpura.  Some  of  these  iodide  eruptions  nuiy  closely  resemble  syjihilis. 
Hutchinson  has  reported  instances  in  which  they  have  proved  fatal. 

Upon  the  question  of  syphilis  and  marriage  the  family  physician  i> 
often  called  to  decide.  He  should  insist  upon  the  necessity  of  two  full 
years  elapsing  between  the  date  of  infection  and  the  contracting  of  iiiar- 
riage.  This,  it  should  be  borne  in  mind,  is  the  earliest  possible  limit,  ami 
there  should  be  at  least  a  year  of  complete  immunity  from  all  manifesta- 
tions of  the  disease. 

In  relation  to  life  insurance,  an  individual  witli  syphilis  can  not  lie 
regarded  as  a  first-class  risk  unless  he  can  furnish  evidence  of  proloiigoiJ 
and  thorough  treatment  and  of  immunity  for  two  or  three  years  fi'om  all 
manifestations.  Even  then,  when  we  consider  the  extraordinary  frequeiii'v 
of  the  cerebral  and  other  complicatiotis  in  persons  who  have  had  this  dis- 
ease and  who  may  even  have  undergone  thorough  treatment,  the  risk  to 
the  company  is  certainly  increased. 


TUBEIICULOSIS.  203 

XXVII,    TUBERCULOSIS. 

I,  General  Etiolocjy  and  Mouiiid  Anatomy. 

Definition. — An  infective  liisoaso,  ciiused  by  the  htirilliis  iuhercuhsis, 
tho  l('si<'ii.>  '"f  wliicli  are  eliariuUcrized  by  ikh;  iltir  bodies  called  tubercles 
ur  (lilTii>t'  iiililtrations  of  tuberculous  tisdue  wliicli  uiidcr;,'o  caseation  or 
sckM'dsis  ;inil  may  finally  ulcerate,  or  in  some  situations  calcify. 

Etiology. — 1-  Zoological  Distribution. — Tuberculosis  is  one  of  the 
most  wiili'-sprcad  of  maladies. 

Ill  colii-lilooded  anitnals  it  is  rare,  owing  doubtless  to  temperature 
oomlitiini.-!  uiifavoral)le  to  the  develo])nient  of  the  bacillus.  Among  rep- 
tilis  ill  I'oiitinemcnt  it  is,  however,  occasionally  seen  (Sibley).  In  fowls  it 
1^  nil  cxtrcnioly  common  disease,  but  recent  facts  indicate  that  there  are 
ilillViciicos  in  avian  tuberculosis  sutiicient  to  warrant  its  separation  from 
t!io  (irdiuury  form. 

Among  domestic  animals  tuberculosis  is  widely  but  unevenly  dis- 
tributed. Among  rumimuits,  boviiU'S  are  chielly  affected.  The  percent- 
iisre  for  oxen  and  cows  at  the  Herlin  abattoir  in  the  year  ISO^-'iW  was  15-1. 
In  this  coiuitry  much  has  been  done,  particidarly  in  Massacliusetts  and 
iViinsylvimia,  to  determine  the  presence  of  the  disease  in  the  dairy  herds, 
fur  wliich  purpose  the  tuberculin  test  has  been  extensively  employed. 
The  results  show  a  wide-spread  prevalence  of  the  disease. 

Of  r).'.'!»7  cattle  slaughtered  in  ^Faryland  only  150  were  tuberculous 
(A.  W.  Clement).  Of  l."),50(!  slaughtered  at  the  Brighton  abattoir,  Boston, 
unly  '^y  were  tuberculous  (A.  Burr). 

Ill  sheep  the  disease  is  very  rare.  In  pigs  it  is  common,  but  not  so 
i^onimnu  in  this  country  as  in  Europe.  In  the  inspection  of  one  thousand 
linir>,  whieli  was  made  by  A.  W.  Clement  and  myself  in  Montreal  in  1880, 
tubiTCiilosis  was  seen  only  once  or  twice.  At  the  Berlin  abattoir  in 
l^ST-'88  there  were  6,.303  pigs  affected  with  the  disease. 

Horses  are  rarely  attacked.  Dogs  and  cats  are  not  prone  to  the  disease, 
biiteiises  are  described  in  which  infection  of  pet  animals  has  taken  place 
from  phthisical  masters.  Among  the  semi-domestic  animals,  such  as  the 
riibbit  and  guinea-pig,  the  disease  under  natural  conditions  is  rare, 
although  these  animals,  particularly  the  latter,  are  extremely  susceptible 
tn  the  disease  when  inoculated.  Among  apes  and  monkeys  in  the  wild 
Jtiito,  tuberculosis  is  unknown,  but  in  confinement  it  is  the  most  formi- 
dable disease  with  Avhich  they  have  to  contend. 

The  important  etiological  fact  in  connection  with  tuberculosis  in  ani- 
mals is  the  wide-spread  occurrence  of  the  disease  in  bovines,  from  which 
'la<s  wo  derive  nearly  all  the  milk  and  a  very  large  proportion  of  the 
meat  used  for  food. 

'I  Geographical  Distribution.— The  disease  exists  in  all  countries.    It 


t  III 


I   ii] 


f!    'I 


i 


if' 


204 


SPECIFIC  infi<x;tious  diseases. 


prevails  more  in  the  largo  cities  ami  wlierover  the  impulatioii  is  inussoil 
toffotluT.  'I'liiis,  wiiile  the  general  deatli-rate  from  it  is  tlirce  per  Ukui. 
sand,  tiiat  of  \'ieiina  is  7'7,  and  of  Munieli  and  (Jlasgow  fonr  per  tiuiiisainl, 
Hirs(Oi,  fritm  wliosc  ciassicai  work  tliese  facts  are  taken,  thinks  thiit  ir^n. 
graphical  position  has  less  iidliienee  than  has  been  snpjiosed.  lt;ilv  iiii,| 
England  snlTer  alike,  and  the  disease  is  very  ])revalent  in  the  W<?.4  Imlio 
and  the  South  Sea  islands.  Toward  the  poles  it  is  rare ;  hut  it  is  a  eommon 
disease  in  Canada,  and  prevails  extensively  among  the  I''ren('h  CariiKHaiij 
and  the  Kngli.sii.  Altitude  is  a  more  potent  factor  than  latitude.  In  thi 
liigh  regions  of  the  Alps  and  Andes,  anil  in  the  central  jdateau  of  .Mcxi.o 
the  disease  is  very  rare.  Mountainous  countries,  such  us  Switzerland,  havf 
a  very  low  death-rate  from  tuberculosis. 

3.  Race. — No  race  is  immune.  The  Indians  of  this  continoiit  are 
very  prone  to  the  disease.  Matthews,  whose  e.xjjerience  with  the  native 
race  is  large,  states  that  the  disease  is  on  the  increase  among  them.  He 
quotes  the  ratio  from  the  United  States  census,  1880,  us  white  W\ 
negroes  18(),  Indians  28G.  The  death-rate  in  the  older  reservations,  ;ij 
in  ^'ew  York,  is  three  times  as  great  as  in  Dakota.  In  the  Blood  Iniliim 
Keserve  of  the  Camulian  Northwest  Territ(  ''ies.  Surgeon  Keiui(.i!\ 
(M.  W.  M.  P.)  has  given  me  the  ligures  for  six  years.  In  a  population  of 
about  ^,000  there  were  1^7  deaths  from  pulmoiuiry  consumi)tion,  twenty- 
three  per  cent  of  the  total  rate.  This  does  not  include  deaths  from 
"diseases  of  infancy."  This  enormous  death-rate,  it  is  to  be  renienihi'ml, 
occurs  in  a  tribe  occui)ying  one  of  the  linest  climates  of  the  world  among 
the  foot-hills  of  the  Kocky  Mountains,  a  region  in  which  consumption  is 
extremely  rare  among  the  white  population,  and  in  which  cases  of  tiilxr- 
culosis  from  the  eastern  provinces  do  remarkably  well. 

The  negro  race  is  very  susceptible  to  tuberculosis,  more  particularly  the 
glandular  and  osseous  forms.  Of  the  i'i]  cases  of  pulmonary  tuberculosit 
at  the  Johns  Hopkins  Hosi)ital  for  the  two  years  ending  June  1,  18!il. 
there  were  41  cases  in  the  colored — i.  e.,  about  1:10.  The  ratio  of  colored 
to  white  of  all  patients  in  the  wards  has  been  1  to  7. 

4.  The  Bacillus  Tuberculosis. — The  history  of  the  discovery  of  tlie 
■bacillus  presents  many  poitits  of  interest.  Coidklently  expected  by  such 
observers  as  Yillemin,  Chauveau,  Cohnheim,  and  others,  and  claimcil  to 
have  been  demonstrated  by  many,  notably  by  Klebs  and  Aufrecht,  it  re- 
mained for  Koch  to  demonsti'ate  its  existence  and  its  invariable  associatiun 
with  the  disease.  The  investigations  which  he  had  previously  made  upon 
anthrax  and  experimental  traumatic  infi'ctions,  by  perfecting  the  inetliwi: 
of  research,  paved  the  way  for  this  biilliant  d'~covery.  His  preliminary 
article  *  and  his  more  elaborate  later  work  f  should  be  carefully  studied  hy 
any  one  who  wishes  to  appreciate  the  value  of  scientific  methods.     It  forms 

*  Berliner  klinische  Woclii^iischrift,  1882. 

f  Mittheilungen  iv.  d.  k.  Gesuudiicitsainte,  Bd.  3. 


TUIlKRCUIiOSIS. 


205 


one  of  tlio  Jiir»st  mnstorly  (lonionstr.'itioii'i  of  moflorn  niiMlifliiP.  Its  tlior- 
oii<'liiK'ss  apiu'iirs  in  tliu  fact  that,  in  the  twi'lve  yvuvn  wliicii  liavo  elapsed 
jiiiu't'  it.-i  aiiiiouiuH'iiu'nt  tlu;  iiimmu'i'alilc  workiTs  at  the  Htibjcct  have  not, 
,<()far!W  1  know,  addocl  a  Holitary  essential  fact  to  those  presented  l)y  Kocii. 
MiifplKihujiral  C/idracfi'rs, — 'I'he  tubercle  bacillus  is  a  short,  fine  rod, 
ofU'ii  slii:iitly  bent  or  curved,  and  has  iiii  avera<,'e  IcJi^th  of  nearly  half  the 
iliiiim'tcr  of  a  red  blood-eorpuscle  {'.i  to  4  ft).  When  stained  it  often  pre- 
nciits  11  Ixadi'd  appearance,  which  some  have  attributed  to  the  presence  of 

spores. 

With  the  basic  aniline  dyes  it  stains  slowly,  except  at  the  body  tem- 
ponitun',  but  retains  the  ilye  after  treatment  with  acids — a  cliaracterislic 
which  sc))iirates  it  from  all  other  known  forms  of  bacteria,  with  the  excep- 
tion of  the  bacillus  of  leprosy. 

.]liii/i's  (if  (Iroioth. — It  grows  on  blood-sernni,  glycerin-agar,  or  on  po- 
tato—most readily  on  the  former.  ^J'he  cultures  must  be  kejjt  at  blood- 
hi'Ut.  Tlicy  grow  slowly,  and  do  not  appear  until  about  the  erid  of  the 
sw'ond  week.  The  colonies  form  thin,  grayish-white,  dry,  scale-like  masses 
on  the  i^urface  of  the  culture  medium.  Successive  inoculations  may  be 
HKiile  from  the  cultures,  and  at  the  end  of  an  indefinite  series  mat(  "ial 
from  one  of  them  inoculated  into  a  guinea-pig  will  produce  tuberculosis. 

Prm/iicfs  of  the  Growth. — Little  is  yet  known  of  the  chemical  charac- 
ters of  tlie  materials  which  result  from  the  growth  of  the  tubercle  bacilli. 
Koch's  tubcrcidin  is  stated  to  be  a  glycerin  extract  of  the  cultures.  Crook- 
i-h;iiik  Mild  Ilerroun  have  separated  an  albumose  and  a  ptomaine. 

UUlributioii  of  the  JiaciUL — The  bacilli  arc  found  in  all  tuberculous 
lesions;  in  some  in  great  abundance,  in  others  sparsely.  They  are  par- 
tieuliirly  numerous  in  actively  developing  tubercles,  but  in  the  chronic 
tiibereiilotis  processes  of  lymph-glands  and  of  the  Joints  they  are  scanty. 
When  a  tuberculous  focus  communicates  with  a  vein  or  with  lymph-ves- 
sel?, the  Ijiicilli  may  be  spread  widely  throughout  the  body.  In  old  lesions 
they  may  not  be  found  in  the  sections,  and  the  demonstration  of  the  true 
nature  may  be  possible  only  by  culture  or  inoculation. 

The  liaciUi  outxide  the  Bodi/. — Patients  with  advanced  pulmonary 
tuberculosis  throw  off  in  the  expectoration  countless  millions  of  the  bacilli 
tiaily.  Some  idea  of  the  extraordinary  numbers  may  be  gained  from  the 
simlies  of  Nnttall.*  From  a  patient  with  moderately  advanced  disciise, 
the  amount  of  wiiose  expectoration  was  from  seventy  to  a  liundred  and 
thirty  cubic  centimetres  daily,  he  estimated  by  his  method  that  there 
^vere  in  sixteen  Counts,  between  January  lOth  and  March  1st,  from  one 
find  a  half  to  four  and  a  third  billions  of  bacilli  thrown  off  in  the  twenty- 
foiir  hours.  These  figures  emphasize  the  danger  associated  with  phthisical 
>pata  nidoss  most  carefully  dealt  with.  When  expectorated  and  allowed 
todry,  the  sputum  rapidly  becomes  dust,  and  is  distributed  far  and  wide. 

*  Johns  Hopkins  Hospital  Bulletin,  May,  1891. 


IP 


is 


w^ 


200 


SrKClFIC  INFKCTIOUS  DISKASKS. 


The  ohworvntions  nisuli'  by  Cornot  undor  KopIj'h  siiptTvision  nro  in  {\\U 
cuniicclioii  most  inslniclivc  He  collcctctl  the  dust  Iroiii  tlic  walls  ainl 
bi'dsti'iids  of  various  lociditics,  and  dftcriiuiu'd  its  vindciicu  or  iiiiKMiKm^. 
tiess  by  inoculation  into  Husci-'ptiblc  animals.  Matorial  \va.s  jjiithcrcd  finm 
twimty-onu  warils  of  sevon  bosjiitals,  tlirt'c  asyliiiuy,  two  prisons,  finm 
the  sMrroiindin<fs  of  sixty-two  jilitliisical  juiticnts  in  privati'  iiraciin, 
and  from  twcnty-nino  otlu-r  localitii's  in  wbicb  tMbcrcnloiis  i)atii'nl>  wiiv 
oidy  transit-nt  frciiiu'iiti'rs  (ont-patii^nt  di'partnu'nts,  strci'ts,  etc.).  Of 
ono  liundrt'd  and  figbtocn  dust  .sampk's  from  hospital  wards  or  iIr. 
rooms  of  j)litbisiL'al  patients,  forty  were;  infective  and  jirodueed  tuljcmi- 
losis.  ^ie;.;ative  results  were  obtained  with  the  twenty-nine  dust  .sMiiiplc^ 
from  the  localities  ot'casionally  occupied  by  consumjitives.  \  irulciit  Im- 
cilli  were  (jbtaineil  fioni  the  dust  of  the  walls  of  lifteen  out  of  twciiiv-iiu, 
medical  wards.  It  is  interesting  to  note  that  in  two  wards  with  iii;iiiy 
phthisical  i)atients  the  results  were  negative,  iiulicating  that  the  dii.-t  in 
.such  regions  is  not  necessarily  infective.  The  infectiousness  of  the  (lust 
of  the  medical  and  surgical  divisioius  of  a  hospital  is  in  tiie  jjrojxirtidii  ir( 
7C'G  to  r^%j.  In  a  ro(»m  in  which  a  tuberculous  woman  had  lived  the 
dust  from  the  wall  in  the  neigldiorhood  of  the  bed  was  infective  six  wwh 
after  her  death.  No  bacilli  were  found  in  the  dust  of  an  inbalation-cluiiii- 
her  for  e()nsum2)tives.  The  experiments  of  Strauss  at  the  C'harite  lln.-iiiia;, 
Paris,  are  important.  In  the  nostrils  of  twenty-nine  assistants,  mir.<i-. 
and  ward-tenders  he  ))laced  plugs  of  cotton-wool  to  collect  the  dust  of  the 
wards.  In  nine  of  the  twenty-nine  cases  these  contained  tubercle  bacilli 
and  ])rove(l  infective  to  unimuls. 

The  tubercle  bacillus  is  thus  a  wide-spread  organism  in  regions  fri- 
quented  by  phthisical  patients. 

5.  Modes  of  Infection. — {ti)  Ilnrditanj  Transmission. — In  extroiiul} 
rare  instances  the  disease  is  congenital.  The  rarity  with  which  it  oeciii- 
may  be  gathered  from  the  fact  that  of  15,400  calves  killed  at  the  Hciiiii 
abattoir  there  were  oidy  four  instances  of  tuberculosis.  Js'ine  or  ten  nisi? 
of  congenital  tuljcrculo.sis  in  man  have  been  described.  Tuberculosis  of 
the  i)lacenta  has  been  carefully  studied  in  recent  years  by  Lcluiiauii. 
Schmorl,  and  others.  The  bacilli  may  be  present  in  a  foetus  which  shows 
no  signs  of  tubercles.  Birch-llirscbfeld  found  portions  of  the  viseeni 
of  such  a  fuitus  infective  to  guinen-pigs. 

There  is  no  evidence  to  show  that  a  tuberculous  father  can  diroctly 
transmit  the  disease.  The  experimental  evidence  is  also  negative,  (iiirt- 
ner  (wdiose  recent  article  on  Heredity  in  Tuberculosis  is  the  most  impor- 
tant contribution  made  to  the  subject  of  late  years)  found  that  in  valiliii? 
and  guinea-pigs,  with  artilicially  induced  tuberculosis  of  the  testes,  aiiii 
whose  semen  contained  bacilli,  the  embryos  were  never  infected.  On  the 
other  hand,  of  Go  female  guinea  pigs  which  had  consorted  with  the  tuber- 
culous bucks,  5  presented  genital  tuberculo.sis,  and  of  59  female  rabbits 
under  similar  conditions  11  became  infected. 


TriJKiicuLosia. 


207 


Hull iit;,Mr It'll  holds  tliut  in  nuuiy  oiiscs  the  vinin  is  traiisniittod,  hut  tho 
(lisciise  (li»fri  not  appear  until  koiuc  time  aftiT  birth.  Ho  bu8((8  this  opinion 
uiHiii  the  fnllnuititr  facts: 

Till'  ^'I'cat  frc(|iu'ii(!_v  of  tulu'rciihisis  in  su('kliii;;s.  'riius,  in  Itl.rtSl 
;iiito|isics  on  sucklinjis,  Krohclius  found  41ti  with  tuhiTculous  k'sions.  In 
;M',t  cases  i>\'  tiilicrciilosis  in  childrt'n  under  two,  from  Parrot's  clinii', 
tJR'R'  wi'ic  ■■i'5  uiidiT  three  months,  and  a  total  of  1 1 1  iindiT  one  year. 
It  siriiis  prnl)iil)k!  that  in  many  of  these;  oases  the  virus  itself  was  trans- 
iiiittfd. 

Till'  couiiiiou  occurrence  of  tuberculosis  in  the  liones  and  in  tlio  joints 
uf  cliiliii'cu,  re;:ioiKS  to  which  it  seems  unlikely  that  the  bacilli  would  bo 
(.(iiivfyt'd  ill  accidental  infccticui.  To  make  this  objection  valid  we  should 
roi|iiiro  a  series  of  cases  of  bone  tul)erculosis  in  children  in  which  oxami- 
iiatimi  sluuved  tin'  lyjni)h  portals  of  the  bronchi  and  the  mesentery  to  bo 
fiw  from  disease,  lie  rejj;ards  the  late  manifestation  as  analoj^ous  to  the 
siijiliilis  hrrrilitaria  f(/r</<i,  and  suggests  that  the  growth  of  the  germs  is, 
as  a  rule,  restrained  or 
iicld  in  check  i)y  the  ac- 
tivi'ly  developing  tissues 
(if  the  chilli. 

Ill  any  series  of  cases 
of  piiliiKiiiary  tuberculo- 
sis thi're  is  a  8Usj)iciou3 
niiiiihfr  in  which  the  as- 
cendants have  also  been 
tiiborcnlous.  Thus,  in 
4"-i7  cases  at  the  Johns 
Hopkins  Hospital  there 
were  53  in  which  tho 
mother  was  afTeeted,  52 
in  which  tho  father  had 
tuberculosis,  and  105  in 
which  brother  or  sister 
liad  iiad  the  disease.  Tho 
estimates  by  various  au- 
thors raiiffe  from  10  per 
cent  (bonis),  :25  per  cent 
(Walslie),  to  even  50  per 
cent.  VmsG  very  iustlv 
I  remarks  that  it  is  impossible  to  draw  a  line  between  hereditary  and  acci- 
I  dental  tuberculosis,  and  luiturally  the  children  of  an  afTeeted  jiarcnt  are 
jiinn'e  liable  to  accidental  contamination.  Maternal  is  very  nuich  more 
I  common  than  paternal  inheritance.  A  family  tree,  such  as  is  here  given, 
ofsix  generations  tells  its  own  tale,     It  is  interesting  to  note  the  almost 

'i>tant  transmission  through  the  mother. 


Chart  XI. — Heredity  in  pulmounry  tuberculosis. 


i;;  ^'1 


..I 


>A'  Q 


208 


SPECIFIC  INFECTIOUS  DISEASES. 


(/y)  hinciilation. — The  infective  Tiature  of  tuberculosis  was  first  dcninn. 
strated  by  Viilorniu,  wlio  showed  couchisively  in  18G5  tluit  it  could  be  trims- 
niitted  to  aninuds  by  inoculation.  The  question  was  hotly  contested,  iind 
Villeniin's  observations  were  confirmed  by  Simon,  Andrew  Clark,  and  ()tlK'i>, 
but  Bunion  Sanderson,  Wilson  Fox,  and  others  held  that  the  disease  could 
be  transmitted  by  non-tuberculous  materials.  The  beautiful  experiments 
of  C'olinheim  and  Salamonson,  who  produced  tubercidosis  in  the  oyos 
of  guinea-pigs  and  rabbits  by  inoculating  fresh  tubercle  into  the  ante- 
rior chamber,  confirn.ed  and  extended  Villemin's  original  observations 
and  paved  the  way  for  the  reception  of  Kocdi's  announcement.  It  is 
now  universally  conceded  that  only  tuberculous  matter  can  produce,  wlun 
inoculated,  tuberculosis.  In  man  tuberculosis  is  not  often  transMiit- 
ted  by  inoculation,  and  when  it  does  occur  the  disease  usually  remains 
local.  This  mode  of  infection  is  seen  in  persons  whose  occupation  l)iiiij;s 
them  in  contact  with  dead  bodies  or  animal  products.  Demonstrators  of 
morbid  anatomy,  butchers,  and  handlers  of  hides  are  subject  to  a  local 
tubercle  of  the  skin,  which  forms  a  reddened  nuiss  of  granulation  tissnc. 
usually  ca})ping  the  dorsal  surfaces  of  the  hands  or  fingers.  Tliisistlu 
so-called  2)<)st-mortem  wart,  the  verruca  necnxjenica  of  Wilks.  'i'lic  ik'ni- 
onstration  of  its  nature  is  showi.  by  the  presence  of  tubercle  bacilli,  and 
by  inoculation  experiments  in  animals. 

The  statement  that  Laennec  cf)ntracted  phthisis  from  this  sourcpis 
probably  false,  since  he  did  not  die  until  twenty  years  after  the  iiKn'iilii- 
tion  and  in  the  interval  presented  no  manifestations.  The  possiliility, 
however,  of  general  infection  must  be  borne  in  mind.  Gerber  rcpoit; 
that  after  accidental  inoculation  of  the  hand  from  a  case  of  plillii.si> 
he  had  for  months  a  *'  Leichen-tubercle,"  which  was  excised.  Slioitly 
afterward  the  lymph-glands  of  the  axilla  became  enlarged  and  pain- 
ful, and  when  removed  showed  characteristic  tuberculous  changes,  with 
bacilli. 

In  the  performance  of  the  rite  of  circumcision  children  have  hcoii  acii- 
dentally  inocidated.  Infection  in  these  cases  is  i)rol)ably  always  associatui 
with  disease  in  the  operator,  and  occurs  in  connection  with  the  liabit  of 
cleansing  the  wound  by  suction. 

Other  means  of  inoculation  have  been  described  :  as  the  wearing  of 
ear-rings,  washing  the  clothes  of  phthisical  patients,  the  bite  of  a  tiilu'icii- 
lous  subject,  or  itioculation  from  a  cut  by  a  broken  s])it-glass  of  a  con- 
sumptive; and  Czerny  has  reported  two  cases  of  infection  by  transjilanta- 
tion  of  skin. 

It  has  been  urged  by  the  opjionents  of  vaccination  that  tuberculosiNa- 
well  as  syjthilis,  may  be  thus  conveyed,  but  of  this  there  is  no  e\iilcini, 
and  the  lymph  from  the  vesicles  of  revaccimited  consumptives  has  Invn 
shown  l)y  many  observers  to  be  non-infective.  It  may  be  saiil,  on  tlii' 
whole,  that  inocidation  in  man  plays  a  trilling  role  in  the  transmissioi'if 
tubercidosis. 


TUBERCULOSIS. 


209 


(r)  Infirtinn  Jnj  Inhalation. — It  has  been  fully  proved  that  the  ex- 
iiiml  air  of  tuberculous  patients  is  not  infective.  On  the  other  hand,  the 
virii>  i^  contaiuod  in  enorinous  amounts  in  the  sputum,  which,  when  dried, 
is  sdiiii  widely  disseminated  in  the  form  of  dust,  and  unless  carefully 
strrilizt'il  constitutes  a  great  medium  of  transmission.  A  belief  in  the 
coiitaLriousness  of  pulmonary  tuberculosis  has  existed  from  the  days  of 
tiio  v\w\\  (ireok  physicians,  and  has  persisted  among  the  Latin  races. 

The  investigations  of  Cornot  afford  conclusive  })roof  that  the  dust  of  a 
room  or  other  locality  frequented  by  patients  with  pulmonary  tubercu- 
losis is  infective.  The  bacilli  are  attached  to  fine  ])articles  of  dust  and  in 
tiiis  way  gain  entrance  to  the  system  through  the  lungs.  The  following 
arc  some  of  the  facts  in  favor  of  this  view  : 

(1)  I'rimary  tuberculous  lesions  are  in  a  majority  of  all  cases  connected 
witli  tiic  respiratory  system.  The  frequency  with  which  foci  are  met  with 
in  the  lungs  and  in  the  bronchial  glands  is  extraordinary,  and  the  statis- 
tics of  the  Paris  morgue  show  that  a  considerable  proportion  of  all  j)ersons 
dviii;,'  of  accident  or  by  suicide  present  evidences  of  the  disease  in  these 
mrts  The  ])ost-mortem  statistics  of  hospitals  show  the  same  wide-spread 
[jrevidonce  of  infection  through  the  air-passages.  Biggs  re])orts  that  more 
than  GO  per  cent  of  his  post-mortems  showed  lesions  of  ])uhnonary  tuber- 
oiilosLs.  In  one  hundred  and  twenty-five  post-mortems  at  the  Foundling 
lIos)iilal,  Xew  York,  the  bronchial  glands  were  tuberculous  in  every  case. 
Ill  adults  tlic  bronchial  glands  may  be  infected  while  the  individu;il  is  in 
good  liealth.  II.  P.  Loomis  found  in  eigiit  of  thirty  cases  in  which  there 
wore  no  signs  of  old  or  recent  tuberculous  lesions  that  the  bronchial  glands 
were  infective  to  rabbits. 

(■.*)  The  greater  prevalence  of  tuberculosis  in  institutions  in  which  the 
residents  are  confined  and  restricted  in  the  matter  of  fresh  air  and  a  free 
open  life — conditions  which  would  favor,  on  the  one  hand,  the  presence 
of  the  Iweilli  in  the  atmos})here,  and,  on  the  other,  lower  the  vital  resist- 
ance of  the  individual.  The  investigations  of  Cornet  u[)on  the  death-rate 
from  consumption  among  certain  religious  orders  devoted  to  nursing  give 
some  striking  facts  in  illustration  of  this.  In  a  review  of  thirty-eight 
cloisters,  embracing  the  average  number  of  4,0^>S  residents,  among  2,01)9 
deaths  in  the  course  of  twenty-five  years,  1,;)'^()  (((•'•SS  per  cent)  were  from 
tuberculosis.  In  some  cloisters  more  than  three  fourths  of  the  deaths  are 
fioni  this  disease,  and  the  mortality  in  all  the  residents,  up  to  the  fortieth 
year,  is  greatly  above  the  average,  the  inci'ease  being  due  entirely  to  the 
prevalence  of  tuberculosis.  It  has  been  stated  that  nurses  are  not  more 
prone  to  the  disease  than  other  individuals,  but  C'ornet  says  that  of  a  hun- 
dred nurses  deceased,  sixty-three  died  of  tuberculosis,  'i'he  more  perfect 
tile  prophylaxis  and  hygienic  arrangements  of  an  asylum  or  institution, 
the  lower  the  mortality  from  tuberculosis.  The  mortality  in  prisons  has 
been  shown  by  Baer  to  be  four  times  as  great  as  outside.  The  death-rate 
fi'"in  phthisis  is  estimated  at  1")  per  cent  of  the  total  mortality,  while  in 


1'  !* 


t 


210 


SPECIFIC   INFECTIOUS  DISEASES. 


prisons  it  constitutes  from  40  to  50  per  cent,  aiul  in  some  countrios,  as 
Austria,  over  00  per  cent.  Fliclf  lias  studied  tlie  distribution  of  the  (icaths 
from  tnlierculosis  in  a  single  city  ward  in  Philadelphia  for  twenty-live 
years.  His  researches  go  far  to  show  that  it  is  a  house  disease.  About 
33  per  cent  of  infected  houses  have  had  more  than  one  case.  Less  tliaii 
one  third  of  the  houses  of  the  ward  became  infected  with  tuberculosis  (hir- 
ing the  twenty-five  years  prior  to  18S8.  Yet  more  than  one  half  of  tlie 
deaths  from  this  disease  during  the  year  1888  occurred  in  those  iiifcctcil 
house:;.  There  are,  however,  opposing  facts.  The  statistics  of  the  Uronip- 
ton  Consumption  Hospital  show  that  doctors,  nurses,  and  attendants  are 
rarely  attacked.  Dettweiler  claims  that  no  case  of  tuberculosis  has  been 
contracted  among  his  nurses  or  attendants  at  Falkenstein.  On  the  other 
hand,  in  the  Paris  Hospitals  tuberculosis  decimates  the  attendants. 

(3)  Special  danger  exists  when  the  contact  is  very  intimate,  such,  fin- 
instance,  as  between  num  and  wife.  On  this  point  much  dilferenee  cf 
opinion -exists,  but  the  figures  seem  to  indicate  that  under  these  circum- 
stances the  husband  or  wife  is  much  more  liable  subsecjuently  to  dio  of 
consumption.  Of  4'i7  eases  of  puhnonary  tulierculosis  at  the  Johns  Ihip- 
kins  Hospital,  in  'rlo  either  husband  or  wife  had  been  affected  with  i,  n. 
had  died  of  tul)erculosis.  In  resi)onse  to  a  question  as  to  contagion,  askei". 
by  the  Collective  Investigation  Committee  of  the  British  Medical  Assopia- 
tioii,  there  were  201  replies  in  the  aillriuative,  among  which  were  V)H  ca>('S 
of  supposed  contagion  through  marriage.  Weber's  cases  are  of  special 
interest.  One  of  his  patients  lost  four  wives  in  succession,  one  lost  three. 
and  four  lost  two  each. 

('/)  L/fer/ioii  hij  Milk. — 'I'he  milk  of  an  animal  sulTering  from  tul)cr- 
culosis  may  contain  the  virus,  and  is  capable  of  communicating  the  dis- 
ease, as  shoM'u  by  (Jerlach,  Bang,  liollinger,  and  others.  Striking  illustra- 
tions of  this  are  sometimes  atforded  in  the  lower  aninuils.  The  pigs,  for 
instance,  of  a  tuberculous  sow  have  been  shown  to  jiresent  intestinal  tubonni- 
k)sis  of  the  most  exfpiisito  form.  Of  late  years  the  experimental  procif  liiis 
been  entirely  conclusive.  It  was  formerly  thought  that  the  cow  must  pre- 
sent tuberculous  disease  of  the  udder,  but  Ernst  has  shown  that  the  liaoilli 
may  be  present  and  the  milk  be  infective  in  a  large  proportion  of  cases  in 
Avhich  there  is  no  tuberculous  mammitis;  an  observation  nuide  also  bv 
Hirschberger  and  others.  This  author  states  the  inti'ri'stiiig  1.  tti.atan 
owiuM-  of  a  herd  known  to  be  tuberculous  withdrew  the  milk  from 
market  and  used  it  without  boiling  to  fatten  his  pigs,  which,  almost  with- 
out exception,  became  tuberculous,  so  that  the  whole  stock  had  to  be 
slaughtered.  Sidney  Martin  could  not  induce  the  disease  artifici;illy  in 
aninuUs  inoculated  or  fed  with  milk  of  tuberculous  cows  with  lualthy 
udders.*     Butter  nuule  from  the  milk  of  tuberculous  cows  has  provcl  in- 


I** 


■*<i), 


*  See  Report  of  Royal  Commission  on  Tuborculosis,  1805,  and  Ernst,  Infecliousiio^s 
of  Milk,  Boston,  1895. 


TUBERCULOSIS. 


2U 


foctivc  (IJiing).  Tliere  is  no  reason  to  boliove  that  young  oliildrcn,  or 
ovt'ii  iuliilts,  are  less  susceptible  to  the  virus  than  calves  or  pigs,  so  that  the 
(liiiifrtT  of  the  disease  from  this  source  is  real  and  serious.  Tlic  great  fre- 
niiencv  of  intestinal  and  mesenteric  tuberculosis  in  childreji  no  doubt  finds 
lioiv  its  explanation.  As  noted  in  Woodhead's  analysis  of  one  hundred 
ami  twenty-seven  cases  of  fatal  tuberculosis  in  children,  the  mesenteric 
fliiiids  were  involved  in  one  hundred. 

((')  Infection  hy  Meat. — The  meat  of  tuberculous  aninuils  is  not  neces- 
Siirilv  infective.  The  results  of  experiments  with  the  flesh  of  cows  are 
nut  in  accord.  This  mode  of  infection  ])robably  ])lays  a  minor  rule  in  the 
etioki<ry  of  human  tuberculosis,  as  usually  the  flesh  is  thoroughly  cooked 
before  eating.  The  possibility,  however,  must  be  borne  in  mind,  and  it 
would  certainly  be  safer  in  the  interests  of  a  community  to  uionfiscate  the 
carcasses  of  all  tuberculous  aninnds.  Ex2)eriments  in  Bollinger's  labora- 
tory sliow  that  the  flesh  of  tuberculous  subjects  is  very  infective  to  guinea- 
pigs.  Martin  suggests  that  when  the  meat  is  infective  it  commonly  ac- 
qiiiros  this  property  by  accidental  contamination  with  tuberculous  matter 
during  its  removal. 

(J.  Conditions  influencing  Infection.— (^0  Constitutional  Pendiio-itiex. — 
ii  was  foniu'rly  thought  that  iiulividuals  of  a  certain  habit  of  body,  ami  of 
a  certain  physiognomy,  the  habitus  p/itJiisirus,  were  specially  jirone  to 
tul)crcnl()us  disease ;  but  few  now  regard  the  so-called  tuberculous  or 
si  nifulous  diathesis  as  more  than  an  indication  of  a  certain  ty])e  of  con- 
{oriiKition,  in  which  the  tissues  are  more  vulnerable  and  less  cajiable  of 
rcsisiiiig  infection.  In  many  itistances  Cc!iidieim  is  unquestionably  cor- 
rect ill  staling  that  the  so-called  phthisical  Iial/it  is  not  an  indication  of  a 
tcMilency  to,  hut  actually  of  the  existence  of,  tuberculosis.  The  lielief  in 
a  special  phthisical  frame  has  existed  in  the  profession  from  the  days  of 
llippoorati'S,  who  says,  "  The  form  of  body  peculiar  to  subjects  of  phthisi- 
ral  Cdiuplaints  was  the  smooth,  the  whitish,  tliat  resembling  the  lentil ; 
the  roihlisli,  the  blue-eyed,  the  leuco-])lileg(natic,  and  that  with  the  scajjida^ 
having  the,  appearance  of  wings."  (Jalen  also  wrote  upon  this  type  of  chest 
as?pc  ■.  :"r-  "h:r;icteristic  of  the  disease.  Certainly  the  long,  mirrow,  flat 
che.-i  v>  (,;  j)t  ssed  sternum  is  most  commonly  seen  in  tuberculous  per- 
sons, init  !;■ 'V  common  it  is  also  to  meet  with  patients  who  have  well- 
forineil,  well-L.'.l.i,  chests,  with  wide  costal  angle  ami  good  ])ulm(Miary  ex- 
pansion !  The  investigations  of  Beneke  with  reference  to  the  formation 
(!■  iiie  viscera  in  the  subjects  of  phthisis  are  very  interesting.  His  meas- 
urements indicate  that  the  heart  is  relatively  small,  the  arteries  are  })ro- 
porticiiately  narrow,  and  the  puliuonary  artery  is  relatively  wider  than  the 
iwrta.  This  point,  he  suggests,  would  lead  to  increase  in  the  blood-press- 
ure in  the  lup.gs  and  favor  catarrh.  The  lung  volume  ho  found  to  be 
ri'i'n.iy  greater  in  those  affected  with  phthisis. 

''!'  M  and  Mahomed  nuule  observations  upon  tlie  composite  jiortrait- 
tireol  ;i!uliisis.     In  44:'-2  patients  they  separated  two  types  of  face;  one 


''t 


I'll 


n 


•'!  Pi 

'   m 


212 


SPECIFIC   INFECTIOUS  DISEASES. 


...  'Sflf' 


'    .    i      i 


it:v) 


?""*' 


ovoid  and  narrow,  tlio  other  Ijroad  and  coarse  featured.  Tliis  corre- 
sponds in  an  interesting  way  to  the  diathetic  states  formerly  reeonnjzeil 
— !ianiely,  tlic  tiibenndoiis,  with  thin  skin,  ])right  eyes,  ovul  face,  ami 
long,  thin  bones;  and  the  scmfiUons,  with  thick  lips  and  nose,  (ii>a(|iie 
skin,  large  thick  bones,  and  heavy  figure.  These  conditions,  on  which 
so  much  stress  was  formerly  laid,  indicate,  as  Fagge  states,  nothing  v.vtn 
than  delicacy  of  constitution,  incomplete  growth,  and  imperfect  devddp. 
ment. 

(/>)  Influfnce  of  Age. — Tuberculosis  occurs  at  all  periods  of  life,  in  the 
suckling  as  well  as  in  the  octogenarian.  The  distribution  of  the  lesicms 
varies  greatly  at  ditferent  ages.  In  the  first  decade  the  lymphatic  glands, 
bones,  and  meninges  are  much  more  frerpiently  affected  thati  at  siilise- 
quent  periods.  Meningeal  tuberculosis  is  most  common  between  the  third 
and  eightii  years. 

The  mesenteric  glands  -ire  specially  prone  to  be  involved  in  young 
children,  as  before  mentioned.  Of  \'11  cases  of  tuberculosis  in  children, 
Woodhead  found  ,"  ''odie's  affected  in  lOU  instances,  in  1-4  of  whieli 
there  were  no  tuber.  other  parts  of  the  body.    The  majority  of  those 

cases  occur  boiween  tlu.  ,irst  and  fifth  years.  The  bronchial  glands  are 
still  more  fre(piently  involved,  and  of  \'lh  cases  at  the  Xew  York  Foiuid- 
ling  Hospital  in  every  one  were  these  structures  the  seat  of  more  or  less 
e.xtensive  tuberculosis. 

In  adults  the  lungs  usually  contain  tubercle  when  it  is  present  in  tlie 
body  (Louis'  law). 

(r)  ,V(//7  and  hnuOltii  are  held  by  many  to  have  an  im]iortant  i!i(liicnoe 
in  tuberculosis.  The  observations  of  II.  I.  Bowditch  in  this  country,  and 
of  Buchanan  in  England,  show  that  ])ulmonary  tubercidosis  is  more  preva- 
lent in  dam}),  ill-drained  districts;  but  this  increased  incidence  is  must 
prol)ably  associated  with  a  heightened  vulnerability  due  to  an  increased 
liability  to  catarrhal  afl'ei^tions  of  all  kinds. 

{(})  Liicnl  Coiiililiuns  injliivncitKi  Iiifrcfioii. — These  are  doubtless  of 
the  highest  importance,  ami  second  only  to  the  constitutional  vulnera- 
bility.    Among  the  more  important  may  be  mentioned: 

Ca/arr/iftl  Infhuninatiim. — This  ])rol)aI)Iy  acts  ))y  lowering  the  resist- 
ance, or,  in  modern  parlance,  redui-iiig  the  activity  of  the  phagocytes 
and  allowing  the  bacilli  to  pass  the  portals.  The  liability  of  infVi'tion 
in  the  cervical  and  bronchial  glands  in  children  is  probably  associated 
with  the  common  occurrence  of  catarrhal  processes  in  the  tonsils,  tliroat. 
and  bronchi. 

The  influence  of  bronchial  catarrh  in  pulmonary  tuberculosis  is  all-im- 
portant. How  often  is  it  said  that  the  disease  has  started  in  a  neglected 
cold  ;  which  means,  in  other  words,  that  the  bronchial  catarrh  has  enfwliled 
the  power  of  ti.ssue-resistance,  or  jnoduced  conditions  favorable  to  tbe 
growth  and  development  of  the  bacilli. 

The  subjects  of  congenital  or  acquired   contraction  of  the  orifice 


TUBERCULOSIS. 


218 


of  tlio  inilmonary  artery  usually,  as  is  well  known,  die  of  tnboroulosis. 
Prior  to  the  development  of  the  disease  many  subjects  show  a  marked 
auivmia.  iiiul  unquestionably  elilorosis  olTers  favoring  conditions  for  the 
(li'Vi'li»iiiiK'iit  of  this  alfection.  Diseases  of  the  stomach  and  intes- 
tines, ]);ulicularly  chronic  entero-colitis,  increase  the  susceptibility  to 
iiifi'cti(>;i. 

All  important  part  in  the  etiology  of  tuberculous  processes  is  played  by 
'M  trninnK.  Surgeons  have  for  years  laid  great  stress  ui)on  this  association, 
but  tilt;  relation,  though  universally  recognized,  is  by  no  means  easy  of  ex- 
planation. Bacteriological  experiments,  however,  indicate  that  in  tissues 
uiiicli  have  been  injured  organisms,  which  would  in  health  have  been 
reaililv  and  r!ij)idly  destroyed  by  the  action  of  the  normal  juices  or  cells, 
uiiilcr  these  altered  circumstances  grow  rapidly  and  develop.  Probably 
in  the  case  of  tul)erculosis  following  trauma  the  injured  part  is  for  a  time 
a /y(7^'^  niiiioris  resisk'nfm,  imd  if  bacilli  are  present  they  may  by  it  re- 
ceive a  stimulus  to  growth,  or  under  the  altered  comlitions  be  capable  of 
niultiplying.  Xot  oidy  in  arthritis  but  in  pulruonary  tuberculosis  trau- 
iiiatisiii  may  play  a  part.  The  (juestion  has  been  thorouglily  studied  by 
MeiuUlsohn,*  who  reports  nine  cases  in  which,  without  fracture  of  the 
rib  or  hiccration  of  the  lung,  tuberculosis  developed  shortly  after  contu- 
.-iuii  of  the  chest. 

The  i)roduction  of  general  tuberculosis  is  sometimes  favored  by  opcm- 
tinii  ii|i(iii  ttil)erculous  lesions.  Surgeons  have  long  known  that  resection 
of  a  ft  ruinous  joint  is  occasionally  followed  by  acute  tuberculosis.  The 
(|iie,<iiiiii  lias  boon  carefully  studied  by  Wartmann,t  who  gives  statistics  of 
Ku  rcscftioiis.  Of  tliese,  2'i')  emletl  fatally,  'Zi\  with  acute  tuberculosis, 
the  outbreak  of  which  was  directly  associated  with  operation. 

The  acute  miliary  tuberculosis  whii'h,  as  Litten  has  shown,  occasion- 
ally follows  the  as})iration  of  the  effusion  in  tuberculous  pleurisy,  may 
loiiie  under  this  division. 

The  constant  inhalation  of  impure  air  in  occupations  associated  with 
a  very  dusty  atmosjihere  renders  the  lungs  less  callable  of  resisting  infec- 
tion, 'I'lie  pulmonary  affection  of  stone-cutters  and  coal-miners,  though 
iion-tiiherculous  at  the  outset  and  often  a  simple  chronic  interstitial  pneu- 
uiniiia,  is  iiltiniately  in  a  large  proportion  of  the  cases  tuberculous.  In 
iiiamifactories  metallic  seems  more  hurtful  than  mineral  dust.  Peterson  J 
'|U(itos  the  incidence  of  luilmonary  tuberculosis  among  the  trades  as  fol- 
lows: (i lass-workers,  80  per  cent;  needle-sharpener.s,  70;  lile-cutters,  G'^; 
and  stone-cutters,  (!0.  And,  lastly,  circumstances  which  temporarily  lower 
the  nutrition,  as  the  spvcijir  ferers  render  the  tissues  more  susceptible.  In 
this  way  alone  can  we  explain  the  frequent  onset  of  tuberculosis  after  an 


*  Zeitschrift  f.  klin.  Aft'dicin,  Hd.  10. 

t  Oeiitfiehe  Zeitschrift  f.  Chirurgic,  Ikl.  24, 

J  Mediciil  News,  1885. 


U1 


fi 


'^iy.); 


Siii 


214 


SPiX'IFIC   INFECTIOUS  DISEASES. 


c\hiuistini?  illiioss.  Fevers,  such  as  measles  and  wlioopinrf-couji;!),  wliich 
are  associated  with  broneliial  catarrh,  are  more  prone  tliaii  others  lu  liy 
foUowed  by  tuberculosis.  This  is  often  o'lly  the  blazing  of  a  snujuklur- 
ing  fire. 

Witli  reference  to  infection  and  the  conditions  whicli  inlluence  it  tlif 
following  may  ])e  stated  : 

{(i)  In  a  few  cases  the  disease  is  directly  transmitted  from  the  mutliur, 
and  apj tears  in  the  ehikl  at  birth. 

(b)  The  primary  tuberculosis  of  the  bones,  joints,  kidney,  spleen,  liver, 
etc.,  of  early  youth  is  very  possibly  associated  with  a  fu;tal  iuenuitogeiioiis 
infection  (Hauingarten,  Giirtner). 

{(■)  Direct  pateriud  transmission  has  not  been  proved,  and  experimental 
evidence  is  strongly  against  it. 

{(l)  In  a  vast  majority  of  all  cases  the  infection  is  post-foptal — through 
the  lungs,  intestines,  or  skin. 

{(')  Heredity  intluences  the  soil.  All  are  tiihcrcKlizable^  to  use  a 
French  expression,  and  very  many  of  us  actually  become  infeoti'il. 
AVhelher  or  not  the  seed  develops  depends,  firstly,  ujion  the  chai'ai.'tcr  of 
the  tissue-siiil ;  and,  secondly,  upon  the  existence  of  special  favoring  cir- 
cumstances. 

(/)  Immunity,  a  relative  condition,  enjoyed  chiedy  in  consequence  of 
inherited  tissue-resistaiu-e,  is  lessened  by  all  circumstances  which  depress 
nutrition,  such  as  l)ad  air,  bad  food,  and  imperfect  hygienics  surrouiuliiii's. 
>«ext  to  the  gerju,  a  vulnerability  of  tissue,  however  brought  aboiit,  whcilier 
congenital  or  actpiired,  is  the  most  important  factor  in  the  etiology  of  the 
disease. 

General  Morbid  Anatomy  and  Histology  of  Tuberculous 
juesions. 

(1)  Distribution  of  the  Tubercles  in  the  Body.— 'I'he  organs  of  the 

body  are  variously  aifected  by  tuberculosis.  In  adults,  the  lungs  maybe 
regarded  as  the  seat  of  election  ;  in  children,  the  lymph-glands,  boiu^s,  ;iiul 
joints.  In  1,000  autopsies  there  were  "Z'Hb  cases  witli  tuberculous  lesions. 
With  but  two  or  three  exceptions  the  lungs  were  alTected.  Tiie  distrilm- 
tion  in  the  otiier  organs  was  as  follows:  Pericardium,  7;  peritonaniui,  ;!•!; 
brain,  31 ;  spleen,  •^;5 ;  liver,  lli  ;  kidneys,  32;  intestines,  Go  ;  heart,  4;  and 
generative  organs,  8. 

The  tuberculosis  which  comes  under  tlie  care  of  the  surgeon  has  a  dif- 
ferent distribution,  as  shown  by  the  following  figures  from  the  Wiirxburg 
clinic.  Among  8,873  patients  there  were  1,287  tuberculous,  with  the  fol- 
lowing distribution  of  lesions:  Bones  and  joints,  1,037;  lymph-ghuuls, 
19(1;  skin  and  connective  tissues,  77;  mucous  membranes,  10;  genito- 
urinary organs,  20. 

(2)  The  Changes  produced  by  the  Tubercle  Bacilli. 

{(t)  The  Aoduldi'  Tubercle. — The  body  which  we  term  a  "tubercle" 
presents  in  its  early  fortnation  nothing  distinctive  or  peculiar,  eHh(r  ui 


TURERCULOSIS. 


215 


/7\  ('(iiiijiiiiii'iits  or  in  tliciv  arrtDif/rmriif.  Idontioal  Rtriipfiircs  aro  prn- 
(liiccil  ii\  nilicr  parasites,  such  as  tlio  iietliioniyces,  and  by  tlii' stroiii^ylus 
ill  the  lungs  of  sheep. 

The  researches  (if  T?anniparton  have  enabled  us  to  follow  in  detail  all 


tlu'  >tel»>  in  the  devclopniont  of  a  tubcrole. 
These  are:  (a)  The  nuutiplieation  of  th 


(a)  The  niu'ltipTTeation  of  the  fixed  colls,  especially  those  of 
coiiiici'tive  tissue  and  the  endothelium  of  the  caj)illaries«,  and  the  <j:radual 
|ir(i(liieiiuii  from  them  of  roniuled,  cul)oidal,  or  polygonal  bodies  with  vo- 
sjeiilar  nuclei — the  vjtitlidioid  cells — inside  some  of  which  the  bacilli  are 

SUdU  SI'I'II. 

(/3)  I'mm  the  vessels  of  the  infected  focus,  leucocytes,  chiefly  polynu- 
clcar,  luigrii'e  in  numbers  and  accumulate  about  the  focus  of  infection. 
'I'lu'V  (111  not  subdivide.  ]\rany  undergo  rapid  destruction.  Tiater,  as  the 
little  tuheri'le  grows,  the  leucocytes  are  chielly  of  monoiniclear  variety 
(IviiiiiIi(H'ytes),  and  these  do  not  undergo  the  rapid  degeneration  of  the 
liolyiuick'ur  forms. 

(y)  A  reticulum  of  fibres  is  formed  hy  the  fibrillation  and  rarefaction 
of  the  cdiincctive-tissue  matrix.  This  is  most  apparent,  as  a  rule,  at  the 
margins  of  the  growth. 

((5)  In  some,  but  not  all,  tuhercles  ///«///  cells  are  formed  hy  an  increase 
ill  the  (iiotojilasin  and  in  the  nuclei  of  an  individual  cell,  or  ]»ossibly  by 
the  fusion  of  several  cells.  The  giant  cells  seem  to  be  in  inverse  ratio  to 
the  uuinber  and  virulence  of  the  bacilli.  In  lupus,  joint  tuberculosis, 
ami  scrofulous  glands,  in  which  the  bacilli  aro  scanty,  the  giant  cells  are 
iiuiiieniiis ;  while  in  miliary  tubercles  and  all  lesions  in  which  the  bacilli 
are  al)iui(iant  the  giant  cells  are  few  in  number. 

The  bacilli  then  cause,  in  the  first  ])lace,  a  proliferation  of  the  fixed 
ileuieiits,  with  the  production  of  e])ithelioid  and  giant  cells;  and,  secondly, 
ill  iiillanunatory  reaction,  associated  with  exudation  of  leucocytes.  How 
11'  the  leucocytes  attack  and  destroy  the  bacilli  has  not  been  delinitely 
•iitled— MctschnikofT  claiming,  Baumgarten  denying,  an  active  phago- 
'■vtiisis. 

Once  f<n'mcd^  a  tubcrole  undergoes  caseation  and  sclerosis. 
CiiscdliiDi. — At  the  central  part  of  the  growth,  owing  to  the  direct 
I'tioii  <if  tl.e  bacilli,  a  process  of  coagulation  necrosis  goes  on  in  the  cells, 
wliicli  lose  tlieir  outline,  become  irregular,  no  longer  take  stains,  and  are 
tliially  (Mmverted  into  a  homogeneous,  structureless  substance.  Proceed- 
iiiir  t'l'nin  the  centre  outward,  the  tubercle  may  be  gradually  converted 
iiitoayelhiwish-gray  body,  in  which,  however,  the  bacilli  are  still  abundant. 
No  lijood-vesselsare  found  in  them.  Aggregated  together  these  form  the 
liw>y  masses  so  common  in  tuberculosis,  which  may  undergo  {a)  .soiten- 
'"S-'t  ('')  libroid  limitation  (encapsulation)  ;  (c)  cahnlicatjon. 

Siivninin. — With  the  necrosis  of  the  cell  efements  at  the  centre  of  the 
'^I'x'i'ek',  hyaline  transformation  proceeds,  together  with  great  increase  in 
tilt' libioiil  elcjuents;  so  that  the  tubercle  is  converted  into  a  11  rm,  hard 
15 


i 


u    "'.if 


!  ft! 


M^W' 


210 


SPECIFIC  INFECTIOUS  DISEASES. 


fi 


■M 


^  J 


1f~- 


strucliii'o.  Often  the  cliiingo  is  nither  of  a"  fibro-caseons  nature  ;  but  thi' 
Bclerosis  preilominiUos.  Jii  .sumo  i^itiiatioiis,  as  \\w  pcritonauun,  this  seems 
to  be  this  natural  transformation  of  tubcrc'lc,  and  it  is  by  no  moans  rare  in 
tiie  hmgs. 

In  all  tuberclos  two  procossos  go  on  :  the  one — casoatioii — doslriictivo 
and  dangerous  ;  aiid  the  other — solorosis — conservative  and  liealing.  The 
ultimate  T'osult  in  a  given  case  depends  upon  the  capabilities  of  the  body 
to  restrict  iind  limit  the  growtii  of  the  bacilli.  There  are  tissue-soils  in 
which  the  bacilli  are,  in  ail  i)rubability,  killed  at  once— /Ae  >>i'cd  luts  fnUn, 
bij  llie  H'dijside.  There  are  others  in  which  a  l(Klgment  is  gained  ami 
more  or  less  damage  done,  but  finally  the  day  is  with  the  conservative, 
protecting  forces — the  wed  hasfii/leii  upon  felony  (jrouud.  Thirdly,  there 
are  tissue-soils  in  which  the  bacilli  grow  luxuriantly,  caseation  and  t^nft- 
ening,  not  limitation  and  sclerosis,  j)revail,  and  the  day  is  with  the  in- 
vaders— tlic  .seed  luiii  fallen  upon  (jood  n round. 

The  action  of  the  bacilli  injected  directly  into  the  blood-vessels  illus- 
trates many  points  in  the  hisloh)gy  and  pathology  of  tuberculosis.  If  into 
the  vein  of  a  rabbit  a  jjure  culture  of  the  bacilli  is  injected,  the  niierolu's 
accumulate  chiefly  in  th"  liver  aiul  spleen.  The  animal  dies  usually  with- 
in two  weeks,  and  the  organs  ni)parently  show  no  trace  of  tulx'relis. 
Microscopically,  in  both  spleen  and  liver  the  young  tubercles  in  process  (if 
formation  are  very  numerous,  and  the  })rocess  of  karyokinesis  is  seen  in 
the  liver-colls.  After  an  injection  of  a  more  dilute  culture,  or  one  whosf 
virulence  has  been  mitigaied  by  age,  instead  of  dying  within  a  fortni;,'lit 
the  animal  survives  for  live  or  six  weeks,  by  which  time  the  tubercles  are 
apparent  in  the  spleen  and  liver,  and  often  in  the  other  organs. 

{b)  The  Diffuse  InJiUraled  Tubercle. — This  is  most  frequently  seen  in 
the  lungs.  Only  a  great  master  like  Virchow  could  have  won  the  pru- 
fessioii  from  a  belief  in  the  uniln  of  phthisis,  which  the  genius  of  Laeniiee 
had,  on  anatomical  ground,  annouiu'od.  Here  and  there  a  teacher,  as 
Wilson  Fox,  protested,  but  the  heresy  pi'cvailcd,  iiiul  we  repeated  the  strik- 
ing aphorism  of  Niemeyer,  "  The  greatest  evil  which  can  hai)pen  to  a  con- 
sumptive is  that  he  shouhl  become  tuberculous."  It  was  thought  that  tlie 
products  of  any  simple  inflammation  might  become  caseous  and  that  ordi- 
nary catarrhal  j)ncumonia  terminated  in  phthisis.  It  was  peculiarly  litting 
that  from  (icrmany,  in  which  the  dualistic  heresy  arose,  the  truth  of  Laen- 
nec's  views  should  receive  incontestable  proof,  in  the  denu)nstratioii  by 
Koch  of  the  etiological  unity  of  all  the  various  processes  known  as  tuber- 
culous and  scrofulous. 

Infiltrated  tubercle  results  from  the  fusion  of  many  small  foci  of  in 
fection — so  small  indeed  that  they  may  not  be  visible  to  the  naked  eye,  but 
which  liistologically  are  seen  to  be  coni])osed  of  scattered  centres,  sur- 
rounded by  areas  in  which  the  air-cells  ai'e  filled  with  the  products  of  exu- 
dation and  of  the  proliferation  of  the  alveolar  epithelium.  Under  tlio 
influence  of  the  bacilli,  caseation  takes  place,  usually  in  small  groups  ol 


TUBERCULOSIS. 


217 


Idhiilcs,  (icoasioiuilly  in  an  entire  lobe,  or  even  tlio  greater  part  of  a  liitijj. 
Ill  till'  I'iirly  stage  of  tli(!  proecss,  tlio  tissue  lias  a  gray  gi'latiiious  appear- 
iiiifc,  till'  ijrtiii  itijil/nition  of  [jaennec.  'riie  alveoli  contain  a  sero-fihrinons 
Ijiiid  witli  cells,  and  the  septa  are  also  in  lilt  rated.  These  cells  acouniulato 
1111(1  undergo  coagulation  necrosis,  forming  areas  of  caseation,  the  hifdlni- 
limi  liiliifrulciiso  jiitnir  of  Fjaennec,  the  scrofulous  or  cheesy  jinouinonia 
of  later  writers,  'i'iiere  may  also  bo  a  dilTuse  infiltration  and  caseation 
without  liny  s})eeial  foci,  a  wide-spread  tuberculous  pneumonia  induced  by 
the  bacilli. 

After  all,  the  two  processes  are  identical.  As  Haumgarten  states; 
"there  is  no  well-marked  dilTerence  between  miliary  tulfcrcle  and  chronic 
casi'diis  pneumonia.  Speaking  liistol(>gically,  miliary  tuberculosis  is  noth- 
ing else  tlum  a  chronic  caijcous  miliarv  pncnmonia,  and  chronic  caseous 
pneumonia  is  nothing  but  a  tubercidosis  of  the  lungs." 

{(■)  Srriiiiiffiri/  /iiJldHiiiKt/ori/  J'ni'rssrs. — (I)  The  irritation  of  the 
bacilli  invariultiy  pr<iduces  an  inilammation  which  may,  as  has  been  de- 
scribeii,  be  limited  to  exudation  of  leucocytes  and  scnini,  but  may  also  1)o 
iiuirli  more  extensive,  and  varies  with  varying  conditions.  We  find,  for 
(■xaiii|ile,  about  the  smaller  tubercles  in  the  lungs,  pneumonia — either 
catarrhal  or  lil)rinous,  proliferation  of  the  connective-tissue  elements  in  the 
si'[)ta  (which  also  become  infiltrated  with  round  cells),  and  changes  in  the 
blood  and  lymph  vessels. 

(•*)  In  proces.ses  of  minor  intensity  tlie  inflammation  is  of  the  slow 
ri'itctive  nature,  which  results  in  the  |iroduction  of  a  cicatricial  connective 
tissue  which  limits  and  restricts  the  (lcvcloi)nicnt  of  the  tubercles  and  is 
the  essential  conservative  element  in  the  disease.  It  is  to  be  remembered 
that  ii;  chronic  pulmonary  tuberculosis  much  of  the  fibroid  tissue  which  is 
prcseiit  is  not  in  any  way  associated  with  the  action  of  the  bacilli. 

(;j)  Suppuration.  Do  the  bacilli  themselves  induce  suppuration?  In 
so  called  cold  tuberculous  abscess  the  material  is  not  histologically  pus, 
hnt  11  f/r/iri.^  consisting  of  broken-dovvu  cells  and  cheesy  nuiterial.  It  is 
moreover  sterile — that  is,  does  not  contain  the  usual  pus  organisms.  The 
liroiliiets  of  the  tubercle  bacilli  are  probably  able  to  induce  suppuration, 
as  ill  jdiiit  and  bone  tuberculosis  pus  is  fre(|uenlly  produced,  although  this 
may  be  due  to  a  mixed  infection.  Koch,  it  will  be  remembered,  states 
that  the  ^'  tuberculin  "  is  one  of  the  best  agents  for  the  production  of  ex- 
IKTiiiieiital  suppuration.  In  tuberculosis  of  the  lungs  the  suppuration  is 
largely  the  result  of  an  infection  with  pus  organisms. 


i 


II 


1! 


I'll!  ]\  \ 

1  ! 

! 


II 


^1  <       ' 

i 


II.  Acute  Tuberculosis. 


The  truly  infective  nature  of  tubercle  is  best  shown  in  this  affection, 
which  i.^  characterized  by  an  eruption  of  miliary  tubercles  in  various  parts 
of  the  body.  The  clinical  picture  varies  with  the  general  or  localized  dis- 
inbulioii  of  the  growths.     The  tubercles  are  found  upon  the  pleura  and 


218 


SPECIFIC   INFECTIOUS  DISKASES. 


& 


pcriton.Timi ;  in  tlic  luii^s,  liver,  kidiu-vs,  lyjiipli-iflaiids,  and  sploon  ;  ii|inn 
the  iiiciiihriiiU'S  ol'  the  ln'aiii,  ncciisioiiiilly  in  the  cluu'did  coat,  of  the  v\t; 
ami  ill  llu)  boiii'-niaiTow.  'i'lit-y  iiitiy  bi;  iil)undiiiit  in  soiiio  orf:aii>  mihI 
scaiily  ill  otluTs.  'I'liiis,  ir,  tiu;  iii('Miii<rc's  of  the  brain  tbcy  may  \k'  tliicklv 
set,  wiiilu  tbuiT  aro  frw  or  none  in  tbu  ubdomiiial  viscera  or  in  the  liiii^'s. 
On  the  other  hand,  tiie  liiii^s  may  bo  stiilTcd  with  frranulations  wliile  the 
meninjfcs  of  the  brain  are  free.  In  other  cascti,  aj^aiii,  tlie  distribiitidu  u 
uniform  in  all  the  viscera. 

The  rh'oliii/i/  iia.s  been  in  ])art  considered,  and  the  only  additional  stato- 
nient  necessary  i.s  that  in  a  <:;reat  majority  of  all  cases  it  is  an  ((ii/ii-infir. 
Hon,  arising  from  a  [ire-existinj^  tuberculous  focus,  which  may  be  latcii; 
and  unsuspectted.  Tlii!  followin<(  are  tlie  most  common  sources  of  jfencial 
infection:  Local  disease  of  the  hinsfs,  which  may  be  f|uite  limiti'd  and  uu- 
})rodiictive  of  symptoms ;  tuberculous  aircction  of  the  lymph-glands,  par- 
ticularly  ill  children ;  and  tuberculosis  of  the  bones  aiul  of  the  ki(hu'ys. 
Of  these  sources  perhaps  the  nuxst  common  are  the  tracheal  and  bniinliial 
lymph-glands,  which  are  so  often  the  seat  of  local  tubei'iuilosis.  Weip;; 
has  shown  that  in  many  cases  the  infection  results  from  tin;  riiptiuvufa 
caseous  pulmonary  nodule  into  a  vein,  or  of  a  caseous  bronchial  glaiKi  into 
one  of  the  i)iilmoiiary  veins.  A  general  infection  may,  as  shown  by  \\<\\. 
fick,  result  from  invasion  of  the  thoracic  duct  by  tubercles.  AVitli  s|»Mi;il 
care  the  source  of  infcctioi-.  can  usually  l)e  discovered  at  jxtst-iiiortriii 
examination.  The  conne-tion  bitweeii  tuberculous  lymph-glands  aii'l 
veins  has  often  lieen  dem.onstrated.  In  many  instances  it  is  impossililf  to 
say  what  determines  the  sudden  am'  violent  onset  of  the  disease.  It  WduU 
seem  sometimes  as  if  general  rather  than  local  conditions  intluonetd  ilio 
outl>K'ik.  After  certain  feve's,  partiiuilarly  measles  and  whooping-cMUL'li 
in  children — alTe(;tions,  it  is  true,  which  are  associated  with  Inng-continiinl 
bronchitis — miliary  tuberculosis  is  not  uiicommon.  The  prostratimi  aii'l 
constitutional  weakness  whicdi  follow  protracted  fevers  frequently  soeiii  in 
the  adult  a  predisj)osing  cause. 

Clinical  Forms. — For  practical  purposes  the  cases  may  be  dividul 
into  those  with  the  symptoms  of  itciitc  (jnirrdJ  ijifrc/ioit  without  s|i(rial 
localization;  cases  with  marked  pKhiiinuirii  symptoms;  and  cases  wit'a 
ceri'ltval  or  ccrvlini-spinal  symiitoms. 

Other  foi'ins  have  been  recognized,  but  this  division  covers  a  huge  iiui- 
jority  of  the  cases. 

Taking  any  series  of  cases  it  will  be  found  that  the  meningeal  fnriinf 
acute  tuberculosis  exceeds  in  numbers  the  cases  with  general  or  iiiarki'l 
pulmonary  symptoms. 

1.  General  or  Typhoid  Form.— <*^///»7^/f'»^s'.— The  patient  here  itre-^riu- 
the  symptoms  of  an  infectious  disease  with  few  if  atiy  local  syiiiiiteiii.-. 
The  cases  simulate  and  aro  fre(piently  mistaken  for  typhoid  fever.  Aftti 
a  period  of  failing  health,  with  loss  of  ai)petite,  the  patient  liccunns 
feverish  and  weak.     Occasionally  the  disease  sets  in  more  abruptly.  !)Ut  in 


TrnEiiruLosis. 


21U 


many  instanoos  tlip  nnamnosis  closely  rosomblcs  tluit  of  typhoid  fcviT. 
\iiS('-lil<'('ilinjj;,  luiwcvcf,  is  rare.  Tlit'  tciiiiicratui'c  iiioroasos,  tiic  piilso 
lircoiiH's  rapid  and  foi-blo,  tlio  ton,i,nii'  dry;  ilcliriiirn  Ix'coiiics  iiiui'kcd  and 
the  clu'cks  arc  lluslicd.  Tlu)  pnliiioiuiry  symptoms  may  he  very  sliirlit  ^ 
ii.suallv  l)roiKdutis  exists, but  not  more  severe  lliaii  is  eotiimou  with  tyi)hoid 
fever.  Till'  pidse  is  seldom  dicrotic,  Imt  is  rapid  in  jiropdrlion  to  the 
iivrc\i.i.  I'l'i'liaps  the  most  strikiii!,'  featui'c  of  the  temperatnre  is  tlio 
irrt';.'ularity ;  and  if  seen  from  the  ontset  there  is  not  the  steady  ascent 
notcil  in  typhoid  fever.  There  is  nsiially  an  evenini^  rise  to  10;j°,  some- 
times lii4\and  a  morning  ri'inission  of  from  two  to  three  de;^nves.  Some- 
times (lie  pvrcxia  is  intermittent, and  the  tlierinomctcr  may  register  below 

iiornial  during  the  early  morning  honrs.    The  inverse  ty[ f  temperatnre, 

ill  which  the  rise  takes  })lace  in  the  morning,  is  held  by  some  M'riters  to  be 
more  freijuent  in  general  tulienndosis  than  in  other  diseases.  In  rare  in- 
staiicos  there  may  be  little  or  no  fever.  On  two  f)Ccasions  I  have  had  a 
patient  ailmitted  to  my  wards  in  a  condition  of  profound  debility,  with  a 
liistcry  of  illness  of  from  three  to  four  weeks'  duration,  with  rajjid  pulse, 
Hushed  checks,  dry  tongue,  and  very  slight  elevation  in  'mperature,  in 
whom  (post  mortem)  the  condition  proved  to  be  general  tuboirulosis.  h\ 
one  iiisiaiice  there  wasj  toleraldy  extensive  disease  at  the  right  apex,  liiin- 
Imlil,  from  Hilunder's  clinic,  has  recently  called  attention  to  these  afebrile 
forms  of  acute  tul)erculosis.  In  nine  of  fifty-two  cases  there  was  no  fever, 
or  only  a  transient  rise. 

Ill  a  considerable  number  of  these  cases  the  respirations  are  increased 
in  freipieiicy,  particularly  in  the  early  stage,  and  there  nuiy  be  signs  of 
ililTust!  I»roiichitis  and  slight  cyanosis.  Cheyne-.Stokes  breathing  devel- 
ojis  toward  the  close. 

Active  delirium  is  rare.  ^lore  commonly  there  are  torpor  and  dullness, 
gradually  deepening  into  coma,  in  which  the  patient  dies.  In  some  cases 
tho  pulmonary  symptoms  become  more  marked;  in  others,  meningeal  or 
ci'i'ehral  features  develop. 

Diti^/iias'is. — The  ditTerential  diagnosis  between  general  miliary  tuber- 
culosis without  local  juanifestations  and  typhoid  fever  is  extremely  dilli- 
ciih.  A  point  of  importance,  to  which  reference  has  already  been  made, 
is  the  irregularity  of  the  temperature  curve.  The  greater  frequency  of 
the  respirations  and  the  tendency  to  slight  cyanosis  is  mnch  more  com- 
mon ill  tuberculosis.  There  are  cases,  however,  of  typhoid  fever  in  Avhieh 
the  initial  bronchitis  is  severe  and  nuiy  lead  to  dys])n(ca  and  disturb-,  d 
oxytreiiation.  The  cough  maybe  slight  or  absent.  Diarrluea  is  rare  in 
tuhorenlosis ;  the  bowels  are  usually  constipated ;  but  diarrluea  may  oc- 
cur and  jH'rsist  for  da3's.  In  certain  cases  the  diagnosis  has  been  conijdi- 
catcd  still  further  by  the  occurrence  of  blood  iii  the  stools.  Enlargement 
of  the  s[ileen  occurs  in  general  tuberculosis,  but  is  neither  so  early  iior  so 
'Harked  as  in  typhoid  fever.  In  children,  however,  the  enlargement  may 
Ijt'  L'onsiderablo.     The  urine  may  show  traces  of  albumen,  and  unfortu- 


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220 


SPKCIFIC   INKKCTIOUS   DISKASKS. 


imtcly  Mlirlicirs  (liiizo-roiiotion,  wliicli  is  so  constutit  in  t yplioid  f(>V(  r,  is 
also  iiii't  wilii  ill  j,'t'iii'i'iil  tiihiTciilDsis.  The  iibscticiMit' iln-  cliuriictiTistic 
rosi'olii  is  nil  iiiiportuiil  fcatiirc.  Ocfiisjoimlly  ii;  iiciitc  tiilx-rciilosis  rccMi.li 
spots  ifiiiy  'U'vclop  iiiul  for  a  tiiiu'  cause  (iiiriculty,  but  tlu-y  <lo  not  cunic 
out  in  crofis,  and  rarely  have  tlic  cluiradters  of  the  true  typlioid  crniiiidii. 
llcrpos  is  pcrliups  inoro  comiuoii  in  tuberculnsiH.  Towiird  the  close,  jkIi'- 
ci>ia'  iniiy  appear  on  the  si\in,  [tarlicularly  ubout  the  wrists.  A  runt  cvtMii 
is  jaundice,  (hie  possilily  to  the  ei'iiptioii  of  tiilicndes  in  tiie  liver,  ll  is  id 
lie  reinenihered  that  the  ii'sioiis  of  acute  tuherciilosis  and  of  ty|)hoid  fever 
liavo  been  demonstrated  in  the  siune  body. 

In  a  few  instances  the  jiresence  of  tubercle  bunilli  bus  been  deinon- 
titrated  in  the  blood,  which  in  doubtful  cases  should  therefore  be  examiiicil. 
The  spleen  has  been  luinctiiriMl  ami  cultivations  made  to  determine  tln' 
])i'eseiice  or  absence  of  the  tyiihoid  bacilli,  but  in  tlu;  acute  splenic  tiiiiKir 
this  is  a  diuifjerous  proceilure.  The  eye-grounds  should  be  carefully  exam- 
ined  for  choroidal  tubercles.  The  blood  may  show  u  alight  leuccxfytosis,  hut 
in  the  very  acute  cases  wliere  there  are  no  suppnratiiif^  foci  this  is  absent. 

2.  Pulmonary  Form. — Siimplonis. —  From  the  out.set  the  pulnioii;iiT 
symjitoms  are  marked.  Tiie  jiatient  nuiy  have  had  a  cough  for  moiitliser 
for  years  without  miieh  impairment  of  health,  or  he  may  be  known  to  he 
the  subject  of  chronic  pulmonary  tuberculosis.  In  other  instances,  partic- 
ularly in  children,  the  disease  follows  measles  and  whooping-cough,  iiml 
is  of  a  dislinctly  broiicho-pneumonic!  ty])e.  The  disease  begins  with  tlii' 
symptoms  of  dilTuse  bronchitis.  The  cough  is  marked,  the  ex[)ectoratiim 
muco-purulent,  occasionally  rusty.  Ilannoptysis  has  been  noted  in  a  few 
instances.  From  the  outset  dyspmea  is  a  striking  feature  and  may  lie  init 
of  proportion  to  the  intensity  of  the  ])hysieal  signs.  'I'here  is  more  or  less 
cyanosis  of  the  lips  ami  linger-tips,  and  the.  cheeks  are  sulTused.  .\imi't 
from  emphysema  ami  the  later  stages  of  severe  pneumonia  I  know  ef  no 
other  pulmonary  condition  in  which  the  cyanosis  is  so  marked.  The  phys- 
ical signs  are  those  of  bronchitis.  In  children  there  may  be  defective  roso- 
iiance  at  the  bases,  from  scattered  areas  of  broncho-pneumonia;  or,  wluitis 
equally  suggestive,  areas  of  hyper-resonance.  Indeed,  the  percussion  imte, 
particularly  in  the  front  of  the  chest,  in  some  cases  of  miliary  tuberculosis, 
is  full  and  clear,  aiul  it  will  be  noted  ([)ost  mortem)  that  the  li'iigs  are 
unusually  voluminous.  This  is  probably  the  result  of  more  or  less  wido- 
sprcad  acute  emphysema.  On  auscultation,  the  rales  are  either  sibilant 
and  sonorous  or  small,  fine,  and  crepitant.  There  may  be  fine  (irepilMlioii 
from  the  occurrence  of  tubercles  on  the  pleura  (Jiirgensen).  In  chiMiTii 
there  may  be  high-pitched  tubular  breathing  at  the  bases  or  towan'  tho 
root  of  the  lung.  Toward  the  close  the  rules  may  be  larger  and  more  mu- 
cous. The  temperature  rises  to  102°  or  103°,  and  may  present  the  iiivcr?!' 
type.  The  pulse  is  rapid  and  feeble.  In  the  very  acute  cases  the  sjilomi 
is  always  enlarged.  The  disease  may  prove  fatal  iu  ten  or  twelve  days,  or 
may  be  protracted  for  weeks  or  even  months. 


TUUKUCUIiOSIH. 


221 


Piti/liidxis. — Tho  (liiiL'iiosis  of  this  form  ofTcrs  loss  difTiciilty  aii<l  is 
inorc  riv(|iu'iitly  nuuh'.  'I'liiTt'  is  often  a  liistoi-y  of  jtrcvioiis  foii^rJi^  ,,r  tlir 
iiMticiii  i-  known  to  bo  the  siibji'ct  of  local  disciiso  of  the  lunj;,  or  of  tin- 
|vm|ili-;.'l!iinls,  or  of  tho  bones.  ]n  childicn  these  syini)t()nia  foUowinj.' 
tiir.islrs  or  \vhoo|iin^f-('on;r]i  indicate  in  the  majority  of  canes  aente  miliary 
lulicn'uliisis,  with  or  withont-  l)roiic]io-|iiiemnonia.  ()e(iisionally  the  si)n- 
liiiii  (■(iiilaiiis  tiiberele  bacilli. 

Tlic  clioroidal  tnluM'cle  occiirs  in  a  limited  niiml)cr  of  cases  and  may 
|ii'l|i  llic  diairnosis.  More  important  in  an  adidt  is  tiie  combination  of 
ilvs|m(i'ii  with  cyanosis  and  the  si^iis  of  a  dilTiise  ttromdiitis.  In  some  in- 
stMiiri's  the  occurrence  of  cerebral  symplonis  at  once  ^dve  ii  clew  to  tho 
iiahiiv  of  the  troid)lo. 

:!  Meningeal  Form  {Tnhemihms  McniiKjilis). — This  alTectioii,  whicli  is 
also  known  as  aetitc  by<lroce|ihaliis  or  "  water  on  the  brain,"  is  essentially 
;m  acute  tid)erciilosis  in  which  the  mcmbi'anes  of  the  brain,  sometimes  of 
the  ceril,  l)car  the  brnnt  of  the  attack. 

Tlii'ie  are  several  special  c/idlai/icd/  factors  in  connection  wilii  this 
I'diin.  It  is  much  more  common  in  children  than  in  adults.  It  is  rare 
(liirini,'  the  first  year  of  life,  more  frc(pu'nt  between  the  second  and  tho 
liftli  years.  In  a  majority  of  the  cases  a  focus  of  old  tuberculous  disease 
will  he  found,  ('(tmmoidy  in  the  bronchial  or  mesenteric;  glamls.  In  a  few 
iiistaiiccs  the  alt'ection  seems  to  be  [»riniary  in  the  menin'jfcs.  It,  is  very 
ilitlicuir,  however,  in  an  ordinary  [lost-mortem  to  make  an  exhausiive 
SI  arch,  and  the  lesion  may  be  in  the  l)ones,  .sometimes  in  the  middle  ear, 
or  in  the  p'liito-urinary  organs.  In  those  instances  in  which  no  primary 
Incus  has  been  discovered  it  has  been  suLri^'estcd  that  the  bacilli  reach  the 
meninges  through  the  cribriform  ])late  of  the  ethmoid  from  the  upper 
piirt  of  the  nostrils,  luit  this  is  not  j)robabl.'. 

Murliid  Aiiatoiinj. — Tuberculous  meniii'.ritis  presents  a  very  character- 
istic picture.  The  nu'ninge.s  at  the  base  are  niosi  involved,  hence  the  term 
hiisilar  meningitis.  The  })arts  about  the  opt^c  (diiasm,  the  Sylvian  fi.ssuresi 
iiiid  the  interpeduncular  s])ace  are  aU'ected.  There  jnay  be  oidy  .slight 
tiu'lii'lily  and  matting  of  the  mem1)raiu^s,  and  a  certain  stickiness  with 
serous  iiililtration ;  but  more  comnutidy  there  is  a  turbid  exiulate,  librino- 
piirulent  iu  character,  which  covers  the  structures  at  the  base,  surrounds 
the  nerves,  extends  out  in  the  Sylvian  ilssures,  and  appears  on  the  lateral, 
rarely  on  the  upper,  surfaces  of  the  hemispheres.  The  tubei'clcs  nuiy  be 
very  apparent,  particularly  in  the  Sylvian  fissures,  api)eariiig  as  snuill, 
"liitish  nodules  on  the  membrajies.  They  vary  much  in  number  and  size, 
and  maybe  ditlicult  to  find.  The  amount  of  exudate  bears  no  definite  re- 
liilii'n  to  the  abundance  of  tubercles.  The  arteries  of  the  anterior  and 
posterior  perforated  spaces  .should  be  carefully  withdrawn  and  searched, 
as  upon  tliem  nodular  tubercles  may  be  found  when  not  present  elsewhere. 
In  doubtful  cases  the  middle  cerebral  arteries  should  be  very  carefully  re- 
moved, spread  on  a  glass  plate  with  a  black  background,  and  examined 


1/  i^f 


■  i'.  Ill 


222 


SPECIFIC  INFECTIOUS  DISEASES. 


I'    ffeiS   - 


with  :i  low  objoctivc.  The  tuberclos  tiro  then  seen  us  noduhir  onlurge- 
ments  >.!»  Ll.<.  siUiiUer  arteries.  The  hitenil  veiitrielcs  are  dihited  (acute 
hydrocoidiiihis)  and  contain  a  turbid  Ihiid',  the  epcndyma  may  be  sdft. 
ene<i,  and  the  septum  hieidum  and  fornix  are  usually  broivcn  (h)wn.  The 
convohitions  are  often  llattened  and  the  sulci  obliterated  owiinr  to  tin. 
increased  intra-ventricular  pressure.  Histologically  the  tubercles  mic  .seen 
to  develop  in  the  perivascular  slieaths,  })roducing  circumscribed  ajrgroiru- 
tions  of  lymphoid  and  ci)itbelioid  cells.  The  lumen  of  the  vessel  is  nar- 
rowed  and  thrombosis  nuiy  result.  The  meninges  are  not  alone  invdlveil, 
but  the  contiguous  cerebral  substance  is  more  or  less  u'denuitous  and  iiitil- 
trated  with  leucocytes,  so  that  anatomically  the  condition  is  in  re:ilit\  a 
mcniiHio-ourphdJillx. 

There  arc  instances  in  which  the  acute  process  is  associated  with 
chronic  meningeal  tuberculosis;  cases  which  nuiy  for  months  present  lb 
clinical  i)icture  of  brain  tumor. 

Although  in  a  majority  of  instances  the  process  is  cerebral,  the  siijiial 
meninges  may  also  be  involved,  particularly  those  of  the  cervical  w\i\. 
There  are  cases  iiuleed  in  which  the  symjjtonis  are  chielly  s[)in!d.  A  sailor, 
who  had  fallen  on  the  deck  three  weeks  before  his  death,  was  admitted  to 
the  Montreal  (ieneral  Hospital,  lie  presented  signs  of  nieiungitis,  ihiclly 
spinal,  which  were  naturally  attributed  to  traumatism.  The  i)ost-niortt'iii 
showed  absence  of  tubendes  and  lymph  at  the  base  of  the  brain,  anil  an 
extensive  eruption  of  miliary  tubercles  with  much  turbid  lymph  over  tln' 
entire  s])inal  meninges.  There  were  small  cheesy  masses  at  the  a[)ieL's »[ 
the  lungs. 

Si/iiip/oiiis. — Tuberculous  meningitis  presents  :m  extremely  coin])]ox 
clinical  i)icture.     It  will  be  best  to  describe  the  form  found  in  childnii, 

Trodronial  symptoms  are  common.  The  child  may  have  been  in  fail- 
ing health  for  some  weeks,  or  may  be  convalescent  from  measles  or  wlionji- 
ing-cough.  In  many  instances  there  is  a  history  of  a  fall.  The  cliild 
gets  thin,  is  restless,  peevish,  irritable,  loses  its  appetite,  and  the  dispn- 
sition  may  completely  change.  Symptoms  pointing  to  the  disease  may 
then  set  in,  either  quite  suddenly  with  a  convulsion,  or  more  coininniily 
with  headache,  vomiting,  and  fever,  three  essential  symptoms  of  the  onset 
which  are  rarely  absent.  The  pain  may  be  intense  and  agonizing.  The 
child  puts  its  hand  to  its  head  and  occasionally,  when  the  pain  hecuiiies 
worse,  gives  a  short,  sudden  cry,  the  so-called  hydrocephalic  cry.  Suim'- 
times  the  (diiUl  screams  continuously  until  utterly  exhausted.  I  saw  in 
West  rhiladelphia  a  case  of  basilar  meningitis  in  a  girl  of  thirtecMi,  who 
for  three  days,  when  not  under  '.he  iniluence  of  a  ])owerfid  sedative  or  of 
chloroform,  screamed  at  the  top  of  her  voice  so  as  to  be  heard  a  sciiiarcor 
more  away.  Tiie  vomiting  is  without  apparent  cause,  and  is  inde[)i'iitliiii 
of  taking  of  food.  Constipation  is  usually  present.  The  fever  is  sliu'lii. 
but  gradually  rises  to  U)2°  r  103°.  The  \n\\se  is  at  llrst  rapid,  sulise- 
quently  irregular  and  slow.     The  respirations  are  rarely  altered.     Diiriiu' 


TUBERCULOSIS. 


223 


sleep  tlio  rhild  is  restless  und  disturbed.  There  may  be  twitebin^s  of  tlie 
iiiuscli's,  (ir  sudden  startiiii^s;  or  the  child  may  wake  up  from  sleep  in 
":v;it  ternir.  lu  this  early  stage  the  pupils  are  usually  >  )utraeted.  These 
an.  the  eliiff  symptoms  of  the  initial  stage,  or,  as  it  is  termed,  tlie  sUnjv  of 

iirlhilmii- 

In  the  .second  ])eri()d  of  the  disease  these  irritative  sym})toms  subside; 
voinitiiig  is  no  longer  marked,  the  abdomen  Ijceoines  retracted,  b  .ii- 
tfhapeil  or  r<(ri)i(i/('(l.  The  bowels  are  obstinately  eonsti[)ated,  the  child  ii.» 
luiiu'er  e()iH[)lains  of  headache,  but  is  dull  and  apathetic;  and  when  roused 
is  more  ^>v  less  delirious.  The  lu'ad  is  often  retracted  and  the  child  utters 
an  oeeasioii'd  cry.  The  i)U[)ils  are  dilated  or  irregular,  aiul  a  squint  may 
tlevfl(i|t.  Sighing  respiration  is  common.  Convulsions  may  occur,  or 
liiriditv  (if  till'  uiuscles  of  one  side  or  of  one  limb.  Th.'  temperature  is 
variable,  ranging  from  1(IU°  to  Id^i'o''.  A  bloti-hy  erythenui  is  not  uncom- 
mon (in  the  skin.  If  the  finger-nail  is  drawn  across  the  skin  of  any  region 
a  nil  line  comes  out  quickly,  tlie  so-called  Idc/ie  arcOfd/v,  which,  however, 
has  nil  diagnostic  significance. 

Ill  the  linal  period,  or  stage  of  paraJi/sis,  the  coma  increases  and  the 
ehild  eaniiot  be  roused.  Convulsions  an;  not  infreipieiit,  and  tliere  are 
fjiasniodic  contractions  of  the  muscles  of  the  back  and  neck.  Spasms 
may  occur  in  the  limbs  of  one  si;le.  Optic  neuritis  and  paralysis  of  the 
(leular  nuiscles  may  be  present.  The  pupils  liccome  dilated,  the  eyelids 
,iie  only  partially  closed,  and  the  eyeballs  are  rolled  up  so  that  the  cornete 
■ire  (inly  eoverei,  in  jiart  by  the  upper  eyelid.  Diarrluea  may  develop,  the 
pulse  ln'C(imes  rai)i(i,  and  the  child  may  sink  into  a  tyi)hoid  state  with  dry 
toiiirne,  l(i\v  (1.  ii'ium,  ami  involuntary  passages  of  urine  and  fu'ces.  The 
temperature  often  becomes  subnormal,  sinking  in  rare  instances  to  (I3°  or 
W  .  In  some  cases  there  is  ante-mortem  elevation  of  teiiipeiature,  th© 
fever  rising  to  100°.  The  entire  duration  of  the  disease  is  from  a  fort- 
night to  three  or  four  weeks.  A  leucocytosis  is  not  infrequently  present 
throughout  the  disease. 

There  are  cases  of  tuberculous  meningitis  which  pursue  a  more  rapid 
roui'se.  They  set  in  with  great  violence,  often  in  persons  ap])arently  in 
j;n(i(l  health,  and  may  prove  fatal  within  a  few  days.  In  tiie.-i'  instances, 
mure  com monly  seen  in  adults,  the  convex  surfai^e  of  the  brain  is  usually 
iiivdlvitl.  There  are  again  instances  which  are  essentially  (dironic  ami 
ilis|ilay  symptoms  of  a  limited  meningitis;  sduietimcs  wiiii  pronounced 
p-yeliie; ;  symptoms,  and  sometimes  with  those  (if  cerebral  tumor. 

'I'll'  /e  are  certain  features  which  call  for  special  conn  leiit. 

Tl  ,■  irregularity  and  slowness  of  the  pulse  in  the  early  and  middle 
stage  of  the  disease  are  points  upon  which  all  authors  agree.  Toward  tlie 
'I'ls  ,  as  the  heart's  action  becomes  weaker,  the  pulsations  are  more  fre- 
'I'li'iit.  The  temperature  is  usually  elevated,  but  there  are  instances  in 
^nii<h  it  does  not  rise  in  the  whole  ccmrseof  tlie  disease  much  above  10tl°. 
It  may  bo  extremely  irregular,  and  the  oscillations  are  often  as  much  as 
tlii'ee  or  four  degrees  in  the  day.     Toward  the  close  the  teuiiierature  may 


'  I  IS'! 


I.  !  ] 


i;!  t 


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-'•f^ 


iii  ^*|    J 


m 


4    ; 


224 


SPECIFIC   INFECTIOUS  DISEASES. 


^^11: 


li 


sink  to  95°,  occasionally  to  94°,  or  there  may  i)e  hyperpyrexia.  In  a  case 
of  Biiumler's  the  tonipcrature  rose  before  death  to  4;5-T°  C  (lJ0-7°  R). 

The  ocular  sym])tonis  of  the  disease  are  of  special  importance.  In  tlie 
early  stages  narrowing  of  the  pupils  is  the  rule.  Toward  the  close,  with 
increase  in  the  intra-cranial  pressure,  the  pupils  dilate  and  are  irregular. 
There  nuiy  be  conjugate  deviation  of  the  eyes.  Of  ocular  palsies  the 
third  nerve  is  nu)st  frequently  involved,  sometimes  with  jiaralysis  of  the 
face,  limbs,  and  hypoglossal  nerve  on  the  opposite  side  (syiulronic  (if 
Weber),  duo  to  a  lesion  limited  to  the  inferior  and  internal  part  of  the 
cms.  Tlie  changes  in  the  eye-grounds  are  very  important.  Neuritis  is  the 
most  common.  According  to  (lowers,  the  disk  at  tirst  becomes  full  colored 
and  has  hazy  outlines,  and  tlu;  veiiis  ari'  dilated.  Swelling  and  striatioti 
become  })ronounced,  but  the  neuritis  is  rarely  inteiise.  Of  twenty-six 
cases  studied  by  (Jariick,  in  six  the  condition  was  of  diagnostic  value, 
The  tubercles  in  the  choroid  are  rare  and  much  less  frequently  seen  during 
life  than  post-mortem  ligures  Avould  indicate.  Thus  Litten  found  them 
(post  mortem)  in  thirty-nine  out  of  iifty-two  cases.  They  were  })reseiit  in 
oidy  one  of  the  twenty-six  cases  of  tuberculous  meningitis  examined  by 
(iarlick.     Ileinzel  examined  with  negative  results  forty-one  cases. 

Among  the  motor  symptoms  convulsions  are  most  common,  but  there 
are  other  changes  which  deserve  special  mention.  A  tetanic  contractidii 
of  one  lindj  may  persist  for  s.'veral  <lays,  or  a  cataleptic  coiulition.  Tremor 
and  athetoid  movements  are  sometimes  seen.  The  paralyses  are  either 
hemiplegias  or  mono[)legias.  IIcmi})legia  may  result  frouT  disturbance  in 
the  cortical  branches  of  the  middle  cerebral  artery,  occasionally  from 
softening  in  the  internal  capsule,  due  to  involvement  of  the  cciitrul 
branches.  Of  monoplegias,  that  of  the  face  is  perhaps  most  common,  ami 
*f  on  the  right  side  it  may  occur  with  apluisia.  In  two  of  my  cases  in 
adults  aphasia  developed.  Hraidiial  monoplegia  may  be  associated  with  it 
In  the  more  chronic  ca.se^  the  synij)t()ins  persist  for  months,  and  there  may 
be  a  characteristic  Jacksonian  epilepsy  when  the  tubercles  involve  the 
meninges  of  the  motor  cortex. 

The  prof/iKisis  in  this  form  of  meningitis  is  always  most  serious.  I 
have  neither  seen  a  case  which  I  regarded  as  tuberculous  recover,  nor 
have  i  en  post-mortem  evidence  of  past  di.sease  of  this  nature.  Cases  (if 
recovery  have  been  nqjorted  by  reliable  authorities,  but  they  are  extiemely 
rare,  and  there  is  always  a  reasonable  doubt  as  to  the  correctness  of  the 
diagnosis.  The  differential  features  and  treatment  will  be  considered  in 
connection  with  acute  meningitis. 

III.  TuBEUCULOKis  OK  TiiK  Ly.m iTf-dLAN i)s  {Scrofula). 

Scrorula  is  tubercle,  as  it  has  been  shown  that  the  bacillus  of  Koch  is 

the  essential  element.     It  is  not  yet  definitely  settled  whether  the  virii> 

which  produces  the  chronic  adenitis  or  scrofula  differs  from  that  which 

produces  tuberculosis  in  other  parts,  or  whether  it  is  the  local  conditiuus 


yp-- 


TUBERCULOSIS, 


225 


ill  tlio  glands  which  account  for  tho  slow  development  and  milder  course,  u 
Tlu'  exiH'fiments  of  Arloing  would  indicate  tint  the  virus  was  attenuated  | 
or  niihli  r.  for  he  has  shown  that  the  caseous  material  of  a  lymph-gland  | 
killed  uniueu-pigs,  while  rabbits  escaped.      The    guinea-pig,  as  is  well 
kiiDwii.  is  the  more  susceptible  animal  of  the  two>     The  observations  of 
Liui,nird  arc  still  more  conclusive,  as  showiiiL''  a  variation  in  the  virulence 
of  the  tubercle  bacillus.     (Juinea-pigs  inoculated  with  ordinary  tubercle 
jhowcil  Ivmphatic  infection  within  the  first  week,  and  the  animals  died 
\vitlii?i  tlii'oe  months;  infected  with  materia!  from  scrofulous  glands,  the 
Iviiiphatic  enlargement  did  not  apjtear  until  the  second  or  third  week,  and 
till.'  aiiiiiials  survived  for  six  or  seven  months.     He  showed,  moreover,  that 
tho  vinilcnee  of  the  infection  obtained    from  the  scrofidous  glands  in- 
rreased  in  intensity  by  passing  through  a  series  of  guinea-pigs.     Eve's  ex- 
|Ri'iiiicnts  sliow  that  scrofulous  material  invariably  produces  tuberculosis 
ill  'uiiiu'a-iiigs  and  very  often  in  raljbits. 

Tuberculous  adenitis  is  met  with  at  all  ages.  It  is  more  common  in 
cliildrcii  than  in  adults,  but  it  is  not  infrequent  in  the  middle  period  of 
litV,  and  may  occur  in  old  age. 

I'lie  tubercle  bacillus  is  id)iqnitous.  All  are  exposed  to  infection,  and 
upon  the  local  conditions,  whether  favorable  or  unfavorable,  depend  the 
f:ite  of  those  organisms  which  find  lodgment  in  our  bodies.  It  is  possible,  i 
i»t  ootu'se,  that  tubei'culous  adenitis  may  be  congenital,  but  such  instances 
must  be  extremely  rare.  A  spe(dal  predisposing  factor  in  lymphatic  tuber- 
I'lilosis  is  catarrhal  infianunation  of  the  muccus  membranes,  which  in  itself 
cxoites  slight  adenitis  of  the  neighboring  glands..  In  a  child  with  con- 
stiintly  recurring  naso-pharyngeal  catarrh,  the  bacilli  which  lodge  on  the 
mucous  iiieuibranes  find  in  all  prol)ability  the  gateways  less  strictly 
guarded  and  are  taken  up  by  the  lymphatics  and  passed  to  the  nearest 
glands.  The  importance  of  the  tonsils  as  an  infection-;  ntn  lias  of  late 
bi'cn  lu'ged.  In  conditions  of  health  the  loc^al  resistaii'  ,  or.  as  sonic 
would  put  it,  the  phagocytes,  would  be  active  enough  to  deal  with  t\\f  in- 
vaders, hut  the  irritation  of  a  chronic  catarrh  weakens  tho  resistance  of  the 
iMiipli-tissiia  and  the  bacilli  are  enabled  to  develop  and  gradually  to  change 
a  simple  into  a  tuberculous  adenitis*  The  frequent  association  of  tuber- 
culous adenitis  of  the  bronchial  glands  with  whooping-cough  and  with 
measles,  and  the  frequent  development  of  tubercle  in  the  mesenteric 
glands  in  children  with  intestinal  catarrh,  find  in  this  way  a  rational  ex- 
lilaiiatiiMi.  After  all,  as  Vindiow  pointed  out,  an  increased  vulnerability 
of  the  tissue,  however  brought  about,  is  the  imiiortant  factor  in  the  disease. 

The  following  are  some  of  the  features  of  interest  in  tuberculous  ade- 
nitis : 

{(i)  Tlie  local  character  of  the  disease.     Thus,  the  glands  of  the  neck,  or 
!it  the  l)ifiu'cation  of  the  bronchi,  or  those  of  the  mesentery,  may  be  alone 

iiivolvoil. 

[li)  Tiie  tendency  to  spontaneous  liealing.    In  a  large  proportion  of 
the  cases  the  battle  which  ensues  between  the  bacilli  and  the  tissue-cells  is 


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226 


SPECIFIC   INFECTIOUS  DISEASES. 


mz 


long;  but  tlio  latter  are  finally  successful,  and  wo  lind  in  the  calcilicd 
remnants  in  the  bronchial  and  mesenteric  lympli-glands  evidences  of  vir. 
tory.  Too  often  in  the  bronchial  glands  a  triu'e  only  is  declared  and  lid... 
tilities  may  break  out  afresh  in  the  form  of  an  acute  tuberculosis. 

(c)  The  tendency  of  tuberculous  adenitis  to  pass  on  to  supimnition, 
The  frequency  witli  which,  particularly  in  the  glands  of  the  neck,  we  iiii,i 
the  tuberculous  })roci'sses  associated  with  pus  is  a  special  feature  of  thi, 
form  of  adenitis.  In  nearly  all  instances  tlie  pus  is  sterile.  Whether  tli.' 
suppuration  is  excited  by  the  bacilli  or  by  their  products,  or  whetluTitb 
the  result  of  a  mixed  infection  with  pus  organisms,  which  are  saba'. 
quentiy  destroyed,  has  not  been  settled. 

(<l)  Tlie  existence  of  an  unhealed  focus  of  tuberculous  adenitis  i^;i 
constant  meinice  to  the  organisju.  It  is  safe  to  say  that  in  three  fourtlij 
of  the  instances  of  acute  tuberculosis  the  infection  is  derived  from  tliij 
source.  On  the  other  hand,  it;  has  been  urged  that  scrofula  in  childluidil 
gives  a  sort  of  protection  against  tuberculosis  in  adult  life.  We  certainlv 
do  meet  with  many  ))ersons  of  ex(H^ptional  bodily  vigor  who  in  chiklhuml 
had  enlarged  glands,  but  the  evidence  which  Marfan  brings  forward  in 
support  of  this  view  is  not  conclusive. 

Clinical  Forms.— l.  General  Tuberculous  Lymphadenitis.— In  ox- 
ceptional  instances  we  find  dilTu.se  tuberculosis  of  nearly  all  the  Iviiijiii- 
glands  of  the  body  with  little  or  no  involvement  of  other  parts.  The  nio.-: 
extreme  cases  of  it  which  I  have  .seen  have  been  in  negro  patients.  Tuo 
well-marked  cases  occurred  at  the  Philadelphia  Hospital.  In  a  woinaii, 
the  chart  from  April,  1S88,  until  March,  IScS!),  showed  persistent  fever, 
ranging  from  101°  to  103°,  occasionally  rising  to  104".  On  Deceinher  liltii 
the  glands  on  the  right  side  of  the  neck  were  removed.  After  an  attiuk 
of  erysipelas,  on  February  ITtli,  she  gradually  sank  and  died  March  5tii. 
The  lungs  presented  only  oiu;  or  two  puckered  spots  at  the  apices.  Tin- 
bronchial,  retro-j)erit(UU'al,  and  mesenteric  glands  were  greatly  eiilariroii 
and  caseous.  Xo  intestimd,  uterine,  or  bone  disease.  The  contimiMiif 
high  fever  in  this  case  depended  a])parently  upon  the  tuberculous  adeimk 
which  was  much  more  extensive  than  was  sa|)posed  during  life.  In  tliw 
instances  the  enlargement  is  most  marked  in  the  retro-peritoneal,  liruii- 
dual,  and  mesenteric  glands,  l)ut  may  be  also  }>rcsent  in  the  groups  if 
external  glands.  Occurring  acutely,  it  presents  a  picture  resemljliiiu'  Ileil:'- 
kin's  disease.  In  a  case  which  died  in  the  Montreal  General  Hospital  tlii> 
diagnosis  was  made.  The  cervical  and  axillary  glands  were  eiiornioii'ly 
enlarged,  aiul  death  was  caused  by  infiltration  of  the  larynx.  In  iiifniit- 
and  children  there  is  a  fcn-tu  of  general  tuberculous  adenitis  in  w  liicli  tin 
various  groups  of  glands  are  successively,  more  rarely  simultaneon.-ly,  iti- 
volved,  and  in  which  death  is  caused  either  by  cachexia,  or  by  an  acitti 
infection  of  the  meninges. 

2.  Local  Tuberculous  Adenitis.— (^/)  Cervical    This  is  the  most  cmi: 
men  form  met  with  in  children.     It  is  seen  particularly  among  the  \m' 


TUBERCULOSIS. 


22'i 


ami  tli">«'  "^10  1'^'^  continuously  in  tlio  inipuro  atmosphere  of  1);ully  venti- 
luldl  Idiiiiiuirs.  Children  in  rouiulliu^r  hos]»it;il,s  and  asyluni.s  are  speeially 
jii'oiic  to  the  disease.  In  this  country  it  is  most  common  in  the  negro 
nict'.  As  idready  stated,  it  is  often  met  with  in  catarrh  of  the  nose  and 
throat,  111'  I'lironic  enlargement  of  the  tonsils  ;  or  the  child  may  have 
had  dv.eiiiii  of  the  scalp  or  a  purulent  otitis. 

The  siil)iMaxillary  glands  are  th-st  involved,  and  are  popularly  spoken 
of  as  (iiLirged  kerneh.  They  are  usually  larger  on  one  side  than  on  the 
othiT.  As  they  increase  in  size,  the  individual  tunujrs  can  be  felt;  the 
siii'fai'e  is  smooth  aiul  the  consistence  iirm.  They  may  remain  isolated, 
but  more  commonly  they  fcjrm  large,  knotted  nuisses,  over  which  the 
t-kiii  is,  as  a  rule,  freely  movable.  In  many  cases  the  skin  ultimately  be- 
coims  adlicrcnt,  and  inllammation  and  suppuration  occur.  An  abscess 
jioiiils  anil,  unless  o])ened,  bursts,  leaving  a  sinus  which  heals  slowly. 
Tho  disease  is  frequently  associated  with  coryza,  Avith  eczenui  of  the  scalp, 
tar,  or  lips,  and  with  conjunctivitis  or  keratitis.  AVlien  the  glands  are 
largo  and  growing  actively,  there  is  fever.  The  subjects  are  usiudly  ante- 
iiiic,  particularly  if  suppuration  has  occurred.  The  })rogress  of  this  form 
uf  adenitis  is  slow  and  tedious.  Death,  however,  rarely  follows,  and  many 
aggravated  cases  in  children  ultimately  get  well.  Mot  only  tlu;  submaxil- 
lary group,  but  the  glands  above  the  clavicle  and  in  the  posterior  cervical 
triaiiglf,  may  be  involved.  In  other  instances  the  cervical  aiul  axillary 
glands  are  involved  together,  forming  a  contiinuius  chain  Mhich  extemls 
liciicath  the  clavicle  ami  the  2)ectoral  muscle.  With  them  the  bronchial 
glands  may  also  be  enlarged  and  caseous.  Mot  infrecpu'iitly  the  cnlarge- 
iiieiit  of  the  supraclavicular  and  axillary  grouji  of  glands  on  one  side 
precedes  the  development  of  a  tuberculous  pleurisy  or  of  pidmonary 
tuberculosis. 

(//)  I'lnnirhidh — The  tnediastinal  lymph-glands  constitute  filters  in 
winch  lodge  the  various  foreign  2)articles  which  escape  the  normal  ])bago- 
nfcs  (tf  bronchi  aiul  lungs.  Among  these  foreign  particles,  and  probably 
iltaclu'il  to  them,  tubercle  bacilli  are  not  uncommon,  and  we  find  tuber- 
cles and  caseous  matter  with  great  frecpiency  in  the  nuMliastinal  glands, 
pinticuhirly  those  about  the  bronchi.  It  is  stated  that  this  ]u-ocess  is 
always  secondary  to  a  focus,  however  suudl.  in  the  lungs,  but  my  experi- 
eiiei' d(}(.'s  not  bear  out  such  a  statement.  As  alreadv  mentioned,  North- 
rup  foniid  them  involved  in  every  ofu'  of  a  hundred  ami  twenty-seven 
eases  at  the  Xew  York  Foundling  Hospital.  This  tuberculous  adenitis 
may,  in  tlie  bronchial  glands,  attain  the  ditnensions  of  a  tumor  of  large 
■a'.  Hut  even  when  this  occiu's  there  may  be  no  })ressnrc  symptoms. 
InehiMren  the  brontdiial  adenitis  is  apt  to  l)e  associated  with  suppuration. 

A  more  serious  danger  in  tuberculous  disease  of  the  broiu'hial  glands 
■  ~  systoiijo  infection,  which  takes  place  through  the  vessels.  Local  in- 
'•'■tinn  (if  tlie  lungs  may  also  occur.  In  the  tuberculous  broiudio-pneu- 
li'iiiia  of  eliildreii  it  is  usual  to  find  the  bronchial  glands  enormously  en- 


'!l 


U 


1'- 


I 


I 

111 

II    '  *'  . 


228 


SPECIFIC  INFECTIOUS  DISEASES. 


largcd,  passing  deeply  into  the  hiliis,  adjoining,  and  in  some  instances 
even  merging  with,  aiviis  of  caseation  of  the  pulmonary  tissue  itself. 

There  is  a  s[H'cial  (hmger  of  infection  of  tlie  pericardium  by  tiiheiTii- 
lous  lyni|)h-ghinds  in  the  anterior  mediastinum. 

(r)  Masciiterii' ;  Tnhrs  mcsoilvrica. — In  tliis  afTection,  tlie  ahdominal 
scrofula  of  old  writers,  the  glands  of  the  nu'sei\tery  and  retro-perit(iii,viiiii 
become  enlarged  and  caseate  ;  nu)re  rarely  tlwy  suppurate  or  calcifv.  A 
slight  tuberculous  adenitis  is  extremely  common  in  children,  and  is  often 
accidentally  found  (post  mortem)  when  the  children  have  died  of  nther 
diseases.  It  may  be  a  primary  lesion  associated  with  intestinal  catarrh,  or 
it  may  bo  secondary  to  tuberculous  disease  of  the  intestines. 

The  primary  cases  are  very  cf)mmon  in  children,  as  may  be  gatlioivil 
from  Woodhead's  figures.  The  general  involvement  of  the  glands  inter- 
feres seriously  with  nutrition,  and  the  ])atients  are  puny,  wasted,  and  aiiiv- 
mic.  The  abdomen  is  enlarged  and  tymi)anitic;  diarrluea  is  a  con.^tant 
feature;  the  stools  are  thin  and  olfensive.  There  is  nu)derate  fever,  but 
the  general  wasting  and  debility  are  the  most  characteristic  features.  The 
enlarged  glands  cannot  often  be  felt,  owing  to  the  distended  conditidiiof 
tlie  bowels.  These  cases  arc  often  sjjoken  of  as  consumption  of  tlie 
bowels,  but  in  a  niajority  of  them  the  intestines  do  not  present  tuber- 
culous lesions.  In.  a  considerable  number  of  the  cases  of  tabes  iiiospii- 
terica  the  2)eritona'um  is  also  involved,  and  in  such  the  abdomen  is  larp:e 
and  hard,  and  nodules  may  be  felt.  The  condition  is  one  to  which  the 
French  have  given  the  name  carrcau. 

In  adults  tuberculous  disease  of  the  mesenteric  glands  may  occur  a?  a 
primary  atfeclion,  or  in  association  with  pulmonary  disease.  Gairdiier* 
gives  a  remarkable  instance  of  the  kind  in  a  man  aged  twenty-one.  In- 
stances of  this  sort  arc  not  uncommon  in  .the  literature.  Larsre  tuiimrs 
may  exist  without  tuberculous  disease  in  the  intestines  or  in  auv  other 
parts. 

The  diagnosis  of  local  and  general  tuberculous  adenitis  from  lym- 
phadenoma  will  be  subsequently  considered. 


/«•       ii 


IV.  Pl'lmoxaky  Tuberculosis  {Phthisis,  Consumption). 

Three  clinical  groups  may  be  conveniently  recognized :  (1)  tulxTrnh- 
pneunionic phthisis — acute  phthisis;  (2)  chronic  ulcerative j'hthisis ;  and 
(3)  fil)roid  jihthisis. 

According  to  the  mode  of  infection  there  are  two  distinct  types  cf 
lesions : 

{a)  When  the  bacilli  reach  the  lungs  through  the  blood-vessels  oi'  lym- 
phatics the  primary  lesion  is  usually  in  the  tissues  of  the  alveolar  wall.'^.  in  the 
ca})illary  vessels,  the  epithelium  of  the  air-cells,  and  in  the  connectivi'-tis.<iii' 


*  Lectures  to  Practitioners,  Gairdner  and  Coats,  1888, 


TUBERCULOSIS. 


229 


framowoik  of  tlio  septa.  The  proces.s  of  cell  division  proceeds  as  al?eady 
(lo^cril)i'il  ill  tlio  general  liistology  of  tiilxTcle.  The  irritation  of  the 
bacilli  ))ro(luccs,  within  a  few  da^s,  the  small,  gray  miliary  nodules,  iiivolv- 
iiiff  several  alveoli  and  eonsisting  largely  of  round,  cidjoidal,  uninuclear 
fnitliclioiii  cells.  Depending  u])on  the  number  of  bacilli  which  reach  the 
lull"-  in  this  way,  either  a  localized  or  a  general  tubercidosis  is  excited. 
The  tubercles  may  be  uniformly  scattered  through  both  lungs  and  form 
a  part  of  a  general  miliary  tubercuktsis,  or  they  may  be  confined  to  the 
lungs  or  even  in  great  part  to  one  lung.  The  changes  which  the  tuber- 
ck'.s  umlcrgo  have  already  been  referred  to.  The  further  changes  may  be: 
(1)  Arrest  of  the  process  of  cell  division,  gradual  sclerosis  of  the  ibccle, 
and  uhitnatcly  complete  fibroid  transformation.  {'2)  Caseation  „f  the 
centre  of  the  tubercle,  extension  iit  the  periphery  by  j)roliferatiou  of  the 
epitliclioicl  and  lym[)hoid  cells,  so  that  the  individual  tul)en;les  or  small 
groups  become  conlhient  and  form  dilfuse  areas  which  uiidci'go  caseation 
and  softening.  (3)  OccasioTuilly  as  a  result  of  intense  infection  of  a 
localized  region  through  the  blood-vessels  the  tubeirlcs  arc  thickly  set. 
The  interveiung  tissue  becomes  acutidy  inilamcd,  the  air-cells  are  filled 
with  the  products  of  a  desquamative  pneumonia,  and  many  lobules  are 
involved. 

(h)  When  the  bacilli  reach  the  lung  through  the  bronchi — inhalation 
or  aspiration  tuberculosis — the  picture  differs.  The  smaller  bronchi  and 
l)roiR'hi(ih's  are  more  extensively  affected  ;  the  process  is  not  coulined  to 
single  groujis  of  alveoli,  but  has  a  more  lobular  arrangement,  ami  the 
tuberculous  masses  from  the  outset  are  larger,  more  diffuse,  and  may  in 
MMiie  cMses  involve  an  entire  lobe  or  the  greater  part  of  a  lung.  It  is  in 
this  inoile  of  infection  that  we  see  the  characteristic  peri-bronchial  granu- 
lations and  the  areasof  the  so-called  luidular  bronclu)-pneumonia.  These 
hiiinehopMcumonic  areas,  with  on  thu  one  haiul  caseation,  ulceration,  and 
eavity  formation,  and  on  the  other  sclerosis  and  limitatioti,  nnike  up  the 
essential  elements  in  the  anatomical  picture  of  tuberculous  phthisis. 


1 

11 

i! 

*       1 3 

' 

1 1  a 

,;:!i'iiil 

:}i| 

^   I' ill 


I 


^t^ 


1.  Acute  Pneumonic  Phthisis. 

This  form,  known  also  by  the  name  of  oiiUophif/  cnnsnmptmi,  is 
nut  with  liotli  in  (diildren  aiul  adults.  In  the  former  ninny  of  the  cases 
lie  niislakeii  for  simple  broncho-pneumonia. 

Two  types  may  be  recognized,  the  pncHtHOnir  and  hniurho-pnenmonir. 

(")  In  the  /men iitotn'c  form  one  lol)e  nuiy  be  involved,  or  in  some  in- 
■tunees  an  entire  lung.  The  organ  is  heavy,  the  affected  jiortion  airless, 
'III'  pleura  usually  covered  with  thin  exudation,  and  on  section  the  picture 
:ivenibles  ejoselv  that  of  ordinarv  hepatization.  The  following  is  an  extract 
'riiui  tile  post-mortem  report  of  a  case  in  which  death  occurred  twenty-nitie 
lays  after  the  onset  of  the  ilhu^ss,  having  all  the  characters  of  an  acute 
i'lH'iniionia  ;  "  Left  lung  weighs  1,500  grammes  (double  the  weight  of  the 


230 


SPECIFIC  IXFPX'TIOUS  DISEASES. 


!         m 


othor  orpin)  and  is  lioavy  and  airless,  crepitant  ordy  at  the  anterior  mar- 
gins Section  sliows  a  siuull  cavity  tlie  size  of  a  walnut  at  tho  ajjcx,  iilmiit 
which  aiv  .scattered  tubercles  in  a  consolidated  tissue,  'I'lic  greater  imrt 
of  the  lung  i)resents  a  grayish-white  appearance  due  to  the  aggrcLration 
of  tuljercles  which  in  some  i)laces  have  a  continuous,  uniforni  appt'aiuiu'i', 
in  others  are  surrounded  by  an  injected  and  consolid-ited  lung-tissue. 
Toward  the  margins  of  tlie  lower  lobe  strands  of  this  linn  reddish  tissue 
separate  anauuic,  dry  arenas.  There  are  in  the  right  lung  three  oi'  four 
small  groujjs  of  tul)ercles  but  no  caseous  inasses.  The  ])ronchial  glantl> 
are  not  tidjcrcidous."  Here  the  intense  local  infection  was  due  to  the 
small  focus  at  the  apex  of  the  lung,  probably  an  aspiration  process. 

Only  the  most  careful  inspection  may  reveal  tho  presence  of  uHliinv 
tubercles,  or  the  attention  may  bo  arrested  by  the  detection  of  tubercles  in 
the  other  lung  or  in  tho  bronchial  glaiuls.  The  jn'oce.ss  nuiy  involve  only 
one  loljc.  There  nuiy  be  older  areas  which  are  of  a  peculiarly  yellowi.-li- 
white  color  and  distinctly  caseous.  'I'he  most  renuirkable  picture  is  pre- 
sented by  cases  of  this  kind  in  which  the  disease  lasts  for  some  luoiitli?. 
A  loljc  or  an  entire  lung  may  be  eidarged,  tirm,  airless  throughout,  ami 
converted  into  a  dry,  yellowi.sh-white,  cheesy  substance.  Cases  are  met 
with  in  which  tlie  entire  lung  from  apex  to  base  is  in  this  condition,  with 
l)orhaps  only  a  small,  luirrow  area  of  iiir-containing  ti.ssue  on  tho  margin, 
More  commonly,  if  tho  case  has  lasted  for  two  or  three  months,  rapid 
softening  has  taken  place  at  the  apex  -with  extensive  cavity  formation. 

In  a  recent  study  A.  Fraeidvcl  and  'J'roje  found  tubercle  bacilli  alone 
in  eleven  of  twelve  cases.  The\  suggest  that  in  these  cases  of  inffctkiii 
by  aspiration  the  large  areas  of  exiidative  iutlammation,  at  some  distance 
even  from  the  seat  of  growth  of  the  bacilli,  are  due  to  tho  presence  of  .<oiiie 
diffusible  poison  }iroduced  by  the  germs. 

Symptoms. — The  attack  sets  in  abruptly  with  a  chill,  usiuiUy  in  an 
individiuil  who  has  enjoyed  good  health,  although  in  nuiny  cases  the  onset 
has  been  preceded  by  ex])osure  to  cold,  or  tliere  have  been  debilitating  cir- 
cunistances.  Tho  temperature  rises  rapidly  after  the  chill,  there  arc  pain 
in  the  side,  and  cough,  with  at  first  mucoid,  subsequently  rusty-coloreii 
expectoration  which  may  contain  tubercle  bacilli.  The  dyspnoea  may  be- 
come extreme  and  the  patient  may  have  suffocative  attacks.  The  i)liysical 
examination  shows  involvement  of  one  lobe  or  of  one  lung,  with  signs  of 
consolidation,  dulness,  increa.sed  fremitus,  at  first  feeble  or  su})pre>seil 
vesicular  tnurmur,  and  subseriuently  well-marked  bronchial  breathiiiL'. 
The  np]ier  or  lower  lobe  may  be  involved,  or  in  some  cases  tho  entire  lung. 

At  this  time,  as  a  rule,  no  suspicion  enters  the  mind  of  the  praQtitioner 
that  the  case  is  anything  but  one  of  frank  lol)ar  pneumonia.  Occasionally 
there  may  be  suspicious  circumstances  in  the  history  of  the  patient  or  in 
his  family;  but.  as  a  rule,  no  stress  is  laid  upon  them  in  comparison  with 
the  intense  and  characteristic  mode  of  onset.  Between  the  eighth  anil 
tenth  day,  instead  of  the  expected  crisis,  the  condition  becomes  aggra- 


TU  HE  RC  uresis. 


231 


viitot],  till'  tcinpcrature  is  irregular,  and  tlio  pulse  inoro  rapiil.  Tlicrc  ifiiiy 
1)0  sweat inj;,  and  the  expeetoralion  becomes  muco-purulent.  and  greenish 
i^  ^.,,ii,|_;i  [loint  of  sj)ecial  importance,  to  which  'j'raube  called  attention. 
Kvcii  in  the  second  or  third  week,  with  the  ju'rsistenee  of  these  symptoms, 
till'  ulivsiciaii  tries  to  console  himself  with  tlie  iilea  that  the  case  is  one  of 
uiirc-nlvcd  pneunioiua,  and  that  all  will  yet  be  well.  Ciradually,  liowever, 
the  sevcrilv  of  the  sym2)toms,  the  i)resence  of  })hysical  signs  indicating 
softeniu",  the  existence  of  elastic  tissue  and  tubercle  bacilli  in  the  sputa 
iiicsi'iit  lilt'  mournful  proofs  that  the  case  is  one  of  acute  pneumonic 
|ihtlii-is.  Death  may  occur  before  softening  takes  jdace,  even  in  the 
-iroiid  or  third  week.  In  other  cases  there  is  extensive  destrnction  at 
till'  apex,  with  rapid  formation  of  cavity,  and  the  case  may  drag  on  for 
two  or  llirt'c  months. 

Diagnosis. — It  is  by  no  means  widely  recognized  in  the  professioii 
thill  ilii'ii'  i~  a  form  of  acute  i)hthisis  which  may  closely  simnlate  ordinary 
piieiinionia.     Waters,  of  Liverpool,  gave  an  admirable  description  of  these 
rases,  and  called  attention  to  the  dilliculty  in  dislingnishing  them  from 
(niliiiary  pneumonia.     Certainly  the  mode  of  onset  atfords  no  criterion 
uhaifver.     A  healthy,  robusl-Iooking  young  Irishman,  a  cab-driver,  who 
hail  heeii  kept  waiting  on  a  cold,  blustering  night  until  three  in  the  morn- 
ing, was  seized  the  next  afternoon  with  a  violent  chill,  and  the  following 
(lay  was  admitted  to  my  wards  at  the  University  Hospital,  riiiladeliihia. 
lie  was  made  the  subject  of  a  clinical  lecture  on  the  fifth  day,  when  there 
was  absent  no  single  feature  in  liistory,  symptoms,  or  })hysical  signs  of 
aiute  liiiiar  jmenmonia  of  the  i-ight  npper  hdte.     It  was  not  until  tun  days 
later,  when  bacilli  were  found  in  his  exjiectoratioji,  that  we  were  made 
aware  of  the  true  nature  of  tlic  case.     I  know  of  no  criterion  by  which 
cases  (if  this  kind  can  be  distinguished  in  the  early  stage.     The  tubercle 
haeilli  may  not  be  present  at  first,  but  in  one  of  Fraenkel  and  Troje's  cases 
they  existed  alone  in  the  typical  pneumonic  sputum.     A  point  to  which 
Traube  called  attention,  and   w  hich  is  also  referred   to  as  important  by 
Ibiard  and  Cornil,  is  the  absence  of  breath-sounds  in  the  cons(didated 
ivirioii;  hut  this,  I  am  sure,  does  not  hold  good  in  all  cases.     The  tubular 
hreuthing  may  be  intense  and  marked  as  early  as  the  fourth  day;  and 
a:'aiii,  how  common  it  is  to  have,  as  one  of  the  earliest  and  most  suggest- 
ive syni]itoms  of   lobar  pneumonia,  sup[)ression  or  enfeeblement  of    the 
;  vesicular  iinu'imir  I     In  many  cases,  however,  there  are  suspicious  circum- 
staiiees  in  the  onset:  the  patient  has  been  in  bad  health,  or  may  have  liad 
IH'evioiis  pulmonary  trouble,  or  there  are  recurring  chills.     Careful  exami- 
iiatieii  of  the  sputa  and  a  study  of  the  physical  signs  from  day  to  day  can 
alone  deteniiine  the  true  nature  of  the  case.     A  point  of  some  moment  is 
the  eliaracter  of  the  fever,  which  in  true  [)neumonia  is  more  continuous, 
jwi'tieidarly  in  severe  cases,  whereas  in  this  form  of  tuberculosis  remissions 
^'■)°  or  'j°  are  not  infrequent. 

(/')  Ariifc  tuberculous  bronclto-pneumoiiin  is  more  common,  particu- 
larly in  children,  and  forms  a  majority  of  the  cases  oi  phthinisjlorida,  or 
10 


232 


SPECIFIC   I.VFF/TIOITS   DISEASES. 


II  I 


\  ■    1. 


s  'i 


"galloping  consumption."  It  is  an  acute  caseous  bronclio-pneiimonin, 
starling  in  tlie  smaller  tubes,  wliicili  liccome  blocked  witli  a  choosy  sub. 
stani^e,  wliile  tiie  air-cells  of  tiie  lobule  are  filled  with  the  j)r()dn(Ms  nf  u 
catarrhal  ])iieuiu(Hiia.  In  the  early  stages  the  areas  have  a  grayish-nil.  lutir 
an  opaque-white,  caseous  appearance.  By  the  fusion  of  contigjioiis  inasscs 
an  entire  lobe  may  be  rendered  nearly  solid,  but  there  can  usually  bo  seen 
between  thft  groups  an^as  of  crepitant  air  tissue.  This  is  not  an  iiiicoin. 
mon  picture  in  the  acute  phthisis  of  udidts,  but  it  is  still  more  frofiiiom  in 
children.  The  following  is  an  extract  from  the  j)ost-mortem  of  a  oaso  on 
a  child  aged  four  niontiis,  which  died  in  the  sixth  week  of  illness:  "On 
section,  the  riglit  upper  lobe  is  occupied  with  caseous  masses  from  live  to 
twelve  millimetres  in  diameter,  separated  from  eacdi  other  by  an  inurvcn. 
ing  tissue  of  a  deep-red  (Htlor.  The  bronchi  are  tilled  with  cheesy  sulistancc 
The  middle  and  lower  lobes  are  stulTed  with  tubercles,  many  of  which  are 
becoming  caseous.  Towani  the  diaj>hragnmtic  surface  of  the  lower  lobe 
there  is  a  small  cavity  the  size  of  a  marlile.  The  left  lung  is  more  crepitant 
and  uniforndy  studded  with  tubercles  of  all  sizes,  some  as  large  as  jkus.  The 
bronchial  ghuuls  are  very  large,  aiul  one  contains  a  tuberculous  abscess." 

There  is  a  form  of  tuberculous  inspiration  pneumonia,  to  which  biiiim- 
ler  has  called  attention,  developing  as  a  sequence  of  ha'mopty.si.s,  and  due 
to  the  aspiration  of  blood  and  the  contents  of  pulmonary  cavities  iiitotlie 
finer  tubes.  Following  the  ha'uu)i)tysis,  which  may  have  oceurroil  in  an 
individual  without  suspected  lesion,  there  are  fever,  dyspntea,  and  .^iirnsof 
a  diffuse  broncho-pneumonia.  Some  of  these  cases  run  a  very  rapiil  ((iiii;:', 
and  are  examples  of  galloping  consumption  following  liaMuoptysis.  This 
accident  may  occur  not  alone  early-  in  the  disease,  but  may  follow  liiKiiior- 
rhage  in  a  well-developed  ca.se  of  pulmonary  tuberculoses. 

In  children  the  enlarged  bronchial  glnrtds  usually  surround  the  root  of 
the  lung,  and  even  pass  deeply  into  the  substance,  and  the  lobules  are 
often  involved  by  direct  contact. 

In  other  (-ases  the  caseous  broncho-pneumonia  involves  group.?  of 
alveoli  or  lobides  in  different  portions  of  the  lungs,  more  commonly  at 
both  apices,  forming  areas  from  one  to  three  centimetres  in  dianiot(>r.  The 
size  of  the  mass  depends  largely  upon  that  of  the  bronchus  iiivolvni. 
There  are  cases  which  prol)ably  should  come  in  this  category,  in  wliiili, 
with  a  history  of  an  acute  illness  of  from  four  to  eight  weeks,  the  liuigs 
are  extensively  studded  with  largo  gray  tubercles,  ranging  in  »m  from 
five  to  ten  millimetres.  In  some  instances  there  are  cheesy  ma.-i.*os  the 
size  of  a  cherry.  All  of  these  are  grayisli-white  in  color,  distinctly  rhcOfS, 
and  between  the  adjacent  ones,  particularly  in  the  lower  lobe,  tliorc  in;iv 
be  recent  pneumonia,  or  the  condition  of  lung  which  has  boon  tcrmtJ 
splonization.  In  a  case  of  this  kind  at  the  Philadelphia  Ilospitiil  iloatli 
took  place  about  the  eighth  week  from  the  abrupt  onset  of  the  illi.'s.'i  witii 
haemorrhage.  Tliore  were  no  extensive  areas  of  consolidation,  but  the 
cheesy  nodules  were  uniformly  scattered  throughout  both  lungs.  No  soft- 
ening had  taken  place. 


TUBERCULOSIS. 


233 


Symptoms. — Tlio  symptoms  of  acute  broncho-pneumonic  plithisisj 
are  very  vuiiiiblc.  In  iidults  the  disease  may  uttack  persons  in  good  iu'ulth, 
but  wiio  luv  ovcrworkeil  or  "  run  down  "  from  any  cause.  Ila-morrhngo 
iiiitialts  \hv  attack  in  a  few  cases.  Tiiere  maybe  repeated  cliills ;  the 
U'tiiiii'i'iitiiif  H  liigli,  tlie  pidse  ra])id,  and  tlie  respirations  are  increased. 
Tlie  loss  (if  llesli  and  strength  is  very  striking. 

The  piiysical  signs  may  at  first  be  uncertain  and  indefinite,  but  finally 
tlicre  arc  areas  of  impaired  resonaiu^e,  usually  at  the  api(!es ;  the  breath- 
sdiiiids  are  liarsh  and  tubular,  with  numerous  rales.  The  sputa  may  early 
show  ela.-iii' tissue  and  tubercle  bacilli.  In  the  acute  cases,  within  three 
wi'iks,  till'  patient  nuiy  be  in  u  marked  typhoid  state,  with  delirium,  dry 
tongue,  anil  high  fever.  Death  may  occur  within  three  weeks.  In  otlier 
cuhi's  the  onset  is  severe,  with  high  fever,  rapid  loss  of  flesh  anil  strength, 
and  signs  of  extensive  unilateral  or  bilateral  disease.  kSoftening  takes 
])law;  there  are  sweats,  chills,  and  progressive  emaciation,  and  all  the 
fixtures  of  iihthtxin  Jhvidu.  Si.x  or  eight  weeks  or  later  the  patient  nuiy 
lii'iriu  to  ini[irove,  the  fever  lessens,  tlie  general  symptoms  mitigates  and  a 
(■use  which  lo<tked  as  if  it  would  certainly  terminate  fatally  within  a  few 
wi'cks  drags  on  and  becomes  chronic. 

Ill  rhihlrcn  the  disease  most  commonly  follows  the  infectious  diseases, 
piiiticiilarly  measles  and  whooping-cougli,*  The  profession  is  gradtudly 
m'(i.i.'iiizing  the  fact  that  a  majority  of  all  such  cases  are  tuberculous. 
.\t  k'ast  llirve  (/roups  of  these  cases  of  tuberculous  broncho-])neiimonia 
may  be  recognized.  In  the  Jirsi  the  child  is  taken  ill  suddenly  while 
tnihiiig  or  (luring  convalescence  from  fever;  the  temperature  rises  rapidly, 
the  cough  is  severe,  and  there  may  be  signs  of  consolidation  at  one  or  both 
a|iiiTS  wilii  rales.  Death  may  occur  within  a  few  days,  and  the  lung  shows 
ari;i.s  of  broncho-pneumonia,  with  })erhai)s  here  and  there  scattered  opaque 
i::;iyish-yeliow  nodules.  Macroscoj)ic:;lly  the  affection  does  not  look  tuber- 
I  ilous,  but  histologically  miliary  granulations  and  bacilli  may  be  found. f 
Tiilierek's  arc  usually  i)resent  in  the  bronchial  glands,  but  the  ap]tearance 
if  tlio  l)roncho-{tiieunionia  may  be  exceetlingly  decejitive,  and  it  may  re- 
'[iiin'  careful  microscopical  examination  to  determine  its  tulierculous  char- 
:ii  tir.  T\ni  siroiid  (/I'oiip  is  repre.sentod  by  the  case  of  the  child  previously 
i|Uiiti'l,  whicli  died  at  the  sixth  week  with  the  ordinary  symptoms  of  severe 
''idiK'lio-pneumonia.  And  the  f/n'rd  (/roup  is  that  in  which,  during  the 
'  'iiviilcsccncc  from  an  infectious  disease,  the  child  is  taken  ill  with  fever, 
"  u:.'li,  iiuil  shortness  of  breath.  The  severity  of  the  symptoms  miti- 
L'atcs  within  the  first  fortniglit;  but  there  is  loss  of  flesh,  the  general 
•■"iiilitioii  is  had,  and  the  physical  examination  shows  the  presence  of 
s<;itteiv(l  rales  throughout  the  lungs,  and  here  and  there  areas  of  de- 
[feotive  resonance.     The  child  has  sweats,  the  fever  becomes  hectic  in 


*  "Tussis  con\Milsivii  vcslibuluni  tnl)is"  (Willis). 
f  Cornil  and  liubes,  Les  Bucteries,  tome  ii,  1890. 


'i^:-\ 


II  ,H 


Mil'' 


■  U 


n;u 


SPECIFIC   INKKCTIOUS   DISEASES. 


ir; 


,'1 


iTi^ 


chanic'tcr,   uinl   in    riuiiiy  cusoh   the   clinical    picture   {,'rii(luall)'   dcvolops 
into  tliiit  of  cliroiiic  phthisis. 

2.  Chronic  Ulcerative  Phthisis. 

Unilor  this  heading  may  be  grouped  the  great  majority  of  cases  of  piiI. 
moiiary  tuborculosis,  in  whieh  the  lesions  procee(|  to  MJci'ration  and  sdfuii. 
ing,  and  ultimately  proiluee  thc^  well-known  picture  of  clironie  plitlii>is. 
At  lirst  a  strictly  tuberculous  alTcction,  it  ultimately  l)econu's,  in  a  imijniitv 
of  cases,  a  mixed  disease,  many  of  the  most  prominent  syini)toms  of  whlih 
are  duo  to  septic  infeiition  from  purulent  foci  and  cavities. 

Morbid  Anatomy. — Inspection  of  the  lungs  ill  a  case  of  clironie 
phthisis  shows  a  remarkalile  variety  of  lesions,  comprising  nodular  tuber- 
(des,  dilfiisc  tuberculous  iiililtration,  cast'oiis  masses,  pneumonic  aiviis, 
cavities  of  various  size,  with  changes  in  the  pleura,  bronchi,  and  bronchial 
glanils 

1.  The  Distribution  of  the  Lesions.  — For  years  it  has  been  rocognimi 
that  the  most  advaiieed  lesions  are  at  tlu:  apices,  and    that  the  disease 
prDgr.Nsps  downward,  usually  more  rapidly  in  one  of   the  lungs.    This 
gi'iieral  statement,  which  has  passed  current  in  tlie  text-books  ever  .'•iiice 
tile  masterly  descrijition  of  l.aenncc,  has  recently  been  carefully  cIiiIk). 
rateil  V)y  Kingston   l-'owler,  who  linds  that  the  disease  in  its  onward  pro- 
grt'ss  through  the  lungs  follows,  in  a  majority  of  the  cases,  distinct  nuiti'i 
In  the  upper  lolie  the  primary  lesion   is  not,  as  a  rule,  at  the  extrciiie 
a])!:'X,  but  from  an  inch  to  an  inch  and  a  half  below  the  summit  nf  ilio 
lung,  and  nearer  to  the  posterior  and  extern.al  borders.     The  lesion  hire 
tends   to  spread  downward,  i)roba!jly   from  inhahition  of  the  vims,  ami 
this  accounts  for  the  frequent  circumstance  that  examination  bcliind.  in 
the  supraspinous  fossa,  will  give  indications  of  disease  before  any  evldt'ini's 
exist  at  the  apex  in  front.     Anteriorly  this  initial  focus  corresponds  to  a 
spot  just  below  the  centre  of  the  clavicle,  and  the  direction  of  cxti'iisiDii 
in  front  is  along  the  anterior  aspect  of  the  ujiper  lobe,  along  a  liiii' niii- 
ning  about  an  inch  and  a  half  from  the  inner  ends  of  the  first,  socoml, 
and  third  interspaces.     A  second  less  common  site  of  the  primary  Itsinn 
in  the  apex  "corresjjonds  on  the  chest  wall  with  the  first  and  swiinl 
inters])aces  below  the  outer  third  of  the  clavicle."     The  extension  is  down- 
ward, so  that  the  outer  part  of  the  upper  lobe  is  chiefly  involved. 

In  the  middle  lobe  of  the  right  lung  the  alTection  usually  follows  the 
upper  lobe  on  tin;  same  side.  In  the  involvement  of  the  lower  h 'lie  tlie 
first  secondary  infiltration  is  about  an  inch  to  an  inch  and  a  half  licli'"' 
the  posterior  extremity  of  its  apex,  and  corresponds  on  the  (diest  wall  tnii 
spot  opposite  the  fifth  dorsal  spine.  This  involvement  is  of  the  grcntt't 
importance  clinically,  as  "in  the  great  majority  of  cases,  when  the  i»liy*i- 
cal  signs  of  the  disease  at  the  apex  are  sufficiently  definite  to  allow  of  tlie 
diagnosis  of  phthisis  being  made,  the  lower  lobe  is  already  ailected."   K^- 


TUnKIlCL'LOSIS. 


235 


iiiiiiiiiitinii.  tlicri'foro,  sliouM  1h'  iiiudo  caivfiilly  of  this  {jostfrioi*  iipox  in 
all  siisi>i<'ii)iiH  ciWL'8.  Ill  tills  sitii!iti<m  llii'  lesion  spreads  tlDWUwunl  and 
jiilcralh  aliiiijj  the  lino  of  the  interlobidar  septa,  a  line  which  is  marked 
l)V  tlie  M'ltfliral  border  <>(  the  si-apida,  when  the  hand  is  placed  on  tlio 
oniMJsite  scapula  and  the  elhow  raised  aliove  the  level  of  the  slmuliler. 
0::"!'  present  in  an  apex,  the  disease  nsiially  extends  in  time  to  the  ujipo- 
sitc  ii|ycr  ImIjc;  hut  not,  as  a  rule,  until  tiie  aj)ex  of  the  lower  lnhc  of  tjio 
liui^'  lii^t  alTected  has  heen  attacked. 

Of  I.T  cases  above  mentioned,  the  right  api'X  was  involved  in  V,'l,  the 
left  ill  1:0,  both  in  111. 

Lisiiiiis  of  the  base  may  be  primary,  thongh  this  is  rare.  IVrey  Kidd 
iiiakt's  the  jiroportion  of  basic  to  ai)icic  phthisis  one  to  live  hniulred,  a 
siimllrr  luimlier  than  existed  in  my  series.  In  very  chronic  cases  there 
uiuv  be  arrested  lesions  iit  the  apex  and  moi'e  recent  lesions  at  the  base. 

■I  Summary  of  the  Lesions  in  Chronic  Ulcerative  Phthisis.— (^^)  Mi/i- 
Hfij  'I'lilirrrli's. — These  may  not  he  evident  on  mierose()])ieal  exanunati(»n, 
or  ih-ro  nniy  be  a  few  colonies,  "the  secondaiT  crop"  of  Laennec,  abont 
the  ciiscous  areas.  In  other  instances,  with  old  lesions  at  the  aiu'X,  there 
arr,  throughout  the  lower  lobes,  scatteri'd  groups  of  miliary  tubercles 
which  have  undergone  libroid  and  i)igmentary  changes.  Sometimes,  in 
casi's  with  cavity  formation  at  the  ai)ex,  the  gi'iiater  part  of  the  lower  Icjbes 
jiivsi'Ut  many  gronps  of  firm,  sclerotic,  miliary  tubercles,  wliich  may  in- 
(hril  I'oim  the  distinguishing  anatomical  feature — aehronie  miliary  tuber- 
culosis. 

(//)  TitlmTuhuH  Jirourho-pneumonid. — In  a  large  proportion  of  the 
cn-'<  "<■  Iironic  idithisis  the  terminal  bronchiole  is  the  jjoint  of  origin  of 
tln'  iiruiH'ss,  consequently  we  lind  the  smaller  broiu-hi  and  their  alveolar 
turritories  blocked  with  the  accumnlated  j)rodncts  of  inHainmalioii  in  all 
staucs  of  cnftealioH',  At  an  early  period  a  cross-section  of  an  area  of  tuber- 
ciilou.si)roncho-pneumonia  gives  the  most  characteristic  appearunce.  The 
ci'iilral  lirouehiole  is  seen  as  a  small  orilice,  or  it  is  plugged  with  clu'osy  con- 
t(.'iUs,  while  surrounding  it  is  a  caseous  nodule,  tlie  so-called  peribronchial 
tul)iMvle.  The  longitmlinal  section  has  a  somewhat  dendritic  or  foliaceons 
uppwu'ance.  The  condition  of  the  picture  dejjends  mnch  upon  the  slow- 
lU'ss  or  rapidity  with  which  the  process  has  advanced.  The  following 
cliaiiires  may  occur : 

I'hrru/ioti.  —  When  the  caseation  takes  place  rapidly  or  ulceration 
occurs  in  the  bronchial  wall,  the  mass  may  break  down  and  form  a  small 
cavity. 

Sflrnisi.'<. — In  other  instances  the  process  is  more  chronic.  Filn-oid 
cliaiijfi's  gradually  produce  a  sclerosis  of  the  affected  area,  a  condition 
•  which  is  sometimes  called  cirr/iosLs  nodosa  fiibeirnhmi.  The  sclerosis  may 
be  oontiiK'd  to  the  margin  of  the  mass,  forming  a  limiting  capsule,  within 
fliiicli  is  a  uniform,  firm,  cheesy  substance,  in  which  lime  salts  are  often 
(lL'positt.d.    This  represents  the  healing  of  one  of  these  areas  of  caseous 


K: 


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2:50 


SPECIFIC  INFECTIOUS  DISEASES. 


broncho-pneumonia.  It  is  onh',  however,  wlieii  complete  fibroid  trang- 
formiition  or  calciiloiition  has  occurred  that  we  can  reallv  speak  ol"  lieuliiir 
In  numy  instances  the  colonies  of  miliary  tubercles  uliout  these  iiiius.s(s 
show  that  the  virus  is  still  active  in  tliem.  Subsequently,  in  uictTutivf 
processes,  the.io  calcareous  bodies  —  lung-stones,  as  they  are  sometiiius 
called — may  bo  expectorated. 

(6')  Pueninoniu. — An  important  though  secondary  place  is  occupiod 
by  iiithunnuition  of  the  alveoli  surrounding  the  tubercles,  which  become 
filled  with  ei»ithelioid  cells.  The  consolidation  may  extend  for  some  dis- 
tance about  the  tuberculous  foci  and  unite  them  into  areas  of  uniform  cmi- 
solidation.  Although  in  some  instances  this  infiitnimatory  process  iiiay  he 
simple,  in  others  it  is  undoubtedly  sijecific.  It  i.-:  ^xcited  by  the  tuhenic 
bacilli  and  is  a  manifestation  of  their  action.  It  may  i)resent  a  very  vaviwl 
aiipearance;  in  some  instances  resembling  closely  ordinary  red  hepiitiza- 
lion,  in  others  more  homogjueous  und  infiltrated,  the  so-called  injillnitiuu 
tuberculense  of  Laennec.  In  other  cases  the  contents  of  the  alveoli  un- 
dergo fatty  degeneration,  and  appear  on  the  cut  surface  as  opa(pu-  whiiu 
or  yellowish-white  bixlies.  In  early  j;bthisis  much  of  the  consolidation  is 
due  to  this  pneumonic  infiltration,  which  may  surround  for  some  di.stainu 
the  smaller  tuberculous  foci. 

(rf)  Cai'ilies. — A  vomica  is  a  cavity  in  the  lung  tissue,  produced  bv 
necrosis  and  ulceration.  It  ditfers  nuiterially  from  the  bronchicctatic 
form.  The  procies.-?  usually  begins  in  the  wall  of  the  bronchus  in  a  tuber- 
culous area.  Dilatation  is  produced  by  retained  secretion,  and  necnisisaml 
ulceration  of  the  wall  occur  with  gradual  destruction  of  the  coutiijiioiis 
tissues.  By  extension  of  the  necrosis  and  ulceration  the  cavity  iiu'iciws, 
contiguous  ones  unite,  and  in  an  alTccted  region  there  luay  be  a  scries  of 
small  excavations  communicating  with  a  bronchus.  In  nearly  all  iustaiioe^ 
the  process  extends  from  the  bronchi,  though  it  is  possible  lor  lurrovj 
and  softening  to  take  place  i»i  the  centre  of  a  caseous  arei^  without  pri- 
mary involvement  of  the  bronchial  wall.  Three  forms  of  cuvities  may  be 
recognized  : 

The  fresh  ulcerative,  seen  in  acute  phthisis,  in  wlii(  h  there  is  no 
limiting  membrane,  but  the  walls  are  made  uj)  of  softene(i,  necrotic,  ami 
caseous  nuisses.  Siiudl  vomiciv  of  this  sort,  situatt'd  just  beneath  the 
pleura,  may  rupture  and  cause  piu'umotliorax.  In  cases  of  acute  tuber- 
cido-piu!umonic  phthisis  they  may  be  larg*,  of.nipying  the  greater  pDitien 
of  the  upper  lobe.  In  the  chron" ;  ulcerative  jjlithisis,  cavities  of  tliis  sort 
ore  invariably  present  in  tliose  portions  of  t'.ie  Inri^r  i'i  which  the  disease  i* 
advaiunng.  At  the  apex  there  may  be  a  largo  old  cavity  with  well-tli'fim'l 
walls,  whilo  at  the  anterior  margin  of  the  upper  lobes,  or  in  the  a]iii'esiif 
tlie  lower  lobe,  there  are  recent  ulcerating  cavities  communicutiii;,'  «itlr 
the  bronchi. 

''hvifies  with  weU-ffeflned  walh. — A  majority  of  the  cav'tie?  in  the 
chronic  form  of  phthisis  have  u  well-defined   limiting  membrane,  the 


TUBERCULOSIS. 


237 


innor  sJiuface  of  which  constantly  prodiiocs  jais.  The  walls  arc  crossed 
1)V  tr:il)t'L'iiliu  which  represent  reiiinjints  of  bronchi  and  Liood-vcssels. 
Kvt'ii  till!  voinicib  with  the  well-denned  walls  extend  gradually  by  u  slow 
necrosis  and  destruction  of  the  contiguous  lung  tissue.  The  contents  are 
ii.-iiallv  jnirulent,  similar  in  character  to  the  grayish  iniinniular  sputa 
coiii'IihI  ii[)  by  ])hthisical  ])atients.  Not  infrecjuently  the  ineinbraiu>  is 
va.s(;iilar  or  il  may  be  lueinorrhagic.  OecasionallN',  when  gangrene  has 
Offairnd  in  the  wall,  the  contents  are  horribly  fu'tid.  These  cavities  may 
(ii'ciipy  the  greater  portion  of  the  apex,  forming  an  irregular  scries  which 
(oiiUMUiiicate  with  each  other  and  witii  the  bronchi,  or  the  entire  upper 
lobe  except  the  anterior  margin  may  be  excavated,  forming  a  thin- walled 
oavitv.  Ill  rare  instances  the  process  has  proceeded  to  total  excavation  of 
the  liiiiij;,  not  a  remnant  of  which  rcnuiins,  except  perhaps  a  narrow  strip 
at  tlie  anterior  margin.  In  a  case  of  this  kind,  in  a  young  girl,  the  cavity 
held  flirty  tluiil  ounces. 

Qiiitsiriit  Curilies. — When  quite  small  and  surrounded  by  dense  cica- 
trieial  tissije  communicating  with  the  bronchi  they  l\)rm  the  cicutriccs 
ji.tnkiisr!<  of  Laenncc.  Occasionally  one  apex  may  be  represented  by  a 
series  of  these  small  cavities,  surnuinded  by  dense  fibrous  tissue.  The 
lining  membrane  of  these  old  cavities  may  be  quite  smooth,  almost  like 
a  iiiiicdii.s  membrane.     Cavities  of  any  size  do  not  heal  eomjiletely. 

Cases  are  often  seen  in  which  it  has  been  supposed  tiiat  a  cavity  has 
healed;  but  the  signs  of  excavation  are  notoriously  uncertain,  and  there 
may  be  peetorilofpiy  and  cavernous  sounds  with  gurgling,  resonant  rales 
ill  ail  area  of  consolidation  close  to  a  largi^  bronchus. 

Ill  the  formation  of  vomica}  the  blood -vesstio  gradually  become  clo.sed 
by  an  obliterating  inllammation.  Tliey  are  tlu!  last  structures  to  yield 
and  may  be  coni|)lrtely  exjiosed  in  a  cavity,  even  ulier  the  circulation  is 
still  going  on  in  them.  Unfortunately,  the  erosion  oT  a  large  vessel  which 
lia::  iiot  yet  been  obliterated  is  by  no  means  infrequent,  and  causes  profuse 
:nnl  ofieii  fatal  hamiorrhage.  Another  common  event  is  the  development 
iif  aneurisms  on  the  arteries  running  in  the  walls  of  cavities.  These  may 
lie  small,  bunch-like  dilatations,  or  they  may  furm  cavities  the  size  of  a 
'laliiiit  or  even  larger.  l{a.smussen,  Douglas  Powell  and  others  have 
called  attention  to  their  importance  in  lKemoj)tysis,  under  which  section 
tlioy  are  dealt  with  more  fully. 

And  linally,  about  cavities  of  all  sorts,  the  conne(!tive  tissue  develops 
and  tends  to  limit  the  extent.  ''  'le  thickening  is  particularly  marked 
beneath  the  pleura,  and  in  chronic  cases  an  entire  ape\  may  be  converted 
into  a  niasi;  of  fibrous  tissue,  enclosing  a  few  small  cavities. 

('')  Plriirn. — Practically,  in  all  casis  of  chronic!  phthi.-is  the  pleura  is 
involved.  Adhesions  take  place  which  may  he  thin  and  readily  torn,  or 
"leiiso  and  firm,  uniting  layers  of  from  two  to  five  millimetres  in  thickness. 
Ibis  pleurisy  may  be  simple,  but  in  many  cases  it  is  tuberculous,  and  niili- 
iiry  tubercles  or  caseous  masses  are  seen  in  the  thickened  pleural  mem 


I  ni 


4.  ^g 


41 


t^^ 


IIMn 


1   : 


ii:   i^ 


vw 


238 


SPECIFIC  INFECTIOUS   DISEASES, 


brane.     Pleural  cfTiision  is  not  iit  jill  infroqu(M\t,  oithor  serous,  purulent, 
or  haimorrhagic.     PiuMiniotliorax  is  a  {'otnnion  accident. 

(/)  Clian<j;os  in  the  snitil/rr  hnnwhi  control  the  sit-'iation  in  tlic  oarlv 
stages  of  tul)erculous  plithisis,  and  ])lay  an  important  rnle  tlirouplimit  the 
disease.  The  process  very  often  bcirins  in  the  wails  of  the  snuiUcr  IiiIi,k 
and  leads  to  caseation,  distention  wiili  products  of  inllaniniation,  ami 
broncho-pneumonia  of  the  lol)uies.  In  numy  cases  the  visible  implication 
of  the  bronchus  is  an  extension  ujiward  of  a  process  which  has  bcfrmi  in 
the  smallest  bronchiole.  This  involvement  weakens  the  wall,  leaditifr  to 
bronchie(^tasis,  not  an  uiu'ommon  event  in  phthisis.  The  mucous  mem- 
brane of  the  larsfer  broiudii,  which  is  usually  involved  in  a  chronic  catarrh, 
is  more  or  less  swollen,  and  in  some  instances  ulcerated. 

(tj)  The  /ironr/iinl  r/hd/ds,  in  the  more  acute  cases,  are  swollen  and 
cedematous.  Miliary  tul)ercles  and  caseous  foci  are  usually  present.  In 
cases  of  chronic  phthisis  ihv.  caseous  areas  are  common,  calcification  may 
occur,  and  not  iufrcfpiently  purulent  softening. 

(//)  ('f/(i)i(/i's  in  thr  oilier  Orf/triis-. — Of  tiiese,  tu1)erculosis  is  tlio  most 
common.  In  my  series  of  autopsies  the  brain  jiresented  tiihereiiloiis 
lesions  in  31,  the  spleen  in  33,  the  liver  in  I'-i,  the  kiilneys  in  3'i,  the  intes- 
tines in  G5,  and  the  pericardium  in  T.  Other  groups  of  lymphatic  glainls 
})esides  the  bronchial  may  be  affected. 

Certain  degenerations  are  common.  Amyloid  rJirtiif/r  is  frequent  in 
the  liver,  spleen,  kidneys,  nnd  mucous  membrane  of  the  intestines.  The 
liirr  is  often  tlu'  seat  of  extensive  fatty  iniiltration,  whicdi  may  caiisi' 
marked  enlargement.  The  iiiti'slimiJ  fiihcrciihixis  occurs  in  ailvan>t'l 
cases  and  is  responsiiile  in  great  part  for  the  trouhlesome  diarrho'a. 

h'ndort'rdi/is  is  not  very  uncommon,  and  was  preserit  in  1"^  of  my  po-t 
mortems  and  in  27  of  Percy  Kidd's  TittO  cases.  Tubercle  bacilli  have  linn 
found  in  the  vegetations.  Tluf  subject  has  been  considered  in  an  iniji'ii- 
tant  !uon(tgraph  by  Teissier  (Paris,  IS!*!),  'i'uht'rcles  may  be  present  on 
the  endocanlium,  particularly  of  the  right  ventricle.  As  pointed  mit  liy 
Xorman  t'hever.s,  and  coiiiirmed  by  subsequent  writ(!rs,  the  subjects  of 
congenital  stenosis  of  the  jiulmonary  orifice  very  fretpuMitly  have  plitliisi> 

The  /itri/H.r  is  frequently  involve(l,  and  nlceralioTi  of  the  vocal  rnnl- 
and  destruction  of  the  epiglottis  are  not  at  all  uncommon. 

Modes  of  Onset.-  -We  have  already  seen  that  tul)erculosis  nf  tlu' 
lungs  uuiy  occur  as  the  chief  jtart  of  a  general  infection,  or  fuay  set  in 
with  symptoms  which  closely  simulate  acute  pneumonia.  In  the  cniinarv 
type  of  pulmonary  tuberculosis  the  invasion  is  gradual  and  le.ss  striking'. 
but  presents  an  extraordimiiily  div(M'se  picture,  so  that  the  practitioner  i^ 
often  led  into  error.  Among  the  most,  charac^teristic  of  these  types  nf  on- 
set are  the  following:  (it)  With  difs/it'/dii;  and  anwuiir  sijmjdiiniii^  fdrniin: 
a  large  ami  important  group.  The  patients  nuiy  naturally  have  had  feelili 
digestion.  They  begin  to  show  nuirked  signs  of  dyspepsia  atui  ln'ooiiu' 
pale,  lose  flesh,  and  look  chlorotic  before  any  pulmonary  sympt'mi!!  are 


^>W 


TUBKItCULOSIS. 


239 


mnnifo?t.  (h)  Wifh  chiJh  rind  fcvvr.  Tlii.?  nindo  of  onset  is  particiihirlv 
important  in  malarial  regions,  as  tlie  diagnosis  of  ordinary  inturniittont 
frvt'i-  is  often  inadc,  and  the  nature  of  tli<^  disease  entindy  ovirlooked. 
In  riiiliiilt'lpliia  it  was  very  common  to  have  patients  sent  to  li()s]tit;d 
sii|)|M)sc(l  to  he  siiiTering  Avith  malaria,  who  had  well-developed  signs  of 
iiiihin'iiiU'v  tidtereulosis.  (r)  Jirunchi/ic  onset,  Tiiese  are  the  instiinees 
wliicli  arise  in  what  the  patient  calls  a  neglected  cold.  The  patient  has 
lii'vliaps  been  subject  to  naso-pharyngeal  catarrh,  and  has  been  liable  to 
l;ikr  i(iM  readily;  tlu'M  a  bronchial  cough  devt'lops,  which  proves  iiitrac- 
i;ilile,  Sometimes  the  bronchitic  symptoms  are  associated  with  wlieezing, 
like  mild  asthma.  The  development  in  these  instances  may  be  extremely 
insidious  and,  without  any  special  aggrav.ation  of  the  general  symptoms 
iir  increase  in  the  fever,  the  tuberculous  natiir(>  of  the  troul)le  may  l)e 
discovered  accidentally  by  tlie  examination  of  the  sputum,  [d)  Oiii<ei 
irilli  iKriiKiptijxis.  The  relation  of  Inrmoptysis  to  pulmonary  tulierculosis 
will  he  discussed  elsewhere.  The  luemoptysis  may  come  on  in  a  con- 
dition (»f  roliust  liealth,  and  it  occasionally,  though  rarcdy,  happens  that 
the  pulmimary  sym[itoms  follow  rapidly.  In  other  cases  a  long  intt'rval 
tiipses.  riidoubfedly  these  are  cases  in  which  there  lias  been  a  small 
]iM;ili/ed  lesion  in  the  lung  whi(di  has  not  produced  constitutional  dis- 
liirhaiiee.  (')  Plcuritii:  (juH't.  This  nuiy  be  a  dry  jilcurisy,  developing  at 
till'  \\\w\  or  in  a  scapular  region,  or  in  souu'  instances  extending  generally. 
It  may  he  acute  pleuri.sy  with  effusion,  or  the  eniisiou  may  have  come  on 
insidiously  without  any  a(Hite  manifestations.  J'lnhisis  devidoped  in  a 
third  of  ninety  cases  of  pleurisy  with  cITusion,  the  subsetpu'iit  history  of 
whiidi  was  followed  by  Howditch.  ( /')  Withjaj-jiiiijral  si/iiiji/(i»is.  In  rare 
instances  Iniskiness  and  loss  of  voice  arc  the  .symptoms  for  which  the  pa- 
tient stcks  advice,  .lud  the  epiglottis  or  cords  nuiy  be  involved  in  a  wcdl- 
iliaracterized  tid)crculosis  before  the  pliysical  signs  in  the  lungs  are  .it  all 
ilciu'.  It.  is  in  these  instaiujes  that  the  exanunatioii  of  the  sputa  is  of  the 
f:n'iit(><t  value. 

These  represent  the  usual  moilcs  of  onset  of  the  ordinary  chronic 
phthisis.  It  oceasioindlv  hap|»cns  that  in  an  instince  with  an  acute  pneu- 
Mionii'  olivet  the  severity  of  the  symptoms  sul»sides,  and,  instead  of  tcnni- 
ii:iting  .IS  a  majority  of  these  cases  do  within  ten  or  twelve  weeks,  the  case 
drag's  on  >ind  liecomcs  chronic. 

Symptoms. — In  discussing  the  symptoms  it  is  iisiml  to  divide  the 
disciisc  into  iliree  periods:  the  lirst  embracing  the  time  of  the  growth  atul 
dcvclojimeid  of  the  tubendes;  the  second,  in  wliiidi  they  soften:  aiul  the 
third.  111  which  thi'rc  is  a  fornuition  of  cavities.  I'lifortuinitely,  these  ana- 
teiniral  stages  eim  not  be  satisfactorily  corndated  with  corresponding  clini- 
I'iil  periods,  and  \vc  often  find  that  a  patient  in  the  third  stage  with  well- 
iHiirked  cavity  is  in  n  far  better  condition  and  has  greater  prospects  of  re- 
fovi'iy  than  a  patient  in  the  first  stage  with  diiru.se  consolidation.  It  is 
tlicrefore  better  perhaps  to  disregard  them  altogether. 


'I  iiil; 


240 


SPECIFIC   INFECTIOUS   DISEASES. 


fr^i 


1.  Local  Symptoms. — Pain  in  the  chest  may  bo  eurly  and  tronblfsonie 
or  absent  throughout.  It  is  usuiilly  associated  with  pleurisy,  n.nd  may  be 
sharp  and  stabl)ing  in  character,  and  either  constant  or  felt  only  iluiiii" 
coughing.  Perhaps  the  commonest  situation  is  in  tiie  lower  thorinic 
zone,  though  in  some  instances  it  is  beneath  the  scapula  or  referred  to  tlic 
apex.  The  attacks  may  recur  at  long  intervals.  Intercostal  neiual;^'ia 
occasionally  develops  in  the  course  of  ordinary  phthisis. 

CW^  is  one  of  the  earliest  symptoms,  and  is  ])resent  in  the  niajorily 
of  ca.scsii'oin  beginning  to  end.  There  is  nothing  peculiar  or  distinctive 
about  it.  At  lir.-t  dry  and  hacking,  and  j)erhai)s  scarcely  oxcitiiif:  the 
attention  of  the  patient,  it  subsequently  becomes  looser,  more  constant, 
and  associated  with  a  glairy,  nuuo-purulent  exjiectoration.  In  the  early 
stages  of  the  disease  the  cough  is  broncliial  in  its  origin.  Wheu  cavities 
have  formed  it  becomes  more  paroxysmal,  and  is  most  marked  in  tlie 
morning  or  after  a  sleep.  Cough  is  not  a  constant  symptom,  however, 
and  a  patient  nuiy  present  himself  with  well-marked  excavation  at  one 
apex  who  will  declare  that  he  has  had  little  or  no  cough.  So,  too,  tliere 
may  be  well-marked  physical  signs,  dulness  and  moist  sounds,  without 
either  expectoration  or  cough.  In  well-established  cases  the  nocturnal 
paroxysms  are  most  distressing  and  jtreveiit  sleep.  The  cough  juay  be  of 
such  persisteiu'c  and  severity  as  to  cause  vomiting,  and  the  patient  becomes 
rapidly  enuiciated  from  loss  of  food. 

Sjiiifum. — I'hiis  varies  greatly  in  amount  and  character  at  the  different 
stages  of  ordinary  plitliLsis.  There  are  eases  with  well-marked  local  sijins 
at  one  apex,  with  slight  cough  and  moderately  liigh  fever,  without  from 
day  to  day  a  trace  of  expectoration.  So,  also,  there  nre  instances  with  the 
mostextcnsive  consolidation  (caseous  pneumonia),  with  high  fever,ami,a! 
in  a  recent  instance  under  observation  for  several  months,  without  eiiongli 
exjiectoration  to  enable  an  examination  f,)r  bacilli  to  be  nuule.  In  the 
early  stage  of  pulmonary  tuberculosis  the  sputum  is  chiefly  catarrhal  and 
lias  a  glairy,  sago-like  appearance,  due  to  the  presence  of  alve<ilar  eells 
which  have  undergone  the  myelin  degeneration.  There  is  notliinL,uliv 
tinctive  or  peculiar  in  this  form  of  expectoration,  which  may  pei.^ist  fur 
ihonths  without  iiulicating  serious  trouble.  The  earliest  trace  of  cliurae- 
teristic  sputum  is  seen  in  the  presence  of  snuill  grayish  or  green ish-gray 
puruhnit  nuisses.  These,  when  coughed  up,  are  always  suggestive  ami 
should  be  the  portions  picked  out  for  microscopical  examination.  As 
softening  comes  on,  the  expectoration  becomes  more  profuse  and  puni- 
lent,  but  nuiy  still  contain  a  considerable  quantity  of  alveolar  epittieliinii. 
Finally,  when  cavities  exist,  the  sputa  assume  the  so-called  nnnunular 
form;  each  mass  is  isolated,  flattened,  greenish-gray  in  color,  quite  airiest. 
and  sinks  to  the  bottom  when  spat  into  water. 

By  the  microscopical  examination  of  the  sputum  we  determine  whetlici' 
the  process  is  tuberculous,  and  whether  softening  has  occurred.  Vot  tu- 
bercle bacilli  the  Ehrlich-Weigert  method  is  the  best.     Eleven  centinu'trei 


ill 


TUBERCULOSIS. 


241 


of  a  saturated  solution  of  fiiclisiii  in  ubsoluto  alcohol  is  added  to  o)ic  hun- 
dred ci'iitiiiu'tres  of  tlie  siiturated  solution  of  coinnKTcial  aniliiU'  oil  (made 
bv  sliakiiiij  up  the  oil  in  water  atul  then  liltering).  This  should  he  made 
fitsli  cvt'iy  tiiird  or  fourth  day.  A  snudl  hit  of  the  sputum  is  picked  out 
(III  a  iu'imIIc  or  ])hitinum  wire  and  sprea<l  thin  on  tlie  top-(M)vcr  .so  as  to 
make  a  uniformly  thin  layer.  The  top-cover  is  .slowly  dried  about  a  foot 
above  !i  linnsen  burner.  Sutticient  of  the  staining  iluid  is  then  drojjped 
upon  tho  top-cover,  which  is  held  at  a  little  distance  aljove  the  llanu'  un- 
til tlic  tliiid  boils.  The  staining  flui<l  is  then  washed  otT  in  distilled  water 
or  put  under  the  tap,  decohu'ized  in  thirty  per  cent  nitric-a(ud  tliiid,  again 
wiislied  olT  in  water,  and  mounted  on  the  slide.  In  doubtful  cases  the 
loiiji;  |»roccss  is  used,  the  cover-sli})s  remaining  twenty-fcur  hours  in  the 
stain.  The  bacilli  are  .seen  as  elongated,  slightly  curved,  red  rod.s,  some- 
tiiiiis  presenting  a  beaded  ajipearance.  They  are  frequently  in  groups  of 
tliroo  or  four,  but  the  number  varies  considerably.  Oidy  one  or  two  may 
])('  found  iu  a  jtreparation,  or,  in  some  instances,  they  are  so  abundant 
that  the  entire  tield  is  occupied. 

Till'  jnrsfHce  (if  these  hariUi  in  the  Kputum  is  an  infaUihh;  indication 
of  the  e.iisfenre  of  tubeiruhtsis. 

Sometimes  they  are  found  only  after  repeated  examination.  They 
may  be  aliundant  early  in  the  disease  and  are  usually  nunu>rous  in  the 
iiMiiunular  s])utum  of  the  later  stages. 

Ehislii  lixsve  may  be  derived  from  the  bronchi,  the  alveoli,  or  fi'om 
\h\  arterial  coats ;  and  lutturally  the  apjtearance  of  the  tissue  will  vary 
with  the  locality  from  which  it  comes.  In  the  exan)i nation  for  this  it  is 
not  ncce.s.sary  to  boil  the  sputum  with  caustic  potash.  Kor  years  I  have 
usod  a  simple  plan  which  was  sho\sn  to  me  at  the  London  Ilospilid-h^- 
Sir  .Vmlrew  Clark.  This  nu'thod  depends  upon  the  fact  that  in  almost 
all  ii'.siaiiccs  if  the  sputum  is  sj)read  in  a  sutlieiently  thin  layer  the  frag- 
ments of  elastic  tissue  can  be  seen  with  the  miked  eye.  The  thick,  puru- 
lent portions  are  placed  ujmn  a  glass  plate  fifteen  by  fifteen  centimetres 
and  IV.iteiied  into  a  thin  layer  by  a  second  glass  plate  ten  by  ten  conti- 
nn'tros.  III  this  compressed  grayish  layer  between  the  glass  slips  any 
fragments  of  elastic  tissue  show  on  a  l)lack  background  as  grayish-yellow 
spots  and  can  cither  be  examined  at  once  under  a  low  power  or  the  upper- 
most piece  of  <r]nn)i  is  slid  along  until  the  fragment  is  expo.sed,  when  it  is 
picked  out  and  placed  uj)on  the  ordinary  microscopic  slide.  Fragments 
of  bread  and  collections  of  milk-globules  may  also  j)res<'nt  an  oi)a(pie 
white  appearance,  but  with  a  little  practice  they  can  readily  be  recog- 
nized. I'ragnients  of  epithelium  from  the  tongue,  infiltrated  with  micro- 
f'oeei,  are  still  more  deceptive,  but  the  microscope  at  once  shows  the  dif- 
feivilee. 

The  bronchial  elastic  tissue  forms  an  elongated  network,  or  two  or 
three  long,  narrow  fibres  are  found  close  together.  From  the  blood-vcs- 
st'Ls  a  sorucwhat  similar   form  may  be  seen  and  occasionally  a  distinct 


I" 


!i 


11      i 


ill 


1       ' '  t 


Hi 


M 


i 


1! 


1^:;  'i' 


242 


SPECIFIC   INFECTIOUS  DISExVSES. 


r^^yi 


.* ' 


■li 


i,i 


sheeting  is  found  txs  if  it  Imd  come  from  tlie  intiina  of  a  good-sizwl  ar- 
tery. Tlie  clastic  tissue  of  the  ulveohir  wall  is  quite  distinctive;  the  tlba;) 
are  briiiifhed  and  often  show  the  outline  of  the  arrangeuiont  of  the  air 
cells.  The  elastic  tissue  from  bronchus  or  alveoli  indicates  extensive 
erosion  of  a  tube  and  softening  of  the  lung-tissue. 

Another  occasional  constituent  of  the  sputum  is  blood,  which  maybe 
j)resent  as  the  chief  constitucni  of  the  ex])ectoration  in  ha'iiu)|)lysis  (jr 
may  simply  tinge  the  sputum.  In  chronic  cases  with  large  cavitius,  in 
addition  to  bacteria,  various  forms  of  fungi  nuiy  devcloj),  of  which  the 
aspergillus  is  the  nu)st  important.     Sarcinui  may  also  occur. 

The  daily  amount  of  expectoration  varies.  In  rapidly  advaiuiii" 
cases,  with  much  cough,  it  may  reach  as  high  as  live  hundred  cubic  cciui- 
niotrcs  in  the  day.  In  cases  with  large  cavities  the  chief  amount  i? 
brought  u^)  in  tiie  morning.  The  expectoration  of  tuberculous  patients 
usiuilly  has  a  heavy,  sweetish  odor,  and  occasionally  it  is  fetid,  oaiug  Uj 
dei'omi)osition  in  th(>  cavities. 

yA/'/y/(;yi//^.v/.s'.— iIa'moj)tysis  is  met  with  either  early  in  the  disea.<i',  bc- 
f()re  there  are  physical  signs,  or  during  the  course  of  the  alU'ction  wlicii 
there  is  softening  or  excavation.  A  majority  of  the  luemorrhages  Ijcliovid 
to  be  precursory  are  really  due  to  already  existing  disease  of  the  lung,  ami 
there  is  no  ground  whatever  for  the  opinion,  so  long  held,  that  plitliiM< 
can  originate  directly  from  haMuoptysis,  Ww  pfdhLsis  ab  luvinoptw  of  Hii'li- 
ard  Morton.  The  blood  may  be  either  pure  or  mixed  witli  si)utuiii.  A 
distinction  should  be  made  between  these  two  forms.  When  the  sputa 
are  simply  tinged  or  the  l)lo()d  is  admixed,  it  comes,  in  all  probability,  fnmi 
hypenenuc  bronchial  mucosa  or  locally  congested  areas  of  hing-tissiu'; 
but  \.\w  brisk  luemorrliage  in  which  the  blood  comes  up  in  moutlil'iiU  i,- 
always  due  to  erosion  of  vessels,  small  or  large,  in  the  process  of  softeniiiir. 
or,  in  the  later  stages  of  the  disease,  comes  from  the  erosion  of  a  bramli 
of  the  ]ndmoiiary  artery  or  from  a  ruptured  aneurism  of  the  puliuoiiaiy 
artery  in  a  cavity.  This  latter  is  the  most  frequent  cause  of  tiiu  fatal 
hamiorrhage  in  consumi)tion. 

Ihlsjimva  is  not  a  common  aeeompanitnent  of  ordimiry  plithisis.  'Ww 
greater  part  of  one  lung  nuiy  be  diseased  and  local  trouV)le  exist  at  the 
other  apex  without  any  shortness  of  breath.  Even  in  the  paroxysms  (if 
very  high  fever  the  respirations  may  not  be  much  increased.  Hapiil  ad- 
vance of  a  bron(!ho-pnenmonia,  or  the  development  of  nuliary  tiilnnlc- 
throughout  the  lung,  causes  great  increase  in  the  number  of  respiratioiiN 
A  degree  of  dyspmea  leading  to  cyanosis  is  almost  unknown,  a])art  frmn 
extensive  invasion  of  the  sound  portions  by  miliary  tubercles. 

In  long  stantling  cases,  with  contracted  apices  or  great  thickt'iiiiii: 
of  the  pleura,  the  right  heart  is  eidarged,  aiul  the  dyspmea  may  K 
cardiac. 

2.  General  Symptoms  —  Fever r— To  get  a  correct  idea  of  the  tciniu'ra- 
ture  range  in  pulmonary  tuberculosis  it  is  necessary,  as  Kinger  pdiutod 


TUBEIICL'LOSIS. 


243 


out,  to  iiiukc  tolembly  frequent  observiitions.  Tlio  usiuil  8  A.  M.  and  8  i*.  M. 
record  i>,  in  u  majority  of  the  cases,  very  deceptive,  giving  neither  tho 
iiiiiiiMinin  imr  iiiaxiniuni.  Tlie  former  usually  occurs  between  2  and  (i  a.  m. 
and  tlic  latter  hi'tween  'i  and  (!  \\  M. 

A  n  riPLinition  of  various  forms  of  fever,  viz.,  of  tuberculization,  of 
ulci'raliiiii,  and  of  al^sorption,  euii)hasizes  tlu'  anatomical  stages  of  growth, 
siit'tciiin.i:'  and  cavity  formation  ;  but  practically  such  a  division  is  of  little 
iijo,  us  in  a  majority  of  cases  these  proccssi-s  are  going,  on  together. 

I'Vvcr  is  the  most  itni)ortant  initial  symptom  an<l  throughout  the  entire 
coiiisf  the  liicrnionuHer  is  the  most  trustworthy  guide  as  to  the  progress 
(if  tlir  alTtctioii.  With  i)yrexia  a  })atient  loses  in  weight  and  strength, 
and  I  he  local  disease  usually  ]>rogri'sses.  'I'he  j)eriods  of  a])yrexia  are 
llmse  i)f  gain  in  weight.and  striMigth  and  in  limitation  of  the  local  lesion. 
It  liy  no  means  necessarily  follows  that  a  jtatient  w  ilh  tul)erculosis  has 
jivrcxia.  There  may  b((  quite  extensive  disease  without  coexisting  fever. 
At  the  moineiit  of  writing,  I  have  eighteen  instances  of  (dironic  phthisis 
iiiider  observation,  of  whom  ten  are  ]iractical!y  free  from  fever;  but  in  the 
early  stage,  when  tubercdes  are  developing  and  caseous  areas  are  in  pro- 
less  (if  formation  and  when  softening  is  in  protrress,  fever  is  a  constant 


sv 


iiqit 


iiin. 


war 


1' 

jiresent  in  one  hundred  consecutive  cases  at  my  d 


is- 


[H'lisary  sei'vice, 


Two  tvpes  of  fever  are  seen — the    remittent  and   the  intermittent. 


se  inav  occur  indiirerentlv  in   the  eaidv  or  in   tlu'  late  stairi 


of  th 


(II 


<i'ase  or  niav  alternate  with  eaidi  other,  a  vai'iabiliiy  whicdi  depends  Uj 


)on 


tile  fact  that  phthisis  is  a  jirogressive  disease  and  that  all  stages  of  lesions 


IIKIV 


lu'  found  in  a  sii\gle   lung.     Spctdal  stress  should   b(>  laid  upon  tl 


10 


fact,  particularly  in  malarial  regions,  that  tuberi'ulosis  may  set  in  Avith  a 
ty)iically  intermittent  in  cliHracter — u  daily  chill,  with  subsequent 


ever 


fi  Vfi'  and   sweat.     In    Montreal,  wliere  nudaria  U 


pv 


acticallv  unknown. 


tliis  was  always  regarded  as  a  suggestive  8yin])tom  ;  Imt  in  l'hiladelj)hia 
lialtimore,  wliere  ague  jirevails,  it  is  no  exaggeration  to  say  that  yearly 


iUUl 
SCIH'I 


)f  cases  of  carlv  tuberculosis  are  treated  for  a'nie.     These  are  ofleu 


cases  liiat  pursue  a  ra])id  course 


The  fever  of  onset — tubcrculization- 


iiiiiv  he  almost  continuous,  with  slight  daily  exacerbations;  ami  at  anv 


ring  tho  course  of  (dironic  phthisi 


Iiiiie  liii 

tlie  reini>~i(ins  become  less  marked. 


if  tl 


lere  is  rapid  extension 


A  remittent  fever,  in  which  the  teinperalun"  is  CMiistantly  above 
iMiiiial  hiit  drops  two  or  three  degrees  towai'(I  morning,  is  nut  uncommon 
in  tho  middle  and  later  stajres  and  is  usuallv  associated  with  softeiiin<j 


ir  exteii.>i()n  of  the  disease.     Here,  t 


1 


,  too,  a  smii)le  moriung  and  evening 
i'c;dster  may  give  an  entirely  erroneous  idea  as  to  the  range  of  the  fever. 
^\  iili  hreaking  down  of  tho  lung-tissue  and  formation  of  cavities,  associ- 
ated as  these  processes  always  are  with  sujipuration  and  with  more  or  kss 
-ysfeniie  contaiiiinaiion,  the  fever  assumes  a  characteristically  intermittent 
or  lieetie  lyjie.    For  a  large  part  of  the  day  the  patient  is  not  only  afebrile, 


t 


."  I  t 


Jii/  WM 


p. 


244 


SPECIFIC   INFECTIOUS  DISEASES. 


but  tlie  temperature  is  .subuoriiiiil.  In  the  auiiexed  two-hourly  chiirt, 
from  ii  case  of  chronic  tuberculosis  of  the  lungs,  it  will  be  seen  that  from 
10  p.  M.  to  8  or  V^  A.  M.,  the  teuipeniture  continuously  fell  and  rfacluil 
as  low  iis  1)5°.  A  slow  rise  then  took  place  through  the  late  n'orniMgaiiil 
early  afternoon  hoiirs  and  reached  its  niiixinunn  between  G  and  lop.  m. 
As  shown  in  the  (ihart  there  were  in  the  three  days  about  forty-tlnce 
hours  of  pyrexia  and  twenty-nine  hours  of  apyrexia.     The  rapid  full  of 


N0.5A<\  ^W.'i^■^.Wft.-..5^4.6!ii^:i.  ADMITTEaVitUvt^ 


Heap. 


.«...:...»..  :...  i. ..;...;. ...J... 


Chart  XII. — Three  days.    Chronic  tuberculosis. 


i\ 


the  temperature  in  the  early  morTiing  hours  is  usually  associated  with 
sweating.  This  hectic,  as  it  is  called,  which  is  a  typical  fever  of  peptic 
infection,  is  nu't  with  when  the  process  of  cavity  fornuition  and  softiiii'ig 
is  advaniied  and  extending. 

A  continuous  fever  with  remissions  of  not  more  than  a  degree,  develop- 
ing  in  the  course  of  pulmonary  tuberculosis,  is  suggestive  of  acute  |ineii- 
monia.  When  a  two-hourly  chart  is  made,  the  remissions  even  in  acute 
tuberculous  pneumonia  are  usually  well  nuirked.     A  continued  fever,  such 


.1 


TUBERCULOSIS. 


245 


as  ia  sciii  in  the  first  week  of  typhoid,  or  in  sorno  cases  of  iuflammation 
of  tlio  liin,!,',  is  rare  in  tuberculosis. 

Sirivtiiiij. — Drenchiiij,'  perspirations  are  common  in  plithisis  and  con- 
stitute ('lie  iif  tiie  most  distressing  features  of  the  disease,  'i'hey  occur 
iisiiallv  lit  iii,i,'ht,  or  at  any  time  in  the  (hiy  when  the  i)atient  sli-eps.  Tliey 
nmv  coiuc  on  early  in  the  disease,  but  are  more  j)ersistent  and  frc<juent 
ftfltT  cavil ics  have  formed.     Some  patients  csciipe  altogether. 

Thi'  /iiiisc  is  iiicrea.sed  in  frecpiency,  fsj)ei'ially  when  the  fever  is  high. 
It  is  (ifieii  renuirkaldy  full,  though  soft  and  compressiljle.  rulsatioii  nuiy 
somc'liines  bo  seen  in  the  capillaries  and  in  the  veins  on  the  back  of  the 
hitnd. 

KiiKicidlidii  is  a  pronounced  feature.  The  loss  of  weight  is  gradual 
but,  if  the  disease  is  extending,  progressive.  The  scales  give  one  of  the 
best  iiiilications  of  the  progress  of  the  case. 

3.  Physical  Signs. — {a)  Insjjedioii. — The  shape  of  the  chest  is  often 
suggestive,  though  it  is  to  be  reniemlu'red  that  pidmonary  tuberculosis 
may  be  met  with  in  chests  of  any  build.  I'ractically,  ho\v»'ver,  in  a  con- 
siileralile  proportion  of  cases  the  thorax  is  long  and  narrow,  with  very 
wide  intercostal  spaces,  the  ribs  more  vertical  in  direction  and  thc;_costal 
iingle  very  narrow.  The  scapula;  are  "  winged,"  a  point  noted  by  Hip- 
pocrates. Another  type  of  chest  which  is  very  common  is  that  which  is 
flattened  in  the  antero-jjoiiterior  diameter.  The  costal  cartihiges  may  bo 
proiuineiit  and  the  sternum  depressed.  Occasionally  the  lower  sternum 
forms  a  deep  concavity,  the  so-called  funnel  breast  {TrUlilm'-Itntxt).  In- 
spection gives  valuable  information  in  all  stages  of  the  disease.  Special 
examination  should  be  nuuic  of  the  clavicular  regions  to  see  if  one  clavicle 
stands  out  more  distinctly  than  the  other,  or  if  the  .spaces  above  or  below 
it  are  more  nuirkcd.  Defective  expansion  at  one  apex  is  an  early  and  im- 
portant sign.  The  condition  of  expansion  of  the  lower  zone  of  the  thorax 
may  be  well  estimated  by  inspection.  The  condition  of  the  pra>cordia 
should  also  be  noted,  as  a  wide  area  of  impulse,  particularly  in  the  second, 
third,  and  fourth  inter.spaces,  often  results  from  disease  of  the  left  apex. 
From  a  point  behind  the  patient,  looking  over  the  shoulders,  one  can 
often  better  estimate  the  relative  expansion  of  the  apices. 

(//)  /'(iljH(fioii. — Deficiency  in  expansion  at  the  apices  or  bases  is  per- 
haps liesf  ganged  by  i)lacing  the  hands  in  the  subclavicular  spaces  and 
then  in  the  lateral  regions  of  the  chest  and  asking  the  patient  to  draw 
slowly  a  full  breath.  Standing  behind  the  ])atient  ainl  placing  the 
thmnbs  in  the  supraclavicular  ami  the  fingers  in  the  infraclavicular 
spaces  oiu'  can  judge  a(;curately  as  to  tb.e  relative  mobility  of  the  two 
sides.  Disease  at  an  apex,  though  earl}  and  before  dulness  is  at  all 
iiiarke(],  luay  be  indicated  by  deficient  expansion.  On  a.sking  the  patient 
to  count,  the  tactile  fremitus  is  increased  wdierever  there  is  local  growth  of 
tubercle  (ir  extensive  caseation.  In  comparing  the  ai)ices  it  is  important 
to  bear  in  niiml  that  luirmally  the  fremitus  is  stronger   at  the  right  than 


■'i 


5'  lita 


ii'il 
'ifi 


1^ 

i 


I!, 


nil 

m 


iU 


'''Ik 


4  4'\ ' 

1  i  } 


240 


SI'KC'IKR*    INFIOCTIOL'S   DISIOASKS. 


at  tlie  left.  So  too  at  tho  base,  wliiui  tliorc  is  coiisolidiitioii  of  tlu'  liinpr, 
tlio  fri'iiiUiis  Is  iiicroascd  ;  \v  lie  reus,  if  tlitTo  is  iiloiinil  cITii.sion,  it  is 
diiniiiislu'd  or  iibsnit.  In  tlic  lalcr  stiij^cs,  when  ciiviLii's  form,  llu'  liU'tik' 
fi'i-riiitiis  is  iisiiiilly  iiiiu'h  (•.\ag;ffnitf(l  ovi-r  tlii'in.  Wiii'ii  iho  pK  lira  is 
<jri>atlv  tliifkoiu'd  liiu  frt'iiiilus  iiiav  bo  siiiiiewhat  diiiiiiiislit'd, 

(')  l^'fiix^ion. — 'I'libiTck's,  iiillamiiiatdry  i»i'odiicls,  libroid  'liangis, 
and  (.'aviiics  pniducc  inijiorUint  rban^^'os  in  tlio  pulmonary  rfSdiKimr, 
There  may  bo  localized  disease,  even  of  some  extent,  wiiliout  iniliiciii;,' 
inneli  alteration  ;  as  when  the  tubercles  uro  scattered  and  have  uir-nm- 
tainiiig  tissue  between  them.  One  of  tho  earlii'st  and  most  valuable  .si^'iiji 
is  defective  resonance  mton  ami  above  a  clavicle.  lu  a  c(»nsideraiilc  ihd- 
])ortion  of  all  eases  of  phthisis  tho  didness  is  lirst  noted  in  these  rt';,'i()iis 
Tho  comparison  lu'tween  tho  two  sides  should  bo  made  also  wluii  the 
breath  is  held  after  a  fidl  inspiration,  as  tho  defectivo  resonance  mav  tlini 
bo  inoro  clearly  marked.  In  the  early  stages  tho  percussion  note  is  iisurilli' 
liiLrher  in  pitch,  and  may  recjuirc  an  experienced  ear  to  detect  the  diUVr- 
enco.  In  recent  consolidation  from  caseous  pneumonia  tho  perciissiuii 
note  often  has  a  tul)ular  or  tymi)anitic  (piality.  A  wooden  diiliicss  is 
rarely  heanl  except  in  old  cases  with  exti'usive  libroid  change  at  the  iqnx 
or  base.  Over  large,  thin- walled  cavities  at  tho  apex  tho  so-called  crackul- 
pot  sound  may  be  obtained.  In  thin  subjects  tho  percussion  shoiilil  be 
carefully  prai'tised  in  the  supraspinous  fo.-sa'  I  the  inter.-ca])ula!- s)i;i(t, 
as  they  corros})ond  to  very  imi)ortant  art-as  eaiiy  involved  in  the  dista*. 
In  cases  with  numerous  separated  cavities  at  the  a}iex,  without  iiimli 
ilbi'oid  tissue  or  thickening  of  the  jiU'ura,  the  jjcrcussion  note  may  slmw 
little  change,  aiul  tlu?  contrast  between  tho  signs  obtained  on  auscultation 
and  perc'ussion  is  most  nnirked. 

(//)  Ausnilhtlldii. — Feeble  breath-.sounds  arc  among  the  most  charac- 
teristic early  signs,  since  not  as  much  air  enters  tho  tubes  and  vesicles  of 
the  alTccted  area.  It  is  well  at  lirst  always  to  compare  carefully  the  cur- 
ri'sponding  points  on  the  two  sides  of  the  chest  witiiont  asking  the  patient 
cither  to  draw  a  dci'p  l)i'eath  or  to  cough.  With  early  apical  disease  the 
insj)iration  (iu  ipaet  breathing  nuiy  be  scarcely  audildc.  Expiraticii  is 
usually  prolonged.  On  the  other  hand  there  are  cases  in  whicdi  tluMMiiicst 
sign  is  a  harsh,  rude,  resj)iratory  murmur.  On  deep  lireathing  it  is  I'lu- 
quently  tobenoteil  that  inspiratiiju  is  jerking  or  wavy,  the  so-called  "en!,'- 
•wheel  "  rhythm  ;  which,  however,  is  by  no  means  conliiu'd  to  tid)ereid()sii 
With  extension  of  tho  disease  tho  inspiratory  murmur  is  harsh,  and,  \\\w\\ 
consolidation  o(.'cnr~,  whilling  and  bronchial.  With  these  (dianges  in  the 
chaiactiM'  of  the  murmur  ihore  are  rales,  due  to  the  acc(jmi)anying  hn'H- 
chilis.  They  may  bo  heard  only  on  detfp  inspiration  or  on  coughing,  ami 
early  in  the  disease  are  often  crackling  in  character.  When  softening 
occurs  they  are  louder  and  havi;  a  bubbling,  sometinu's  a  (diaradcristic 
clicking  (luality.  These  "moist  sounds,"  as  they  are  called,  wiieu  as.^o- 
ciatod  with  chango  iu  the  porcussiou  rosouauco  are  extremely  suggestive. 


TUBKRCULOSIS. 


24; 


Whon  ciivitii'S  form,  llio  rules  arn  louder,  inoro  gurgling,  and  resonant  in 

(Mi.ilitv.     Wlitii  tliere  is  euiisolidtitioii  of  any  extent  the  breath-sounds  are 

luhiilar,  ami  in  (he  large  ('."cavations  loud  and  cavernous,  or  have  an  am- 

iilioric  (|ii;ility.     In  the  unalTi'ded  portions  of  the  lohc  and  in  the  opposite 

luii;,' tlie  l)ri'iith-soii:ids  may  he  harsh  and  even  puerile.     The  voeal   reso- 

I  aiiir  is  usually  inireased  in  all  stages  of  the  proec-ss,  and  bronchophony 

aiid  |it'i  iiiriliM|uy  ari'  met  with  in  the  regions  of  consolidation  and  over 

iiiviiii's.    I'lcuritic  friction  may  he  present  at  any  stau'c  and,  as  mentioned 

lufdre,  occiu's  very  early.     There  aie  cases  in  which  it  is  a  nuirked  feature 

tlipiiiuliout.     When  the   lappet  of  lung  over  the  heart  is  involved  there 

may  Ijc  a  plcuro-perieanlial  friction,  and  when  this  area  is  consolidated 

tluiv  may  bo  curious  clicking  rales  syiwhronous  with  the  heart-heat,  due 

til  tilt'  compression  by  the  heart  of,  and  the  expnlsioji  of  air  from,  this 

pdrtiuii.    All  interesting  auscultatory  sign,  met  most  commonly  in  phthisis, 

i>  the  so  called  cardio-respiratory  murmur,  a  whilVing  systolic  bruit  due  to 

iiie  propulsion  of  air  out  of  the  tubes  by  the  impulse  of  the  liearti     It  is 

bist  heard  during  inspiration  and  in  the  aiitero-lateral  n'gions  of  the  chest. 

A  systolic  murmur  is  freipiently  heard  in   the  subclavian  artery  on 

titliiT  side,  the  ]»ulsation  of  which  may  be  very  visible.     The  murmur  is 

in  all  probability  due  to  pressure  on  the  vessels  by  the  thickened  pleura. 

The  signs  of  cavity  may  be  here  briefly  enumerated. 

((/)  When  there  is  not  much  thickening  of  the  })leura  or  condensation 

nf  ihc  surrounding  lung-tissue,  the  pei'ciission  souiul  may  be  full  and 

Irar,  ivsriubling  the  normal  note.     More  commonly  there  is  defectivo 

ivsoiiaiiee  or  a  tympanitic  (][uality  which  nuiy  at  times  be  purely  amphoric. 

Tlir  iiitch  of  the  percussion  note  changes  over  a  cavity  when  the  niuuth 

is  o|iciu'd  or  closed  (Wintrich's  sign),  or  it  may  be  brought  out  mon> 

L'liarly  on  change  of  position.     The  cracked-pot  sound  is  oidy  obtaiiudile 

iiviT  toleralily  large  cavities  with  thin  walls.     It  is  best  elicited  by  a  firm, 

f|ui(k  stroke,  the  patient  at  the  time  having  the  mouth  open.     In  tho.se 

rare  instances  of  almost  total  excavation  of  one  lung  the  percussion  note 

iii:iy  he  amphoric  in  ([uality.     (/,•)  On  auscultation  the  so-called  cavernous 

i-muuls  are  heard  :  (1)  Various  grades  of  modified  breathing — blmving  or 

tiilmlar,  cavernous  or  amphoric.     There  may  be  n  curiously  sharp  hissing 

''"iind,  a-:  if  the  air  was  passing  from  a  narrow  opetiing  into  a  wide  spacn 

111  vory  largo  cavities  both  inspiration  and  expiration  may  be  typically 

aiMpliorit'.     (-2)  There  are  coarse  bid)bling  rales  which  liave  a  resonant 

'|iiality,  and  on  coughing  may  have  a  metallic  or  ringing  character.     On 

ciniiihiiig  they  are  often  loud  and  gurgling.     In  very  largo  thin-walled 

cavitii's,  and  more  rarely  in  medium-sized  cavities,  surrounded  by  recent 

C'lnsolidation,  the  rales  nuiy  have  a  distinctly  amphoric  echo,  simulating 

those  of  pneumothorax.     There  are  dry  cavities  in  which  no  rales  are 

hciird.    (,3)  The   vocal   resonance   is   greatly  intensified   and   whispered 

l'i'<torilo,|iiy  is  clearly  heard.     In  largo  apical  cavities  the  heart-sounds 

111'  Hull  heard,  and  occasionallv  there  may  be  an  intense  svstolic  murmur, 

17 


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II 


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f 


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hi 

A,, 

J.— 


^lil 


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4  ■'  »1  • 


^1 


i 


248 


SPKCMl'MC   INKKCTIOI'S   IHSKASKS. 


prohiilily  ahviiVH  traiistiiittuU  to,  uiul  nut  iinnliiccd,  as  has  been  Riiiijiowd. 
in  the  cavity  itself. 

I'siMiilo-cavt'riioiiH  sijjiiH  triuy  lie  faiiscd  by  an  area  of  consolidutidn 
near  a  lar^^'c  hruticliiirt.  'l"lu'  ('(inditidn  may  Ix-  most  di-coptivc— tlic  In.-l,. 
jtitclii'd  <»r  tympatdf  |icr(iissinn  note,  tlic  tiiliular  or  cavi'rnoiis  l)iiiitluii;', 
uiid  tlic  rc.-ionaiit  rali's,  simulate  closely  those  of  cavity. 

4.  Symptoms  referable  to  other  Organs.—!'/)  ('iir(/io-i'iifiriil(n:~T\w 

retract  iuii  (if  ilio  left  ii|i|icr  lolie  exposes  a  lar;:i' ai'ca  of  tlie  lie;irt.  In 
thiii-clu'stcd  stilijcct.s  there  may  l>e  pulsation  in  the  second,  lliiid.  imii 
fourth  inlcrspacH'.s  close  to  the  .sternum.  Somt'tinu's  with  much  retnutiun 
of  the  left  upper  lolie  the  heart  i.s  drawn  up.  .\  .systolic  murmur  ovir  !lir 
pultnonary  area  is  commoi\  in  all  sta;;es  of  phthisis.  ^Npical  miiriuiirs  mv 
also  not  infr"<|ueiit  and  may  lie  extrcnu'ly  rou;.;h  and  harsh  withoiu  lurc*. 
sarily  indicatiuiT  thiit  iMidocarditis  is  presiMit.  'I'lie  a.s.s(K'ialioii  oj'  hcurt. 
disease  with  phthisis  is  not,  however,  very  unconunon.  As  already  men- 
tioned, there  were  twi-lve  instances  of  endocarditis  in  'iH>  autopsies.  Tlio 
arterial  tension  is  usually  low  in  phthisi.-,  and  the  capillary  resistance  It ■■ 
sened  so  that  the  pidsc  is  ofti-n  full  ami  .soft  even  in  the  later  sia^'tsi.f 
the  di.sease.  'i'lic  capillary  [lulse  is  not  infrccpiently  met  with,  and  |iulsa- 
tion  (»f  the  veins  in  the  liack  of  the  hand  is  oceusionalh'  to  be  seen. 

(//)  hltitid  (Ihtiiduldr  Si/sfiiii.  —  The  early  ana'inia  has  already  U'cii 
noted.  It  is  often  more  appan'iit  than  real,  a  cldoro-ana-mia,  luul  tin 
blood-count  rarely  sinks  below  tw<t  million  per  cidtic  millimetre. 

The  hlood-plates  are,  as  a  rule,  enormou.sly  increased  and  are  seen  in  \h 
withdrawn  Itlood  as  the  so-called  Schultze's  jininule  mas.ses.  Witlieiu  iiiiv 
siirniticance,  they  are  of  interest  chielly  from  the  fact  that  every  few  ycm- 
some  tyro  announci's  their  discovery  as  a  lU'W  diiiiriiostie  sij^n  of  plillii.-:-. 
The  leucocytes  are  greatly  increased,  particidarly  in  the  later  sta;:es. 

('')  ('(Jfj.ti'^in/i'Ktindl  Si/s/rm. — The  tonj^iu'  is  usually  furretl,  hut  iiiiiv 
bo  clean  an<l  red.  Small  aphthous  ulcers  are  sonu'times  distressiii;:.  \ 
red  line  on  the  <jums,  a  symptom  tf)  which  at  one  time  much  attciuioii  w;i^ 
liaid  as  a  special  feature  of  phthisis,  occurs  in  other  cachectic  state.'*.  Ks- 
tensivo  tubercidous  disease  of  the  pharynx,  associated  with  similar  iitfcc- 
tion  of  the  larynx,  may  interfere  seriously  with  deglutition  ami  pmvi  a 
very  distressing  and  intractable  symptom. 

Of  late,  special  attention  has  been  paid  to  tlie  gastric  symptom^ 
of  this  affection.  Tubercidous  diseas(^  is  rare.  Ulceration  may  oociiras 
an  accidental  complication  and  multiple  catarrhal  ulcers  are  not  luicum- 
nion.  Ijiterstitial  and  ])arenchymatons  changes  in  the  mucosa  an-  cnin- 
nion  (i)ossibly  associated  with  the  venous  stasis)  and  lead  to  atrophy,  bin 
these  cannot  always  be  connoted  with  the  .symptoms,  and  they  iiiaybe 
found  when  not  expected.  On  the  other  hand,  when  the  gastric  symp- 
toms have  been  most  persistent  the  mucosa  may  show  very  little  ('haiigf. 
It  is  impossible  always  to  refer  the  anorexia,  nau.sea,  and  vomiting  of  con- 
sumptiou  to  local  conditions.     The  hectic  fever  and  the  neurotic  intiu' 


Triu:iuii,(>sis. 


I'lJ) 


ena^  I'l"'"  wliifh  Irnmcrriwimi  Iuvh  rninli  str('s.><,  must  bo  taken  into  ac- 
iiiiiiii,  ii-  iIk'V  play  an  iiii|H>rt»iit  rd/r.  Tlic  (ir;,'an  is  oftt-ii  dilatcil,  ami  to 
iiiiiMiiliir  iiisiinificiicy  ainiir  iiiay  In-  diic  sotiu'  of  tlic  cases  of  dyspepsitt. 
The  niiidilioii  of  tile  <,'astri('  secretion  is  not  constant,  and  the  reports  arc 
(li.ciinlaiit.  In  thu  early  stap's  there  may  be  iiyperacidity  ;  later,  a  de- 
liciiiiry  ol"  ai'id. 

Anon  \ia  is  ot'len  a  marked  syjnptom  at  the  onset ;  there  may  bo  positive 
Imitliiii;,'  nf  I'ood,  and  oven  small  (|iianlitioseanse  nansi'a.  Sdiuotimes  with- 
Diit  aiiv  naiiM'a  or  distress  after  ealini,'  the  feeding:  of  the  patient  is  a  daily 
hatdc.  U'lieii  practical)le,  |)eb(»ve's  forct'tl  alimentation  is  of  jfreat  benetlt 
ill  >ii(li  I'ases.  Nansea  and  vomiting,  though  occasionally  tronblesome  at 
;,iMiiil\  period,  are  more  markeil  in  the  later  stages.  The  latter  may  bo 
caiisctl  liy  the  severe  attacks  of  coughing.  S.  H.  llal)ershon  refers  to  four 
ilillVrci  t  causes  thc^  voniiting  in  phthisis;  (!)  central,  as  from  tuberculou.s 
iiHiiiii;.'ilis;  (•>')  pressure  on  the  vagi  by  caseous  glands;  (:{)  stimidatioii 
fmiii  the  peripheral  brunches  of  ijie  vagus,  eiljier  pulmonary,  i)haryngeal, 
(ir  ga-^lrie  ;  and  (4)  mechanical  causes. 

(If  the  iiilrsliiKil  symptoms  diarrluea  is  the  most  serious.  It  may 
idiiu'  (iM  early,  but  is  moi'c  usually  a  symptom  of  the  later  stages,  and 
is  associated  with  nlceratioii,  particularly  of  the  largo  bowel.  Ivxtensivo 
iikrratioii  of  the  ileum  may  exist  without  any  diarrluea.  'The  associated 
rataniial  comlition  may  account  in  part  for  it,  and  in  some  instances  tlie 
amyloid  degeneration  of  the  mucous  membrane. 

('/)  SirniKx  Si/sfrin.—{\)  Focal  lesions  due  to  the  dovolopment  of 
coarse  tuhereles  and  areas  of  tuberculous  nu'ningo-onceplialitis.  Aj)hasia, 
fur  iiistaneo,  may  result  from  tlio  growth  of  meningeal  tubercles  in  the 
tis-:iuT  (if  Sylvius,  or  oven  hemiplegia  nuiy  develop.  'I'he  .solitary  tubor- 
I'li's  are  more  common  in  llie  (diroiuc  phthisis  of  (diildren.  {'i)  liasilar 
nii'iiiii;ritis  is  an  occasional  complication.  It  may  bo  continod  to  tho 
tiiaiii,  though  more  (commonly  it  is  a  (•'{)  corobro-spinal  meningitis,  which 
may  c'onie  on  in  jtorscms  without  well-developed  local  signs  in  the  chest. 
Twice  have  I  known  strong,  robust  men  Itrougbt  into  hospital  with  signs 
of  (•(•rchni-s])inal  moniiigitis,  in  whom  the  existence  of  jiulmonary  disease 
was  not  discovered  until  tho  post-mortem.  (4)  Peripheral  neuritis.  This 
i- not  fi('(|uent,  and  hiis  occurred  but  five  times  in  tho  large  number  of 
ooiisiniiptives  who  have  come  under  my  observation  during  tho  ])ast  seven 
viars.  It,  is  nearly  always  an  extensor  paralysis  of  tho  arm  or  leg,  more 
pitmnionly  the  latter,  causing  foot-drop.  It  is  usually  a  late  manifes- 
tation, (,■))  Mental  symptoms.  It  was  noted,  oven  by  tlic  older  writers, 
tliat  cotisumptivos  liad  a  jiocnliarly  hopeful  tomporameut,  and  the  spes 
plillnsini  forms  a  curious  characteristic  of  tho  disease.  Patients  with  ox- 
I'lisivc  (iiNiiies,  liigli  fever,  and  too  weak  to  move  will  often  nuike  plans 
I'T  tlu'  future  and  confidently  expect  to  recover. 

.'Vpait  from  tuberculosis  of  tho  brain,  there  is  sometimes  in  chronic 
phtliisisa  form  of  insanity  not  unlike  that  which  develops  in  the  conva- 


''4- 


$ 


H.  ;  * 


yno 


si'Kcifk;  iNFK(;'r(oiTs  diskaskh. 


It'sceme  from  iuiitc  jilTtHitioiis.  Tlio  whole  (jiu'slioii  of  tlio  niiitual  i<  latioiw 
of  iiisiiiiity  uiul  iihtliisi.s  is  dof'L  willi  ;iL  leiigtli  ill  Micivle's  (»ul.sloiiiaii 
lectures. 

{)•)  A  ivmiirk!il)li'  Iiyporlropliy  of  (lie  TimiDiiiarv  jfliiiui  may  occur  in 
])iiliiniiiiirv  tulxTciilosis,*  most  commonly  in  malt's.  It  may  only  he  mi  the 
alTfctfd  side,  'i'wu  cast's  ciiiiu;  ni-dcr  my  iKilico  at  tlio  I'liivTsity  liiisjiiim. 
lMiila(li'l[)liia,  l)i)ili  in  youiij^  males.  It  is  achronio  interstitial,  non-lulur- 
(Hilous  mamniitis  (Allot). 

(/■)  (Iciiihi-iiriiKini  Si/sfnii.—'Vh.-  urine  pr.-sents  no  special  peculiari- 
ties in  amount  or  constituents.  iM^ver,  however,  lias  ;v  .'narked  intlufiicc 
upon  it.  Albumen  is  met  with  fre(|U(ntly  and  may  be  associated  with 
the  fever,  or  is  the  result  of  delinite  (dian^n's  in  the  kidneys.  In  tli^' liilUr 
case  it  is  more  id)iindant  and  more  eunl-like.  Amyloid  d i.seasi' of  the 
kidneys  is  not  uncommon,  its  presence  is  shown  by  albumen  and  tube- 
easts  in  the  urine,  and  sonu-t'tnes  by  a  j^reat  incrt^ase  in  the  amount  nf 
urine.  In  other  instances  then;  is  dropsy,  and  the  i)atients  have  all  the 
chara(;teristic  features  of  chronic;  Jirif^ht's  disease. 

I'u.s  in  the  urine  may  be  due  to  disi'a.se  of  the  bladder  or  of  the 
pelves  of  the  kidneys'  In  some  instantx's  the  entire  urinary  tract  is  iu. 
volved.  In  pidmonary  phthisis,  however,  extensive  tubercidous  disease  is 
rarely  found  in  the  urinary  origans.  Bacilli  may  occasionally  be  dett'cled 
in  the  pus.  lla-niaturia  is  not  a  very  common  .-(ymptom.  It  may  (/cciir 
occasioiudly  as  a  result  of  eon<ifestion  of  the  kidiuns,  which  passes  olT  ami 
leaves  the  urine  all)uniinoiis.  In  oiiier  instances  it  results  from  discascnf 
the  pelvis  or  of  the  bladtlcr,  and  is  associated  either  with  early  tulu'rcii- 
losis  of  tiu>  mucous  membratics  or  more  conwnoidy  with  ulceration.  In 
anv  medical  clinic  the  routine  itispection  of  the  testes  for  tubenlt^  wil! 
save  two  or  three  mistakes  a  year. 

(//)  (' i( t(t until X  Siixfi'iii. — The  skin  is  often  dry  and  harsh,  i.dcju 
tubercles  occasionally  develop  on  the  hands.  There  nuiy  be  pij^'inciitary 
staining,  the  r/ilonsnni.  p/ifhisirorion,  whicrh  is  more  comnuui  wlicn  thi' 
pentonaMim  is  involved.  Upon  tin;  chest  ami  back  the  brown  sl:iins  nf 
the  pitjiriiisis  irrsiro/or  are  "(.py  fre(|uent.  Tlu'  hair  <»f  the  hcinl  inil 
beard  may  become  dry  and  lanky.  The  ternunal  phalaiifres,  in  cliniiiii 
cases,  beconu'  clubbed  ami  the  nails  iiuuirvated — the  llippocratic  liiif;('rs.f 
A  ri'markal)le  and  unusual  complication  is  "general  empliysemi),  wliicli  may 
result  from  ulceration  of  an  adhertiiit  lung  or  perforation  of  the  larynx 

Diagnosis.  — When  well  advan(!ed  there  is  rarely  any  doubt  ii<  tn  the 
existtiuce  of  tubercidous  phthisis,  for  the  sputum  gives  positive  inforina- 
tion,  antl  the  physieiil  signs  of  local  disease  are  well  nuirked.  The  btuiili 
give  an  infallible  indication  of  the  existence  of  tid)ercnlosis  antl  iiiiiy '»' 

♦  Allot.  Paris  Tln>sis.  IH«7. 

+  "  Morlio  i>r<)f;r('(Ii<'nl(',  corfxiM  mmTcscil  pru'ler  criirii;  Iih'c  uutciii  luiiiciil 'i 
jmmIcs,  et  ungiH's  contnriiMfdliir"  (lli|)p<i(TiittM). 


found  in  l!ii 

otlllT    llllllil, 

with  tdleri.'h 
and  many  c 
essential  is  t 
sis  that   I  ui 

this  KH'tlloil 

lilioncr  lias 

tnries  in  niai 

l:'iirli/  i/r/iri 

iif      'III'  nii'i 

Tlic  [ires 

tion  iif  the  Ii 

of  tulierculo 

sijins  arc  '\( 

riu'tliod,  iu)t 

ha'niii|itysis, 

local  si!.Mis,  ii 

spiituni,  froii 

I'xaininalioii. 

fever,  and  lo; 

however,  to  \ 

out  distind)ai 

frien.ls.    '["In 

I'''.;.  Ily  moist 

a  ;dairy  c\p( 

several  I'ascs 

hIucIi  repeat 

They  seem 

some  of  wl 


t( 
hie 


in  llleu' 
lladley  anil 
tilii'oid  plillii.- 

hl'oiil   i|i>eas 
a  tihriiid    cci 

iii'oiii.  lint    V 
may  ecini,.  lO 
I'lii'tminnia,  o 
'he  process  s 
ease  lieeonics 
'l''lise  lilii'du.s 
i'lly  invaded 
liUle  if  at   al 


L....^ 


Tl'FJEUrrLOSIS, 


251 


fdiiiid  in  llio  sputum  before  the  jdiysical  signs  are  at  all  dcliiiiti'.  On  the 
other  liaiiil,  it  must  bo  reinembcred  that  tliere  are  cases  in  whieli,eveu 
with  t(ilt'n:l)lv  well-defined  physical  signs,  (he  spiitunn  is  extremely  scanty 
;ii;il  iiiMiiv  cxatninations  may  Ixi  required  to  detect  tul)ercl('  l)a('i]li.  So 
(SM'iiti.il  is  the  examination  of  the  sputuTu  in  tlie  early  diagnosis  of  phthi- 
sis that  1  would  earnestly  insist  upon  the  more  frequent  employment  of 
this  itirilmd.  'i'lien^  is  no  excuse  iu>w  for  its  omission,  since,  if  the  prac- 
titioner liMS  not  command  of  the  necx^ssary  techni(|ue,  there  are  labora- 
idries  ill  iiiaiiy  parts  of  the  country  at  whicii  the  examination  can  he  made. 
h'ltrhi  (Irhrliiin  is  of  vifiil  i/ii/)(irf<iiir<\  /is  sucrcssfiil  fri'dfiiic/if  dt'pvnils 
11/'      'III'  /iii'ifs7nrs  tdk'pn  hvfnrv.  the  hiwis  (irv  f.rtcnsirchi  iiiru/rn/. 

The  jireseiice  of  elastic  liltres  in  the  sputum  is  an  indication  of  destruc- 
ti(in  of  the  lung-tissue.  In  a  large  proj)ortioi<  of  cases  it  is  indicative,  too, 
of  tuhri'i'iildiis  disease.  It  also  may  he  found  early,  before  the  physical 
>ii;iis  are  well  iiuirkcd.  Its  detection  is  easy  b'  the  aliove-mentioned 
riiithoil,  not  rc(|uiring  high  jiowcrs  of  the  microscwpe.  In  cases  of  early 
ha'tiioplvsis,  before  there  is  miirkcd  consliliitional  disturliance,  or  even 
local  signs,  it  is  very  important  to  make  a  tiioroiigh  examination  of  tlu^ 
split iiin,  from  which  mucoid  and  purulent  portions  may  be  picked  out  for 
cxainiiiatioii.  Witli  localized  and  persistent  signs  in  one  lung,  cough, 
fever,  and  loss  (,•"  flesh,  the  diagiKJsis  is  rarely  dul)ious.  It  is  rciiiarkal)ie, 
hnwe\er.  to  what  an  extent  the  local  process  ma}-  sometimes  prncci'd  with- 
(iiit  ilisliirtiaiici  of  health  siifliciciii  to  excite  the  alarm  of  the  physician  or 
frieii'ls.  'riierc  are  jmzzling  cases  with  localized  physical  signs  at  one  apex, 
!•)':>  lly  moist  rales,  rarely  any  pcr"Ussion  changes,  perhaps  slight  fever,  and 
a  L'lairy  expectoration  containing  numerous  alveolar  cells.  1  have  seen 
si'venil  eases  of  this  kind  whi(di  have  been  for  a  time  very  obscure,  and  in 
wliieji  repeated  examiii"»ions  failed  to  detect  either  bacilli  or  elastic  tissue. 
Tliev  sei'in  to  be  instance's  of  local  catarrhal  trouble  in  the  smaller  tubes, 
i>oi!ie  i»f  which  clear  in  a  few  weeks. 


;5.  Fibroid  Phthisis. 

111  ih(ir  monograph  on  I-'ibroid  l>iseascs  of  the  liUiig  (IS'.l-l)  Clark 
!L(l!iv  and  Cliaplin  make  the  following  classification  :  1.  I'lirc  tiltroid  ; 
tilii'oid  phthisis — a  condition  in  wlii<'h  tlierc  is  no  tubercle,  'i.  'i'uhei'ciilo- 
lihi'oiil  disease — a  cojidition  piimarily  tuber  uloiis,  but  wiiich  has  run 
II  lihniid  cciirse.  ;{.  l-'ibro-tiibercidous  disease--a  condition  primarily 
liliroid.  Iiiit  which  has  become  tuberculous.  The  tuberciilo-fibroid  form 
may  (dine  on  gradually  as  a  seipicnce  of  a  i  hroiiic  tuberculous  broinho- 
imeiiiiiDiiia,  or  I'ollow  a  chroidc.  tuberculous  pleurisy.  In  other  iii>lances 
tlio  pmcess  supervenes  upon  an  ordinary  tilcerativc  phthisis.  The  dis- 
eii.se  liecdiiies  limited  to  (Mie  apex,  the  cavity  is  surroiiiideil  by  layers  of 
'l''iise  tihiuiis  ti.ssue,  the  pleura  is  thickened,  and  the  lower  lobe  is  gradu- 
ally invaded  l»y  the  siderotic  tdiange.  I'ltimalely  a  picture  is  prodiicetl 
httle  if  at  ;dl  dilTerent  from   the  condition   known  as  cirrhosis  of   the 


iP 


;  )y 


n 

'm    ■ 


I'' 


1 


I  I 


1 


!    ''' 


.'P 


I      '1l 


W 


ni\ 


252 


SPECIFIC   INFI'X'TIOUS  DISEASES. 


^-4i... 


h 


lunf,'s.  It  may  even  be  (litliciilt  to  say  that  tlic  process  is  tiiberculons,  Imt 
in  advanced  cases  l,lie  bacilli  are  usually  jjresent  in  the  walls  of  the  raviiv 
at  th(!  apex,  or  old,  enca[)sulat(.'d  caseous  areas  exist  in  the  lun<f,  or  tlifie 
may  bt;  tuixTcles  at  the  apex  of  the  other  lung  aid  in  the  in'onclii;,] 
glands.  Dilatation  of  the  bronchi  is  present;  the  right  ventricle,  isniiiu- 
times  the  entire  heart,  is  iiypertrophied. 

The  disease  is  chronic,  lasting  from  ten  to  twenty  or  more  yeai.-,  dur- 
ing which  time  the  [tat lent  may  hav(!  fair  health. 

'i'hc  child"  symi»louis  aic  cough,  which  is  often  paroxysnud  in  character 
and  most  nuirked  in  the  luorning.  The  expectoration  is  purulent,  luid 
in  some  instances,  when  the  bi'onchieiitasis  is  extensive,  fa3tid.  There  i> 
djs|in(ea  on  exertion,  but  little  or  no  fever. 

'l"he  |>liysical  signs  are  vi'ry  (duiracteristic.  'I'he  idlest  is  sunken  and 
the  shoulder  lower  on  the  alTected  side;  the  heart  is  often  drawn  over  and 
displaced.  If  the  left  lung  is  involved  there  may  l)e  an  uuusuall\  l;iri;c 
area  of  cardiac  <)nlsalion  in  the  third,  fourth,  and  lifth  interspaces.  IJiari- 
murmurs  are  common.  Thei'c  is  didne.ss  over  liic  ail'ei'ied  side  and  (jitj. 
cient  tactile  fremitus.  .\t  the  apex  there  may  be  well-marked  cavenl(lll^ 
sounds;  at  the  base,  distant  bronchial  bicathing.  The  condition  iii;iv 
persist  indelinitely.  In  some  cases  t!ie  other  lung  becomes  inv<il\eil, or 
the  patient  has  repeateil  attacks  of  ha'mo})l\sis,  in  one  of  which  he  iliiti, 
As  a  residt  of  tiie  ebrouic  suppuration,  amyloid  degeneration  of  the  liver, 
spleen,  and  intestines  may  take  place;  drop.sy  fre<picntly  supervenes  tioin 
failure  of  tiie  riudil  heart. 

A  more  deiaik'd  account  is  fou;i  1  under  CirrIio.sis  of  the  Lung,  witii 
which  this  form  is  clinically  identical. 

Concurri'/i/  hifccliiDis  in  /'nlnitindri/  Tiif/crnilnsis. 

It  has  long  been  known  that  in  pulmoiuiry  tuberculosis  orgaiiisnis 
other  than  the  specitii-  bacilli  are  present,  particularly  the  nMcrocdciiif 
lanceolatus,  the  streptococcus  pyogenes,  and  the  staphylococcus  aiir('ii>; 
less  frtM|uently  the  bai'illus  pyocyanens. 

A  nnijority  of  all  eases  nf  pulmonary  tuberculoHis  are  combined  infer 
tioiis;  streploeucci  and  piieumococci  may  be  found  in  the  -^piita.  .iiid  tin 
former  have  been  isolated  from  the  IiIikmI.  The  great  impnrtanee  of  tin 
.secondary  streptococcus  infection  is  einphasized  by  the  extierinu'iits  ef 
I'ruddeii  (New  York  .Medical  .lournal,  IS'.M,  ii),  who  found  that  a  liirjie 
proportion  of  experinn'Otal  animals,  wlmsc  lungs  bad  been  the  seat  of  emi 
current  infection  with  the  tubercle  bacillus  and  the  8tre|)tococcus,  sli^nud 
in  addition  to  the  lesions  of  a  tuberculous  bromdio-pneumonia  the  iiin-l 
rcnnukalile  fornuition  of  cavities.  It  is  p-tssiblc  that  in  rmin  this  uiiiijni- 
tons  streptococcus  has  a  similar  cITect  in  promoting  softening  and  lauiy 
formation.  'I'he  exmlative  pin'umoida,  whi<li,  as  mentioned  above  in 
couneetiou  with  the  acute  pneiimouic  tiiliercidnsis,  mav  lie  cau.sed  dii'eetlv 
by  the  tubercle  bacilli,  is  in  many  instances  the  result  of  secoudaiy  in- 


TUBERCULOSIS. 


'25:^ 


fivtiim  with  otluM"  "jcrns,  particularly  the  stroptococcus  pyor^enes  and  the 
iiiicrocociMis  laiU'i'ohiUis. 

/>/'.vm>7'.v  (tstiuriiilvd  ii'ith  I'liinunidnj  TiihrrcKlnsis. 

J,iihitr  iiiii'inniiiiiit  is  a  not  iiiicdiiiintiii  caiiso  uf  ili'atii.  It  is  mot  with 
most  fn'i|iii'iitly,  iiidciMl,  as  a  tiTiiiiiial  cviMit  in  tiu-  chrnnic  cast-s.  Il 
iiKiv,  lii>\M'\«'r,  occur  early,  and  1k(  ditlicult  to  distiiijfiiish  froin  an  acute 
i;i«('ous  jiiu'inuonia.  'I"hc  sj)Uta  in  the  latter  are  raivly  rusty,  wliilc  (lie 
tVvcr  in  ihr  former  is  more  continuous  and  hi^rlier,  liul  in  n\any  casi's  it 
i.s  iiniiessilile  to  ilitTercntiatc  between  the  two  i;onditioiis. 

'I'liplmiil  fvrer  occasionally  occurs  in  persons  the  subjects  of  pulmonary 
tiilifrculosis.  In  ('(tsr  S  of  my  series  of  post  mortems  in  this  disease,  a 
L'irl. aired  eiirhteeii,  had  peritoneal  adhesions,  local  disease  at  both  apii'cs, 
i.inl  perfcitly  charai'teristic  lesions  of  enteric  fever.  ,  In  ('use  .^.'4,  a  male 
;i^V(l  tweiitv-iivc,  with  tidu'reulous  cavities,  bad  u  very  acute  attack.  Tlie 
IVvcr's  ;:lutids  were  greatly  swollen  with  adherent  slouirbs.  Tlie  spleen 
wiiirlu'd  .'>;;:}  grammes.  The  characters  of  the  ulceration  are  usually 
(listilietive. 

Knifijic'its  not  infreipK'iitly  attacks  .'  '  /loiin'ntn'rcs  in  hospital  wards 
ami  aliushouses.  'I'lu're  are  instances  in  which  the  attack  seems  to  be 
hciu'licial,  as  the  cough  lessens  and  the  symptoms  amelioiate.  it  may. 
however,  prove  fatal. 

The  iriijifirc  f'rrrrs,  particularly  mea-les,  frcipiently  precede,  but  rarely 
ilr'  lep  ill  th(!  course  of  [ndmoiiary  lidierculnsis.  In  the  ri'vaccination 
(if  a  tiilieri'ulons  subject  the  vesiides  run  a  tioi-mal  course. 

Fisliiiii  ill  anil  is  associated  with  jihthisis  in  an  interesting  manner. 
Ill  M  majority  of  such  cases  it  is  a  tuiierculous  process.  The  general  alTec- 
\\»\\  may  progress  rapidly  after  an  operation.  The  <pH'stion  is  considered 
ill  iiilierciilosis  of  the  aliineiitary  canal. 

//'(//•/  hisi'iise. —  1  have  already  referred  (page '■••IJS)  to  the  occurrence  of 
iiiilncurditis  in  tuberculosis.  The  antagonism  between  heart  lesions  and 
[ilitliisis.  ii|)iin  which  Uokitansky  laid  stress,  is  not  p'-oiioiinced.  Stenosis 
III' till'  |iiilinoiiaiT  artery  and  aneurism  of  the  aorta  preijispose  to  t.iiberc^u- 
lii'is  |iiiliiioiium,  probably  by  reducing  the  activity  of  tin  lesser  (drciila- 
tii'ii.  Ill  iiiiira)  stenosis  pulmotiary  tubei.  iilosis  is  imt  infre<pu'nt,  in  nine 
"f  llfty-loiir  eases  (Po(ain).  A  terminal  a(Mi!e  tuberculosis  of  tme  or  the 
I'llitT  of  the  .serous  membr.ines  is  a  vei'y  common  event  in  all  forrtis  of 
i'anlii)-vasenlur  tli.sease. 

in  I'liniuie  and  arrested  phthisis  urtviin-sclfnisix  is  not  uncommon. 
■'''iin'riMl  uott'd  thirty  eases  of  chronic  renal  disea.sc!  in  one  iiundrcd  post 
iimrtems. 

Till'  as.oeiation   of  tiilierculosi.-    with   r/inniir  11  rt  lint  is,   upon   which 
ii'i'taiti  wi'i  ci's  lay  stress,  Hnds  its  e:<planation  in  the  lowtred  resistance  of 
tlitsc  patients,  and  the  si-eater  liability  to  infection  in  tlie  institutions  in 
R    ^fliifh  .-^o  nia'iv  of  them  live. 


ill 


I  ,:■■*. 


m 


^i\jii 

':'! 


■Jh 


254 


SPECIFIC   INFECTIOUS   DISEASES. 


Peculiar  i  lie  ft  of  Piilmotiar;/  Tuberculosis  at  the  Extremes  of  Life, 

(ti)  Old  Aijc, — It  is  reniarkitblc  liow  foininnii  tulHTculosis  is  in  the 
aged,  ])iirli('iiliirly  in  iiistitiitioiis.  McLat'liliin  noted  ii  limuirt'd  ami  fdrty. 
live  eases  in  wliieli  tuliereulosis  was  tlie  cause  of  death  in  old  persons  in 
Chelsea  Hospital.  All  were  over  sixty  years  of  ajife.  The  experience  at 
Sal])etiiere  is  the  same.  Laennee  met  with  a  case  in  a  per.son  over  ninotv- 
nine  years  of  age. 

At  the  l'hiladel[ihia  Hospital,  in  the  hodies  of  aifed  persons  sent  over 
from  the  almshouse  it  was  extrenjely  common  to  find  either  old  or  rwi'iit 
tuberculosis.  A  ^latient  died  under  my  care  at  the  ai;e  o'"  eitjhty-twd  witli 
extensive  peritoneal  tuberculosis.  I'ulmonary  tuln'rculosis  in  the  ajrrd  is 
usually  latent  and  runs  a  slow  course.  The  physical  sii^ns  are  oftei;  iiiask((i 
by  emphysema  ajid  ])y  the  coexisting  chronic  bronchitis.  The  (lia:,'iii]si« 
may  dei)end  entirely  upon  tiie  discovery  of  the  bacilli  and  elastic  tis.-iic. 
Contrary  to  the  opinion  which  was  held  some  years  ago,  tuberculosis  is  \\\ 
no  nu'uns  uncommon  with  senile  emphysema.  Sotiieof  the  cases  of  tiilnv- 
culosis  in  tlie  aged  are  instances  of  (juiescent  disease  which  may  have 
dated  from  an  early  ])eriod. 

{b)  /ii/'it/i/s.—Tho  occurrence  of  acute  tuberculosis  in  children  ha- al- 
ready been  mculioned,  and  also  the  fact  that  the  disease  is  occa.-idMalh 
congenital.  Recent  studies,  particulai'ly  of  French  writers,  have  sliown 
that  it  is  a  fre(|uent  alTcction  in  ciiildren  under  two  years  of  age.  l.cnmx 
has  analyzed  the  sbitistics  of  the  late  Prof.  I'arrot,  embracing  21!)  ca:i('>  in 
children  undi'r  three  yeai's.  Of  the.se  there  were  froju  one  day  to  three 
months,  ;!;{;  from  three  to  six  months,  I?.") :  from  six  to  twelvemonths 
53  (a  total  of  111  under  one  year);  and  from  one  to  three  years,  los.  Pul- 
monary cavities  were  present  in  57  of  the  ca.^e.s,  ami  in  only  50  ua.s  the 
pulmonary  lesion  the  sole  manifestation.  .\t  the  St.  IVtersburg  Koiiml- 
ling  A.sylum,  in  the  ten  years  ending  ISSl,  there  were  4Hi  cases  ()f  tuber- 
culosis in  1(!,5S1  auto{)sies.  The  ob.servations  of  Northrup,  at  the  New 
York  Foundling  Hospital,  are  of  special  interest  in  connectien  with  the 
mode  of  infecti(tn.  <  M"  \'i'}  cases  of  tuberculosis  on  the  records  of  ihi-:  in- 
stitution, in  ;.U  till'  ravages  were  extensive,  the  .seat  of  the  primary  allti- 
tion  was  not  clear,  an<l  the  l)ronchial  glands  were  large  and  chec>v.  In 
'U)  cases  of  general  tuberculosis  there  were  chee.sy  mas.ses  in  the  breiicliial 
glaiuls  aiul  in  the  lungs.  In  42  (jases  of  general  tuberculosis  tlic  eiily 
cheesy  ma.s.ses  were  in  the  bronchial  lym})h-glauiis.  In  !>  ca.ses  the  Iiiifi 
(des  were  limited  to  the  bronchial  iioiles  and  the  lungs;  the  latter  coiitaiii- 
ing  otdy  discrete  miliary  bodies,  while  the  bronchial  glands  were  in  ail- 
vance<l  caseation.  In  13  cases  there  was  tidu'rculosis  of  the  hroneliial 
nodes  oidy.  In  most  of  these  cases  the  j)atients  died  of  infectious ili- 
oases.  These!  figures  ar(>  very  suggestive,  asid  point,  as  already  nctvil.  i'' 
itifection  through  the  bronchial  passages  us  the  most  common  iiHlhu'i. 
even  in  children.     Of  500  autojisies  in  cliildrcn  at  the  Munich  I'lUhologi- 


TUBKRCULOSIS. 


255 


cal  Iiislitiito,  in  IHO  (thirty  per  cotit)  tiilu'rculosis  was  present  and  in  over 
iiiiK'tv-two  |H'r  cent  tin;  liinj^s  were  involvcil  ^Mi'illiT). 

Mndi'x  of  Heath  in  I'lilnionarif  Tubn'cuhms. 

[ii)  I'll  asthvuia,  n  ^M-atluiil  failiire  of  tlu'  stren<^tli.  The  end  is  usu- 
allv  iH'ai'tahlt'  and  quiet,*  occasionally  (list iirlicd  hy  jjaroxysnis  of  cough. 
C()n.«'ii>ii.->nt'ss  is  ol'lcn  retained  until  near  tlu;  close. 

{h)  />!/  (isp/ii/.ria,  us  in  some  oaso.s  oi!  acute  miliary  tubercuh)sis  and 
ill  iiiiitc  piieunionic  phtliisis.  In  chronic  phthisis  it  i.s  rarely  seen,  even 
wlu'ii  piieiiiuothonix  develop?). 

(')  /''/  \'//"''V"'-  This  is  not  coninion.  I  have  known  it  to  happen 
, line  or  twice  in  patients  wlio  insisted  upon  going  alxtiit  wlic';  in  the  ad- 
vaiucil  stages  of  the  disease.  Tliere  may  he,  hut  not  neccs^iirily,  fatty  de- 
<'eni'ration  of  the  heart.  A  rapidly  devt'loping  syncope  may  follow  luemor- 
iliii<;('  or  may  he  due  to  throndjosis  or  eniliolism  of  the  pulmonary  artery, 
or  to  piuMUuothorax. 

((/)  Fruni  /i(Pin»rr/i(i</r.  The  fatal  bleeding  in  chronic  piilliisis  is  due 
tocrosion  <if  a  large  vessel  or  rupture  of  an  aneurism  in  the  pulmonary 
cavity,  most  commonly  the  latter.  Of  twenty-six  analyzec  liy  S.  West,  in 
ek'vcn  oasf's  the  fatal  luemoptysis  was  due  to  ani'urism,  and  of  thirty-five 
lasi's  ('(illccted  hy  Percy  Kidd,  aneurism  was  j>resent  in  thirty,  in  a  case 
of  Ciirtiirs,  at  the  i'liihuleljihia  Hospital,  the  l)leeiling  proved  fatal  l)efore 
lia'iii(ii)lysis  occurred,  as  the  eroded  vessel  opened  into  a  caiuicious 
cavity. 

{<■)  Willi  icrchntl  .^i/in/ifunis.  Coma  may  be  due  to  meningitis,  le.'^s 
"ftfii  t(i  iira-mia.  Deatii  in  convulsions  is  rare.  The  haMiioriliagic  pachy- 
imiiiiigitis  which  develops  in  some  cases  of  phthisis  occasiomdly  causes 
loss  (if  cdusciousness,  hut  is  rarely  a  direct  cui'se  of  death.  In  one  of  my 
cases,  death  resulted  from  throndjosis  of  the  cerebral  sinuses  with  symp- 
luiufi  uf  niciiinuitis. 


:l 


( 


h 


■  I'il! 


f, 


\.  Tt  iu;k("1'i,()sis  of  tiii;  Siiuots  M  i'MUkanes, 

General  Serous  Membrane  Tuberculosis.—  'I'iie  serous  mctnhraiu's  may 
'icchiiily  involved,  either  simultaneously  or  consecutively,  forming  a  di.s- 
tinctivc  and  readily  recogni/ahle  clinical  type  of  tuberculosis.  There  are 
three  ;,f|i nips  of  cases,  b'irst,  tho.se  in  which  an  acute  tuliercniosis  of  tlie 
peritoiiii'iim  and  pleura'  develops  rapidly,  cause(l  by  local  disease  of  the 
tiilx's  ill  >,o'>irn,  or  of  the  mediastimd  or  l)ronchial  lymph-glaTuls.  Sec- 
oiiilly.  cases  i'l  which  the  diseas(j  is  more  chronic,  with  cMulation  iti  both 
"■■!'iliiii:c  Ml)  ,ni(l  pleura',  the  formation  of  cheesy  masses,  and  the  occiir- 
rci'.c"  ■'■  ,|ci'  vi'  and  suppurative  processes.  Thirdly,  there  a.-e  ca>es  in 
"  lie  jth'iM'o  peritoneal  alTection  is  still   more  cliroiiic.  the  liilierdes 

"As  In  Ml  vvi.||  ili'M'riliecl  liy  Sir  Thomas  itnisviif.  wlinse  licller  to  ii  l''rieii(l  {.'ivcs 
a  >i;iii|iic  aic"  :iil  of  the  lust  illiiess  of  iv  coiisumiitive.  lluod's  I)eiitli-I5( d  is  true  of 
I'lilliisis  ii'.oiv   reijuL'iitly  than  ol  luiy  otlior  diseiiM'. 


250 


SPKCIFIC   INFKCTIOrs   DISKASES. 


4;^ 


liiinl  ami  til)r(ii(l,  \\h'.  ni(Miil)riUie3  miicli  tliiokeiicd,  iiiid  with  little  or  r.fi 
oxiidatc.  ill  any  ono  of  these  three  forms  the  |u'ricariliimi  may  lie  [n. 
V()Iv('(l  witli  tile  pleura'  ami  ])eritona'iiin.  It  is  important  to  bear  in  iniini 
that  there  may  lie  in  these  eases  !io  visceral  tiihereiilosis. 

Tuberculosis  of  the  Pleura.— 1.  Aento  tuhereulous  i)leurisy.  \\  ,, 
ciillieiilt  in  tiie  present  state  of  our  kiiowled^re  to  estiinute  the  prupdrtinn 
of  instanees  of  acute  pleurisy  due  to  tiihcreulosis.  'I'he  eases  are  ranh 
fatal,  in  the  study  of  ihi'  eases  in  the  Johns  Hopkins  ll(is|tital,  which  I 
made  for  the  Shattnttk  Lecture  in  1S!>;5,  there  were  three  f;rou])s  of  rn>v:^: 
(fi)  Acute  tuhereulous  pleurisy  with  subsequent  chronic  course.  (//)  Sir- 
ondary  and  terminal  forms  of  acute  pleurisy  (these  are  not  uncoiiiiiinn  in 
hosj)ital  practice).  .\nd  (r)  a  form  of  acute  tultereuloiis  suppurative  |i|iii- 
risy.  A  consideraliic!  number  of  the  purulent  pleurisies,  dcsii,Mial(d  a. 
latent  and  chronic,  are  caused  by  tubercle  bacilli,  but  the  fact  is  imt  sn 
widely  recoj^nized  that  there  is  an  acute,  ulcerative,  and  suppurative  (lisia>c 
which  may  run  a  very  rapid  course.  The  disease  sets  in  abriipily,  with 
pain  in  the  side,  fever,  coii;;!!.  and  .sometimes  with  a  chill.  'I'here  may  Im 
iiothin<;  to  suirirest  u  tub»'rculoiis  process,  and  the  subject  may  have  ii  title 
physi(jue  and  come  of  healthy  stock,  'i.  The  subacute  and  chritiie  tiili(r- 
culous  pleurisies  are  more  common.  The  lar^'est  <rroupof  cases  eniii|iriM> 
those  with  sero-librinoiis  etTiision.  The  onset  is  insidious,  the  true  char 
aetcr  of  the  discii.se  is  frc(piently  overlooked,  and  in  almost  every  iii-liitui' 
tiiei'e  are  tuberculous  foci  in  the  lnii<j:s  and  in  the  i)ronehial  jrliiiul*. 
These  are  ca.ses  in  which  the  termination  is  often  in  pninioniiiy  tiilnr. 
ciilosis  or  ;:eneral  miliary  tuberculosis.  In  not  a  few  of  tlu'se  case.-;  tin 
t'.xudate  becomes  purulent. 

And,  lastly,  there  is  a  chronic  adhesive  pleuri.sy,a  primary  prolifeialiv. 
form  which  is  of  long  staiuling,  may  lead  to  very  great  tliiekeniii_f  of  tin 
membrane,  and  sometimes  to  invasion  of  the  lung. 

Si'idiii/f/rif  tuberculous  pleurisy  is  very  common,  'i'he  visceral  layi'ii- 
always  involved  in  pulmonary  tuberculosis,  .\dhesions  usually  form  uini 
ii  chnuiic  pleuri.sy  re.'-ults,  which  may  be  simple,  but  usually  tubcnles  aiv 
scattered  through  the  adhesions.  An  ai'Utc  t;.oerculous  pleuri.-y  iiia\  re- 
suit  from  ilirect  extension,  'i'he  iliiid  may  be  sero-librinoiis  or  liMMiinr- 
ihagic,  or  may  become  purulent.  .\iid,  lastly,  a  very  common  event  ii. 
pulmonary  tuberculosis  is  the  perforation  of  asuperlieial  spot  of  .softi'iiiiis:. 
and  the  production  n(  /)iti)-/iiii'iniiii//i()ni.r. 

'I'he  general  symptomatology  of  these  forms  will  be  considered  iiiiiltr 
diseases  of  the  pleura. 

Tuberculosis  of  the  Pericardium.  — Miliary  tnliercles  may  n.nir  i- 
a  jvart  of  a  g(  icral  infection,  but  the  term  is  ])roperly  limited  to  lli"* 
cases  in  which,  either  as  a  primary  or  second.'iry  process,  their  i>  iv- 
tensive  disease  of  the  membrane.  'i'uberciilosis  is  not  so  coiuiiinii  n. 
the  pericjirdiiim  as  in  the  pleura  and  peritona'uni,  b\i(  it  is  eertiiiii} 
more  common  than  the  litt'rature  woulii  lead  us  to  HUpposo.     Si  viiitii^ii 


TUIlEUrULOSIS. 


2: 


)« 


oasis  hail    (■(.iiif    iiiider    my   obscrvatioii    to   .lamiiirv,    iSlC?    (Anioricaii 
Jdiinial  <•[  tilt'  Medicul  Scit'iices).     It  occurs  in  two  fornus :  chronic  ami 

atiiti.'. 

(if)  Chriiiiir  y'nfirrriiloiis  Prn'ran/i/is. — Tliis  may  occur  as  a  jtrirnary 
allci'li'iu  associated  only  willi  the  casiMlioii  of  tiic  l)roiicliial  or  particu- 
larly the  anterior  mediastinal  lyni|>li-f,dands.  More  conininrdy  tliero  in 
tiiiiiTciiloiis  disease  cLsewhere,  cillier  ol'  tlie  j)li  lira  (tr  of  tlie  liiii;;s,  some- 
liiiii'.s  of  the  peritona'um.  In  a  lunnher  of  cases  the  perii'arditis  is  only  a, 
nart  of  a  ;:eneral  inft'ction  of  the  serous  nicndirancs.  The  instances  are 
viTV  rare  in  which  tlu'  process  is  conlineil  to  the  perieardiiini.  In  tmv  of 
iiiv  la.-cs  a  man  aged  seventy-two,  wlio  diid  of  pneumonia  in  the  I'hila- 
(ifl|ihia  ilnspilal,  tlie  pericardium  was  thickened,  lioth  leaves  were  adhcr- 
I'lil  ami  presented  cheesy  masses  and  gray  nodules.  The  heart  weighed 
.■|.'i4  grannues ;  the  hroiichial  glands  were  calcitied  ;  there  were  no  liilier- 
L'li's  in  the  other  organs.  'I'hc  disease  occurs  ut  all  agi-s.  .My  young- 
est ease  was  in  a  child,  aged  hve,  in  whom  ijoth  layers  of  the  pericardium 
wiTe  greatly  thiekeiied  and  I'heesy.  In  nearly  every  instance  the  hroti- 
ihial  or  ineiliastinal  glands  arc  tuhercidous.  Oecasionally  it  is  due  to 
txlciisinh  from  tuin'rrulous  disease  of  the  stei'num  or  of  the  spiiu';  occa- 
sioiiallv  to  extension  fi'om  the  Inugs.  in  one  case,  a  man,  agcil  lifty,  wlio 
(iicci  ill  tile  I'iiiladelphia  Hospital,  the  outer  layer  of  the  pericardium  was 
aldiii'  involved  and  thickened,  in  coniieclioji  with  a  tulteiculous  abscess  in 
the  aiilrrior  mediaslinum.  'I"hc  condition  is  usually  unsuspecU'il.  'J'ho 
|ili\>i(al  signs  are  those  of  hypertrophy  of  tiie  heart.  In  a  recent  case  the 
oi^Mii  weighed  (UK)  grammes,  and  the  clinical  .symptoms  were  those  of 
li\]ifrtni|ihy  and  dilatation. 

Tilt'  /i/ijitinil  sii/Hs  arc  somewhat  uncertain,  since  they  are  those  of  ad- 
lici'i'iit  |icricanliiini.  'I'he  diilness  may  reaih  high  along  the  left  sternal 
iiiaigiii.  and  in  one  (;ase,  in  which  it  was  as  high  as  the  iiii  Idle  of  the 
maiuiliniiiii,  tlio  thickened  pericardial  layers  formed  a  soliii  ciieesy  mass 
whirli  siirroimdetl  ihe  aorta. 

(//)  Aiit/i'  Tiihriridoiis  J'crirdrdi/is. -—'IUIa  may  ociur  as  a  secondary 
iiifi'cliou  from  tuhercle  in  other  parts,  or  it  may  arise  liy  direct  extension 
fi'iiii  ttic  lungs,  (,r  more  coiunutnl;,  liy  invasion  .'Vom  inedia^linal  Ivmpli- 
'.'lanils.  The  exudation  may  he  limited  in  anioiii;!  ami  chiellv  'ihriiious, 
111' ii  may  he  serous,  and  in  many  cases  is  lueniorrhagic.  I'liless  cari'fully 
siiiii.'lii,  for,  the  tul)er''es  may  he  overlooked.  Lastly,  some  of  the  cases  of 
I'linili'iii  pericarditis  are  tuherculous.  The  mi'mhraiics  may  he  much 
lliii'kciieil  iidd  no  tnice  of  tuhereles  apparent.  The  nature  of  the  case 
may,  tlieii,  \h-  gathered  chietly  from  the  existence  of  tuhereiihuis  bronchial 
'ir  ineiliastinal  ghind.s,  or  the  existence  of  tuberculous  foci  in  other  re- 
!J">iH.  The  elTusion  in  tliese  cases  imi\  be  enormous,  as  in  one  reported 
'H  Miisser,  in  wlueii  the  sac  contained  si\t\  four  ounce.-;  of  Ihiid. 

riic  symptoms  and  physical  signs  of  this  condition  will  be  considered 
wall  lliiise  (if  ordinary  pericarditis  with  elTusion. 


!'  ■  if   111 


i 


:':^:i 


■ii 


.^•; 


i ' ' 


258 


SPKCIFIC   INFECTIOUS   DISKASKS. 


{(f)  Tuberculosis  of  the  PeritoniBum.--Iti  lomu'ction  with  miliar  -m] 
(thniiiic  piiliiKiiiiiry  tiilMTcnlosis  it  is  not  imcdiiinioti  to  find  the  jicritiMiainn 
stiuhU'd  with  small  ojray  j^n-amihitions.  'riicy  arc  constantly  piv^int  nn 
tho  serous  siirfa(!C  of  tulKTciiloiis  iiIcits  of  the  intestiiiis.  A  pan  fnim 
these  eonditictns  the  ineinl)nine  is  often  the  seat  of  extensive  tiihci-i  uluiis 
disease,  wliieh  (xumm's  in  tlie  followini,'  forms: 

(1)  Acute  luiliary  liibvi'cuh)si,s  with  sero-lihrinous  or  bloody  ixiula- 
tion. 

(•*)  r///V);//V' ////>('/vv//as/.v,  eharaeterized  Ity  larjrer  LTowths,  wliirji  tend 
to  easeate  and  ulcerate.  It  may  lead  to  jterforatioii  of  the  intestinal  roils. 
The  exudate  is  |^)urulent  or  sero-purulent,  uiul  is  often  saeeulated. 

(;5)  Clironii' jihroid  tiiberntlnsis,  \\\\'w\\  imiy  he  suliaeute  from  ilir(,ii- 
set,  or  whieli  may  re[)resent  the  linal  sta,<,'e  of  an  aeute  miliary  erii|ptiiiii. 
The  tubercles  are  hard  and  itiu:niente(l.  Tbere  is  little  or  no  exudatidii, 
and  till'  tenuis  surfaces  are  matted  toj,'ether  by  adhesions. 

The  process  may  be  primary  and  local,  which  was  the  case  in  tivcdf 
niy  seventeen  post-mortems.  In  children  the  infection  appears  tn  |iiis,< 
from  the  iiilcstincs,  and  in  adults  this  is  the  source  in  the  cases  axiMJaicil 
with  chronic  jihtliisis.  In  women  the  di.M'a.se  extends  commonly  from 
the  Fallopian  lubes.  In  at  least  ;J0  or  40  per  cent  of  the  instaiiccs  of 
laparotomy  in  this  alTeetion  reported  by  o;yiuecolo<j;ist8  the  infeetioii  iv;i> 
from  them.  The  jirostate  or  the  seminal  vesicles  may  be  the  slartiiiL' 
point.  In  many  cases  the  peritomiMim  is  invitlvcd  with  the  })lei!ra  uml 
jtericardiiim,  particularly  with  the  former  membrane. 

It  is  fionerally  stated  that  males  are  attacked  oftener  than  feiualos. 
In  my  own  series  of  '.'1  cases,  l.'»  were  males.  The  recent  laparotomies, 
however,  wliicli  have  been  perforiiie(l  in  this  disease  have  been  cliiotly  in 
females;  so  that  in  the  collei-ti'd  statistics  I  tind  the  ca.ses  to  be  twici-as 
numerous  in  females  as  in  males;  in  the  ratio,  indeed,  of  KU  to  (in. 

Tuberculous  peritoniti-s  occurs  at  all  age.s.  It  is  common  in  chililiin 
associated  with  intestinal  and  mesenteric  disease.  The  inciilenee  is  luost 
freipient  between  the  aojes  of  twenty  and  forty.  It  may  occur  in  aihaiunl 
life.  In  one  of  my  cases  the  patient  was  eiylity-two  years  of  ap".  "f 
357  (;a8es  collected  from  the  literature,*  tbere  were  under  ten  years.;'?; 
between  ten  and  twenty,  i.") ;  from  twenty  to  thirty,  H7;  between  tliirtv 
and  forty,  71  ;  from  forty  to  lifty,  (11  ;  from  tifty  to  sixty,  I'.i  ;  frmii  sixty 
to  seventy,  4  ;  above  .seventy,  'i.  In  Auu-rica  it  is  more  common  in  tlif 
negro  than  in  the  white  race. 

Symptoms. -In  certain  special  features  the  tuberculous  varies  con- 

.siderably  from  other  forms  of  peritonitis.     It  jirescnts  a  syniptoin-inaipliv 
of  extraordinary  diversity. 

In  the  lirsl  place,  the  process  may  be  Uiloit  and  not  rau.se  a  sini!li' 
symptom.     Such  are  the  cases  met  with  aecidenlally  in  the  operation  fiT 


*  Johns  Hopkins  HosjiituI  Uofiorts,  vol.  ii. 


m  '■!■:( 


TUMKitrri.osis. 


2r.9 


liiTiiiii  I'l"  for  ovarian  turnor.  In  direct  roiilrust  iiro  the  instftiioos  in  whicih 
tlif  oiiM'l  is  f^o  hiiddt'ii  and  violent  that  the  dia;,'n(i.-is  nl'  vntirilis  uv  liirnid 
is  iiiiide.  'I'Ik!  openilitMi  for  St  langidated  hernia  has,  indi-ed,  been  per- 
foiiiii'd.  Many  easo8  set  in  aculelv  with  fever,  al)d»>niiinil  tiMKh-rness,  and 
\\w  sviniituiiis  of  ordinary  ai'nie  ))eritoniiis.  Cases  with  a  shivv  onset, 
aliilomiiial  tenderness,  tympanites,  and  h>\v  conlinuons  fever  resondjlo 
tiiiiliui'l  fii'i'V  verv  closely,  and  may  h-ad  to  error  in  (".ia^'iiosis. 

Asiihs  is  freijuent,  l)iit  the  elliision  is  rarely  lar^c.  It  is  sonietimca 
ti;i'inoirhiij,de.  It  nuiy  simnlale  the  elTn.-ion  in  cirrhosis  of  the  liver,  of 
wliicii  liisease  it  is  to  he  noted  that  tiiherculoiis  peritonitis  in  often  u  linul 
(MPiiiplii'ation.  7'i/iii/)iiiii/('i  may  l»e  pn-sent  in  the  very  acute  eases,  wliea 
it  is  due  til  loss  of  lone  in  the  intestines,  ovvin^  to  inilainniatory  inliltra- 
tiuii ;  or  il  may  oeenr  in  the  old,  lon;^-standin;^  eases  when  universal 
aiilusiiiii  lias  taken  plat:e  between  the  parietal  and  viseerul  layers.  Fcrcr 
is  a  marked  symptom  in  the  acut((  eases,  and  the  temperature  may  reach 
W.i  ov  iiil'.  In  many  instances  Uw.  fever  is  sli;;ht.  In  the  more  chronic; 
(•uses  sulaidrnuil  temperaUires  art  common,  and  for  days  the  temperature 
iii;iv  not  rise  above  'J^°,  and  the  norning  temi)erature  may  be  as  low  as 
'.t.V.V.  All  occasional  syjnptom  Is  pigmentation  of  tl\e  skin,  which  in 
some  etisi^s  has  led  to  the  diagnosis  of  Addison's  disease.  \  striking 
[icculiaritv  of  tuiierculous  peritonitis  is  the  freipuMicy  vvitli  which  either 
the  ciiMilitiou  simulates  or  is  associiated  with  liininr.     Thesu  may  be  : 

(«/)  (hin'iUaU  ilwo  to  puckering  aiul  rolling  of  this  nu!nd)rane  until  it 
fornix  an  eIot\gated  lirm  mass,  attached  to  the  transverse  colon  and  lying 
iiihwiiit  llitMipper  i)art  of  the  abdonuMi.  This  cord-like  stru(!tiire  is  found 
:ilsu  with  cancerous  peritonitis,  but  is  much  more  common  in  tubercu- 
lositi.  (iairdner  has  called  Kj)ecial  attention  to  this  form  of  tumor,  and  in 
chihht'u  lias  seen  it  undergo  gradual  resolution.  A  resonant  ])ercus.«ion 
note  may  sometimes  be  elicited  above  the  mass.  Thougli  usually  situated 
ill  the  inniiiiieal  rt'gion,  the  omental  mass  inay  form  u  ])roniinent  tumor 
ill  tlic  riglit  iliac  region. 

(/')  Sarviilatcd  exudation,  m  which  the  effusion  is  limited  and  confined 
liy  ailliisioiis  between  the  coils,  the  jiarictal  pcritonanim,  the  mesentery, 
uiiil  the  alidoininal  or  iielvic;  organs.  This  encysted  cx'udate  is  most 
liiiiiiiKni  ill  the  middle  zone,  and  lias  freipicntly  liceii  mistaken  for  ovarian 
imiKir.  It  may  occujiy  the  entire  anterior  portion  of  the  peritomeuni,  or 
tlure  limy  ho  a  more  limited  saccular  exudate  on  one  side  or  the  other. 
It  may  lie  eompletely  within  the  pelvis  proper,  associated  with  tuberculous 
ili.-t'use  of  the  Fallojiian  tubi^s. 

('■)  111  rare  cases  the  tumor  formations  may  be  due  to  great  retraction 
<ir  thick>  ning  of  the  infcxfinal  cdHs.  The  small  intestine  is  found  short- 
'iifd,  the  walls  enormously  thickened,  and  the  entire  coil  may  form  a  firm 
Kiiut  Close  against  the  spine,  giving  on  examination  the  idea  of  a  solid 
'"iiss.  .Vol  the  small  intestine  only,  luit  the  entire  bowel  from  the  duode- 
'""»  to  the  rectum,  has  been  found  forming  such  a  hard  nodular  tumor. 


1,' ' 


li 


!1 


i 

-t 

i; 

■I'l  I 


'llfj 

mi. 


f 


,^■ 


i,r 


.  .11. 


Hi^^ 

.KfW 

Mm 

Birr    '  %  i     >  i 

1  T^M 

■Hli 

2fiO 


SF'F:(Fn('   INTKCTIOl'S   DISKASKS. 


'   II 


,f  5  ;i 


(7)  ]fi'st')ili'ni'  f/fiinifs,  wliii'h  occnsioimlly  form  very  liir;:i',  liitiinr-likc 
masses,  more  coiiiinoiily  foiiiiil  in  cliildt-iti  lliitn  in  ikIuIIs.  This  ('(indition 
nmy  Im>  cniilincil  t<t  tlio  alMlniniiiul  ^'hr.ids.  Ascites  iimy  t'oexist.  The 
coinlitidii  must  he  distiii^'iiislied  from  that  in  children,  in  wliich.  \\iiliii.<. 
ci'es  or  tympanites  sometimes  holh— there  can  he  felt  irre;.'idar  innhilar 
masses,  dm?  to  larfj(>  caseons  formations  hj'tween  the  intestinal  enil.i.  Xo 
(louht  in  a  eonsideral»le  nnmhernf  ea-es  of  tin-  so-called  lalies  me^enlctici, 
particnlarly  in  those  with  erdarL;ement  and  liardness  of  the  alulniiicii.- 
the  condition  which  tlie  l-'n-neh  call  ((irrruii — there  i^  involvement  alviuf 
tlie  perilomeiim. 

'The  (/iiti/iiiisis  of  these  peritoiieiil  tumors  is  sometimes  very  dillii'iilt. 
Tin*  omental  tumor  is  u  less  frei[iieiit  scaircc  of  orror  than  any  other:  Imf, 


IS  a 


I  real  h 


V  mentioned,  a  similar  condition  mav  occur  in  cancer. 


'he  iiKijt 


im|)orlant  prolijem  is  tlie  dia^nmsis  of  Ihe  saccular  exudation  from  (ivnn.iii 
tumor.      In   fully  one  third  of  llie  recorded  eases  of  laparotomy  in  t 


lllir: 


eiiloiis  perit(»nilis,  the  diairiu'sis  of  cystic  ovarian  disease  had  hecn  iiiai!)., 
'I'liD  most  suirL^estive  points  for  eo!isidi'ratioii  are  the  history  of  the  patient 


and  the  evidence  of  old   tnlii'rciilous  lesions 


Th 


jthysieal  conniiiipii  \< 


not  of  miii'h  moment,  as  in  many  instances  Ihe  patients  have?  hecn  rnhiiiit 
and   Weil   iioiirislu'd.     Irre;rular  fchrile  attacks,  pistro-intestinal  dist 


aiiee,  aiitl   pains  are  more  ( ommon   in  tul)ereuloiis  disease.     I'liless 


urn- 
ill- 


11; 


imet 


1    tl 


lere   IS   iisii;illy   not    liiiu 
d 


li    fever  with  ovarian  cvsts. 
h 


local 


sij:ns  are  very  deceptive,  and   in   certain  cases  have  conlormed  m  cvm 


particular  to  those  of  cystic  diseiisi 
nr 


'III'  outlines  in  wiecnlar  exudation 


0  rarely  so  well  detined.     The  position  jind  forn>  may  be  varialile.  owuv: 
to  alterations  in   the  size  of  the  etiils  of  which  in  t>arts  the  walls  ar m- 


P 


■led.     Nodular  cdieesv  masses  mav  sometimes  ])c   felt  at  the 


pcnplnTy. 


|)epression  of  the  vairinal  wall  is  melltionel^  as  oceiirrinir  in  eiieysted  inri- 
tonilis;  hut-  it  is  also  found  in  ovnriiin  tumor.  Lastly,  the  comlitinii  df 
the  F.'dlopian  tiihes,  of  the  lunj.'s  and  of  the  pleura',  should  lie  thurnuirlily 


examiiieil 


■iiition  of  salpiiitritis  with  an   ill-detined  aiKimiilm' 


m 


iss  ill  the  ahdomen  should  arouse  suspicion,  as  shoiihl  also  invulvc 


llU'llt 


of  the  pleura,  the  upe.x  of  one  luni,',  or  a  testi.s  in  tho  male. 

VI.  TrnKurii.osis  oi'  tiii;  .Vi.imk.m ahv  Canal. 

{(i)  Lipo. — Tiiheroulosis  of  the  li])  is  Ncry  r.ire.  It  occurs  nceiision- 
ally  in  the  form  of  an  ulcer,  either  alone  or  more  eotnmonly  in  as-nciaiiiwi 
with  larynjifeal  or  pulmonary  disease.  Two  oases  are  reported  and  the 
literature  analyzed  in  Vernenil's  Ktndes.*  'I'he  ulcer  is  usually  viTvsc!i>i- 
tive  and  may  he  mistaken  for  a  chancre  or  an  epithtdioma.  'I'he  (hai'ii'i-i* 
may  be  made  in  ca.ses  of  doubt  by  inoculation  or  the  examination  ef  a  I""- 
tioii  for  tubendo  bac  illi. 


*  Tomo  iii,  Fas.  I. 


TrUKHClT.OSIfl. 


2<5l 


(//)  ToiKjuc — 'I'lit'  liisciisi-  l»('>,'iiis  l»y  ati  iij:;:f('triiti<in  of  small  jrrimiilar 


iiiifs  oil  llii'  f<l^'<'  •'!•  tlorsiiiii. 


r 


Icrratinii   |ir<ic(T(ls,  li'iis  nil,'  an  iirr^nilar 


son' 


will)  iMii>iiiii't   lull    iiiii'M'ii   iiiiii'L'iii,  and  H  riMi;r|i,  ortcii  imsi'diis  i 


>aso. 


The  ilixM-t'  i'\li'ii«l'*  slowly  anil   rniiy  t'onii  an   iilccr  ul"  cniiMidcraltlo  sizo. 
Uhiwiiil  lo  Ik'   niislaki'ii   for  I'liiiliclinnia  ami   the  tonirm'  to  I 


I 


liavf 


)0 


(AilM'il 


ill'l'l 


It   is  rari'ly  nifl  uiili  cxccpL  when  other  or;.'ans  arc  involved. 

L'laiiii>  of  till'  an^de  of  llie  Jaw  are  not  enlarLred  and  the  sore  does  not 

li>  idilide  of  potasNinni,  wliiidi   are  jioiiils  of  di>lim'iiiiii   iMtwrrn  llie 

tiilii'i'i'iilniis  and  tliu  syphilitic  ulcer.      In  doubtful  cases  the  imx'ulatiou 

u>t  slioiild  lie  made,  or  a  portion  excised  for  ndcroscopical  cxaniimilioii. 

[r)  'I'lilien  Ics  may  develop  on  tin.   hard  or  sid't  jid/afc.     In  a  recent 


I'llSC  llllill 


I'  llic  care  <> 


f  niv 


coiica'nic 


alsU'd   tlieie  was  a  roii< 


irre'Milar 


jiaii'li  III!  llic  I'oiif  of  llie  inoutli,  ;,n'ayi>h  in  spots,  and  tissured. 

((/)  'ridiirculosis  of  the  /c//.<//  has  heeii  recorded  in  a  few  cases,  cither 
in  llic  fiiriii  of  the  miliary  },'ranules  or  as  caseous  foci,  rici'ratioii  may 
iM-ciir.     Ill  the  acute  cases  the  sniunaxillary  <,dands  may  be  enlar;;ed, 

(( )  l'liinijii.i\-~\\\  extensive  larynjrcal  tiilicrriilusis  an  eriiplion  of 
rv  i^nimdes  on  the  posterior  wall  of  the  pharynx  is  not  \ery  nncom- 


niiiia 
iiiiiii. 


ill  cliroiiic  phthisis  an  ulcerative  pliaryii;:ilis,  due  to  extensi<in  of 
till' disease  from  the  cpi;,dott is  and  lar\  n\,  is  one  of  the  most  distressing 
of  luiiiplicatidtis,  reuderinj;  dcfi^lutitioii  acutely  painful. 

( /')  A  few  instances  occur  in  literature  of  tiilurculosis  of  the  tisiiphu' 
tjiK.    The  cuiidition  is  a  patholoj^ical  curiosity,  except  in  the  sli;,dit  i-xteii- 


joii  fnuii  the  larvnx,  which  is  m 


it  iiifr 


reiiucnt;  but  in  a  case  in  mv  wards 


thf  iilecr  perforated  and  caused  purulent  pleurisy. 


('/)  Sliiiiiiifi 


.Manv 


cases  are  I'cpiirted  which  are  doi 


ilitfiil.      I'rimarv 


disease  is  iiukiiown.     Marfan*  was   alile   to  collect   only  about  a  dozen 
aiitlieiitic  cases.     Perforation  of  slfuiiach  occiirreil  six   times,  thrice  bv  a 


tlllMTcu!iill.> 


am 


1.       Ill  (>p|>o| 


l/er  s  case 


II    ulcer   of   til 


(•  colon   perforated 


llii'orL'MU.     Ill  Miisser's  case  llii'rc  was  a  larirc  tiilierciilniis  ulcer  three  by 


'111'  Mini  a 


half 


lliclies  III  extell 


t.      Il 


recent   case   in  mv  waril  tiiere  were 


iiiiiicrniis  ulcers  o 


f  vari 


ops  si/es. 


(/;)   liilisliHcx.-'V\\\'   tubercles   may   be   (!)     primary   in   the  mucous 
aiie,  nr  iiion mnioiily  {'V)  secondary  to  disease  of  the  liinirs,  or  in 


the  atTcctioii  mav  (■$)  pass  from  the  peiitniia'iim. 


Mli'llllll' 

niv  CM 

(I)  Primary  intestinal  tuberculosis  occars  most  frcfpiently  in  children, 
III  ttiioiii  it  may  be  associated  with  enlar<:ement  :iiid  ca'^cation  of  the 
iiirsi'iilerii'  olatids,  or  with  peritonitis.  It  may  lie  diniciill  to  say  at  the 
'iiiii'  (if  the  autopsy  whetiier  the  primary  lesion  has  been  inioiinal  or 
!"'ritoiieal.  I  havi-  already  referred  to  Woodhead's  statistics  sliowin;r  the 
it'iiiaikalile  freipieiK-y  of  infection  tlir(iii;.di  the  bowel.  In  adults  primary 
I'ltf^tiiKil  tuberciilosis  is  rare,  oi  >  nrrin;;  in  but  one  instance  in  one  thousand 
iiiitoiisics  upon  tuberculou.    adul'.:!  at  the  Munich  I'atlioloj^ical  Institute; 


;■)  !■! 


I'l'.i 


:;tii  • 


m 


•K 


\ 


f^ 


*  p 


ii-is  Thosis,  1887. 


IMAGE  EVALUATION 
TEST  TARGET  (MT-3) 


i?, 


^. 


V  €P^ 


1.0 


I.I 


I 


iO 


2.5 
2.0 


1.8 


1.25      1.4 

11^ 

■• ♦"  — 

► 

P^ 


<^ 


/a 


7: 


y 


>^ 


Photographic 

Sciences 
Corporation 


23  WEST  MAIN  STREET 

WEBSTER,  N\  M580 

(71^'  «>  1-4503 


I 


t^ 


o 


/ 


'^ 


i '  I. 


■if: 


202 


SPECIFIC   INFECTIOUS   DISEASES. 


but  now  and  tlien  cases  occur  in  which  the  disease  sets  in  with  irrojrnlar 
diarrh(«a,  moderate  fever,  and  colicky  pains.  In  a  few  cases  hiemoniiafre 
lias  been  the  initial  symptom.  Regarded  at  first  as  a  chronic  catai'il,,it  U 
not  until  the  emaciation  becomes  tnarked  or  the  sii^ns  of  disease;  aiiiu'arin 
the  lungs  that  liie  true  nature  is  apparent.  Still  more  deceptive  nva  the 
cases  in  which  the  tuberculosis  begins  in  the  ca'cum  and  there  are  symp- 
toms of  ai)peiulicitis — tenderness  in  tiie  right  iliac  fossa,  constipation,  or 
an  irregular  diarriuea  and  fever.  These  signs  nuiy  gradually  disappear, 
to  recur  again  in  a  few  weeks  and  still  further  comiilicate  the  diai:iiosi<. 
Fatal  lucmorrhage  has  occurred  in  several  of  my  cases.  Perfonitimi  mav 
occur  with  the  forniation  of  a  pericsecal  abscess,  or  perforation  into  the 
poritoniiiuni  may  take  place,  or  in  very  rare  instances  there  is  partial  liwil- 
ing  with  great  thickening  of  the  walls  and  narrowing  of  the  lumen. 

(2)  Secondary  involvement  of  the  bowels  is  very  common  in  chronic 
pulmonary  tuberculosis,  in  500  of  the  1,000  Munich  autojisies  in  tubercu- 
losis just  referred  to.  In  only  three  of  these  cases  wore  the  lungs  not  in- 
volved. The  lesions  are  chiefly  in  the  ileum,  ca'cum,  and  colon.  The 
affection  begins  in  the  solitary  and  agminated  glands  or  on  the  surfaeo 
of  or  within  the  mucosa.  The  caseation  and  necrosis  lead  to  uleenition. 
which  may  be  very  extensive  and  involve  the  greater  portion  of  the  inucosi 
of  the  large  and  small  bowels.  In  the  ileum  the  Peyer's  patches  are 
chiefly  involved  and  the  ulcer  may  be  ovoid,  but  in  the  j(!Junum  ami  coldn 
the  ulcers  are  usually  round  or  transverse  to  the  long  axis.  The  tubercu- 
lous ulcer  has  the  following  characters:  (a)  It  is  irregular,  rarely  ovoid  or 
in  the  long  axis,  more  frequently  girdling  the  bowel ;  (b)  the  edges  and 
base  are  infiltrated,  often  caseous;  (c)  the  submucosa  and  museularis 
are  usually  "uvolved  ;  and  (d)  on  the  serosa  may  be  seen  colonies  of  youns; 
tubercles  or  a  well-marked  tuberculous  lymphangitis.  Perforation  anil 
peritonitis  are  not  uncommon  events  in  the  secondary  ulceration.  Steno- 
sis of  the  bowel  from  cicatrization  may  occur;  the  strictures  may  Ix' 
multiple. 

Tuberculosis  of  the  rectum  has  a  special  interest  in  connection  with 
fistula  in  nno,  which,  according  to  Spillman's  statistics,  occurs  in  about 
3'5  per  cent  of  cases  of  pulmonary  disease.  In  many  instances  the 
lesion  has  been  shown  to  be  tuberculous.  It  is  very  rarely  primary,  luit 
if  the  tissue  on  removal  contains  bacilli  and  is  infective  the  lun<rs  arc 
almost  invariably  found  to  be  involved.  It  is  a  common  opinion  that  the 
pulmonary  symptoms  may  develop  rapidly  after  the  fistula  is  cut.  'I'lii- 
may  have  some  basis  if  the  operation  consists  in  laying  the  tract  open, 
and  not  in  a  free  excision. 

(3)  Extension  from  the  peritoniBum  may  excite  tuberculous  disoafcin 
the  bowels.  The  affection  may  be  primary  in  the  peritonanim  or  extend 
from  the  tubes  in  women  or  the  mesenteric  glaiuls  in  children.  The  coils 
of  intestines  become  matted  together,  caseous  and  suppurating  foci  (1p- 
velop  between  the  folds,  and  perforation  may  take  place  between  the  coil? 


nh\ 


K  I 


TUBERCULOSIS. 


VII.  Tuberculosis  of  tiik  Liveu. 


263 


Thi.s  (ii-^an  is  very  constantly  involved  in  (a)  general  tuberculosis. 
The  niiliiiry  granulation  may  be  very  small  aiid  in  acute  cases  scarcely 
porceptiblo.     The  liver  is  pale  and  often  fatty. 

(b)  A  roinarkable  condition  of  the  organ  is  produced  by  the  develop- 
ment (if  the  tubercles  in  the  liner  bile- vessels.  They  may  attain  a  con- 
siderable size  and  are  aluiost  always  softened  in  the  centre,  resembling 
small  abscesses.  The  contents  are  always  bile-stained.  The  organ  may 
be  honovcoiid)ed  with  these  tuberculous  abscesses. 

(e)  i.arge,  coarse  caseous  nuisses  are  occasitinally  found,  sometimes  in 
as'soeiiitioii  witli  perihepatitis  or  tuberculous  peritonitis.  They  may  attain 
the  size  of  an  orange  or  larger. 

((/)  Tuberculous  cirrhosis.  With  the  eruption  of  miliary  tubercles 
there  may  be  slight  increase  in  the  connective  tissue,  which  is  over- 
■sluidowed  by  the  fatty  change.  In  all  the  chronic  forms  of  tid)ercle  in 
this  ori,MU  there  nuiy  be  tlbrous  overgrowth.  Ilanot,  who  has  described 
several  varieties,  states  that  the  condition  may  be  primary.  Practically  it 
i.s  very  rare,  except  in  connection  with  chronic  tuberculous  peritonitis  and 
perihepatitis,  when  the  organ  may  Ije  much  deformed  by  a  sclerosis  in- 
volving the  })ortal  caiuds. 

In  this  last  group  there  may  be  symptoms  of  ascites;  as  a  rule,  tuber- 
luldsis  of  the  liver  has  a  purely  anatomical  interest. 


it  !     I  ' 


I        t 


I  Si 


VIII.  TunEucuLosis  of  the  Buaix  and  Cord. 

Tuberculosis  of  the  brain  occurs  as  {a)  an  acute  miliary  infection  caus- 
iiit;  meningitis  and  acute  hydrocephalus;  (li)  as  u  chronic  meningo-en- 
i\'j)haliti^,  usually  localized,  and  containing  small  luxlular  tubercles;  arul 
(' )  as  the  so-called  solitary  tubercle.  Jk'twecn  the  last  two  fortns  there 
.lie  all  gradations,  and  it  is  rare  to  see  the  meninges  uninvolved.  The 
iifiite  variety  has  already  been  considered.  I  shall  here  consider  the 
rhniinc  form,  which  develops  slowly  ar>d  has  the  clinical  characters  of  a 
tumor. 

It  is  most  common  in  the  young.  Of  148  cases  collected  by  Pribram 
118  were  under  fifteen  years  of  age.  Other  organs  are  usually  involved, 
partieularly  the  lungs,  the  bronchial  glands,  or  the  bones.  In  rare  in- 
s-tam-es  no  tnl)erclcs  are  found  elsewhere.  They  occur  most  frequently  in 
the  cerebellum  ;  next  in  the  (cerebrum  and  then  in  the  i)ons.  The  growtlis 
are  often  multiple,  in  100  out  of  183  cases  (Gowers).  They  range  in  size 
I'lotn  a  jiea  to  a  walnut;  larger  tumors  occasionally  occur,  aiul  sometimes 
iiu  entire  lobe  of  the  cerebellum  is  affei'fed.  On  section  the  tubercle  pre- 
-'iits  a  grayish-yellow,  caseous  apjiearance,  usually  firm  and  hard,  and  en- 
iireled  l)y  a  translucent,  softer  tissue.  The  centre  of  the  growth  may  be 
I  ^cmi-diffluent.  As  in  other  localities  the  tubercle  ma}  calcify.  The  tu- 
18 


h 


1  i< 


,'i 


204 


SPECIFIC   INFECTIOUS   DISEASES. 


mors  arc  as  a  rule  attached  to  tlio  meninges,  often  to  tlio  iiiii  at  the  bottom 
of  a  sulcus  so  that  tlu'y  look  iiubediled  in  tlic  l)rain-sul)stance.  Alxjiit  the 
lonjfitudiual  fissure  tliero  may  he  an  a:,'L,n"('n:itiiin  (jf  tI)o  gro\vlli>,  with 
coni))ressiou  of  the  siuus,  and  the  fornuitioii  of  a  llirornbus.  '["lie  tuber- 
culous tumor  not  iufrecjuently  excites  ucute  meningitis.  In  lucalizwl 
meiiingo-encephalitis  the  pia  is  tbickened,  tubereU'S  are  adherent  to  thr 
under  surface  and  grow  about  the  arteries.  It  is  often  combined  vitli 
cerel)ral  softening  from  intei'ference  with  the  circulation.  Several  of  tlie 
most  characteristic  instances  whieh  I  have  seen  were  on  the  lueiiinfro.'i 
covering  the  insula.  This  fdrin  may  develoj)  in  pulmonary  tuberculosis 
causing  hemiplegia  or  aphasia  which  may  persist  for  moi'ths. 

The  sym[)t()ms  of  tuberculous  growths  in  the  brain  are  those  of  tumor, 
and  will  be  considered  in  the  section  on  the  brain. 

In  the  sptiial  cord  the  same  forms  are  found.  The  acute  tuberoulou^ 
meniugitis  has  been  considered  and  is  almost  alwa\'s  cerebro-s])inal.  'Jlic 
solitary  tubercle  of  the  cord  is  I'are.  Ilerter  has  rejjorted  three  cases  ainl 
collected  tweuty-foiu' instances  from  the  literature.  It  was  secondary  in 
all  save  one  case.    The  symptoms  are  those  of  spinal  tumor  or  meiiiiigitij. 


IX.    Tl'BERCULOSIS    01'   TilR    (i  ENITO-URINAUY    SYSTEM. 

{a)  Tuberculosis  of  the  Kidneys  {/'/tt/iis'is  rc)n(in).—ln  general  tub.:. 
culosis  the  kidneys  fre(jiiently  [)rescnt  scattered  miliary  tubercles.  In  |nil- 
monary  tuberculosis  it  is  common  to  tind  a  few  nodules  in  the  substain'c 
of  the  organ,  or  there  may  be  pyelitis.  Primary  tuberculosis  of  the  kid- 
neys is  not  very  rare.  In  a  majority  of  the  cases  the  process  involves  tlie 
pelvis  and  the  ureter  as  well,  sometimes  the  bladder  and  prostate.  In  only 
one  of  eight  cases  was  tlie  prostate  involved.  It  may  be  diftlcult  to  suy  in 
advanced  cases  whether  the  disease  has  started  in  the  bladder,  prostate,  or 
vesicles,  and  crei)t  u[)  tlie  ureters,  or  whether  it  started  in  the  kidneys  ami 
proceeded  downward.  In  a  majority  of  cases  it  is,  I  believe,  the  latter,  ami 
the  infection  is  through  the  blood.  One  kidney  alone  may  be  invohoil, 
and  the  disease  creeps  down  the  ureter  and  may  oidy  extend  a  l\'w  milli- 
metres on  the  vesical  mucosa.  In  a  recent  instance  a  man  with  aorlii'iu- 
sufficiency,  who  had  no  lesions  in  the  lungs,  presented  a  localized  iiatcli  in 
the  pelvis  of  the  kidney,  involving  a  pyramid,  while  the  ureter,  live  ciiili- 
metres  from  the  bladder  and  at  its  orifice,  was  thickened  and  tuberculous. 
The  i)rostate  showed  an  area  of  caseation.  It  is  most  common  in  tliemiJ- 
die  period  of  life,  but  it  may  occur  at  the  extremes  of  age.  It  is  more  fre- 
quent in  men  than  in  women.  In  the  earliest  stage,  which  may  be  imt 
with  accidentallv,  the  disease  is  seen  to  begin  in  the  pyramids  and  calyccj. 
Necrosis  and  caseation  proceed  rapidly,  and  the  colonies  of  tubercles  stiin 
throughout  the  pyramids  and  extend  upon  the  mucous  membrane  of  tiR' 
pelvis.  As  a  rule,  from  the  outset  it  is  a  tuberculous  pyo-nephrosis.  Vk 
diseiise  maybe  confined  to  one  kidney,  or  progress  more  extensively"' 


TUBERCULOSIS. 


205 


one  than  in  tlie  othor.  At  aiitops}'  both  ori^mis  aro  usually  found  onlarpod. 
Oneorsran  may  l)e  completely  destroyed  and  converte(l  into  a  series  of  (>yst:-! 
nuitaininir  elieosy  suhstanee;  a  form  of  kidney  which  the  older  writers 
lallcil  scret'ulous.  In  the  putty-like  contents  dl'  these  cysts  lime  sahs  may 
1h'  ili'po-iteil.  In  other  instances  the  walls  of  the  pelvis  are  thickened  and 
ilircsv,  the  ])vramids  eroded,  and  caseous  nodules  are  seal tered  throuirh 
t!u'  orL'an,  even  to  the  capsule,  which  may  he  thickened  and  adiiercnt. 
Tlic  (illici  (iriifan  is  usually  less  atTccted,  and  shows  oidy  pyelitis  or  a  sn|)er- 
I'liial  iitcresis  of  one  or  two  ])yramids.  'j'lu*  ureters  are  usually  thickened 
;i!i(i  ilu'  mucous  membrane  dccrated  and  caseous.  Involvement  of  the 
l.l:i(liU-r,  vesicular  seminales,  and  testt's  is  not  uncommon  in  males. 

'I'lic  .•<i/iiip/in»s  .ire  those  of  jiyelitis.  Tiie  urine  may  be  i)urulcnt  for 
Vfiirs,  and  there  may  bo  little  or  no  dist'vs.  When  the  bladder  becomes 
invnhcil  mii'tui'ition  is  frequent,  and  many  instanct's  are  mistaken  for  cys- 
titis. The  condition  is  for  many  years  comi)atil)le  with  fair  health.  'Piie 
I  unihiliiv  is  shown  by  the  accidental  discovery  of  the  so-called  scrofulous 
kihii'v,  eoiivertcd  into  cysts  containing  a  jiutty-like  substance.  In  cases 
ill  wjiii'h  the  disease  becomes  advanced  and  both  organs  are  affected,  con- 
Hlitutional  symi)toins  are  more  marked.  There  is  irregular  fever,  with 
iliills,  and  loss  of  weight  and  strength,  (ieneral  tnl)erculosis  is  common. 
hi  (inly  one  of  my  cases  were  the  lungs  nninvolvcd.  In  u  case  nt  the 
Muntreal  General  nos})ital  a  cyst  perforated  and  caused  fatal  peritonitis. 

Physical  examination  may  detect  special  tenderness  on  one  siile,  or  the 
kiilney  may  be  palpable  in  front  on  deep  pressure;  but  tulierculous  pyelo- 
iR'pliritis  seldom  causes  a  large  tumor.  Occasionally  the  pelvis  becomes 
(iifirnioiisly  distended ;  but  this  is  rare  in  comjiarison  with  calculous 
liyclitis,  'I'he  urine  presents  changes  similar  to  tliose  of  ordinary  calcu- 
lous pyelitis  —  pus-cells,  epithelium,  and  occasionally  delinife  caseous 
iii;i.<.<os.  Alhinuen  is,  of  course,  })resent.  Tubercle  bacilli  may  be  demon- 
.-tiiitcd  by  the  ordinary  methods.     Tube-casts  are  not  often  seen. 

To  distinguish  the  condition  from  calculous  pyelitis  Is  often  difTicult. 
ILpinorriiage  may  be  present  in  both,  though  not  nearly  so  frequently  in 
tlio  tiihci,  ulous  disease.  Careful  examination  of  the  pus  for  tubercle 
liai'illi  gives  most  important  information.  The  lungs  or  other  organs  nuiy 
ln'  tiiliorciilous. 

The  incidence  of  I'cnal  in  nro-genital  tuberculosis  may  be  gathered 
from  Orth's  (liUtingen  material,  analyzed  by  Oppcnheim.  Of  GO  cases 
ilicro  wore  :U  m  which  the  kidneys  were  involved. 

(/')  Tuberculosis  of  the  Ureters  and  Bladder.— This  rarely  occurs  as 
ii  primary 'itfection,  but  is  nearly  always  s*. -"ondary  to  involvement  of  other 
pai'ts,  particularly  the  pelvis  of  the  kidney.  In  the  case  of  nro-genital 
tuberculosis,  above  mentioned,  in  a  patient  who  died  of  heart  disease,  the 
"rotor,  just  where  it  enters  the  bladder,  showed  a  fresh  patch  of  tidjer- 
^'iilosis. 

"rotracted  cystitis,  which  Yns  come  on   without  apparent  cause,  is 


11 


CfiXi 


i\ 


266 


SPEOIPIO   INFECTIOUS   DISEASRS. 


always  suj^gestive  of  tuberculosis.  Tlic  renul  regions,  the  testes,  aiid  tlii! 
prostate  .slioukl  be  exaniined  with  cure.  It  may  follow  a  pyelo-uejiliriiis, 
or  be  associated  with  primary  disease  of  the  prostate  or  vesieuhv  seiiiiiiiilcs. 
Primary  tuberculosis  of  tiie  posterior  wall  of  the  bladder  may  situiilute 
stone. 

{(■)  Tuberculosis  of  the  Prostate  and  Vesiculae  Seminales. — The  pros- 
tate  is  frequently  involved  in  tuberculosis  of  the  uro-giiiital  tract.  In 
Krzyincki's  cases,  of  lo  males  the  prostate  was  involved  in  14  and  tlivvc- 
sicula.' seiuinali'S  in  11.  In  Urtii's  eases  the  ])rostate  was  involved  in  In 
of  the  ;57  cases  iti  males.  These  })arts  are  nuudi  more  frequently  invdlvcil 
than  ordinary  ])ost-iii()rtcm  statistics  indicate.  Per  rvclvm  tlie  prostatii' 
lobes  arc  felt  to  be  occupied  by  hard  nodules  varying  in  size  from  a  pcatu 
a  bean.  There  is  great  irrital)ility  of  the  bladder,  ami  agoniziiig  pain  in 
catheterization.  \\\  extremely  rare  lesion  is  primary  urethral  lubcivu- 
losis,  wdiieh  may  simulate  stricture. 

{d)  Tuberculosis  of  the  Testes. — Tins  somewdiat  common  affontion 
may  be  primary,  or,  nioie  frequently,  is  secondary  to  tuberculous  disonsf 
elsewhere.  Many  cases  occur  Ind'ore  tlie  secoiul  year,  and  it  is  statoil  in 
have  been  met  with  in  the  fcetus.  In  infants  it  is  serious  and  usually 
associated  with  tuberculous  disease  in  other  parts.  In  9  cases  rcociitly 
reported  by  Ilutincl  ami  Dcschamjis,*  in  every  one  there  was  a  gciitnu 
affection.  In  '10  cases  reported  by  Jullien,f  G  were  under  one  year,  ami  li 
between  one  and  two  years  old.  lu  5  of  the  cases  both  testi(.'lcs  were 
affected.  Ko})lik  holds  that  most  of  the  cases  of  this  kitid  are  congenital. 
in  Baumgarten's  sense.  In  the  adult  the  tubercles  begin  within  the  siili- 
stance  of  the  gland,  but  in  cliildren  the  tunica  albuginea  is  first  alTcitiil 
The  tubercle  does  not  always  undergo  caseation,  but  it  may  present  ;i 
number  of  embryonic  cells,  not  uidike  a  sarcoma. 

Tubercle  of  the  testes  is  most  likely  to  be  confounded  with  syphili- 
In  the  latter  the  body  of  the  organ  is  most  often  affected,  there  is  les- 
pain,  atul  the  outlines  of  the  growth  are  more  nodular  and  irregular.  Iii 
ob.scure  peritoneal  disease  the  detection  of  tubercle  in  a  testis  li;is  in' 
infrequently  led  to  a  correct  diagnosis.  The  association  of  thetwoemi 
ditions  is  not  uncommon.  'J'he  lesion  in  the  testis  may  heal  conipletdy, 
or  the  disease  may  become  generalized.  General  infe(^tion  has  followt'l 
operation.  Too  much  stress  cannot  be  laid  on  the  importance  of  a  rimtim 
examination  of  the  testes  in  hospitid  patients. 

(e)  Tuberculosis  of  the  Fallopian  Tubes,  Ovaries,  and  Uterus.-'i'l' 
special  attention  which  has  been  ])aid  to  local  affections  of  these  part^l'} 
gyuiecologists  has  taught  us  that  jjrimary  tuberculosis  of  the  tubes  is  ii"' 
at  all  uncommon.  "Within  a  year  my  colleague,  Kelly,  has  operateil  tipi'i 
five  or  six  cases.  The  disease  mr.y  bo  primary  and  produce  a  nio.st  chiir- 
acteristi  J  form  of  salpingitis,  'm  which  the  tubes  are  enlarged,  the  \viili> 


•  Archives  Gencrales  de  Medeeine,  1891. 


flbid.,  1890. 


■Jll. 


TUIJERCUI.OSIS. 


267 


tliif'ktniod  ;uid  iiifiltnitod,  und  tlio  contents  cliocsy,  Adliosion  takes  place 
ln'twi't'ii  till'  (iiiil)ri:r  and  tl)e  ovaries,  or  the  uterus  may  l)e  invaded.  Tlie 
(oiKiiti.iii  i>  usually  bilateral.  It  may  occur  in  young  children.  Although, 
as  ;i  nilr, 'cry  evident  to  the  naked  eye,  tlu;re  are  specimens  resembling 
(inUnarv  salpingilis,  whicdi  show  on  nu('r()sc(i])ieal  examination  numerous 
miliary  tiibt^rcles  (Welch  and  Williams).  Tuberculous  salpingilis  may 
cause  serious  local  disease  with  abscess  formation,  and  it  may  be  the  start- 
iiii;-|)oiiit  of  peritonitis. 

Tuberculosis  of  the  uterus  is  very  rare.  Only  three  examples  have 
(H)inc  uiulcr  my  observation,  all  in  connection  Mith  j)ulmonary  phthisis. 
It  may  he  jiriuiary.  The  mucosa  of  the  fundus  is  thickened  and  caseous, 
and  tubercles  may  be  seen  in  the  muscular  tissue.  OccasioiuiUy  the  pro- 
cess extends  to  the  vagina. 


X.  Tuberculosis  ok  tiik  Mammaky  (Iland. 

Mandry  (15runs's  Beitriigo,  viii)  has  collected  forty  cases,  one  of  which 
was  in  a  male.  The  disease  is  most  common  between  tlie  fortieth  and 
sixtieth  years.  The  breast  is  frequently  fistulous,  unevenly  indurated,  and 
tho  iiip|)le  is  retracted.  'I'he  fistuliw  and  ulcers  {present  a  cliaraeteristic 
tiibercidcus  aspect.  The  ■  is  also  a  cold  tuberculous  abscess  of  the  breast. 
The  axillary  glands  are  alfccted  in  about  two  thirds  of  the  cases.  The 
disease  runs  a  chronic  course  of  months  or  years.  The  diagiuisis  can  be 
made  by  the  general  appearance  of  the  tistuloe  and  ulcers,  and  by  the  exist- 
onee  nf  tubercle  bacilli.  The  prognosis  is  not  bad,  if  total  eradication  of 
tiie  disease  be  possible. 

XI.     AllTKRIES. 

Primary  tuberculosis  of  the  larger  blood-vessels  is  unknown.  The  dis- 
ease may,  liowever,  occur  in  a  large  artery  and  not  result  from  external  in- 
vasion. Ill  a  case  of  chronic  tuberculosis  Flexner  found  a  fresh  tubercu- 
luiis  irrowth  in  tiie  aorta,  which  had  no  connection  with  cheesy  masses 
outside  the  vessel.  - 

In  tlu'  lungs  and  otlier  organs  attacked  by  tuberculosis  the  arteries  are 
involved  in  an  acute  infiltration  which  usually  leads  to  thrombosis,  or 
aiborcles  may  develop  in  the  walls  and  proceed  to  caseation  and  softening 
frequontly  with  the  result  of  ha!morrhage.  By  extension  into  vessels, 
particularly  veins,  tho  bacilli  are  widely  distributed.  In  meningitis  tuber- 
culosis of  the  arteries  plays  an  important  role. 


\i 


^1 


it, 


■!'   r'^'f !  ' 


v.! 


il 


:  ^'  11 


XII.  Tuii;  Prognosis  in  Tuberculosis. 

Not  all  persons  in  whose  bodies  the  bacilli  gain  a  foothold  present 
marked  signs  of  tuberculosis.     As  will  be  stated  in  the  next  section,  local 


WW 


r^ 


\m 


i  yi 


208 


SPECIFIC   INFI'X'TIOUS   DISKASKS. 


'  .  i 


diaciirto  is  foiiiul  in  u  tuni.sidiTiihlo  imnibcr  df  all  ciHlavcrs.  Iiifoctiuii  ili,(; 
not  iifcc'ssai'ilv  mean  the  »'.slalili,>liiiuiit  oi"  a  |ii'(iL;ic's>iv(' ami  Tata!  ili>(;i>^.. 
Ill  my  autopsies,  e.\i'lii(liii>^  casus  (load  ot'  pulnioiiarv  ])lilliisis,  l-'i  iKrcciit 
pri'scnti'd  tiihiTciiloiis  lusions  of  the  liiii^fs — a  low  jicrcfiilajrc  in  coiiiiiMii. 
son  wirli  other  ri'cords,  as  I  carernlly  excluded  the  sinijik'  libroni  luukir- 
itifj;  at  the  apex,  and  the  solitary  ehoesy  nodule,  unless  surrounded  by  colo. 
nies  of  tubereh-s. 

In  many  eases  a  natural  or  sponlaneons  cure  is  elTected,  for  tlie  Cdinlj. 
tions  favorable  to  the  development  of  the  disease  are  not  present— in 
other  words,  the  tissue-soil  is  uiisuitabli'.  Apart  from  this  <f roup,  a  iiia- 
joi'ily  of  which  j)rob)ibly  do  not  show  any  sif^ni  of  disease,  there  iiimv  l,. 
spontaneous  arrest  after  the  symptoms  have  become  decided.  Many  ytnr- 
ago  Flint  called  attention  to  the  self-limitation  and  intrinsic  tendency  in 
recovery  in  well-marked  j)nlmonary  tuberculosis.  Of  his  (»T0  cases,  44  re- 
covered, and  in  'M  the  disease  was  arrested,  spontaneously  in  ;*:!  el'  tln' 
first  group  and  in  15  of  the  second.  This  natural  tendency  to  cmc  iv 
t      still  more  strikingly  shown  in  Iynii)hati(^  and  bone  tuberculosis. 

The  following  may  be  considered  favorable  circumstances  in  the  ino:- 
nosis  of  pulmonary  tuberculosis  :  .\  good  family  history,  i)revi()us  gooi] 
health,  a  strong  digestion,  a  suitable  environment,  and  an  insidious  onset, 
^vitllout  high  fever,  and  without  e.xtensivo  pneumonic  consolidation.  ('u>i  - 
beginning  with  pleurisy  seem  to  run  a  more  ])rotracted  and  more  favoniM- 
course.  lie])eated  attacks  of  Inemoptysis  are  unfavorable.  When  \vi!l 
established  the  course  of  tuberculosis  in  any  organ  is  marked  by  iiiterva!- 
of  weeks  or  months  in  which  the  fever  h'ssens,  the  symptoms  subside,  ainl 
there  is  improvement  in  the  general  health. 

In  })iilmoiiary  cases  the  duration  is  extremely  variable,  riaeniiec  plan  '; 
the  average  duration  at  two  years,  and  for  the  majority  of  cases  this;- 
perhaps  a  correct  estimate.  I'oUoek's  large  statistics  of  over  ',l,')W  oa-i- 
shows  a  mean  duration  of  the  disease  of  over  two  years  and  a  half.  WiW- 
iams's  analysis  of  1,000  cases  in  ])rivate  practice  shows  a  much  luoie  |ii'i  ■ 
tracted  course,  as  the  average  duriition  was  over  seven  years. 

Under  the  subject  of  jirognosis  comes  the  question  of  the  niarriiigcff 
persons  who  have  had  tuberculosis,  or  in  whose  family  the  disease  ])revail.-. 
The  following  brief  statements  may  be  made  with  reference  to  it: 

(ri)  Subjects  with  healed  lymphatic  or  bono  tuberculosis  marry  «i;ii 
personal  imjjiinity  and  may  beget  healthy  children.  It  is  undeniable,  how- 
ever, that  in  such  families,  scrofula,  caries  of  the  bone,  arthritis,  oorobrnl 
and  pulmonary  tuberculosis  are  more  common.  AVhich  is  it,  "  lu'i'etiii>' 
de  graiiie  ou  heredite  de  tcirrain,"  as  the  French  have  it,  the  seed  or  tlif 
soil,  or  both':*  We  cannot  yet  say.  Tlie  risks,  however,  are  such  at*  nu} 
properly  be  taken, 

{b)  The  question  of  marriage  of  a  person  who  has  arrested  or  cuie'l 
lung  tuberculosis  is  more  ditlicult  to  decide.  If  a  male,  the  personal  ri.-» 
is  not  so  great;  and  when  the  health  and  strength  are  good,  the  extoriini 


-i,n 


TUBERC'UI.OSIS. 


201) 


eiivirriniiK'iit  fiivorablo,  and  tlio  family  history  not  oxtrcnicly  hw]  \hv 
(.x|it'riiii('!it — for  it  is  such — is  often  sncci'ssfnl,  and  tnany  healthy  and 
luippv  faiiiilii'S  are  bt'^j^ntten  under  lliese  eirennistanees.  In  women  tlu' 
(lUi'siiiiii  is  eomplieated  with  that  (d'  (diild-bojvring,  which  inci'cases  the 
risks  eiiernunisly.  Witli  a  localized  lesion,  absence  of  hereditary  laijit, 
;:(I(m1  ](livsi(jUO,  and  favorable  environment,  marriage  mi.irht  lie  permitted. 
Wiii'ti  tuhercnlosis  has  existed,  however,  in  a  '/\r\  wh>  e  family  history  is 
|i;iil,  uliiiM'  chest  expansion  is  slight,  and  whuse  physi(iue  is  below  the 
.-taiiiliiril,  the  pliysieian  shonld,  if  possible,  place  his  veto  njion  marriage. 

((■)  With  existing  diseiise,  fever,  bacilli,  etc.,  marriage  should  be  abso- 
juti'lv  |in)liiliited.  I'i'egnancy  and  partui'ition  hasten  the  process  in  almost 
ivcrv  e.'isc.  'riierc  is  much  truth,  indeed,  in  the  remaik  of  hnbois:  "If 
;i  uuiiiaii  ilireatened  with  phthisis  nuirries,  she  may  bear  the  lirst  ac- 
ciiiiciu'iiiciU  well;  a  seciiud.  with  diOiculty;  a  third,  never." 

A  I  11.    PuOfllYLAXIS     IN'    TlUKm  L  LOSIS. 


(a)  flincral. — Tlu^  sputa  of  phthisical  patients  should  be  carefully col- 
lertfd  imd  (lestroye(l.  I'atients  should  lie  urged  not  to  spit  about  oare- 
lossly,  hut  always  to  use  a  spit-cup.  {Several  forms  of  portalile  llasks  liavti 
been  devised  and  are  now  on  sale.  The  destruction  of  the  sputa  of  con- 
sumptives should  be  a  routine  measure  in  both  ho.si)ital  and  private  prac- 
tice, 'riiorough  boiling  or  putting  it  into  the  fire  is  sutlicient.  It  sliould 
1)0  explained  to  the  patient  that  the  only  risk,  practically,  is  from  this 
source.  The  chances  of  infection  are  greatest  in  yonrig  children,  'i'he 
nursing  and  care  of  {!()iisunii)tives  involve  vi-ry  slight  risks  indeed  if 
proper  precautious  are  taken.     The  patient  should  occnpy  a  single  bed. 

A  .second  imjiortant  general  prophylactic  measure  relates  to  the  in- 
.^pectioii  of  dairies  and  slaughter-houses.  The  possibility  of  the  transmis- 
sion of  tuberculosis  by  infected  milk  has  been  fully  demonstrated,  and  in 
tlh'  interest  of  public  health  the  state  shonld  take  measures  to  stamp  out 
luherculosis  in  cattle.  Systematic  veterinary  inspection  of  dairies,  par- 
ticularly ill  the  large  cities,  should  be  made,  and  full  power  grajited  to 
loutiscate  and  kill  su.spected  animals.  The  al)attoirs  shoidd  l)e  under 
skilled  Veterinary  control,  and  the  carcasses  of  animals  with  advanced 
tiilRTculosis  contl.scated.  There  is,  however,  nruch  less  danger  of  infection 
through  meat  than  through  milk. 

The  advisability  of  placing  tuberculosis  on  the  list  of  diseases  of  which 
notice  nnist  he  given,  has  been  much  discussed.  I  am  strongly  in  favor 
"fit  in  all  eases  of  pidmonary  tuberculosis,  'i'he  hardships  entailed  upon 
iiHJividuals  would  be  trilling  in  comparison  with  the  imblic  good  which 
"oulil  follow  the  adoption  of  systenuitic  measures  of  inspection  and  dis- 
infection. 

{h)  liidiridnal. — .\  mother  with  pulmonary  tuberculosis  should  not 
suckle  her  child.     An  infant  born  of  tuberculous  parents,  or  of  a  family 


S        •'il 


I    !  '5 


1" 
Mi  • 


270 


SPKCIFIf;   INFRCTIOUS   DISEASES. 


ISIl. 


in  whicli  consunipiidii  iircvuils,  hIiouM  he  liioiinht  up  uitli  tlic  fiivutcst 
cure  ami  giisinU'd  most  luirticiiliii'ly  ii^iiiiist  culiirrliiil  iilTcctioiiH  of  nil 
kinds.  Spcfiiil  {illi'iitidii  should  be  <;iv('ii  In  the  tlirout  uiid  nose,  inid  ,,ii 
tlic  lirst  indication  <d"  nMiiitli-l)rciitliiii,ir,  or  atiyolistrnction  of  tlic  n 
])lianiix,  a  careful  cxaininalion  slioidd  l)c  made  for  adenoid  vc^rct.dj,,,!. 
'I'li(MduId  siioidd  lie  clad  in  ilaiuiel  and  live  in  the  open  air  as  tniich  n, 
])os.sil)le,  avoiding  clo.sc  rooms.  It  is  a  irood  practice  to  sponge  the  llin>;i; 
and  chest  niglit  and  monung  with  cold  water.  Special  attention  slmnjil 
l)e  paid  to  diet  and  to  the  mode  of  feeding.  The  meals  should  ije  at  r('i.'ii 
lar  hours  and  the  food  |)hiin  and  substantial.  l''rom  ilm  outset  the  cliiM 
should  he  oncourage(|  to  drink  freely  of  milk.  ITnfortunutely,  in  llic.-r 
ca.ses  there  seems  to  l)e  an  uncontrollahlc  avcision  to  fats  of  all  kjinlv 
A.s  the  child  grows  ohh'r,  systematically  regulated  exercise  or  a  cimrsM 
of  pidmonary  gymmisti(!s  may  he  taken,  In  tln^  clioiee  of  an  (i(cii|i;i- 
tion  jireforenee  should  he  given  to  an  out-(d'-(loor  life.  l''atniHes  «idi  ;i 
nuirked  predisposition  to  tulu'rculosis  sliould,  if  possible,  reside  in  im 
erpiable  climate.  It  would  be  best  for  a  young  man  belonging  to  smli 
a  fanuly  to  remove  to  Colorado  or  soutliern  Califortua,  or  to  some  dtlici 
suitid)le  climate,  before  trouble  begins. 

The  trilling  ailments  of  children  .should  be  carefully  watclicd.  In  tin 
convalescence  from  the  fevers,  which  so  frequently  prove  diingeroiis,  the 
greatest  caution  should  be  exercised  to  ])revent  catching  cold.  C'oii-livd' 
oil,  the  syrup  of  iodide  of  iron, and  arsenic  may  be  given.  As  montioiicd, 
care  of  the  throat  in  these  -hildren  is  very  important.  When  the  tonsils 
are  chronic, '         larged  thev  should  be  removed. 


.\1V.    TUKATMKNT    OF   TlfBEIlCULOSIS. 

I.  The  Natural  or  Spontaneous  Cure. — The  spontaneous  hotiling  of 
local  tuberculosis  is  an  ev(>ry-day  affair.  ^lany  cases  of  adenitis  and  (li>- 
easc  of  the  bone  or  of  the  joints  ternunate  favorably  without  the  aid  of 
medicines.  The  healing  of  pulmonary  tuberculosis  is  shown  clinically  by 
the  recovery  of  ])atients  in  whose  si)uta  elastic  tissue  and  bacilli  have  been 
found  ;  anatomically,  by  the  presence  of  lesions  in  all  stages  of  repair.  lu 
the  granulation  pi'oductsand  associated  ])neunu)niaa  scar-tissue  is  fermeil, 
while  the  smaller  caseous  areas  become  impregnated  with  lime  salts.  Ti' 
such  conditions  alone  should  the  term  healing  be  applied.  WUcn  tlie 
fibroid  change  encapsulates  but  does  not  involve  the  entire  tuberculous 
tissue,  the  tubercle  may  be  termed  involuted  or  quiescent,  but  is  notdo- 
stroyed.  When  cavities  of  any  size  have  formed,  healing,  in  tlio  proper 
sense  of  the  term,  does  not  occur.  I  have  yet  to  see  a  sj)ecimen  wliieli 
would  indicate  thai  a  vomica  had  cicatrized.  Cavities  may  be  groiitlj 
reduced  in  size — indeed,  an  entire  series  of  cavities  may  be  so  contract^ 
by  sclerosis  of  the  tissue  about  them  that  an  upper  lobe,  in  wliicli  tins 


TUI»KU('UIi()SIH. 


271 


proctvs  iipisi  frri|iu'ntly  tx'ciirs,  iiiiiy  l)e  ri'duccd  to  u  tliird  of  its  onliimry 
(liiiu'ii>ii>n'^.  liiiciiiu'f!  uiiilcrsfoo'l  tlior()iij,HiIy  this  tiatiiral  process  of  euro 
ifi  tiilHTciilnsis,  iiiid  r(H'oj,Mii/,iil  tin'  rrt'(|iniH'y  with  uliidi  old  tiiliii'ddous 
lesions  <>i'<'iii'i't'd  ill  llu;  liiii<:;.s.  lie  dcscrilu'd  rintlricfx  nunji/r/rs  and  rica- 
Irifi'M  lis/nlriisrs,  tlio  latter  hciiii,'  tlic  sliniidxcii  (.'avilics  coimiiiiincatinj^ 
with  till'  linmi'lii;  and  siijfj,'osti'd  that,  as  tidnTclcs  f^rowin;,'  in  the  <,daiidH, 
which  ai'i'  I'allod  scrofula,  often  heal,  why  should  not  the  saiiio  take  j)hu'n 
in  till!  liiiigs';:' 

Then'  is  an  old  (Jennan  axiom,  '■'•Ji'drrmatni  liat  (tin  Kudo  via  hisrhcn 
7'«/i(7'''»Aw',"  a  statement  partly  borne  ont  by  the  statistics  showing  the 
|tropi>rtiun  of  eases  in  jjersoiis  dyin^'  of  all  diseases  in  whom  f|uieseent  or 
tiit)orciiloiis  lesions  ai'e  found  in  the  lunjfs.  We  iind  at  the  apices  tho 
followin.L!;  cdiiditions,  which  have  been  held  to  sijjnify  healed  tubercidoiis 
inoct'sses :  (1)  'I'liicketiin^  of  the  pleiii'a,  iisiially  at  the  posterior  surface 
lit'  the  apex,  with  sultadjacent  induration  for  a  distance  of  a  few  milli- 
iiictrfs.  This  has,  perhaps,  no  f^reater  si<i;nilicance  than  the  milky  [)atch 
1)11  the  pericardium.  (3)  Puckered  oieatriees  at  tho  apex,  depressing'  the 
]il('uni,  and  on  section  showinif  a  lar^e  pif^tnented,  lilirous  scar.  The 
hidiu'hioles  in  tho  neiyhborhood  may  be  dilated,  but  there  are  neither 
tubt.'fch's  nor  cheesy  masses.  'I'his  may  sometimes,  but  not  always,  indi- 
I'iitt;  a  healed  tuberculous  lesion.  (.'})  Puckered  cii-at rices  with  cheesy  or 
I'lrtaceoiis  nodidcs,  and  with  scattered  tubercles  in  the  vicinity.  (4)  The 
r.iratn'rrs  Jishdeii.ses  oi  Laennec,  in  which  the  iibroid  puckering  has  ri;- 
Imoil  the  size  of  one  or  more  cavities  which  communicate  directly  with 
Uu"  hroiu'hi. 

In  1,1)00  autopsies,  excluding  the  21G  cases  dead  of  phthisis,  there  were 
V.I  ciisos  (T'")  per  cent)  which  })reseuted  undoubted  tuberculous  lesions  in 
the  lungs.  I  excluded  the  sim])le  fibroid  i)uckering  and  the  solitary  cheesy 
nodules,  unless,  in  the  latter  case,  there  were  colonies  of  tubercles  in  the 
vii'iiiitv.  'These  59  cases  died  of  various  diseases  ami  at  various  ages.  A 
niajoi'ity  of  them  were  between  forty  and  sixty.  ^ly  experience  tallies 
lIusi'Iv  with  the  larger  analysis  made  by  Ileitler  of  the  N'ieuna  post-mortem 
records,  in  whicli,of  l(l,,jG3  cases  in  which  the  death  was  not  directly  caused 
by  phthisis,  there  were  780  instances  of  obsolete  tubercle — a  percentage  of 
41.  He  excluded,  as  I  have  done,  the  simple  iibroid  induration.  Vari- 
ous ob.servations  have  been  made  of  late  in  which  the  i)ercentage  ranges 
from  twenty-seven  (PjoUingcr)  to  thirty-nine  (Ma.ssini).  In  2U0  autopsies, 
in  which  this  point  was  specially  examined,  Harris  found  o8'S  per  cent  in 
^vhioh  there  were  relics  of  former  active  tuberculosis.  The  statement  is 
made  by  l)unchard  that,  of  the  ticst-mortems  at  the  Paris  morgue — gen- 
erally upon  persons  dying  suddenly — the  percentage  found  with  some 
evidence  of  tuberculous  lesion,  active  or  obsolete,  is  as  high  as  seventy-five. 
These  figures  show  the  extraordinary  frequency  of  jndmonary  infection 
liiul  the  encouraging  fact  that  in  so  large  a  percentage  the  disease  remains 
local  and  undergoes  a  process  of  arrest  or  healing. 


"<  : 


\-A 


; 

1 

it-:-- 

l>7l>  HPI'X'IFIC    IN'TKCTrOUS   DISKASKS. 

II.  General  Moasiires.— Then' an-  tln-fc  iiuIicatioiiH — first,  to  pliicc  tli. 
luitic'iil  ill  .siiiTniimliiii:-^  iim.-t,  i'liVDi'iililc  lor  llic  niaiiitciKiiH'c  ol'  ii  iniixinniin 
(It'jj^rtf  of  iiiitrilioii ;  second,  to  take  siu-li  incasmvs  af,  in  ii  local  or  ;:(ri(r,il 
way.  iiilliiciH.'c  the  tiiltcrciiloiis  processes;  third,  to  alleviate  sviii|it(itiis, 

The  i|iiesli(»ii  of  eiiviroiuiu'Ul  is  of  lirsl  iiiiportaiicc  in  the  trt'atnunt 
of  t  iiiiircidosis.  Ii  is  illiistratiMJ  in  'in  interest  intr  and  i»racti(,'al  \va  y  hv  an 
cxperiiiieiit  of  'i'l'udean,  showing'  tiiat  inoculaictl  rahhits,  conliiii(|  jn  ;, 
dark,  damp  jilacc,  rapidly  siiccMiidi,  while  others,  allowed  to  run  wild, 
either  recover  or  show  sliglit  lesions.  It  is  the  same  in  human  labfivu. 
losis.  .\  ])atient  conliiied  to  the  hoi;se — particularly  in  the  cjci-c,  over. 
heatc<l,  stulTy  dwcllinj^s  of  the  poor,  nv  treated  in  a  hospital  uanl-j. 
in  a  |)o>itiiin  a!ialo;;'ons  to  the  ral)hit  conliiied  to  a  hutch  in  the  icllar; 
whereas  a  patient  livinj^  in  the  fresh  air  and  sunshine!  for  the  iircaid' 
j)arl  of  the  day  lias  (jhaiiees  comparable  to  those  of  the  rabbit  riiiiiiin:.' 
wilih 

III  the  majority  of  eases  the  treatment  has  to  be  carried  out  at  iniine 
and  oflen  under  adverse  conditions.  Still,  much  can  be  done  if  the  jiiitidii 
is  kept  out  of  dooi's  in  'Ik*  fi'csh  air  for  the  jrreater  part  c)f  each  day.  in 
pulmonary  tulierculosis  vcillicr  ihv  ('(iKijh,  the  frrrr,  tlir  Nii/li/sirctfts,  im 
till'  /nriiio/i/i/sis  font ra-iinlic(tl('s  this  ralr.  Only  when  the  W(;illici'!> 
blustering  or  rainy  should  the  patient  i  .nain  in  the  house.  It  is  reiiiaik- 
al)le  liow  (piickly  improvement  in  niiiiiy  iintances  follows  this  frcsli-aiv 
treatment.  In  cities  the  iiatient  can  be  wrajiped  up  and  placed  on  a  tufa 
or  ill  a  reclining-ehair  on  the  baleony  or  even  in  the  yard. 

The  elinialic  treatrrient  of  tuberculosis  is  simply  a  modification  of  ijiij 
plan.  The  requirements  of  a  suitable  climate  are  a  j)urc  ahinisplin-t 
an  eqvablc  tonpvratiire  not  subject  to  rajiid  variations,  and  a  ina.rimim 
amount  of  sunshine.  G'.'cn  these  three  factors,  and  it  makes  little  ditler- 
cnce  where  a  patient  goes  so  long  as  he  lives  an  outdoor  life. 

']l\\q  jiuritij  of  the  atmosphere  is  the  first  consideration,  anil  it  is  this 
re([iiireinent  that  is  met  so  well  in  the  mountains  and  forests.  Altitmlc  is 
a  secondary  consideration.  The  rarefaction  of  the  air  in  high  alliUidL-is 
of  benefit  in  increasing  the  respiratory  movements  in  pulmonary  diseiiiie, 
but  brings  about  in  time  a  condition  of  dilatation  of  the  air-vesicles  a\\\\\ 
permanent  increase  in  the  size  of  the  chest  which  is  a  marked  disadvan- 
tage when  such  persons  attempt  sukseqiiently  to  reside  at  the  sea-Icvcl. 

The  temperature  of  the  air  is  also  a  minor  consideration,  so  lout;  a<  it 
is  tolerably  equable  and  not  subject  to  rapid  variations.  The  wiiitrr  cli- 
mates of  the  Adirondacks,  of  Colorado,  or  of  Davos  have  the  advantage  of 
a  steady  cold  combined  with  sunshine,  just  as  the  resorts  of  the  Sdiillu'rn 
States  and  California, and  of  the  south  of  France  and  Italy,  have  a  telciaMy 
uniform  high  temperature  with  the  maxinunn  amount  of  sunshine.  TIr' 
dryness  of  the  air  is  certainly  an  important  though  not  an  essential  factor. 
That  it  is  not  essential  is  seen  in  the  good  results  obtained  in  the  resorts 
at  the  sea-level,  such  as  Florida,  or  even  Torquay  or  Falmouth,  on  the 
south  coast  of  England — one  of  the  most  humid  atraos|)heres  in  the  world. 


TUIJKUCl'I.OSIS. 


27;{ 


fc-*,  ■•^J^^-^ 


Otlii'i"  cnnsitlcratioiis  which  should  inlliiciicL'  tlic  olioici'  of  u  hiciilitv 
lire  "iHiil  iiiciPiiiiiiodiitioiH  iiiul  L;do(l  Tund.  W'l'v  imicli  is  siiid  coik cniiii;,' 
till' chnin'  nf  hii'iditv  ill  the  dilT(  Tiit  stMp'.^  of  luilnioiiiiry  tiiliciciilosis, 
lull  wlirii  (III'  disciLso  is  liiiiitrd  to  ;iii  iipcv,  ill  11  mail  i>\'  I'airlv  i;iHid  iicrsoiiid 
mid  fiiiiiily  hislorv,  the  chiiiircs  arc  thai  he  may  ti^lit  a  winiiiii.L;'  liatth'  if 
hr  livo  Milt  of  do(»rs  ill  'iiiy  climate,  whctlicr  hiirh,  diy,  and  cold,  or  low, 
iiioi.-l.  and  Wiiriii.  With  hilatcral  disease  and  cavity  formation  there  is  hut 
litllc  |iM|ii'  of  [lermaiienL  cure,  and  the  mild  or  warm  climates  ari'  jtref- 
(•nilile. 

W  lietlief  a  ))atioiit.  slioiild  <^n  from  homo  or  not  is  a  pravo  i|iiostion 
whiili  the  physician  is  called  iijioii  to  decide.  It  is  undoulitedly,  in 
iiiaiiv  iii-tanees,  u  j)ositive  liardshij)  to  send  away  a  |iatieiit.  with  tolerahly 
iiihiiiiri'il  tiiherciilosis.  With  well-marked  cavities,  hectic  fever,  iii;:ht- 
.uviit-.  and  emaciation  he  is  better  at  home,  and  th((  idiysiciaii  should  iiot 
l)i'  too  iiiucli  inlhieiiced  hy  the  imixirtiinities  of  the  sick  man  or  f)f  his 
Iririiils.  Advanced  cases  and  ]iersoiis  with  feehl(>  hearts  should  never  he 
.(■lit  to  hiidi  altitudes.  Of  American  resorts  I  jirefer  the  Adirondack-  for 
iiiily  ciM's.  The  patient  should  go  in  October,  so  as  to  hecome  f,'radiially 
;ici'ii>teiiied  to  the  cold.  It  is  accessible,  the  winter  climalie  is  admiral)Ic, 
;iiiil  the  cani)tdife  delightful.  As  the  reports  of  Saranac  Saiiitt'iiinn  show, 
iirinr  tiihercidosis  does  remarkably  well.  IVrsonally  I  have  seen  better 
results  friiiii  the  Adirondaviks  than  from  any  other  place.  Colorado  and 
.•oiitlicrii  California  liave  this  advanta,ue  for  early  eases — they  arc  pro'iress- 
ivc.  priisperous  couJitries,  in  wlii(di  a  man  may  lind  means  of  livelihoml 
anil  live  in  comfort.* 

I'mler  this  section  reference  ma}'  be  made  to  the  rpiestion  of  the  treat- 
nu'iil  of  tubenadosis  in  sanitaria.  'I'he  larger  cities  should  build  special 
inslitutions  within  easy  access  by  railway,  witli  ])leasant  siirroiii.dings,  in 
vdiieli  early  cases  of  [)ulin()nary  tuberculosis  among  the  poor  could  be 
systuniiitically  treated.  Advanced  cases  should  not  be  admitted,  but  should 
I'c  cared  for  in  separate  wards  of  the  city  liospitals.  Sanitaria  for  the  care 
iif  reeeiit  pulmonary  tuberculosis  among  the  well-to-do  classes  are  also 
iirgoiitly  neeiled.  'IMie  results  obtained  at  Falkenstein  near  Frankfurt 
:i.  M.  (wliicdi  certainly  has  nothing  sj)ecial,  as  far  as  climate  is  coTicerned) 
:i!iil  at  the  Saranac  Sanitarium  illustrate  how  much  can  be  done  by  method 
ainl  eare. 

1 1 1.  Measures  which,  by  their  Local  or  General  Action,  influence  the 

Tuberculous  Process. — Under  tliis  heading  we  may  considiM-  the  sjiecilic, 
the  (lietctic,  and  the  general  medicinal  treatment  of  tuberculosis. 

{(i)  Sjwrijic  Treatment. — The  use  of  Koch's  tuberculin  luis  been  in  great 
part  aliaiidoned  ;  modifications  of  it  are  und( ;;  trial  by  several  trustworthy 
iiivestipitors,  who.se  results  may  justify  its  adojjtion  in  suitable  cases. 

(i)  Dii'lctic  Treatment. — 'J'he  outlook  in  tuberculosis  de])ends  much 


% 

f 

lilil 


if'* 


'.P^- 


,1     1 


^im 
h 


4>  s 

I : 


:  .li!' 


t*"  7. 


1*  J. 4 


On  the  question  of  climate,  Yen's  work  may  bo  consulted  with  advantage. 


-i  ■ 


274 


SPECIFIC  INFECTIOUS   DISEASES. 


upon  the  diifostion.  It  is  rare  to  ^oo  roeovery  in  n  case  in  which  there  is 
persistLMit  jfastrie  trouble,  and  tlie  [ihy.sician  shoulJ  ever  bear  in  luiiul  the 
fact  that  in  tliis  disease  the  priiiiw  vuu  control  the  position.  The  eaiK 
nausea  and  loss  of  apiH>tite  in  many  cases  of  ])hthisis  are  serious  ob.-liiclis. 
Many  patients  loathe  iood  of  all  kinds.  A  chiinge  of  air  or  a  sea  Vdvaiie 
nuiy  jironiptly  restore  the  appetite.  When  either  of  these  is  inipossililc. 
and  if,  as  is  ainii-st  always  the  ease,  fever  is  jiresent,  the  patient  slimild  In 
l)iaced  at  rest,  kept  in  the  open  air  nearly  all  day,  and  fed  at  stated  iiitiT- 
vals  with  small  ([uantitics  either  of  milk,  buttermilk,  or  koumyss,  alternat- 
ing if  necessary  with  meat  juice  and  egg  albumin.  Some  eases  which  aiv 
disturbed  by  eggs  and  milk  do  well  on  koumyss.  It  may  be  necessary 
to  resort  to  Debove's  method  of  over-alimentation  or  forced  feeding.  The 
stomach  is  lirst  washed  out  with  cold  water,  and  then,  through  the  tube, 
a  mixture  is  given  containing  a  litre  of  milk,  an  ^^^^^^  and  one  hmulred 
grammes  of  very  finely  powdered  meat.  This  is  given  three  times  ii  dav. 
Sometimes  the  patients  will  take  this  mixture  without  the  unpleasant  ne- 
cessity of  the  stonuich-tube,  in  which  case  a  smaller  amount  may  be  given. 
I  can  speak  of  the  advantage  of  this  plan  in  cases  in  which  the  gastric 
sym})toms  havt*  l)een  obstinate  and  distressing,  and  the  general  expression 
of  opinion  is,  in  such  instances,  very  favorable  to  this  plan  of  ti'eaiuu'nt. 

In  many  cases  the  digestion  is  not  at  all  disturbed  and  the  patient  eau 
take  an  ordinary  diet.  It  is  remarkiUe  how  rapidly  the  appetite  and 
digestion  improve  on  the  fresh-air  treatment,  even  in  cases  which  liave 
to  remain  in  the  city.  Care  should  bo  taken  that  the  medicines  do  not 
disturb  the  stonuu  h.  Ni)t  infrequently  the  sweet  syrups  used  in  the 
cough  nuxtures,  cod-liver  oil,  creasote,  and  the  hyp()phos[)hitcs  prodnee 
irritation,  and  by  interfering  with  digestion  do  more  harm  than  good. 
On  the  other  hand,  the  bitter  tonics,  with,  acids,  and  the  various  r.ialt 
preparations  are  often  in  these  cases  most  satisfactory.  The  indication.s 
for  alcohol  in  tuberculosis  are  enfeebled  digestion  with  fever,  a  weak 
heart,  and  nipid  pulse.  A  routine  administration  is  not  advisable,  ami 
there  is  no  evidence  that  its  })crsistent  use  promotes  libroitl  procc.-scs  in 
the  tuberculora  areas.  In  the  advanced  stages,  particularly  wluii  the 
temperature  is  low  between  eight  and  ten  in  the  morning,  whisky  and 
milk,  or  whisky,  Q'^^f,,  and  milk  nuiy  be  given  with  great  advantage'.  The 
red  wines  are  also  beneficial  in  mudci'ate  (luantities. 

{(')  llciuTdl  M('(Hf(tl  Treat  nil' lit. — Xo  medicinal  agents  liave  any  i^pecial 
or  })eculiar  action  upon  tuberculous  j)r()cesses.  The  influence  which  they 
exert  is  upon  the  general  nutrition,  increasing  tho  physiological  resist- 
ance, and  rendering  the  tissues  less  susceptible  to  invasion.  The  fol- 
lowing arc  the  most  important  remedies  which  seem  to  act  in  tlii- 
maniu'r  : 

Creatiotc,  which  may  be  administered  in  capsules,  in  increasing  doses, 
beginning  with  one  minim  three  times  a  day  and,  if  well  borne,  iiicroai;- 
ing  tho  dose  to  eight  or  ten  minims.     It  nuiy  also  be  given  in  .'^(diition 


TUIiKRCULOSIS. 


275 


with  tinoturo  of  cardiunoui  ;iiul  alcohol.  It  is  an  ol;l  remedy,  strongly 
rei'omiiii'f.dc'd  by  Addison,  arid  tho  reports  of  Jaccoud,  Fraentzel,  and 
niiinv  (itiii'i'rf  show  that  it  lias  a  positive  value  in  tho  disease.  Cuiaiacol 
may  be  given  as  a  substitute,  either  internally  or  hypoderniically.  In  101 
eiues  ill  whieh  it  was  nsed  at  my  cliiiio,  by  ^Meredith  Keese,  the  ehief 
action  was  on  tlio  cough  and  expectoration,  which  were  much  lessened,  but 
'he  roiiH'dy  had  no  essential  influence  on  the  progress  of  the  disease. 

Coil-lirer  Oil. — In  glandular  and  bone  tuberculosis,  this  remedy  is 
umlonliifilly  beneficial  in  ii'ii)roving  the  nutrition.  In  pulmonary  luber- 
ou'iosis  its  action  is  less  certain,  and  it  is  scarcely  worthy  of  tlie  unl)ounded 
a)iiliileiii'e  which  it  enjoyed  for  so  many  years.  It  should  be  given  in 
small  (liisrs,  not  more  than  a  teaspoonful  three  times  a  day  after  meals. 
It  seems  to  act  better  in  children  than  in  adults.  When  it  is  not  well 
boriio,  a  dessertspoonful  of  rich  cream  three  times  a  day  is  an  excellent 
substitute.     Tlio  clotted  or  Devonshire  cream  is  preferable. 

The  Ilifpophosphites. — These  iu  various  forms  are  useful  tonics,  but 
it  is  doubtful  if  they  have  any  other  action.  They  certainly  exercise  no 
specific  inthienco  upon  tubercle.  They  may  be  given  in  the  form  of  the 
syrup  of  the  hypophosphites  of  calcium,  sodium,  and  potassium  of  the 
U,  S.  P. 

Arsnnr. — Tiiere  is  no  general  tonic  more  satisfactory  in  cases  of  tuber- 
culosis of  all  kinds  tlian  Fowler's  solution.  It  may  be  given  in  iive-minim 
doses  tlnvf  times  a  day  and  gradually  increased  ;  st()p[)ing  its  use  when- 
over  unpleasant  sym2)toms  arise,  and  in  any  case  intermitting  it  every 
third  or  fourth  week. 

One  or  two  sjiecial  methods  of  dealing  with  pulmonary  tuberculosis 
may  here  be  meiuioiied.  The  local  treatment,  by  direct  injection  into  the 
lunirs,  has  been  practised  since  its  strong  advocacy  by  Pepper.  It  has, 
however,  not  gained  tho  general  support  of  the  profession,  and  is  occa- 
sionally followed  by  serious  results.  As  a  rule,  it  may  be  practised  with 
impunity,  and  the  injections  may  be  made  with  a  long  hypodermic 
needle  into  any  portion  of  the  lung  which  is  diseased.  Iodine,  carbolic 
acid,  creasote  (three  per  cent  solution  in  almond  oil),  and  iodoform  have 
been  used  for  the  purpose.  The  remarkable  results  which  surgeons  have 
recently  ol)tained  in  the  treatment  of  joint  tuberculosis  by  injections  of 
iodofiirni  point  to  this  as  a  remedy  which  will  probably  pro'  of  service 
when  injected  directly  into  the  lungs. 

Treatment  by  compressed  air  is  in  many  cases  beneficial,  and  under 
its  use  the  appetite  improv^os,  there  is  gain  in  weight,  and  reduction  of  the 
fever.    The  air  may  be  saturated  with  creasote. 

ly.  Treatment  of  Special  Symptoms  in  Pulmonary  Tuberculosis.— (-^0 
The  Fcirr. — There  is  no  more  dillicult  problem  in  practical  therapeutics 
tlian  the  treatment  of  the  pyrexia  of  tuberculosis.  The  patient  should  be 
at  rest,  and  when  practicable  wheeled  into  the  fresh  air  for  as  long  a  time 
as  possible  during  the  day.     Fever  does  not  contra-indicate  an  out-of-door 


m 


nr 


'Jrl 


'•rj 


276 


SPECIFIC  INFECTIOUS  DISEASES. 


life,  but  it  is  well  for  patients  with  a  tempeniture  above  101°  or  Iii-y  u, 
be  at  rest.  For  the  eontimioiis  ])yri'.\ia  or  the  remittent  type  of  tliu  earlv 
stages,  quinine,  small  doses  of  digitalis,  and  the  salieylates  may  he  triuil; 
but  tliey  are  uncertain  and  rarely  reliable.  Under  no  eircum.stanees  is 
that  priceless  remedy,  quinine,  so  much  abused  as  in  the  fever  of  tiiix'ivu- 
losis.  In  large  doses  it  has  a  moderate  antipyretic  action,  but  it  is  jn-t 
in  these  ellieieiit  doses  that  it  is  so  a[)t  to  disturb  the  stomach. 

Anlipyrin  and  autifebriii  may  be  used  cautiously;  but  it  is  bettiT, 
when  the  fever  rises  above  lo.')'',  to  rely  ujjon  cold  sponging  or  the  tepM 
bath,  gradually  cooled.  When  softening  has  taken  place  and  the  tVvcr 
assumes  the  characteristic  septic  tyj)e,  the  problem  becomes  still  iiKUf 
dinieult.  As  shown  by  Chart  XII  (which  is  not  by  any  means  an  ex- 
ceptional one),  the  pyrexia,  at  this  stage,  lasts  only  for  twelve  or  liflcin 
liours.  As  a  rule  it  is  not  more  than  from  eight  to  ten  hours  in  which 
the  fever  is  high  enough  to  demand  antipyretic  treatment.  SoinetiiiuH 
antifebrin,  given  in  two-grain  doses  every  hour  for  three  or  four  huuii 
before  the  rise  in  temperature  takes  place,  either  jirevents  entirely  or 
limits  the  paroxysm.  If  the  temperature  begins  to  rise  between  two  ami 
three  in  the  afternoon,  the  antifebrin  may  bo  given  at  eleven,  twelve,  oik', 
and,  if  necessary,  at  two.  It  answers  better  in  this  way  than  given  in  ilie 
single  doses.  Careful  sponging  of  the  extremities  for  from  half  an  Imm 
to  an  hour  during  the  height  of  the  fever  is  useful.  Quinine  is  of  lilllo 
benefit  in  this  type  of  fever;  the  salicylates  still  less. 

(//)  Simi/iiH/. — Atropine,  in  doses  of  gr.  y|i5^— jsVi  fi'^d  the  aromatic 
sulphuric  acid  in  large  doses,  are  the  best  remedies.  When  there  are 
cough  and  nocturnal  restlessness,  an  eighth  of  a  grain  of  morphia  may 
be  given  with  the  atropine.  ^luscarin  (nt  v  of  a  one  per  cevit  solution), 
tincture  of  nux  vomica  (ni  xxx),  picrotoxin  (gr.  ^„)  may  be  tried.  'I'iio 
patient  should  use  light  ilannel  night-dresses,  as  the  cotton  night-sliirts, 
when  soakeil  with  perspiration,  have  a  very  unpleasant  cold,  clammy 
feeling. 

(6')  The  cou(/h  is  a  troublesome,  though  necessary,  feature  in  piilinn- 
nary  tuberculosis.  Unless  very  worrying  and  disturbing  sleep  at  night, 
or  so  severe  as  to  produce  vomiting,  it  is  not  well  to  attempt  to  restrict 
it.  When  irritative  and  bronchial  in  character,  inhalations  are  tispfiil 
particularly  the  tincture  of  benzoin  or  preparations  of  tar,  creasote,  or 
turpentine.  The  throat  should  be  carefully  examined,  as  some  of  the 
most  irritable  uid  distressing  forms  of  cough  in  phthisis  result  from 
laryngeal  erosions.  The  distressing  noctin'n:d  cough,  which  begins  just  as 
the  patient  gets  into  bed  and  is  preparing  to  fall  asleep,  requires,  as  a  rule, 
preparations  of  opium.  Codeia,  in  quarter  or  half  grain  doses,  or  the 
syrui)us  codei.e  (  3  j)  may  be  given.  An  excellent  combination  for  the 
nocturnal  cough  of  phthisis  is  morphia  (gr.  i—^),  dilute  hydrocyanic  aoii 
(TTl  ij-iij),  and  syrup  of  wild  cherry  (  3  ,i)-  The  spirits  of  chloroform, 
B.  P.,  or  the  mistura  chloroformi,  U.  8.  P.,  or  Iloirmau's  anodyne,  given 


lii  /■»!■!,  i 


LEPROSy. 


t>T7 


in  wlii.>kv  hcfoi'C  going  to  sleep,  are  ofTicacious.  Mild  coiinter-irritiition, 
or  till' :ii'l'li('iit'oii  of  u  hot  poultice,  will  sometimes  promptly  relieve  the 
i.i)iii,rli.  Ill  the  later  stages  of  the  disease,  when  cavities  have  foniu'd,  the 
.iiTiiinuhitci]  secretion  must  be  expectorated  and  the  paroxysms  of  coughing 
;iir  nil"'  iiii'St  exhausting.  'I'he  sedatives,  such  as  morjihia  and  hydrocyanic 
mill,  sluiiild  he  given  cautiously.  The  aromatic  sj)irit  of  ammonia  in  full 
(lojcs  liclps  to  allay  the  paroxysm.  When  the  expectoration  is  profuse, 
croa.sote  iiitcnially,  oi-  inludations  of  turpentine  and  iodine,  are  useful. 
For  the  troulilesoiue  dys])hagia  a  strong  solution  of  ccn'aine  (gr.  x)  with 
lioric  acid  (gr.  v)  in  glycerine  and  water  (  3  j)  may  be  used  locally. 

(</)  I'ov  the  iliarrhaen  large  doses  of  bismuth,  combined  with  Dover 
piiwder,  and  small  starcdi  enennita,  with  or  without  opium,  may  be  given. 
Thi.' acetate  of  lead  and  ojtium  pill  often  acts  2)rompfly,  ami  the  acid  diar- 
ilio'a  nuxt'U'e,  dilute  acetic  acid  (tti,  .\-xv),  morphia  (gr.  |),  and  acetate 
iil'k'ad  (gr.  j-ij),  may  be  tried. 

{(■)  Till'  treatment  of  the  luomoptysis  will  be  considered  in  the  section 
(111  lui'iiioiTJiage  from  tlie  lungs.  Dyspncca  is  rarely  a  prominent  symptom 
cxii'iit  in  the  advanced  stages,  when  it  nuiy  ba  very  troublesome  and  dis- 
tivssiiig.     Aiiunonia  and  morphia,  cautiously  administered,  may  be  used. 

If  the  pleuritic  pains  are  severe,  the  side  nuiy  be  strapped,  or  painted 
wiili  tiiieture  of  iodine.  The  dyspeptic  symptoms  require  careful  treat- 
iiiciit,  as  the  outlook  in  iiulividual  cases  depends  much  upon  the  coiulition 
(if  the  stomach.  Small  doses  of  calomel  and  soda  often  allay  the  dis- 
tressing nausea  of  the  early  stage. 

XXVni.   LEPROSY. 

Definition.— A  chronic  infectious  disease  caused  by  the  haciUus 
Irprw,  characterized  by  the  i)resence  of  tnbercidar  nodules  in  the  skin 
1111(1  iinu'uiis  membranes  (tubercular  leprosy)  or  by  changes  in  the  nerves 
(aii;v<tlu'tic  leprosy).  At  first  these  forms  may  be  separate,  but  ulti- 
mately both  are  combined,  and  in  the  characteristic  tubercular  form  there 
:iiv  (listiirhaiices  of  sensation. 

Etiology. — The  disease  is  very  widely  spread,  and  within  the  past 
1'  w  years  renewed  attention  has  been  directed  to  it,  oM'ing  to  a  belief  that 
it  is  urcatly  on  the  increase.  It  is  one  of  the  oldest  of  known  disea.ses. 
At  jiresent  it  prevails  widely,  particularly  in  hot  countries.  In  India  it  is 
istiiiiatod  that  there  arc  over  ^.")0,000  lejiers.  In  Euroj)e,  where  it  pre- 
vailed in  the  middle  ages,  it  has  become  almost  unknown  except  in 
Norway  and  in  the  Orient.  On  this  continent  leprosy  exists  in  the 
•'iilf  States  and  extensively  in  Mexico.  At  Key  West  Uerger  states 
'bat  there  are  one  humlnMl  cases,  ami  Bhuic  found  forty  lei)crs  in  New 
•^liwins.  A  few  isolated  cases  arrive  from  time  to  time  in  the  cities  of 
'lu'  .\thuitic  coast.  In  the  Northwestern  States  a  few  cases  exist  among 
'lie  Xiirwogian  and  Icelandic  settlers.  On  the  Pacific  coast  cases  are  seen 
'i"t  infreijiiontly  among  the  Chinese.     An  endemic  focus  is  at  Tracadie, 


ii  '! 


It .  • 


278 


SrECIFlc;   INPKCTIOUS   DISKASKS. 


New  Brunswick.  A  few  cases  are  also  met  with  in  Cape  Breton,  X.  S. 
At  Tracadie,  wliich  is  on  a  bay  of  the  (Jiilf  of  St.  Lawrence,  tlie  disciiseis 
limited  to  two  or  three  counties  wliich  are  settled  by  French  Caiuuliims. 
The  disease  was  imported  from  Normandy  about  the  end  of  the  last 
century.  'J'he  cases  are  confined  in  a  lazaretto,  to  which  they  are  sent  so 
soon  as  the  disease  is  manifest.  I  made  a  visit  to  the  settlement  twn  years 
aj^o  with  the  medical  oHicer,  A.  C.  Smith,  of  Cliatliam,  at  which  time 
there  were  only  eighteen  ])atients  in  the  hospiiul.  It  is  interesiiiif;  to 
note  that  the  disease  has  gradually  diminished  by  segregation;  fciriiierh- 
there  wore  over  forty  under  surveillance. 

In  the  Sandwich  Islands  leprosy  has  developed  to  an  enormous  extent. 
Morrow  states  that  in  188'J  there  were  1,100  lepers  in  the  settlement  at 
Molokai. 

In  the  West  Indies  the  disease  has  been  long  endemic,  and  lU'uvan 
Rake,  of  Trinidad,  has  contributed  some  of  the  most  interesting  of  recent 
clinical  and  jiathological  studies. 

The  disease  attacks  all  classes  and  persons  of  all  ages.  It  is  jiroljubh- 
communicated  by  contagion.  Inoculation  was  successfully  performed  In 
Arning  in  a  Hawaiian  convict.  Graham,  Avho  some  years  ago  carefiilh 
investigated  the  Tracadie  settlement,  came  to  the  conclusion  that  the 
disease  was  there  ])robably  transmitted  by  contagion  ;  and  A.  C.  Sniitli, 
the  present  medical  otlicer,  tells  me  that  he  knows  of  no  facts  whicli  aiv 
opj)osed  to  that  view.  It  is,  however,  only  contagious  in  the  same  seii.^c 
as  syphilis,  and  just  as  accidental  contamination  with  this  virus  is  ex- 
tremely rare  so  it  is  with  leprosy.  The  closest  possible  contact  mn\  take 
place  for  years,  as  between  parent  and  child,  without  transmission,  and 
not  one  of  the  Sisters  of  Charity  who  have  for  more  than  foi'ty  years  jh 
faithfully  nursed  the  lepers  at  Tracadie  has  contracted  the  disease.  It 
is  diflieult  to  exj)lain  the  rapid  spread  of  the  disease  in  the  Sandwich 
Islands  on  air:  other  view  than  contagion,  and  yet  it  is  stiange  that  tlioiv 
is  no  evidence  of  a  primary  lesion  or  external  sore  comparable  to  that  of 
syphilis.  Morrow  states  that  "  in  the  immense  majority  of  cases  the 
disease  is  propagated  by  sexual  congress." 

The  disappearance  of  the  disease  in  the  middle  ages  no  doubt  resiiltei] 
directly  from  the  isnlntion  enforced  at  that  time.  The  disease  has  possi- 
bly in  some  instances  been  transmitted  by  vaccination.  Hereditary  trans- 
mission cannot  be  excluded,  and  there  is  no  good  reason  why  the  discasi' 
should  not  be  communicated,  as  is  syphilis,  from  parent  to  child. 

Jonatlian  Hutchinson  believes  that  the  disease  is  always  associated  witli 
some  special  kind  of  food,  partii-ularly  fish.  Though  he  does  not  denytlic 
specific  nature  of  the  disease  or  the  possibility  of  contagion,  he  wunld 
make  apparently  the  fish  diet  the  tcrtium  quid  which  renders  the  [)atieiit 
susceptib'  or,  if  I  gather  aright  from  his  recent  communicalimi,  with 
which  the  poison  may  be  taken.  The  facts  which  are  manifest  at  tlie 
Tracadie  settlement  are  very  much  opposed  to  this  view.     If  a  fish  diet 


LEPROSY, 


27i^ 


coiikl  al'iiu'  in  any  way  induce  the  disoaso,  by  this  time  leprosy  would  be 
wifli -spivail  in  the  counties  along  the  (.iulf  of  St.  Lawrence,  as  fish  is  the 
iii;iiii  ariiik'  of  diet  winter  and  .-umnier.  There  is  not  the  slightest  dilTer- 
ciur  ih  race,  the  mode  of  life,  or  in  the  surroundings  of  the  inhabitants 
in  the  regions  adjacent  to  Caraquet  and  Tracadie,  and  yet  leprosy  has 
liiTii  for  nearly  a  century  limited  to  two  or  three  counties. 

The  Bacillus  Leprae. — Hansen,  of  Bergen,  first  discovered  this  organ- 
ism, wliirli  has  many  points  of  resembhuice  to  the  buri/his  (ti/n'rcnhisitt, 
bateau  Ite  (liU'erentiated  from  it.  It  occurs  in  extraordinaiT  numbers  in 
the  tuberculous  tissue.  It  has  been  cultivated  successfully  (Babes),  but 
iuoeulation  experiments  on  animals  have  been  negative. 

Morbid  Anatomy. — The  leprosy  tubercles  consist  of  granuloma- 
tous tissue  Tuade  up  of  cells  of  various  sizes  in  a  connective-tissue  matrix. 
The  baeilii  in  extraordinary  numbers  lie  partly  between  and  piirtly  in  the 
cells.  1'lie  growth  gradually  involves  the  skin,  producing  tuberous  out- 
irrowths  witii  intervening  areas  of  ulceration  or  cicatrization,  which  in  the 
f;ice  may  gradually  produce  the  so-called  fades  leontina.  Tlie  mucous 
membranes,  particularly  the  conjunctiva,  the  cornea,  the  larynx,  may  be 
gradually  involved.  In  many  cases  deep  idcers  form  which  result  in 
extensive  loss  of  substance  or  loss  of  fingers  or  toes,  the  so-called  lepra 
iiuitiiaiin.  In  anaesthetic  leprosy  there  is  a  peripheral  nruritis  due  to  the 
lieveloiiinent  of  the  bacilli  in  the  nerve-fibres.  Indeed,  this  involvement 
of  the  nerves  plays  a  prinuiry  part  in  the  etiology  of  nuiny  of  the  im- 
portant features,  particularly  the  trophic  changes  in  the  skin  and  the 
disturbances  of  sensation. 

Clinical  Forms.— (^0  Tubercular  Leprosy.— Prior  to  the  appear- 
ance of  the  i\odulo.s  there  are  areas  of  cutaneous  erythcnui  which  may  be 
sliai'ply  delined  and  often  hyperresthetic.  This  is  sometimes  known  as 
rmidar  lejjrosy.  The  affected  spots  in  time  become  jiigmented.  In  some 
instanees  this  superficial  change  continues  without  the  development  of 
iiotlules,  the  areas  become  anesthetic,  the  pigment  gradually  disappears, 
and  the  skin  gets  perfectly  white — the  lepra  alba.  Among  the  patients 
at  Tracadie  it  was  particularly  interesting  to  see  three  or  four  in  this  early 
stage  presenting  on  the  face  and  forearms  a  patchy  erythema  with  slight 
swelling  of  the  skin.  The  diagnosis  of  the  condition  is  perfectly  clear, 
'liough  it  may  be  a  long  time  before  any  other  than  sensory  changes 
iltvelop.  The  f^velashes  and  eyebrows  and  the  hairs  on  the  face  fall  out. 
I  he  mucous  membranes  finally  become  involved,  particularly  the  mouth, 
throat,  and  larynx  ;  the  voice  becomes  harsh  and.  finally  aphonic.  Death 
residts  not  infrequently  from  the  laryngeal  complications  ami  aspiration 
pneumonia.  The  conjunctivfe  are  frequently  attacked,  and  the  sight  is 
hist  by  a  leprous  keratitis. 

(I'O  Ana3sthetie  Leprosy. — This  remarkable  form  has,  in  characteristic 
cases,  no  external  resemblance  whatever  to  the  other  variety.  It  usually 
begins  with  pains  in  the  limbs  and  ureas  of  hyperaesthesia  or  of  numbness. 


i  f}" 


1    I   cl   I 

1  'I 


i] 


'  f.. 


'  •! 


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280 


SPECIFIC  INFECTIOUS  DISEASES. 


Very  early  there  may  be  trophic  changes,  seen  in  the  formation  of  sniiiH 
bulhi;  (llillis).  Macuhv;  appear  upon  the  trunk  and  extremities,  ami  after 
persisting  for  a  variable  time  gradually  disai)j)ear,  leaving  areas  of  muvi. 
thesia,  but  the  loss  of  sensation  may  come  on  iiule])endently  of  tlio  out- 
break of  macula).  The  nerve-truidvs,  where  superlicial,  may  be  felt  to  be 
large  and  nodular.  The  trophic  disturbances  are  usually  marked.  l\m. 
phigus-likc  bulliii  develop  in  the  atTected  areas,  wliich  break  and  Kmvc 
ulcers  which  may  be  very  destructive.  The  fingers  and  toes  are  li;i!)le  to 
contractures  and  to  necrosis,  so  that  in  chronic  cases  the  phalanges  are 
lost.  The  course  of  anaesthetic  leprosy  is  extraordinarily  chronic  and  niav 
persist  for  years  without  leading  to  much  deformity.  One  of  the  most 
prominent  clergymen  on  tliis  continent  has  had  aiutsthetic  leprosy  for 
more  than  thirty  years,  which  until  recently  has  not  seriously  interfered 
with  his  usefulness,  and  not  in  the  slightest  with  his  career. 

Diagnosis. — Even  in  the  early  stage  the  dusky  erythematous  niaciilit 
with  hyi)era>stliesia  or  areas  of  ana'sthesia  are  very  characteristic.  In  an 
advanced  grade  neither  the  tubercular  nor  auiusthetic  forms  could  possi- 
bly be  mistaken  for  any  other  alfection. 

Treatment. — There  are  no  specific  remedies  in  the  disease,  and  gen- 
eral  tonics  combined  witJi  local  treatment  meet  the  oidy  available  indica- 
tions. The  gurjun  and  chaulmoogra  oils  have  been  recommended,  the 
former  in  doses  of  from  live  to  ten  minims,  the  latter  in  two-drachm  doses. 
The  cases  should  be  isolated,  although  the  risk  of  catching  the  disease  by 
direct  contagion  is  extremely  slight. 


XXIX.  GLANDERS  (/aw/). 

Definition. — An  infectious  disease  of  the  horse,  communicated  occa- 
sionally to  man.  In  the  horse  it  is  characterized  by  the  formation  of 
nodules,  chicUy  in  the  nares  (glanders)  and  beneath  the  skin  (furcv). 

Etiology. — 'L'he  disease  belongs  to  the  infective  graaulomata.  Tlio 
local  manifestations  in  the  nostrils  and  the  skin  of  the  iiorse  are  due  to 
one  and  the  same  cause.  The  specific  germ  bdcUhni  iiudh'i  was  discovercil 
by  Loetller  and  Schiitz.  It  is  a  short,  non-motile  bacillus,  not  unlike  tliat 
of  tubercle.  It  grows  readily  on  the  ordinary  culture  media.  For  the  full 
recognition  of  glanders  in  nnm  we  are  indebted  to  the  labors  of  ivayi'. 
whose  monograph  remains  one  of  the  best  descriptions  ever  given  of  tlio 
disease.  Man  becomes  infected  by  contact  with  diseased  animals,  aii'l 
usually  by  inoculation  on  an  abraded  surface  of  the  skin.  The  cdntagiun 
may  also  be  received  on  the  mucous  membrane.  In  one  of  the  Montreal 
cases  a  gentleman  was  probably  infected  by  tiie  material  expelled  from 
the  nostril  of  his  horse,  which  was  not  suspected  to  have  the  disease. 

Morbid  Anatomy. — As  in  the  horse,  the  disease  nuiy  be  localized 
in   the  nose  (glanders)  or  beneath  the  skin  (farcy).     The  essential  lesiuii 


GLANDERS. 


281 


i-!  tho  pramilomatous  tumor,  characterized  by  the  presence  of  numerous 
Ivmplidid  1111(1  epithelioid  cells,  among  and  in  which  are  seen  the  glanders 
bacilli.  Tliose  nodular  masses  tend  to  break  down  rajjidly,  and  on  the 
mucous  nieiiibrano  form  ulcers,  while  beneath  the  skin  they  form  ab- 
scesses.   'I'ho  glanders  nodules  may  also  occur  in  the  internal  organs. 

Symptoms. — An  acute  and  a  chroi.ic  form  of  glanders  nuiy  be  recog- 
nized in  man,  and  an  acute  and  a  chronic  form  of  farcy. 

Acute  Glanders. — Tho  j)eriod  of  incubation  is  rarely  more  than  three 
or  I'diir  (lays.  Tliere  are  signs  of  general  febrile  disturbance.  At  the 
place  of  infection  there  are  swelling,  redness,  and  lymphangitis.  Within 
two  or  tluee  days  there  is  involvement  of  the  mucous  membrane  of  the 
nose,  the  nodules  break  down  rapidly  to  ulcers,  and  there  is  a  muco- 
)iiinilcnt  cliscliarge.  An  eruption  of  papules,  which  rapidly  become  pust- 
ules, breaks  out  over  the  face  aiul  about  the  joints.  It  has  been  mistaken 
for  variola.  This  was  carefully  studied  by  Kayer  and  is  figured  in  his 
monogniph.  In  a  Montreal  case  this  copious  eruption  led  the  attending 
pliysiciitn  to  suspect  small-pox,  and  tho  patient  was  isolated.  There  is 
irreat  swelling  of  the  nose.  The  ulceration  may  go  on  to  necrosis,  in 
which  case  the  discharge  is  very  olfensive.  The  lymph-glands  of  the  neck 
are  usually  much  enlarged.  Subacute  })neumonia  is  very  apt  to  develop. 
This  t'orni  runs  its  course  in  about  eight  or  ten  days,  and  is  invariably 
fatal. 

Chronic  glanders  is  rare  and  difficult  to  diagnose,  as  it  is  usually 
niistalvcn  for  a  chronic  coryza.  There  are  ulcers  in  the  nose,  and  often 
laryngeal  symptoms.  It  may  last  for  montlis,  or  even  longer,  and  recovery 
soinetiuies  takes  place.  The  diagnosis  may  be  extremely  difficult.  In 
such  cases  cultures  should  be  made  and  portions  of  the  pure  culture  inocu- 
lated in  the  guinea-pig.  The  animal  dies  within  thirty  hours,  and  the 
testicles  are  found  to  be  enormously  swollen  and  already  in  the  condition 
of  abscess. 

Acute  farcy  in  man  results  usually  from  the  iiuiculation  of  the  virus 
into  tho  skin.  There  is  an  intense  local  reaction  witli  a  phlegmonous  in- 
llammation.  The  lymphatics  are  early  affected,  and  along  their  course 
lliero  are  nodular  subcutaneous  onlargemcTits,  the  so-called  farcy  buds, 
whieli  may  rapidly  go  on  to  suppuration.  T'here  are  pains  and  swelling 
in  the  joints  and  ab.scesses  may  form  in  the  muscles.  The  synii)toms  are 
those  of  an  acute  infection,  almost  like  an  acute  septica'mia.  The  nose  is 
not  involved  and  the  superficial  skin  eruption  is  not  common. 

The  disease  is  fatal  in  a  large  proportion  of  the  cases,  usually  in  from 
twelve  to  iifteon  days. 

Chronic  farcy  is  characterized  by  the  presence  of  localized  tumors,  usu- 
ally in  the  extremities.  These  tumors  break  down  into  abscesses,  and 
sometimes  form  deep  ulcers,  without  much  inflammatory  reaction  and 
without  special  involvement  of  the  lymphatics.  I'he  disease  may  last  for 
nionth.s  or  even  years.    Death  may  result  from  pytemia,  or  occasionally 


m 


*  1 ' 


282" 


SPPX'IFIC   INFI'X'TIOUS  DISEASES. 


I       '     ..JLitL. 


aciito  gliindors  develoiis.  The  colobruted  French  veterinarian  Boiiliy  luiil 
it  and  recovered. 

The  disease  is  transmissible  also  from  man  to  man.  Washor-womon 
have  Ixieii  int'ected  i'roni  the  clothes  of  a  patient.  In  the  diagnosis  of  this 
alTection  the  occupation  is  very  inij)ortant.  Nowadays,  in  eases  of  doiibi, 
the  inoculation  should  be  made  in  animals,  as  in  this  way  the  diseusi' ciiii 
be  readily  determined.  Mallein,  a  product  of  the  growth  of  the  bacilli,  ja 
now  used  for  the  purpose  of  diagnosing  glanders  in  animals. 

Treatment. — 'If  seen  early,  the  wound  should  be  either  cut  out  or 
thoroughly  destroyed  by  caustics  and  an  antiseptic  dressing  ai)i)lic(i.  Thu 
farcy  buds  shonld  be  early  opened.  In  the  acute  cases  tliere  is  very  liitJu 
hope.     In  the  chronic  cases  recovery  is  possible,  though  often  tedious. 


XXX.    ACTINOMYCOSIS. 

Definition. — A  chronic  infective  disorder  produced  by  the  acti- 
nomyces  or  ray-fungus. 

Etiology. — The  disease  is  wide-spread  among  cattle,  and  occurs  also 
in  the  pig.  It  was  first  described  by  Bollinger  in  the  ox,  in  which  it  forms 
the  affection  known  in  this  country  as  "big-jaw."  Examples  of  the  dis- 
ease were  common  in  the  cattle  killed  at  the  abattoir  in  Montreal,  luiiian 
the  disease  was  first  desci'ibed  by  James  Israel,  and  sub.sequently  Poufnk 
insisted  upon  the  identity  of  tlie  disease  in  man  and  cattle. 

In  this  country  and  in  England  the  disease  is  rare.  It  is  not  uncom- 
mon in  Germany  and  Russia.  To  the  end  of  1892  about  450  cases  hail 
been  described  (Leith,  Edinburgh  Hospital  lieports,  vol.  ii).  It  is  nearly 
three  times  as  common  in  men  as  in  women. 

The  parasite  belongs  probably  to  the  Cladothrix  group  of  bacteria. 
In  both  man  and  cattle  it  can  be  seen  in  the  pus  from  the  affected  region 
as  yellowish  or  opaque  grannies  from  one  half  to  two  millimetres  in  diam- 
eter, whicli  are  made  up  of  cocci  and  J'adiating  threads,  which  preseiir 
bulbous,  club-like  terminations. 

The  relation  of  these  three  elements  is  still  in  dispute. 

The  parasite  has  been  successfully  cultivated,  and  the  disease  has  been 
inoculated  both  with  the  natural  and  artificially  grown  fungus. 

The  Mode  of  Infection. — There  is  no  evidence  of  direct  infection  with 
the  flesh  or  milk  of  diseased  animals.  The  fungus  has  not  been  detecttJ 
outside  the  body.  It  seems  highly  probable  that  it  is  taken  in  with  tk 
food.  The  site  of  infection  in  a  majority  of  cases  in  man  and  animals  is 
in  the  mouth  or  neighboring  passages.  In  tlie  cow,  possibly  also  iu  man, 
ears  of  barley  or  rye  have  been  carriers  of  the  fungus. 

Morbid  Anatomy. — In  the  earliest  stages  of  its  growth  the  para- 
site gives  rise  to  a  small  granulation  tumor  not  urdike  that  produced  by 
the  bacillus  tubei'ciilosis,  which  contains,  in  addition  to  small  round  cells, 


ACTINOMYCOSIS. 


283 


('nitholi"i<l  eloments  and  giutit  colls.  Afti-r  it  reaches  a  wrtaiii  size  there 
is  irn'iii  Mrolifuration  of  tlie  .siirroiiiidiiig  (loiuioctive  tissue,  and  the  growth 
iiiav,  iiai'irularly  in  tlie  jaw,  look  like,  and  was  long  mistaken  for,  osteo- 
s;iiviiiii;i.  JMiiidly  suppuration  occurs,  which,  according  to  Israel,  may  be 
piddiHi'i  directly  by  the  fungus  itself. 

Clinical  Forms.— (r?)  Alimentary  Canal.— Israel  is  said  to  have 
fdiiiul  llic  fungus  in  tiie  cavities  of  carious  teeth.  The  jaw  has  been  in- 
viilvi'il  in  a  niunljcr  of  cases  in  man.  Tlie  [)atieut  comes  niuler  observation 
with  swelling  of  one  side  of  the  face,  or  with  a  chronic  enlargement  of  the 
jiiw  uliii'li  nuiy  simulate  sarcoma. 

The  tongue  has  been  involved  iti  several  cases,  forming  small  growths, 
which  in  one  instance  were  primary,  in  the  other  secondary,  to  disease  of 
tht!  jaw.  In  the  intestines  the  disease  may  occur  either  as  a  primary  or  .sec- 
(liiilaiv  iill'ection.  At  the  Charite,  Berlin,  in  IiS84,  I  saw  with  Oscar  Israel 
;i  rctiiarkalde  instance  in  which  there  were  actinomycotic  ulcers  in  the 
>iiiall  intestines,  (-'ases  have  been  re])orted  of  {)eriea'cal  abscess  due  to  the 
fiuiiriis.  An  instance  of  prinniry  actinomycosis  of  the  large  intestine  with 
iiictiistases  has  also  been  described.  Ransom  has  found  the  actinomyces 
ill  the  stools.  The  liver  may  be  aiTected  primarily,  as  in  the  ease  reported 
liv  Sharkey  and  Acland.  The  actinomycotic  abscesses  present  a  reticuhir 
or  hniii'yc(Mub-like  arrangemi'nt  (Leith). 

ill)  Pulmonary  Actinomycosis. — In  September,  1878,  James  Israel  de- 
jirilicii  A  remarkable  mycotic  disease  of  the  lungs,  which  subsequent  obser- 
vatiiiu  showed  to  be  the  alTection  descrilx'd  the  year  before  by  Hollinger  in 
cattk'.  Since  that  date  thirty-four  instances  have  been  reported  in  which 
the  lungs  were  alfected.  Ilodenpyl  has  analyzed  these  and  reports  two 
cases  from  the  Roosevelt  Hospital. 

It  is  a  chronic  infectious  disorder  of  the  lungs,  characterized  by  cough, 
fi'ver,  wasting,  and  a  muco-pnrulent,  sometimes  fo'tid,  expectoration. 
The  lesions  are  unilateral  in  a  majority  of  the  cases.  Ilodenpyl  classities 
them  in  three  groups:  (1)  Lesions  of  chronic  bronchitis;  in  one  case  the 
(lia<rnosis  was  made  by  the  presence  of  the  actinomyces  in  the  sputum. 
(;')  Miliary  actinomycosis,  closely  resembling  miliary  tubercle,  but  the 
iiodiilcs  are  seen  to  be  made  up  of  groups  of  fungi,  surrounded  by  granu- 
latiiin  tissue.  This  form  of  pulmomiry  actinomycosis  is  not  infretinent  in 
iixeu  with  advanced  disease  of  the  jaw  or  adjacent  structures.  (3)  The 
cases  in  which  there  is  more  extensive  destructive  disease  of  the  lungs, 
hi'iiiulio-|ineumouia,  interstitial  changes,  and  abscesses,  the  latter  forming 
liivitius  large  enough  to  be  diagnosed  during  life.  Actinomycotic  lesions  of 
other  organs  are  often  present  in  connection  with  the  pulmonary  disease; 
cinsidii  (if  the  vertebne,  necrosis  of  the  ribs  and  sternum,  subcutimeons 
abscesses,  and  occasionally  metastases  in  all  parts  of  the  body. 

Siimpfiiins. — The  fever  is  of  an  irregular  type  atid  depends  largely  on 
the  existence  of  suppuration.  The  cough  is  an  important  symptom,  and 
the  diagnosis  in  eighteen  of  the  cases  was  made  daring  life  by  the  dis- 


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284 


SPKCIFIO   INFKCTIOITS   DISEASES. 


covery  of  tho  aotinoniyoos.  Doiitli  rosults  iisimlly  with  soptie  symptoms, 
Occasionally  tlicrc  is  a  cotiditioii  .simtilalirif^  typhoid  fovcr.  Tiie  uv('riii;(' 
duration  of  tlic  discaso  was  ton  rwonllis.  Of  tlic  tiiirty-foiir  cases  all  diid 
excopt  two.  Cliiiii-ally  the  disciasc  closoly  rcscnihlcs  certain  forms  of  pn). 
nionai'y  tiihcriMilosis  and  of  ftclid  l)rom;liitis.  It  is  not  to  be  for^iiuu  in 
the  exam inati(ni  of  tlic  sputum  that,  us  Hizzozero  mentions,  certain  ilcj^cn. 
crated  epithelial  cells  may  roseml)le  the  fiin<fus.  'I'he  radiatinjf  leptotluix 
threads  alxiut  the  epithelium  of  the  mouth  sometimes  present  a  .striking 
re.semljlance. 

{<■)  Cutaneous  Actinomycosis. — In  several  instances  in  connection  with 
chronic  ulcerative  diseases  of  the  skin  tho  ray-fungus  has  been  found.  1; 
is  a  very  (dironic  alTection  resembling  tuberculosis  of  the  skin,  assoiMiitcil 
with  the  develo[)inent  of  tumors  which  suj)purate  and  leave  open  .soros, 
which  may  remain  for  years. 

(d)  Cerebral  Actinomycosis. — Mollinger  luis  reported  an  instanee  of 
primary  di.sease  of  llie  brain.  'I'he  .symptoms  were  these  of  tumor.  .\ 
second  remarkable  case  has  been  reported  by  Oamgee  and  Delepine.  Thf 
patient  was  admitted  to  St.  (ieorge's  Hospital  with  left-sided  i)leuraUiIii- 
sion.  At  the  ])ost  mortem  three  pints  of  ])urulent  fhiid  were  f(anul  in 
the  left  pleura;  there  was  an  actinomycotic  abscess  of  the  liver,  and  in 
the  brain  there  were  abscesses  in  the  frontal,  parietal,  and  temporo-.sphe- 
noidal  lobes  which  contained  the  mycelium,  but  no  clubs.  A  third  ciisc, 
reported  by  O.  H.  Kcdler,  had  enipyema  nt'ccssilttiis,  which  was  ojkir'iI 
and  actinomyces  were  found  in  the  j)us.  Subsequently  she  had  Jiuk- 
sonian  epilepsy,  for  which  she  was  trephined  twice  and  abscesses  opeiiid, 
which  contained  actinomyces  grains.  Death  occurred  after  the  .second 
operation. 

Diagnosis. — Tlio  disease  is  often  mistaken  for  and  is  in  reality  ;i 
chronic  pya?mia.  The  only  test  is  the  presence  of  the  actinomyces  in  tin 
pus.  Metasta.so.s  may  occur  as  in  pyiiemia  and  in  tumors.  The  tendency, 
however,  is  rather  to  produce  a  local  purulent  affection  which  erodes  the 
bones  and  is  very  destructive.  In  cattle  the  disease  nuiy  cause  nu'tiistases 
without  any  suppuration ;  thus  in  a  Montreal  case  the  jaw  and  toiiijue 
were  the  seat  of  the  most  extensive  disease  with  very  slight  suppunition, 
while  the  lungs  presented  numbers  of  secondary  growths  containing  the 
fungus. 

Treatment. — This  is  largely  surgical  and  is  practically  that  of  py- 
aemia. Incision  of  the  abscess,  removal  of  the  dead  bone,  and  tlioronfrh 
irrigation  are  appropriate  measures.  Thomassen  has  recommended  iodide 
of  potassium,  which,  in  doses  of  from  forty  to  sixty  grains  daily,  has  proved 
curative  iu  a  number  of  recent  cases. 


.1  i*Ci'','  :'[' 


INFECTIOUS  DISEASES  OP  DOLBTFUL  NATURE. 


285 


XXXI.    INFECTIOUS   DISEASES   OF   DOUBTFUL   NATURE. 

(1)  FEKIUCULA— EIMIEMKKAL   FKVElt. 

Definition. — I'Y'vcr  of  sliijlit  (liiration,  probubly  dopondinf];  upon  a 
viii'ii'ty  111'  I'iiiiscs. 

A  fi'lirili'  i)!iro.\yHm  liistiii][^  for  twenty-four  hours  and  disappoiiring  com- 
iilctclv  i<  spoken  of  as  epliciueral  fever.  If  it  persists  for  three,  four,  or 
luoro  <l:iys  without  local  alTeciion  it  is  referred  to  as  febrieula. 

Tlic  ei'.scs  may  he  divided  into  several  ^roiijis: 

(n)  Tlinse  whi(!h  represent  mild  or  ah.)rtive  types  of  the  infectious 
iliscasi's.  It  is  not  very  infrequent,  during  an  epidemic  of  typlioid,  scarlet 
fcvcr,  or  measles,  to  see  cases  with  some  of  tlu^  prodromal  symptoms  and 
sliglit  fever  which  persist  for  two  or  three  days  without  any  distinctive 
fi'iitiircs.  I  have  already  spoken  of  these  in  connection  with  the  al)ortive 
tvpi'  of  typlioiii  fever.  Possibly,  as  Kalder  suggests,  some  of  the  cases  of 
transient  fever  are  due  to  the  rheumatic  poison. 

{//)  111  a  larger  and  i)erhaps  more  important  group  of  cases  the  symp- 
toms develop  with  dyspepsia.  In  children  indigestion  and  gastro-intes- 
tiiial  catari'ii  are  often  accompanied  by  fever.  Possibly  some  instances 
iif  longer  (hiration  may  be  duo  to  the  absorption  of  certain  toxic  snb- 
stancos.  Slight  fever  has  been  known  to  follow  the  eating  of  decompos- 
ing substances  or  the  drinking  of  stale  beer;  but  the  gastric  juice  has 
iviiiaikiiblc  antiseptic  properties,  and  the  frequency  with  which  persons 
take  from  choice  articles  which  are  "  high,"  shows  that  poisoning  is  not 
\\M\-  to  occur  unless  there  is  existing  gastro-intestinal  disturbance. 

((')  Cases  which  follow  exposure  to  foul  odors  or  sewer-gas.  That  a 
fi'bi'ilo  })aroxysm  may  follow  a  })rolongcd  exposure  to  noxious  odors  has 
loii;j  liecu  recognized.  '  The  cases  which  have  been  descril)ed  under  this 
liLiuliiig  are  of  two  kinds:  an  acute  severe  form  with  nausea,  vomiting, 
colic,  and  fever,  followed  perhaps  by  a  condition  of  collapse  or  coma ; 
Hcondly,  a  form  of  low  fever  with  or  without  chills.  A  good  deal  of 
iloiibt  still  exists  in  the  minds  of  the  profession  about  these  cases  of  so- 
calli'il  sewer-gas  poisoning.  It  is  a  notorious  fact  that  workers  in  sewers 
iirc  remarkably  free  from  disease,  and  in  many  of  the  cases  which  have 
lifcn  reported  the  illness  may  have  been  only  a  coincidence.  There  are 
instances  in  which  persons  have  been  taken  ill  with  vomiting  and  slight 
ftviT  after  exposure  to  the  odor  of  a  very  offensive  post-mortem.  Whether 
true  or  not,  the  idea  is  firmly  implanted  in  the  minds  of  the  laity  that  very 
powerful  odors  from  decomposing  matters  may  produce  sickness. 

{(J)  Many  cases  doubtless  depend  upon  slight  unrecognized  lesions, 
wh  as  tonsillitis  or  occasionally  an  abortive  or  larval  pneumonia.  Chil- 
tli't  n  are  nuich  more  frequently  affected  than  adults. 

The  symptoms  set  in,  as  a  rule,  abruptly,  though  in  some  instances 
there  may  have  been  preliminary  malaise  and  indisposition.     Headache, 


!    11 


!  I 


.(•;, 


i:i' 


I    K 


4' 

■■J  If 

i;  It-  t'ilts 


'  i 


1  H^^^H 

■P' 

^^^hK  /'!*''  . 

iHWH 

\  "  '%ffiE 

ki^^m^ 

I 


^h 


*r! 


V''] 


i 


-i! 


280 


SPECIFIC   INKKCTIOUS  DISKASKS. 


loss  of  iiitpctitc,  and  fiirrcil  t()ii<,'iie  iiro  pn'scnt.  Tlioiiriiu!  is  .snuity  ami 
lii«,'li-t'f)l(»n'(l,  the  tVvcr  niiij,'i'S  from  1<>1°  to  1();{°,  somclinic.-i  in  cliililnn  it 
risoa  hij^'lu'r.  'I'lic  ciit't'ks  may  bi^  IluHlicd  and  the  j)atii'iit  lian  the  (Mitwaril 
maiiifi'stiitioiis  of  fever.  In  cliildrcn  thcro  may  l»o  hnmclual  caturrli  wiilj 
»\'>^\\[  cDiiu'li.  llerpi's  on  tlio  lips  is  a  common  symptom.  ()i;<'ii>i(iii;iiiv 
in  cliildrcn  the  ccrehral  symptoms  are  marked  at  the  outset,  ami  tlniv 
may  In-  irritati(tii,  restlessness,  and  ntx'tiirnal  (h'liriiim.  'I'he  tVvcr  tciini. 
nates  ahruptly  l»y  crisis  fror.i  the  second  to  tlic  fourth  day;  in  sinuu  in- 
stances  it  may  continue  for  u  week. 

'riuw//V^///a*.v/.s' trcnerally  rests  upon  the  uhsonce  of  local  manifotiilinii.. 
particularly  the  characteristics  skin  rashes  (»f  the  eruptive  fevers,  iiml  nni.t 
important  of  all  the  rapid  disa|)pearance  of  the  pyrexia.  'I'lie  cases  must 
reailily  rccojjidzed  are  those  wiih  acute  gastro-intestirud  disturhaiu'c, 

'V\w  trrahiinit  is  that  of  mild  pyrexia — rest  in  lu'd,  a  laxative,  aiui  a 
fever  mixture  containing  lutrate  of  potash  and  sweet  spirits  ol'  niui'. 

(3)  WKIL'S   DISKASE. 

Acute  Febrile  Icterus. — In  lisHC  Weil  dcscril)ed  an  aentc  iuftctiuii^ 
disease,  characterized  l)y  fever  and  jaundice.  Much  discussion  has  takiu 
place  concerning  tlic  true  nature  of  this  atTection,  but  it  has  nut  Iimi 
delinitely  determined  whether  it  is  a  specitic  disease  or  only  a  jamiiiirr 
whiiih  may  ho  due  to  various  causes.  The  nuijority  of  the  cases  iiavi'  n  ■ 
ctirred  durinij  tlu^  summer  months.  The  cases  have  occurred  in  ^Tdiiiisiii 
ditferent  cities.  A  few  cases  have  been  reported  in  this  country  (li,iii- 
phear).  Males  are  most  frerpiently  affected.  Many  of  the  cases  Ikho  Iiihi 
in  butchers.     The  ajjfe  of  the  patients  has  been  from  twenty-five  to  forty. 

The  disease  sets  in  abruptly,  usually  'witiiout  prodromes  ami  oftin 
with  a  chill.  There  are  lu'adache,  pains  in  the  back,  and  sonieliiiifs  in- 
tense pains  in  the  legs  and  muscles.  Tlie  fever  is  cliaracterized  l)y  imiikcil 
remissions.  Jaundice  appears  early.  Tlie  liver  and  s()leen  arc  usually 
swollen ;  the  former  may  lie  tender.  The  jaundice  may  be  light,  Init  in 
many  of  the  cases  described  it  has  been  of  the  obstructive  form,  ami  tlie 
stools  have  been  clay-coloved.  Gastro-intestinal  symptoms  arc  nircly  ]nv<- 
ent.  The  fever  lasts  from  ten  to  fourteen  days ;  sometimes  there  are  slight 
recurrences,  but  a  definite  relapse  is  rare. 

Albumen  is  usually  present  in  the  urine;  hnematuria  has  occuiri'd  in 
some  cases. 

Cerebral  symptoms,  delirium  and  coma,  have  been  met. 

In  the  few  post  morteins  which  have  been  made  nothing  distinctive 
has  been  found.  The  investigations  of  Jaeger  render  it  not  impossilik' 
that  this  epidemic  form  of  jaundice  depoids  upon  infection  with  a  pro- 
tens — bacillus  protean  jluorescens. 


INFKCTlorS   DISKASKS  OP  DOUBTFUL  ClIAUACTMR. 


(U)  MII.K-SK'KNKSS. 


iiST 


Tlii.-*  ronmrkablc  disciisc  j)r('vailM  in  ('crtiiiii  districts  of  tlic  rnitid 
States  \^<'st  (tf  the  Alk'fjhuny  iMountaiiis,  iiml  is  rdiiiicclt'il  with  tiu'  afuc- 
tioii  ill  i.ililt'  known  as  the  trniihlva.  It  prcvaiit'd  cxtciisivciv  in  the  early 
sciilriiiciits  in  certain  of  tlic  Weslern  States  and  proved  very  fatal.  'I'lie 
"ciicral  npinion  is  that  it  is  cnMiniiinicaled  to  man  oidy  hy  eatint;  tiie  llcsli 
or  (h'iiikiai,'  tlie  ndlk  of  diseased  animals,  'i'lie  Imlter  and  cheese  are  also 
|i(ii(Hiuiis.  In  unimaJM,  cuttle  and  ilie  yonnjj  of  horses  and  sheep  are  most 
fiusci'ptiltle.  It  is  stated  that  cows  f,MvIn;f  nulk  do  not  tliemselves  show 
iiiiirkcd  symptoms  nidess  driven  rapidly,  and,  aceordin!,'-  to  (iratf,  the  seero- 
Hmii  may  he  infective  when  the  disease!  is  latent.  When  a  cow  is  very  ill, 
fddil  i>  refused,  the  eyes  are  injected,  the  animal  stajr<:ers,  the  entire  nnis- 
ciiliir  system  trembles,  and  death  occnrs  in  <'onvidsions,  sometimes  with 
;.'iviit  siKldcnness.  Nothin^^  definite  is  known  as  to  the  cause  of  the  dis- 
I'iw.     It  is  most  frecpient  in  new  settlements, 

111  111,111  the  symptoms  are  those  of  a  nion;  or  less  acute  Intoxicution. 
After  11  tVw  days  of  uneasiness  and  distress  the  patient  is  seized  with  pains 
in  the  sldinach,  minsea  and  vomitint,',  fever  and  intense  thirst.  There  is 
iisuiilly  olislinate  constipation,  'i'lie  ton^^'iie  is  swollen  and  tremulous,  the 
liivath  is  extremely  foul  and,  accordinj^  to  (JralT,  is  :is  characteristic  of  the 
ilJM'ase  as  the  odor  is  of  small-pox.  Cerebral  symptoms — restlessness, 
irritiihility,  coma,  arid  convulsions — are  sometimes  marked,  and  there  may 
1,'niihiiilly  lie  pro'liiced  a  tyjihoid  state  in  which  the  patient  dies. 

The  liuralion  of  the  disease  is  variable.  In  the  most  acute  forms  death 
oi.riirs  within  two  or  three  days.  It  nniy  last  for  ten  days,  or  I'veti  for 
three  or  fdiir  weeks,  (iratf  states  that  insanity  occurred  in  one  case.  The 
liejsoiioiis  nature  of  the  llesh  and  of  the  milk  has  been  demonstrated  ex- 
jiCTiiiieiilally.  An  ounce  of  butter  or  cheese,  or  four  ounces  of  the  beef, 
raw  or  boiled,  rriven  three  times  a  day,  will  kill  a  don;  within  six  days. 
Xoiietiiiite  ])atliological  lesions  are  known.  Fortunately,  the  disease  has 
limiiiie  rare,  and  the  observation  of  Drake,  Vandcll,  and  others,  that  the 
ilisease  ifnidiially  disappears  with  the  clearinfj  of  tlu;  forests  and  improved 
tillaj;e,  lias  been  amply  substantiated.  It  still  prevails  in  parts  of  North 
Caroliim. 

(4)  MALTA   FEVER. 

This  disease,  also  known  as  Mediterranean  fever,  Xeapolitan  fever,  and 
rook  fever,  has  been  studied  particularly  by  the  naval  and  military  medi- 
cal otlieers  who  have  been  stationed  on  the  island  of  Malta.  It])revails 
also  in  Naples  and  other  districts  of  the  Mediterranean.  Wlnle  endemic 
111  the  island  of  Malta,  the  disease  in  some  years  reaches  epidetnic  propor- 
tions. Young  persons  are,  as  a  rule,  affected.  The  incubation  may  be 
from  six  to  ten  days. 

The  symptoms  are  thus  briefly  and  clearly  described  in  an  ■editorial  in 


ri>j. 


288 


SPECIFIC   INFECTIOUS  DISEASES. 


M^  :'■ 


the  British  Medical  Journal:*  "Tlie  disease  declares  itself  gradually, with 
headache,  sleeplessiu'ss,  loss  of  apjietite,  and  thirst,  often  without  shivor- 
ing  or  (liari'lid'H,  and  without  spots.  Symptoms  of  this  kind,  with  more 
or  less  severity,  last  for  three  or  four  .weeks;  apparent  but  dece2)tivt'  con- 
valescence then  usually  sets  in,  to  be  followed  in  a  few  days  by  a  relapse, 
with  rigors,  intense  headache  and  fever,  with,  frequently,  diarrlui'u.  i,i 
this  state  the  patient  nuiy  continue  for  live  or  six  weeks,  with  more  or  loss 
delirium.  Impi'ovcment  again  sets  in,  to  be  followed,  it  may  be,  by  an- 
other relapse  in  about  ten  tlays  or  a  fortnight,  with  shivering,  hea.laclie 
sleeplessness,  great  debility,  with  night -sweats,  pains  in  the  hips,  kiii'(;;, 
ankles,  anil  ell)o\vs,  and  often  in  one  or  both  testicles.  Again,  the  ]iatient 
enters  on  a  state  of  convalescence,  which  nuiy  last  for  a  month  or  six 
weeks.  The  old  symptcuns  nuiy  again  uj)pear,  with  extreme  debilitv,  a 
thickly  coatcvl  tongue,  with  thirst,  a  temperature  ranging  from  105'' Fahr. 
in  the  evening  to  nearly  normal  in  the  morning,  with  night-sweats  l)''iii('. 
ing  no  relief  to  the  general  distress.  The  rheumatic  symptoms  are  the 
most  constant  and  the  most  distressing ;  all  the  joints,  laig'c  and  .-nialh 
may  suiter.  Dr.  Veale  described  c;ises  in  which  the  intervertebral  juiiits, 
especially  those  of  the  lumbar  region  and  the  sacro-iliac  synchondroses, 
were  so  severely  alTected  that  the  patient  "dreads  every  movement";  he 
will  lie  for  days  in  one  position,  risking  the  formation  of  bed-sores,  and 
resisting  the  desire  to  evacuate  his  bowels  rather  than  encounter  the  snf- 
fering  that  a  movement  will  entail.  Oftentimes  the  tendo  Achillis  ami 
the  fibrous  structures  around  the  ankle-joint  are  involved ;  but  perhaps 
the  lumbar  aponeuroses  and  the  sheaths  of  the  nerves  issuing  from  the 
sacral  plexus  are  still  more  commonly  affected." 

The  alfection  is  distinct  from  either  typhoid  fever  or  malaria.  The 
mortality  is  about  two  per  cent.  According  to  Bruce,  no  characteristio 
typhoid  lesions  are  found  iu  fatal  cases.  This  author  has  descriljed  thi' 
presence  of  a  micrococcus  in  the  s[)lecn.  The  researches  of  Hughes  con- 
firm the  observations  of  Bruce,  and  the  mirronjccus  mclift'iisis,  as  it  is 
called,  has  been  obtained  in  pure  cultures,  and  in  six  cases  the  disease 
has  been  reproduced  in  monkeys. 

Fortumitely,  the  mortality  is  not  great.  With  reference  to  the  treat- 
ment, Bruce  coiududes  that  it  should  be  directed  principally  to  keepini' 
the  patient's  strength  u[)  by  fluid,  easily  digested  food,  by  stimulants  when 
requireil,  and  by  attention  to  ordinary  hygienic  principles.  The  removal 
of  the  patient  from  the  infected  area  does  not  cut  short  the  fever. 


(5)  MOUNTAIN  FEVER— MOUNTAIN   SICKNESS. 

Residence  for  a  time  at  a  high  altitude  is  in  some  instances  followed  hy 
a  group  of  symptoms  to  which  the  term  mountain  sickness  or  mountain 


•  Vol.  i,  1889. 


r'^> 


INFECTIOUS  DISEASES  OF  DOUBTFUL  CITAUA(^TER. 


289 


fever  Ikis  been  giv^n.  Sevonu  distinct  diseases  have  undoubtedly  been 
Uesri'ibi'l-  I^  is  by  no  means  certain  tliat  tbero  is  a  special  ulTection  to 
wliii'li  the  tei'iii  may  be  applied.  An  important  group,  the  mountain 
(unnniit,  is  associated  with  the  anchi^lodoiiia,  which  has  not  yet  been  met 
with  in  tlii--'  country.  A  second  group  of  cases  belongs  uiuiuestionably  to 
tvplioiii  fever,  and  undoubted  instances  of  this  disease  oc^-urringin  mount- 
iiiiuiiis  regions  in  the  West  are  referred  to  as  mountain  fever. 

Ill  the  very  full  and  clear  report  which  lloff*  gives  of  five  cases,  the 
clinieal  picture  is  that  of  typhoid  fever,  aiul  one  of  the  patients  died  of 
perfonitiiiM  of  the  ileum  with  well-defined  typhoid  lesion.  Even  from  the 
cliiiicul  rcjjorts,  unless  biased  by  notions  of  a  rigidly  characteristic  picture 
of  the  disease,  one  might  have  said  that  all  of  Surgeon  Jlolf's  cases  were 
tvphoid  fever,  and  the  post-mortem  record  leaves  no  question  as  to  the 
nature  of  the  malady.  Woodward,  commenting  upon  this  communication, 
ftatcH  that  there  is  in  the  United  Slates  Army  Medical  Museum  a  second 
jpeciiHcn  from  the  case  of  so-called  mountain  fever  contributed  by  Sur- 
geon frirard. 

Smart,  who  reviewed  the  entire  question  a  few  years  ago,  regarded  the 
(lisea.^e  as  a  typho-malarial  fever ;  but  there  is  nothing  in  his  account 
opposed  to  the  opinion  that  it  is  a  ty])hoid  fever. 

The  term  mountain  sickness  should  properly  be  applied  to  the  remark- 
able phenomena  which  develop  in  very  high  altitudes.  The  condition 
iias  been  very  accurately  described  by  Mr.  Whymper.  In  the  ascent  of 
C'iiiniborazo  they  were  first  alTected  at  a  height  of  10,0(14:  feet.  The  symp- 
tonis  were  severe  headache,  gasping  for  breath,  evidently  urgent  twsoin  de 
ri'spiri'r.  The  throat  was  parched,  and  there  was  intense  thirst,  loss  of 
appetite,  and  general  malaise.  Mr.  AVhymper's  temperature  was  100*4°. 
Tlie  symptoms  in  his  case  lasted  for  nearly  three  days.  In  a  less  aggra- 
vated form  such  symptoms  nay  present  themselves  at  much  lower  levels, 
and  in  the  ascent  of  the  railroad  at  Pike's  Peak  many  persons  suffer 
from  distress  in  breadiing.  The  original  cases  described  by  General 
Fremont  were  of  this  nature. 


iii-->« 


i: 


(6)  MILIARY   FEVRR-SWEATING   SICKNESS. 

The  disease  is  charaoterized  by  fever,  profuse  sweats,  and  an  eruption 
i>f  miliary  vesicles.  The  disease  prevailed  and  was  very  fatal  in  England 
in  the  liftoenth  and  sixteenth  centuries,  but  of  late  years  it  has  been  con- 
tined  entirely  to  certain  districts  in  Eranco  (Picardy)  and  Italy.  An 
opidemic  of  some  extent  occurred  in  Erance  in  1887.  Ilirsch  gives  a 
ilin>iioh>(ri('al  account  of  194  epidemics  between  1718  and  1879,  many 
of  whitli  w  M'e  limited  to  a  single  village  or  to  a  few  localities.  Occasion- 
iilly  the  disease  has  become  widely  spread.     Slight  epidemics  have  oc- 


•  American  Journal  of  the  Medical  Sciences,  January,  1880. 


290 


SPECIFIC  INFECTIOUS   DISEASES. 


cnrred  in  CJorniany  and  Switzorland.  They  are  usually  of  short  (hiratioii, 
lasting  only  for  tliroo  or  four  weeks — sometimes  not  more  than  seven  ur 
eijL^lit  days.  As  in  inlhienza,  a  very  large  number  of  persons  are  attacked  in 
rapid  succession.  In  the  mild  cases  tliere  is  oidy  sliglit  fever,  with  Idssof 
appetite,  an  erythematous  eni[)tion,  profuse  perspiration,  and  an  nutbivak 
of  miliary  vesicles.  The  severe  cases  present  the  symptoms  of  iiiteiisi' 
infection — delirium,  high  fever,  profound  prostration,  and  ha^nKiniiairo. 
'''lie  death-rate  at  tlie  outset  of  the  disease  is  usually  high,  and,  as  is  .<n 
graphically  desca-ibed  in  the  account  of  some  of  the  epidemics  of  tlie  mid- 
dle ages,  death  may  follow  in  a  few  hours. 


nm-i 


\4V. 


','!»•''' 


(7)   FOOT  AND  MOUTH    DISEASE— EPIDEMIC   STOMATITIS— 
APHTHOUS  FEVER. 

Foot  and  mouth  disease  is  an  acute  infectious  disorder  met  with  chioilv 
in  cattle,  sheep,  and  pigs,  but  attacking  other  domestic  animals.  It  is  df 
extraordinary  activity,  and  spreads  with  "lightning  rapidity"  over  vnst 
territories,  causing  very  serious  losses.  In  rattle,  after  a  period  of  iiieulm- 
tion  of  three  or  five  days,  the  animal  gets  feverish,  the  mucous  mciiibraiif' 
of  the  mouth  swells,  and  little  grayish  vedcles  the  size  of  a  iiciiip  ?iril 
begin  to  develop  on  the  edges  and  lower  portion  of  the  tongue,  on  the 
gums,  and  on  the  mucous  membrane  of  the  lips.  They  contain  at  lirsta 
clear  lluid,  which  becomes  turbid,  and  then  they  enlarge  and  grailiially 
become  converted  into  superficial  ulcers.  'J'here  is  ptyalism,  aiul  tlio 
animals  lose  flesh  rapidly.  In  the  cow  the  disease  is  also  frequently  siiii 
about  the  udder  and  teats,  and  the  milk  becomes  yellowish-white  in  colur 
aiul  of  a  mucoid  consistency. 

The  transmission  to  man  is  by  no  means  uncommon,  and  of  late  sov- 
eral  important  epidemics  have  been  studied  in  the  neighborhood  of  Berlin, 
Dr.  Salmon  informs  me  that  in  the  United  States  foot  and  mouth  disease 
has  very  rarely  occurred,  but  in  1870,  as  well  as  in  1841,  the  disease  \va.> 
communicated  in  a  few  instances  to  man.  In  ZuilTs  translation  of  Fricii- 
berger  and  Frohner's  Pathology  and  Therapeutics  of  Domestics  Animal- 
(I*hiladel{)liia,  18!)'))  the  disease  is  thus  described:  "  Transmission  uf 
aphthous  fever  to  man  is  not  rare.  The  veterinarian  has  oftener  occasion 
to  observe  it  than  the  physician.  The  use  of  milk  from  aphthous  cows 
contaminates  children  quite  frequently  and  is  fatal  to  them.  This  may 
also  happen  through  ingestion  of  butter  or  cheese  made  of  milk  coiiiin? 
from  aphthous  animals,  or  also  directly  thro\igh  wounds  of  the  arm?, 
hands,  or  by  intermediary  agents.  In  man  the  symptoms  are:  fever, 
digestive  troubles,  and  vesicular  eruption  upon  the  lips,  the  buccal  aiul  plm- 
ryngeal  mucous  membranes  (angimi).  The  disease  does  not  seeui  to  be 
transmissible  through  the  meat  of  diseased  animals.  Perhaps  the  serioii* 
affections  of  the  skin  whioh  were  observed  to  develop  in  childreu  after 


INFKCTIOUS  DISEASES  OF   DOUBTFUL  CHARACTER. 


2Jn 


viiL'L'inat 
takiii;,'  I 

111  w 

u>  liii'im 

Siege  !'■■< 

Scvr 

with  ir. 

Wllr 
;illil  till 

ihc  iiuli 


i,,n   (ospeciiilly  in  lSS3-'S-t)  may  have  been  determiiied  by  niis- 
iie  iiuuninary  oniptioii  of  ajihthous  fever  for  cow-pox." 
idi'-spreail  opidemies  there  has  been  sometimes  a  marked  tendency 
iirhagos.     The  disease  runs,  as  a  rule,  a  favorable  course,  but  in 
report  of  a  recent  epidemic  the  mortality  Avas  8  j)er  cent. 
nil  forms  of  micro-organisuis  have  been  described  in  connectiou 

11  epidemics  are  prevailing  in  cattle   the  milk  shoulil  be  boiled, 
iroper  proi)hylactic  measures  taken  to  isolate  both  the  cattle  and 


u 

1^;'!! 


11 


F 


livitliials  who  come  in  contact  with  them. 


1    1 


Iff" 


If 


!n..'M 


Ml 


SECTION   II. 


CONSTITUTIONAL    DISEASES. 


I.    RHEUMATIC    FEVER. 


-^ 


^11 


•1^ 


Definition. — An  acuto,  non-contagioiis,  febrile  affection,  dopendino: 
upon  iin  unknown  infoctivo  agent,  and  characterized  by  multiple  arthritis 
and  a  special  tendency  to  involve  the  heart. 

Etiology. — Acute  rheumatism  i)revails  in  temperate  and  in  humiil 
climates.  It  is  rare  in  the  tropics.  Newsholme  (Milroy  Lectures,  18!i')i 
concludes  that  the  disease  occurs  in  e})idemics  without  regular  periodiuitv, 
but  which  recur  at  intervals  of  three,  four,  or  six  years;  that  they  van 
much  ill  intensity  ;  a  severe  epidemic  is  apt  to  be  followed  by  two  or  tlntr 
light  outbreaks.  It  prevails  most  extensively  during  the  spring  inotitli,\ 
In  liell's  statistics,  of  4.50  cases  treated  at  the  Montreal  General  Hospital 
during  ten  years,  the  largest  number  of  cases  were  admitted  in  Fehriiarv, 
March,  and  April.  Tiie  same  proportion  seems  true  in  Europe  and  in  tiic 
cities  of  the  Atlantic  coast. 

Age. — Young  adults  are  most  frequently  affected,  but  the  disease  is  by 
no  means  uncommon  in  children  between  the  ages  of  ten  and  iifteen  years. 
Sucklings  are  rarely  affected,  and  prol)ably  many  of  the  cases  which  have 
been  described  belong  to  a  totally  dilTerent  affection,  the  arthritis  of  in- 
fants. In  exceptional  cases,  however.  U'\w  rheumatism  does  occur.  The 
following  age  table  is  based  upon  4r)t'  cases  admitted  to  the  Montreal  Gen- 
eral Hospital:  Under  15  years,  4':}rS  per  cent;  from  15  to  25  yeans,  48'C8 
per  cent;  from  25  to  35  years,  25'8T  per  cent;  from  35  to  45  years,  13'6 
per  cent;  above  45  years,  7*4  per  cent.  Of  the  (!55  eases  analyzed  by 
Whipham  for  the  Collective  Investigation  Committee  of  the  British  Medi- 
cal Association,  only  32  cases  occurred  under  the  tenth  year  and  80  per 
cent  between  the  twentieth  and  fortieth  year.  These  figures  scarcely  give 
the  ratio  of  cases  in  children. 

Sex. — If  all  ages  are  taken,  males  are  affected  oftener  than  females. 
In  the  Collective  Investigation  Keport  there  were  375  males  and  ^^t9 
females.  Up  to  the  age  of  twenty,  however,  females  predominate.  Be- 
tween the  ages  of  ten  and  fifteen  girls  are  more  prone  to  the  disease. 


RHEUMATIC   FEVER. 


293 


Occupations  which  necessitate  exposure  to  cold  and  to  great  changes 
in  tempi '■•tin'P  predispose  strongly  to  rheinnatirfm.  We  meet  the  disease 
oftuiK'^f  111  drivers,  servants,  bakers,  sailors,  and  laborers.  Heredity  seems 
i;i  some  cases  to  have  a  special  inlluence,  and  the  disease  is  more  common 
ill  CTriuin  fiiinilies.  Of  all  etiologicul  factors,  cold  is  believed  to  be  the 
most  potent.  Many  cases  follow  a  sudden  wetting  or  eliilliug  of  the  skin. 
The  essential  cause  of  rheumatism  is  still  unknown.  There  uro  three 
^.liR.f  theories : 

(ii)  MrlabuUc :  that  it  depends  upon  a  morbid  material  produced 
within  the  systeni  in  defective  processes  of  assindlation.  It  has  been  sug- 
iTostcd  tliiit  this  material  is  lactic  acid  (L'rout)  or  certain  combinations 
with  litciic  acitl  (Latham).  Our  kiu)wkHlge  of  the  chemical  relations  of 
the  varitiiis  products  produced  in  the  regressive  nutritive  changes  is  too 
hmiteil  to  huso  much  reliance  upon  these  views.  Ivichardson  claims  to 
hiiVL'  pi'odiieed  rheumatism  by  injecting  lactic  acid  and  by  its  internal  ad- 
iiiinistnuion. 

[h)  The  nervous  theory  advanced  by  J.  K.  'Mitchell  has  many  advo- 
calw.  According  to  this  view,  either  the  nerve-cent I'cs  are  primarily 
[illucted  Ijy  cold  and  the  local  lesions  are  really  trophic  in  character,  or 
\\w  primary  nervous  disturbance  leads  to  errors  in  metabolism  and  the 
iTiiimdaliDn  of  lactic  acid  in  the  system.  The  advocates  of  this  view 
;.  ;.';iid  as  analogous  the  arthropathies  of  myelitis,  locomotor  ataxia,  and 
'•hitroa. 

(r)  Germ  theory :  that  the  arthritis  is  due  to  a  specific  microbe.  In 
f;ivor  of  this  view  may  be  mentioned  the  close  analogy  whirli  exists  be- 
\\\m\  rluMunatism  and  certain  of  the  infectious  diseases.  The  analogy  is 
iiiarla'd  with  gonorrhoea,  scarlet  fever,  and  septic  processes,  which  are  fre- 
liuntly  associated  with  arthritis  and  endocarditis.  The  investigations 
iiithorto  made  have  not,  however,  shown  the  constancy  of  any  niicro- 
orgaiiisiii  in  the  disease.  Sahli  has  found  an  organism  resembling  the 
<tiiphylococeiis  citreus,  but  of  low  virulence ;  and  Leyden  a  diplococcus 
Hlfuriiig  from  that  of  pneumonia. 

Morbid  Anatomy. — There  are  no  changes  characteristic  of  tli3 
Jijrajc.  The  all'ected  joints  show  hypenemia  aiul  swelling  of  the  synovial 
inoiubraucs  and  of  the  ligamentous  tissues.  Tiiere  inav  be  sliuht  erosion 
of  tho  cartilage.  The  fluid  in  the  joint  is  turbid,  albuminous  in  charac- 
tor,  iiiul  contains  leucocytes  ami  a  few  fibrin  flakes.  Pus  is  very  rare  in 
'iiir'oiniilicatcd  cases.  Rheumatism  rarely  jiroves  fatal,  except  when  there 
:r.v  xriuiis  complications,  such  as  pericarditis,  endocarditis,  myocarditis, 
lik'iirisy,  or  pneumonia.  The  conditions  fouiul  have  nothing  peculiar, 
nothing  to  distinguish  them  from  other  forms  of  inllanunation.  In  death 
h'liii  liyporpyrexia  no  special  changes  occur.  The  blood  usmdly  contains 
aiu'xcossivc  amount  of  fibrin.  In  the  secondary  rheumatic  inllammations, 
ii-<  likiirisy  and  pericarditis,  various  pus  organisms  have  been  found,  possi- 
%  the  result  of  a  mixed  infection. 


\  ^'\m\i 


Ik 

i  'I 


i4 


294 


CONSTITUTIONAL  DISEASES. 


Symptoms. — As  n  rule,  tlio  disease  sets  in  abruptly,  but  it  hkivIk 
preceded  by  irregular  pains  in  the  joiiitn,  slight  maha'se,  sore  thi./at.  Mini 
particularly  ])y  tonsillitis.  A  dellTiite  rigor  is  uneomnioti ;  more  ofti,, 
there  is  sliglit  ciiiljiness.  'i'lie  fever  rises  (piiekly,  and  witii  it  one  uriiioiv 
of  tlie  joints  become  painful.  Within  twenty-four  hours  from  tlir  (insc;, 
the  disease  is  fully  developed.  The  temperature  range  is  fiom  in-.'  i,, 
104°.  The  pulse  is  frequent,  soft,  and  usually  above  100.  The  tongue  i- 
moist,  aiul  rajiidly  becsomes  covered  with  a  white;  fur.  There  are  the  ordi- 
nary  symptoms  associated  with  an  acnite  fever,  such  as  loss  of  ainietiU'. 
thirst,  constipation,  and  a  scanty,  highly  acid,  highly  colored  urine  In  a 
nnijority  of  the  cases  there  are  profuse,  very  acid  sweats,  of  a  pecuhar  sour 
odor.  Su'l.iminal  and  miliary  vesicles  ai'e  abundant.  The  mind  is  clear, 
exvjept  in  the  cases  willi  hyperpyrexia.  The  affected  joints  are  painful  td 
iiu)ve,  and  soon  become  swollen  and  hot,  and  jiresent  a  reddish  Hush. 
The  knees,  ankles,  elbows,  and  wrists  are  the  joints  usually  attacked,  not 
together,  but  successively.  l"'or  example,  if  the  knee  is  lirst  affected,  the 
redness  may  disappear  fi'om  it  as  the  wrists  become  painful  and  Imt. 
The  disease  is  seldom  limited  to  a  single  articulation.  The  amount  nf 
swelling  is  variable.  Extensive  ell'usion  into  a  joint  is  rare,  and  mucli  of 
the  eidargement  is  due  to  the  infiltration  of  the  periarticular  tissues  with 
serum.  The  swelling  may  be  limited  to  the  joint  proper,  but  in  the  wrist; 
and  ankles  it  sometimes  involves  the  sheaths  of  the  tendons  and  produee- 
great  eidargement  of  the  hands  and  feet,  (,'orrespoiuling  joints  are  ofteii 
alfected.  In  attacks  of  great  severity  every  one  of  the  larger  joints  miiv 
be  involved.  The  vertebral,  sterno  clavicular,  and  phalangeal  artirnla- 
tions  are  less  often  inllamed  in  acute;  than  in  gonorrlueal  rheiunulijni, 
Perhaps  no  disease  is  more  painful  than  acute  polyarthritis.  'I'lie  in- 
ability to  change  the  posture  without  agonizing  i)ain,  the  dreiiehing 
sweats,  the  prostration  and  utter  helplessness,  cond)ine  to  nuike  it  one  of 
the  most  distressing  of  febrile  alfections.  A  special  feature  of  the  di.>;ease 
is  the  tendency  of  the  inflammation  to  subside  in  one  joint  while  develop- 
ing with  great  intensity  in  aiH)ther. 

The  temperature  range  in  an  ordinary  attack  is  between  ioi°  iuni 
104°.  It  is  peculiarly  irregidar,  with  marked  remissions  and  exacerba- 
tions, depending  very  much  upon  the  intensity  ami  extent  of  the  articular 
inliammatioji.  Defervescence  is  usually  gradual.  The  profuse  sweat; 
nuiterially  influence  the  temperature  curve.  If  a  two-hourly  chart  is  niatle 
and  observations  upon  the  sweats  are  noted,  the  remissions  will  usuall\  be 
found  coiiu'ident  with  the  sweats.  The  perspiration  is  sour-smelling  ami 
acid  at  first;  but,  when  persistent,  becomes  neutral  or  even  alkaliiu'. 

The  blood  is  profoundly  and  rapidly  altered  in  acute  rheiiniatism. 
There  is,  indeed,  no  acute  febrile  disease  in  which  the  an.Tmia  develop; 
with  greater  rapidity.     'I'here  is  a  well-marked  leucocytosis. 

With  the  high  fever  a  nuu'mur  may  often  be  heard  at  the  apex  re- 
gion.    Endocarditis  is  also  a  common  cause  of  an  a])ex  bniit.     The  heart 


f      s-^ 


"  1  If 


RHEUMATIC   FEVER. 


295 


.-,li(mltl  he  (carefully  oxuminod  at  the  lirrft  visit  and  subsequently  each 

tliiy. 

The  urine  is,  as  a  rule,  reduced  in  amount,  of  high  donsity  and  high  col- 
or. It  is  very  ueid,  and,  on  cooling,  di'})osit,s  urates.  The  chloi'ides  may  be 
■TOiitlv  (liiuiuished  or  even  absent.     Febrile  albuminuria  is  not  uneommon. 

'I'hf  saliva  may  become  acid  in  reaction  and  is  said  to  contain  an 
I'xcc'ss  of  sulphocyanides. 

SUHAd-m    IvlIKUMATISM. 

Tlii-  represents  a  milder  foriu  of  ihe  disease,  in  which  all  the  symp- 
toiua  luv  less  pronounced.  The  fever  rarely  rises  above  101°  ;  fewer  joints 
lire  involved ;  and  the  arthritis  is  less  intense.  The  cases  may  drag  on  for 
wiivki  uv  months,  and  the  disease  may  liiudly  become  chrpnic.  It  should 
iiDt  be  fi)rgolten  that  in  children  this  mild  or  subacute  form  may  be  asso- 
I'iatwl  witli  endocarditis  or  ])ericarditis. 

Complications. — These  are  important  and  serious. 

(1)  Hyperpyrexia. — The  temi)erature  may  rise  rapidly  a  few  days  after 
tin;  unset,  and  be  associated  with  delirium;  but  not  necessarily,  for  the 
ti'inpenituro  may  rise  to  108°  or,  as  in  one  of  Da  Costa's  cases,  110°,  without 
aivbfal  symptoms.  The  delirium  may  precede  or  follow  the  onset  of  the 
liy[ierpyrexia.  As  a  rule,  with  the  high  fever,  tlie  pulse  is  j'eeble  and  fre- 
(liu'iir,  tlic  prostration  is  extreme,  and  linally  stui)or  supervenes. 

(;')  Cardiac  Affections. — (n)  /■Jiidocarditis,  the  most  frerpient  and  seri- 
ous c()iii[ilication,  occurs  in  a  eousiderublo  percentage  of  all  cases.  The 
statistics  upon  this  point  are  not  of  much  value,  as  the  diagnosis  has  been 
liiiscd,  as  a  rule,  upon  the  develo{)ment  of  a  sy.stolic  min'mur  at  apex  or 
basf.  This  is  quite  untrustworthy ;  since  it  may  depend  upon  causes 
i'iIkt  than  endocarditis.  The  mitral  segments  are  most  frequently  in- 
viilvcd  and  the  att'ection  is  usiuiUy  of  the  simple,  verrucose  variety.  Ulcer- 
ative omloearditis  in  the  course  of  acute  rheumatism  is  very  rare.  Of  209 
casus  of  this  disease  which  I  analyzed,  in  only  24  did  the  symj)toms  of  a 
severe  endocarditis  arise  during  the  progress  of  acute  or  subacute  rheuma- 
tism. Tills  eoinplication,  in  itself,  is  rarely  dangerous?.  It  produces  few 
symptoms  and  is  usually  overlooked.  Uiiliappily,  though  the  valve  at  the 
tiiiK!  may  nut  be  seriously  damaged,  the  inflammation  starts  changes  which 
load  to  sclerosis  and  retraction  of  the  segments,  and  so  to  chronic  valvular 
disease. 

(//)  Pi'yiriirdilis  may  occur  independently  of  or  together  with  endo- 
larditis.  It  may  be  simple  fdiriuous,  sero-fibrinous,  or  in  children  puru- 
lent, t'liiiically  we  meet  it  more  frequently  in  connection  with  rheuma- 
tism than  all  other  afPeetions  combined.  The  phy.sical  signs  are  very 
diaracteristi(!.  The  condition  will  be  fully  described  under  its  appropriate 
section.  A  ])cculiar  form  of  delirium  may  develop  during  the  progress  of 
riieiiinatic  pericarditis. 
20 


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206 


CONSTITUTIONAL   DISEASES. 


(c)  Afyocnrdifis  is  moat  frccjueiit  in  connection  with  endo-piiicunljal 
cliungcH.  Tlio  iiiiiitoniiciil  condition  is  a  gnmuliir  or  i'.ilty  dcgcniraliduof 
the  heiirt-nnisclc,  \vlii(.'li  leads  to  weakening  of  tiic  walls  and  to  (lilui;i. 
tion.  It  is  not,  I  think,  nearly  so  coinnion  as  the  oilier  cardiac  allcctiinb, 
8.  West  has  re]iorted  instances  of  acnte  dilatation  of  the  lieart  in  rluii- 
nuitie  fever,  in  one  of  which  marked  fatty  changes  were  found  in  ilu 
lieart-tibres. 

(;»)  Pulmonary  Affections. —  I'neninonia  and  ])leiirisy  arc  not  uncdn,. 
men,  anil  frecinenlly  accoiuiiany  the  ca^es  of  endo-pericarditis.  Accotdin: 
to  Howard's  analysis  of  a  large  number  of  cases,  there  were  puhnoriarv 
complications  in  only  1U"5  ])cr  cent  of  cases  of  rheumatic  endocanliiis;  in 
58  per  cent  of  cases  of  pericarditis;  and  in  il  i)er  cent  of  cases  of  I'luld. 
pericarditis.  CJongestion  of  the  lung  is  occasionally  found,  and  in  suvm! 
cases  has  proved  rapidly  fatal. 

(4)  Cerebral  Complications. — These  are  due,  in  part,  to  the  liy|Hi. 
pyrexia  and  in  part  to  the  special  action  upon  the  brain  of  the  toxic  a^'iiit 
of  the  disease.  They  may  be  grouped  as  follows  :  [ii)  DeUriuin.  This  i- 
usually  associated  with  the  hyjjcrpyrexia,  but  may  be  inde])endent  (if  ii. 
It  may  be  active  and  noisy  in  character;  more  rarely  u  low  nnittiriiiij 
delirium,  passing  into  stupor  and  coma.  Special  mention  must  lie  niink' 
of  the  delirium  wliicli  occurs  in  connection  with  rlieumatic  jiericanlitis. 
Delirium,  too,  nuiy  be  excited  by  the  salicylate  of  soda,  either  shortly  iificr 
its  administration,  or  more  commonly  a  week  or  ten  days  later,  {b)  ('mm, 
which  is  more  serious,  may  develop  without  preliminary  delirium  or  con- 
vulsions, and  may  prove  rapidly  fatal.  Certain  of  tliese  cases  are  asifo- 
ciatcd  with  hyperpyrexia;  l)ut  Soiithey  has  reported  the  case  of  a  girl  who, 
■without  previous  delirium  or  high  fever,  became  comatose,  and  died  in  kfS 
than  an  hour.  A  certain  nundjer  of  such  cases,  as  those  reported  by  Da 
Costa,  have  boon  associated  with  marked  renal  changes  and  were  evidently 
urannic.  The  coma  may  develop  during  the  attack,  or  after  convale<criiic 
has  set  in.  (r-)  ('itiwnhioiis  aic  less  common,  though  they  may  premk' 
the  coma.  Of  1^7  observations  cited  by  Besnier,  there  were  137  of  deliiiimi, 
only  7  of  convulsions,  17  (if  coma  and  convulsions,  54  of  delirium,  comii, 
and  convidsions,  and  W  of  other  varieties  (Howard),  {d)  L'liurcn.  The 
relations  of  this  disease  and  i-heunuitism  will  be  subsequently  (li.<cii?jid. 
It  is  sulllcient  here  to  say  that  in  only  88  out  of  554  cases  wliicli  I  have 
analyzed  from  the  Infirmary  for  Diseases  of  the  Nervous  System,  Pliila- 
delphia,  were  chorea  and  rlieumatism  associated.  It  is  most  ajit  to  develup 
in  the  slighter  attacks  in  childhood,  {v)  MvuinfjiUs  is  extremely  nirf. 
though  undoubtedly  it  does  occur.  It  must  not  be  forgotten  that  in 
ulcerative  endocarditis,  which  is  occasionally  associated  with  acute  rlieu- 
matism, meningitis  is  frequent. 

(5)  Cutaneous  Affections. — Sweat- vesicles  have  already  been  nientioneil 
as  extremely  common.  A  red  miliary  rash  may  also  develop.  Scarlatim- 
form  eruptions  are  occasionally  seen.     Purpura,  with  or  without  urticaria, 


RIIRUMATIC  FEVER. 


2»7 


mav  ofi'iir,  iind  various  forms  of  crythoiiiii.  It  is  doubtful  \vlu>ther  tlio 
L'HSL'Sof  fx It'll '^'vo  imrpura  witli  urticiiriii  ami  artliritis — ])('liosis  rlunimatica 
— iH^loiiLr  iiiily  to  acute  rhcuiuatisni. 

(11)  Rheumatic  Nodules.— 'I'lu'so  curious  structures,  in  the  form  of  small 
qilicutaiu'ous  uodules  attaciu'd  to  llio  tendons  aiul  fascia",  have  been  known 
forsoiur  vcars;  but  special  attention  has  been  2>iii<1  !o  them  of  late,  since 
their  canful  study  by  Harlow  ami  Warner.  'J'hey  vary  in  size  from  a 
small  sluil  to  a  large  pea,  and  are  most  numerous  on  the  lingers,  hands, 
iiiid  wrists.  They  also  occur  about  the  elbows,  knees,  the  spiiu's  of  the 
vt^rtelira',  and  the  scapulae  'I'hey  are  not  often  tender.  They  do  iu)t 
lU'iTSsarilv  ciiuu'  on  during  the  f(!Ver,  but  may  be  found  on  its  decline,  or 
uvrii  imlependently  altogether  of  an  acute  attack.  They  may  develop 
with  great  rai)idity  and  usually  last  for  weeks  or  numths.  They  are  more 
iiiiuiiiiin  in  children  than  in  adults,  and  their  presenc^e  may  be  regarded 
asapositive  indication  of  rheumatism.  Tlmy  have  been  noted  ])articularly 
ill  a>>(H'iation  with  severe  and  chronic,  rheumatics  endocarditis.  They  msiy 
incur  in  large  numbers  in  adults,  as  in  a  case  reported  from  my  clinic  in 
l'hihnli'lpliia,  by  J.  K.  Mitchell.  Histologically  they  are  made  up  of  round 
ami  ^iiiiidle-shaped  cells. 

TIk'  ciiursr  of  acute  rheumatism  is  extremely  variable.  It  is, as  Austin 
Flint  iirst  showed,  a  self-limited  disease,  and  it  is  iu)t  probable  that  medi- 
cine.^ have  any  spectial  iniluence  upon  its  ihinUion  ov  course,  (iull  and 
SuttnTi  who  likewise  studied  a  series  of  sixty-two  cases  without  special 
nvatiiu'iit  arrived  at  the  same  conclusion. 

Diagnosis. — Practically,  the  recognition  of  acute  rheumatism  is  very 
ia«\ ;  liiu  there  are  several  aU'ections  which,  in  some  particulars,  closely 
ri'scmble  it. 

(1)  Multiple  Secondary  Arthritis.— Under  this  term  may  be  embraced 
till'  various  forms  of  arthritis  which  come  on  or  follow  in  the  course 
ul'ilic  infective  diseases,  such  as  gonorrluca,  scarlet  fever,  dysentery,  and 
cerebro-spinal  meningitis.  Of  these  the  gonorrhcval  form  will  receive 
special  consideration  and  is  the  type  of  the  entire  group. 

{'I)  Septic  Arthritis,  which  develops  in  the  course  of  pyaemia  from 
any  cause,  and  particularly  in  puer])eral  fever.  Xo  hard  and  fast  line 
can  bo  drawn  between  these  and  the  cases  in  the  first  group  ;  but  the 
iiilliiniination  rapidly  passes  on  to  suppuration  and  there  is  more  or  less 
dtstnietiou  of  the  joints.  The  conditions  under  which  the  arthritis  de- 
vi'iiipsgive  a  clew  at  once  to  the  nature  of  the  case.  Undc  this  section 
may  also  bo  mentioned  : 

(a)  Acule  necrosis  or  acute  osfeo-myelitis,  occurring  in  the  lower  end 
lofthefomur,  or  in  the  tibia,  and  which  may  be  mistaken  for  acute  rheu- 
;  iiiatism.  Sometimes,  too,  it  is  multiple.  The  greater  intensity  of  the  local 
l^yniptoms,  the  involvement  of  the  epiphyses  rather  than  the  joints,  and 
I  the  iiioiv  serious  constitutional  disturbances  are  points  to  be  considered. 
The  condition  is  unfortunately  often  mistaken  for  acute  arthritis,  and,  as 


^1;!!! 


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208 


CONSTITUTIONAL   DISEASES. 


m:  ; 


M 


'  i '  M<' 


tho  treatment  Is  essentially  surgical,  the  error  is  one  which  may  cost  t!ie 
life  of  tli(>  i)a(ient. 

(//)  The  (irttfc  (irthrilis  (if  iiifiDilx  must  ))e  distiiiguislied  fr(iiin'li(.ii. 
iiialisMi.  It  is  a  disease  wliidi  is  usually  conliiunl  to  one  joint  (the  lii|i(,r 
knee),  the  elTusioii  in  which  I'apidly  hecomes  purulent.  The  alTectiiniis 
most  eommon  in  sucklings  and  is  undouhtedly  pyttMuie  in  charactiT.*  It 
may  also  develoii  in  th{>  gonorrho-al  ophthalmia  or  vaginitis  of  iIuhmv. 
horn,  as  pointed  out  hy  Clement  Lueas. 

(;j)  It  is  only  in  rare  instances  that  gout  and  acute  rhenmatism  an 
confounded.  Tlie  localization  in  a  single,  usually  u  small,  joint,  tlicn^'c, 
tiie  history,  the  mode  of  onset — are  features  which  enable  us  to  recogiiiz^ 
the  cases  readily. 

Treatment. — The  bed  should  have  a  smooth,  soft,  yet  elastic  inattrc", 
Tho  patient  should  wear  a  llannel  night-gown,  which  may  be  opened  nil  \h 
way  down  the  front  and  slit  along  the  outer  margin  of  the  sleeves.  Tlirw 
or  four  of  tiiese  should  be  made,  .so  as  to  facilitate  the  fretpieiit  cliuii:.'!" 
re(piired  after  the  sweats.  He  may  wear  also  a  light  llannel  cape  about  tin 
shoulders,  lie  should  sleej)  in  blankets,  not  in  sheets,  so  as  to  reduce  the 
liability  to  I'atch  cold  aiul  obviate  the  unpleasant  clamminess  coiiseqiiHit 
upon  heavy  sweating.  Chambers  insisted  tliat  the  liability  to  eiulocur- 
(litis  and  pericarditis  was  much  reduced  when  the  ])atients  wen;  in  liliiiikil«, 

Milk  is  the  most  suitable  diet.  It  may  be  diluted  with  alkaline  inih- 
cral  waters.  Lemonade  and  oatmeal  or  barley  water  should  lie  i'rnlv 
given.  The  thirst  is  usually  great  and  may  be  fully  satisfied.  Tluroi- 
no  objection  to  broths  and  souj)s  if  the  milk  is  not  well  borne,  'i'lio  W, 
should  be  given  at  short  and  stated  intervals.  As  convalescence  is  o.-tai)- 
lished  a  fuller  diet  may  be  allowed,  but  meat  should  be  used  spariuirly. 

The  local  treatment  is  of  the  greatest  importance.  It  often  siilli(.T>t' 
wrai")  the  altected  joints  in  cotton.  If  the  pain  is  severe,  hot  cloths  iiiaj 
be  apjilied,  saturated  with  Fuller's  lotion  (carbonate  of  soda,  0  driiclini.-; 
laudanum,  1  oz. ;  glycerine,  2  oz. ;  and  water,  0  oz.).  Tincture  of  iienniiv 
or  chloral  may  be  employed  in  an  alkaline  solution.  Chlorofor^a  liiiinieiit 
is  also  a  good  application.  Fixation  of  the  joints  is  of  great  sei'vice  it 
allaying  the  pain.  I  have  seen,  in  a  German  hospital,  the  joints  ('iicln*i 
in  })laster  of  Paris,  ap))arently  with  great  relief.  Splints,  jiaddcil  aiii 
bandaged  with  moderate  firmness,  will  often  be  found  to  relievo  p;ia 
Friction  is  rarely  well  borne  in  an  acutely  inflamed  joint.  Cold  com- 
presses are  much  used  in  Germany.  The  application  of  blisters  iibnvt 
and  below  the  joint,  often  relieves  the  pain.  This  method,  wliich  "^iJ 
used  so  much  a  few  years  ago,  is  not  to  be  compared  with  the  light  appl:- 
cation  of  the  Paquelin  thermo-cautery. 

Medicines  have  little  or  no  control  over  the  duration  or  course  of  tlie 


*  Townsend,  Acute  Arthritis  of  Infants,  American  Journal  of  the  Medical  Science 
January,  1390. 


|ifl-;'(i,:  i 


RIlKUMATir   FKVKU. 


200 


(iiseiLsc,  wliicli,  like  other  st'lf-liuiitcd  alTcctioiis,  pmcticiilly  takra  its  own 
time  to  di^!i^)l)cur.  Siilic'yl  compounds,  which  were  rcj^'unU'd  so  h)ii<,'  ha 
siHM'irK'.  ill  ll't'  disi'iiso,  arc  now  known  to  act  chiefly  hy  relieving  piiin. 
i;  1'.  Iliiw.ird'.s  ehiboratc  analysis  shows  tliat  they  do  not  intliieiice  thu 
iliinitiiiiMif  tlio  disease.  Mor  (lo  1hey  prevent  the  occnrri'nce  of  (cardiac; 
(■oiiiiiliciiioMS,  whilo  under  tlieir  use  rehipses  arc  coiisiderahly  more  fre- 
Miicnl  than  in  any  other  method  of  treatment.  In  acute  cases  with  severe 
iiaiii  till'  salieyl  compDunds  give  prompt  relief  and  rarely  disappoint  us  in 
tlii'ir  artioM.  Sodium  salicyhite,  in  fifte(«n-grain  doses  for  eiglit  or  fen 
(josus,  may  he  given.  Tlie  hicarhonate  of  i)otassiutn  in  twenty-grain  doses 
may  bo  used  with  it.  Many  prefer  salicin  (gr.  'ZO)  in  wafers;  others  the 
salicylic  acid  (gr.  ^0)  or  salol.  I  have  for  tlie  i)!ist  live  or  six  years  used 
ili(M)il  of  wintergreen,  reeommende(l  by  Kinnicutt,and  have  found  it  quite 
a»  I'llieacions.  'J'wenty  minims  n)ay  be  given  every  two  hours  in  milk. 
Tilt'  salicyl  compounds  are  best  given  in  full  doses  at  the  outset  of  tlie 
disease,  to  relieve  the  pain.  Tlien  tlie  dose  should  be  rciiuccd  in  fre- 
niu'iicv,  or,  if  tlu^  Kym[)toms  have  abated,  stopped  altogetlier,  as  relapses 
juv  certainly  more  frequent  uiuler  their  use. 

Alkalies  may  be  coudnned  with  the  salicyhites,  or  may  be  used  alone. 
The  j){itassium  bicarbonate  in  lialf-draehm  doses  may  be  given  every  three 
(ir  fdur  hours  until  the  urine  is  rendered  alkaline.  Fuller,  who  so  warudy 
suiiporli'il  this  method  of  treatment,  was  in  the  haliitof  ordering  a  drachm 
and  a  half  of  the  sodium  bicarbonate  with  half  a  draclun  of  jjotassiuiu 
ai'ctate  in  three  ounces  of  water,  rendered  ctTerveseent  at  the  time  of  ad- 
nuiiistratiou  by  half  a  drachm  of  citric  acid  or  an  ouiu^e  of  lemon-juice. 
This  is  given  every  three  or  four  hours,  and  usually  l)y  the  eiul  of  twenty- 
four  hours  tluMiriue  is  alkaline  in  rea(!tion.  The  alkali  is  then  reduced, 
and  the  amount  subsequently  regulated  by  the  degree  of  acidity  of  the 
uriiic,  only  enough  being  given  to  keep  the  secretion  alkaline.  Ojtinion 
is  almost  auainmous  that,  under  the  alkaline  treatment,  cardiac  complica- 
tiiiiis  arc  loss  common.  The  combination  of  the  salicylates  with  the  alkali 
is  probably  tlie  most  satisfactory.  Care  must  be  taken  to  watch  the  heart 
during  the  adnnnistration  of  these  remedies.  In  the  only  fatal  case  of 
rlieumiitism  which  has  come  in  my  experience  the  patient  had,  owing  to 
an  error,  taken  the  full  first  day's  dose  of  Fuller's  alkaline  treatment  for 
five  saccessive  days,  instead  of  having  the  salt  gradually  reduced.  She 
died  suddeidy  on  the  tifth  day  after  sitting  up  in  bed.  Salicylates  also,  if 
given  largely,  are  very  depressing  to  the  circulation. 

To  allay  the  pain  opium  may  be  given  in  the  form  of  Dover's  powder, 
or  morphia  hypodermically.  Antipyrin,  antifebrin,  and  phenacetin  are 
useful  sometimes  for  the  purpose.  During  convalescence  iron  is  indicated 
"1  full  doses,  and  quinine  is  a  useful  tonic.  Of  the  complications,  hyper- 
pyrexia should  be  treated  by  the  cold  bath  or  the  cold-pack.  The  treat- 
ment of  endocarditis  and  pericarditis  and  the  pulmonary  complications 
^vill  be  considered  under  their  respective  sections. 


lu  I 

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'  I' 

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i  '  ;it"t' ■'?■■?  !i!.^J 


;3()0 


CONSTITUTIONAL   DISKASKS. 


II.    CHRONIC    RHEUMATISM. 


Etiology. — 'riii.s  ulToclion  nmy  fi)ll()\viiii  iiciitiM)!-  Hubiicutu  attack,  but 
nioit'  coiimiuiily  coiiich  on  insidiously  in  persons  who  litivo  ims.-cd  the 
niidtiio  [)L'rio(l  of  life.  Iti  my  I'XiK'ricnco  it  is  extrcnudy  ruru  us  u  s((|ii(iic,. 
of  iUHito  rlieiimatisin.  It  is  most  common  iimonj^  the  poor,  parlii'idiiilv 
waslicr-womcii,  day  laborers,  and  those  whose  oueujuition  (exposes  llicm  td 
cold  and  <la'"p. 

Morbid  Anatomy. — The.  synovial  nicmhranesare  injeeted,  hut  tlicrt' 
ia  nsually  not  much  etTusion.  'I'he  capsule  and  lij,'ameiits  of  the  joints  are 
tliickened,  and  tiie  sheaths  of  tin*  tendons  in  tlu!  iieif,'hl)orhood  uiulcivo 
similar  alterations,  so  that  the  free  ])lay  of  the  joint  is  jfreatly  imjiaind, 
In  lonj;-standin<?  cases  the  cartilages  also  und(!rgo  chanj^es,  and  may  show 
erosions.  Kven  in  eases  with  the  severest  8yni])toms,  the  joint  may  bo 
very  slij^htly  aiti'rcd  in  appearance.  Important  chanjfcs  tak(!  place  in  tlic 
muscles  and  nt-rves  adjacent  to  chronically  intlamed  joints,  ])arliciilai'lv 
in  the  mono-articular  lesions  of  the  shoulder  or  hip.  Muscular  at I'dphy 
supervenes  {)artly  fi'om  disuse,  })artly  through  luirvous  inlluences,  ci  lur 
centric  or  reflex  (N'ulpian),  or  as  a  result  of  peripheral  neuritis.  Jn  hoiiiu 
cases  when  the  joint  is  mu(di  disteiuled  the  wasting  may  be  due  to  inc-." 
ure,  eitlier  on  the  muscdes  themselves  or  on  the  vessels  supitiying  tliciii. 

Symptoms.— St ilTness  and  ))aiii  are  the  cliief  features  of  cliroiiic 
rheunnitism.  'I'lie  latter  is  very  liable  to  exacerbations,  especially  lim- 
ing changes  in  the  weather.  The  joints  may  be  tender  to  tin;  t(tucli  and  ii 
little  swollen,  but  seldom  reddened.  As  a  rule,  many  joints  are  allVcdi]; 
but  there  are  instances  in  which  the  disciiso  is  contitu'd  to  one  slioiiMir. 
knee,  or  hip.  The  stitTne-ss  and  paiji  are  more  marked  after  rest,  and  as  tlip 
day  advances  the  joints  may,  with  exertion,  become  much  more  supple. 
The  general  health  may  not  be  seriously  im])aired.  'J'he  disease  is  not 
immediately  dangerous.  Anchylosis  may  occur,  and  ultinuitely  tlie  joints 
may  become  very  distorted.  In  many  instances,  particularly  tlioso  in 
which  the  pain  is  severe,  the  general  health  may  be  seriously  involved 
and  the  subjects  become  anivmic  and  very  apt  to  suffer  with  neurf.Igia  .nul 
dyspepsia.  Valvular  lesions,  due  to  slow  sclerotic  changes,  are  not  un- 
common. They  are  associated  with,  not  dependent  upon,  the  articular 
disease. 

The  proffnosi's  is  not  favorable,  as  a  majority  of  the  cases  resist  nil 
methods  of  treatment.  It  is,  however,  a  disease  which  persists  imletin- 
itelv,  and  does  not  necessarily  shorten  life. 

Treatment. — Internal  remedies  are  of  little  service.  It  is  important 
to  maintain  the  digestive  functions  and  to  keep  the  general  health  at  a 
high  standard.  Iodide  of  potassium,  sarsaparilla,  and  guaiacum  are  some- 
times beneficial.     The  salicylates  are  useless. 

Local  treatment  is  very  beneficial.  "  Firing "  with  the  Paquelin 
cautery  relieves  the  pain,  and  it  is  perhaps  the  best  form  of  counter- 


PSKL'DO-IlIlKUMATir  AFFE(  TIONS, 


301 


irritation.  Miissjige,  with  passive  motion,  liclps  to  reditno  swcllinjr,  imd 
provciiH  lUicliylosiH.  It  i-s  |)iirli('iiliii'Iy  iisrl'iil  in  ciists  wliich  nvv  iisso- 
ciiitt'ii  witli  atrophy  of  tiiu  iniisclcs.  Electricity  is;  not  of  iiiiicii  liciudlt. 
Cliiiiiitii-  trcatiiiciit,  is  very  atlvaiita.i,'coiis.  Many  ciisi'S  an;  j^rcatly  helped 
liv  |iriiloii;,'i'd  n'si(k'n(;()  in  sontliurn  Knrojjo  or  sontluii'M  ('iilifornia.  Ki<^li 
[aticiil.s  slioidd  always  winter  in  the  South,  and  in  this  \Miy  avoid  the 
cold,  (liiriip  wcallier. 

JlydniiliiTapeutic  measures  are  specially  bonelu'iul  in  (dironi(!  rliou- 
miitism.  (ireat  relief  is  alTorded  i)y  wrap|)in.i^  the  alTected  joints  in  cold 
clotli.1,  covered  with  a  thin  layer  of  blanket,  and  prolcciled  with  oili-il  silk. 
The  Tiirkisli  I):ith  is  useful,  hut  the  full  honelit  (d'  this  Ircattncnt  is  rarely 
seen  cxicpt  al  Ijatliin^jf  eslal)lisliments.  'I'lie  hot  alkaline  waters  are  par- 
tii'iilai'ly  useful,  and  a  resideneo  at  tlio  Hot  Sprini(s  of  V'ir<jinia  or  Ar- 
kansas, or  at  Manlf,  in  the  Uocky  A[onntains,  on  the  Canadian  Pacitlc  Rail- 
way, will  sonictimoa  euro  even  obstinate  cases. 


III.    PSEUDO-RHEUMATIC    AFFECTIONS. 

Those  are  luiiiierous,  aiul  occur  as  ooniplieationa  or  Herpiolffi  of  nniny 
iiifi'ctiiius  diseases  with  wl)i(di  they  luive  been  considered.  The  one  wliioh 
is  of  most  iniportanoe,  and  whi(di,  though  a  nnrgical  alTection,  is  usually 
trt'Utcd  (if  in  works  on  medicine,  is  — 

Gonorrhoeal  Arthritis. — 'i'iiough  custom  has  sanctioned  the  term,  the 
alTcitioii  has  iiotliing  whatever  to  do  witli  rheumatism,  but  is  an  arthritis 
or  synovitis  of  a  septic  nature,  due  to  infecticm  from  the  nretliral  dis- 
iliariro.  It  occurs  eitlier  during  an  acute  attack  of  gonorrluea,  or.  more 
iniiiiiionly,  as  the  attack  subsides,  or  when  it  has  become  (dironic.  It  is 
far  more  frerpient  in  men  than  in  women.  An  attai  k  may  occur  in  a 
newly  married  woman  infected  by  an  old  gleet  of  the  husband.  It  is 
liatile  to  recur,  and  is  an  affection  of  extraordinary  obstinacy.  Many 
joints  may  l)e  alfected,  the  knees  and  ankles  at  times  most  commonly.  It 
IS  peculiar  iji  attacking  certain  joints  which  are  rarely  inv(dved  in  acute 
rlieuniutisni — as  the  sterno-clavicular,  the  intervertebral,  the  temporo- 
iiiaxillary,  and  the  sacro-iliac. 

The  iiiutfomirid  changes  are  variable.  The  inllammation  is  often  peri- 
articular, and  extends  along  the  sheaths  of  the  tendons.  When  effusion 
occurs  ill  the  joints  it  rarely  becomes  purulent.  It  has  more  commonly 
tlio  characters  of  a  synovitis.  About  the  wrist  and  hand  suppuration 
.'ometimcs  occurs  in  the  sheaths,  and  in  a  recent  case  in  Dr.  llalsted's 
wards  the  gouococci  were  obtained  in  jiure  culture.  In  the  bacteriological 
examination  the  gonococci  have  been  found  in  the  exudate,  but  not  often. 
Ihoy  may  be  present  in  the  tissues,  however,  and  cause  an  effusion  which 
•nay  he  sterile.  It  has  been  suggested  that  the  simple  arthritis  or  synovi- 
tis follows  absorption  of  ptomaines  from  the  urethral  discharge,  while  the 
more  severe  suppurating  forms  are  due  to  infection  with  pus  organisms. 


3(12 


CONSTITUTIONAL  DISEASES. 


lU'^ll 


The  sj/i)ip/oms  of  this  disease  are  very  variable.  The  followiiifr  clinii'al 
forms  may  l)i'  rccoffiiizoil  : 

{(i)  Arlhrithjic^  in  wliicli  tliore  are -wandering  pains  about  tlic  Joints, 
without  redness  or  sw(!llin<(.     Tiicse  persist  for  a  long  time. 

{b)  /'(iJi/iir/Iiridc,  in  which  several  joints  become  alTectad,  jtist  as  in 
subacute  articular  rlieiimatihUi.  The  fever  is  slight :  the  local  intliuunm. 
tion  may  fix  itself  in  one  joint,  but  more  commoidy  s^everal  become  swolkn 
and  tender.     In  this  form  cerebral  and  cardiac  complications  may  occur. 

(c)  Acute  <ionorrliwal  a  ikriiis,  in  which  a  single  articulation  liccoiiics 
suddeidy  involved.  The  ])ain  is  severe,  the  swelling  extensive,  and  diifi 
chiedy  to  peri-articular  o'denui."  Tiie  general  fever  is  not  at  all  propor- 
tionate to  tlie  intensity  of  the  local  signs.  'I'he  allection  usually  resolves, 
though  suppuration  occasionally  supervenes. 

{(l)  C/iro/iic  J/j/dnoi/irosis. — This  is  usually  mono-articnhir.  and  is 
particularly  apt  to  involve  the  knee.  It  comes  on  often  without  piiiii, 
redness,  or  swelling.  Formation  of  pus  is  rare.  It  occurred  only  twice  in 
ninety-six  cases  tabulated  by  Molen. 

{(')  llarstil  (Hid  Si/novud  Form. — This  attacks  chiefly  the  tendons  ami 
their  sheaths  and  the  bursa"  and  the  periosteum.  The  articulations  niiiv 
not  h.:  ad'ected.  The  bursie  of  the  patella,  the  olecranon,  and  the  temi" 
Aehillis  are  most  apt  to  be  involved. 

(/)  Septicd'utic. — Occasionally  with  an  acute  arthritis  tlic  gunoeocii 
invade  the  blood,  and  the  j)icture  is  that  of  an  intense  septieo-jnaiiiin. 
usually  with  endocarditis. 

I{.  L.  MacDonneil  recently  analyzed  twenty-seven  cases  of  gonorrliii';il 
rheumatism  at  the  Montreal  (leneral  IIosj)ital,  of  which  four  prosenteil 
signs  of  recent  canliac  disease.  Gluzinski  has  collected  thirty-one  c-bi- 
from  the  literature.  The  eiulocarditis  is  ilsually  simple,  but  oceasioiially 
there  is  an  intense  infeittion  and  ulcerative  endocarditis  with  syinptoins 
resembling  typhoid  fever. 

From  the  blood  of  a  patient,  a  woman,  recently  in  my  wards,  with  iiw- 
lignant  endocarditis,  the  gonococei  were  cultivated  and  the  diagno.«is  iiuulo 
during  life.    Acute  goiu)rrho'al  myocarditis  may  also  occur  (ronneiliiian). 

The  disease  is  mucli  more  intractable  than  ordinary  rheumatism,  aiii 
relapses  are  extremely  common.    It  may  become  chronic  and  last  for  year-. 

Complications. — Iritis  is  not  infrequent  and  may  recur  with  suc- 
cessive attacks.  The  visceral  complications  arc  rare.  Pericarditis  aii'l 
pleurisy  m.'iy  occur. 

Treatment. — 'ilie  salicylates  are  of  very  little  service,  nor  do  they 
often  relieve  the  pains  in  this  alTection.  Iodide  of  potassiinu  has  alsn 
proved  useless  in  my  hands,  even  given  in  large  doses.  A  general  toiiii 
treatment  seems  much  more  suitable — quinine,  iron,  and,  in  the  ehroiii' 
cases,  arsenic. 

The  local  treattnent  of  the  joints  is  very  important.  The  tliprnio- 
cautery  may  be  used  to  allay  the  pain  and  reduce  the  swelling.    In  acute 


! 


IM... 


MUSCULAR  RUFATMATISM. 


303 


cases  fixation  of  the  joints  is  very  berieficiiil,  and  in  the  chronic  forms, 
mussairt'  aiiil  pussivo  motion.  The  surgical  trcatiiicnt  of  tliis  alTection,  as 
carricil  mil  nowadays,  is  nioro  satisfactory,  and  I  have  seen  strikingly  good 
results  follow  incision  and  irrigation. 


IV.  MUSCULAR    RHEUMATISM  {Myalgia). 


Definition.— A  painful  afTection  of  tlie  voluntary  muscles  and  of  the 
faseiii;  ami  })t'riosteum  to  which  they  are  attached.  The  alTection  has  re- 
ceived various  names,  according  to  its  seat,  as  torticollis,  lumbago,  pleuro- 
dynia, etc. 

Etiology. — The  attacks  follow  cold  and  ex^josure,  the  usual  condi- 
tions favorable  to  the  development  of  rheumatism.  It  is  by  no  means  cer- 
tain that  the  muscular  tissues  are  the  seat  of  the  disease.  Many  writers 
dtiini,  pcrliiips  correctly,  that  it  is  a  neuralgia  of  the  sensory  nerves  of  the 
miisclos.  l.'ntil  our  knowledge  is  more  accurate,  however,  it  may  be  con- 
sidered uuiliT  the  rhcunuitic  affections. 

It  is  most  commoidy  met  with  in  men,  particularly  those  exposed  to 
cold  ami  whose  occupatio'  s  are  laborious.  It  is  :>rt  to  follow  ex])osurc  to 
;i.  dnuiijlit  of  air,  as  from  an  open  window  in  a  i.'.ilway  carriage.  A  sud- 
den chilling  after  heavy  exertion  may  also  bring  on  an  attack  of  lumbago. 
Persons  of  a  rheumatic  or  gouty  habit  are  certaiidy  more  prone  to  this 
idleelion.  One  attack  renders  an  individual  more  lialtle  to  another.  It  is 
usually  acute,  but  may  become  subacute  or  even  chronic. 

Symptoms. — The  alfection  is  entirely  local.  The  constitutional  dis- 
turbance is  slight,  and,  even  in  severe  cases,  there  may  be  no  fever.  Pain 
is  a  p.-ominent  symptom.  It  may  be  constant,  or  may  occur  oidy  when 
the  i.ins(di's  are  drawn  into  certain  positions.  It  may  bo  a  dull  ache  or  a 
bruised  pain,  or  sharp,  severe,  and  cramp-like.  It  is  often  sutliciently  in- 
tense to  cause  the  patient  to  cry  out.  Pressure  on  the  affected  part  usu- 
iillv  ifi'es  ndief.  As  a  rule,  myalgia  is  a  transient  affection,  lasting  from 
a  few  hours  to  a  few  days.  Occasionally  it  is  prolonged  for  several  weeks. 
It  is  very  apt  to  recur. 

The  fcdiowing  arc  the  principal  varieties  : 

(1)  Lumbago,  one  of  the  most  common  and  painful  forms,  affects  the 
muscles  of  the  loins  and  their  tendinous  attachments.  It  occurs  chiefly  in 
workingmen.  It  comes  on  suddenly,  and  in  very  severe  casop,  completely 
incapacitates  the  patient,  who  may  be  unable  to  turn  in  bed  or  to  rise  from 
the  sitting  posture. 

(■')  Stiff  neck  or  torticollis  affects  the  muscles  of  the  antero-lateral 
region  of  the  neck.  It  is  very  common,  and  occurs  most  frequently  in 
the  young.  The  person  holds  the  head  in  a  peculiar  manner,  and  rotates 
the  whole  body  in  attempting  to  turn  it.  Usually  it  is  confined  to  one 
side.    The  muscles  at  the  back  of  the  neck  may  also  be  affected. 


'  J  PI       •• 

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304 


CONSTITUTIONAL   DISEASES. 


(3)  Pleurodynia  involves  tlie  intercostal  muscles  on  one  side,  and  in 
some  instances  the  pectorals  and  sorratus  nuignus.  This  is,  perhaps,  tlio 
most  painf  nl  form  of  the  disease,  as  the  chest  cannot  be  at  rest,  ^l  is  nuirt. 
common  on  the  left  than  on  the  right  side.  A  deep  breath,  or  eoii^liiiii;, 
causes  very  intense  })ain,  and  tlie  respiratory  movements  are  restrirunl  on 
the  alleoted  side.  'JMiere  nuiy  be  i)ain  on  pressure,  sometimes  over  a  vcrv 
limited  area.  It  may  be  dilVicidt  to  distinguish  from  intercostal  neuralgia, 
ill  which  alTeetion,  however,  the  pain  is  usually  more  circumscribed  and 
paroxysmal,  ami  there  are  tendei'  points  along  the  course  of  the  nervos. 
It  is  sometimes  mistaken  for  jjleurisy,  but  careful  jdiysical  examination 
readily  distinguishes  between  the  two  alTeetions. 

(4)  Among  other  forms  which  may  be  mentioned  are  cephalodynia, 
affecting  the  muscles  of  the  head  ;  scapulodyiiia,  omodynia,  and  dorsodynia, 
affecting  the  muscles  about  the  shoulder  and  up[icr  jiart  of  the  back,  ib- 
algia  may  also  occur  in  the  abdominal  musclcj  and  in  the  muscles  of  thi 
extremities. 

Treatment. — T^est  of  the  affected  muscles  is  of  the  first  importanec. 
Straj)i)ing  liu!  side  will  sometimes  completely  relieve  pleurodynia.  Nu 
belief  is  more  wide-sjn'cad  among  the  public  tlian  the  cllicacy  of  porous 
plasters  for  muscular  pains  of  all  sorts,  particularly  those  about  the  trunk. 
If  the  pain  is  severe  and  agonizing,  a  hypodermic  of  morphia  gives  im- 
mediate relief.  For  lumbago  acupuncture  is,  in  acute  cases,  the  niD.^t  clli- 
cient  treatment.  Xeedles  of  from  three  to  four  inches  in  length  (ordiiuirv 
bonnet-needles,  sterilized,  will  do)  are  thrust  into  the  lumbar  mu.'^cK'.'^  at 
the  seat  of  the  ])ain,  and  withdrawn  after  five  or  ten  minutes.  In  many 
Instances  the  relief  is  in)mediate,  and  I  can  corroborate  fidly  tlie  stuk- 
ments  of  Kinger,  who  taught  me  thi.s  practice,  as  to  its  extraordinary  aiid 
prompt  ellieaey  in  numy  instances.  The.  cbnsiant  current  is  sonu'tiini.- 
very  beneficial.  In  many  forms  of  myalgia  the  thermo-cautery  gives  great 
relief.  In  obstinate  cases  blisters  may  be  tried.  Hot  fomentations  an' 
soothing,  and  at  the  outset  a  Turkish  bath  may  cut  short  the  attack.  In 
chronic  cases  iodide  of  potassium  nuiy  l)e  used,  and  both  guaiaeiun  and 
sulphur  have  been  strongly  recommemled.  Persons  sul.iject  to  this  affec- 
tion should  be  warmly  clothed,  and  avoid,  if  yiossible,  exposure  to  cold 
and  damp.  In  gouty  persons  the  diet  should  be  restricted  and  tlic  alka- 
line mineral  waters  taken  freely.  Large  doses  of  nux  vomica  are  le- 
times  beneficial. 


Ill  iaiiiilii's  w 


I 


ARTHRITIS   DEFORMANS. 


305 


V.    ARTHRITIS    DEFORMANS   {Rheumaluid  arthritis). 


Definition. — A  chronic  disease  of  the  joints,  cliuraeterizetl  hy  (changes 
ill  the  ciirtilaLTos  and  synovial  membranes,  with  periarticuhir  formation  of 
lioiie  uiitl  L'l'cat  deformity. 

Etiolog'y.  —  \joug  believed  to  be  intimately  associated  both  witli  gout 
;uiil  rl'iCUMiatisin  (whence  the  names  rheumatic  gout  and  rheumatoid  ar- 
tliritis),  tliis  close  relationship  seems  now  very  doubtful,  since  in  a  ma- 
jdi'itv  of  the  cases  no  history  of  eitiier  utfection  can  be  determined.     It  is 
ilitliriih  U)  sejuirate  some  cases  from  ordinary  chronic  rheumatism,  but  the 
inultiple  form  lias,  in  all  probability,  a  nervous  origin,  as  suggested  by  J, 
K.  Mitilu'll.     Tliis  view  is  based  upon  such  facts  as  the  association  of  the 
(lisca-c'with  shock,  worry,  and  grief;  the  simihirity  of  the  arthritis  to  the 
;irthr<>|iathios  diu^  to  disease  of  the  cord,  as  in  locomotor  ataxia;  the  sym- 
iiii'trical  distribution  of  the  lesions  ;  the  remarkable  trophic  changes  which 
Icjid  til  alteration.^  in  the  skin  and  nails,  and  occasionally  to  muscular 
\wi-tii.g  out  of  proportion  to  the  joint  mischief.     Ord  regards  the  disease 
,     '  'iiogous  to  progressive  muscular  atrophy,  and  due  either  to  a  primary 
,  ,11  the  cord  or  to  chang(>s  the  result  of  periiiheral  irritation,  trau- 
iii..;i;;,  nfciine,  urethral,  etc.     The  true  nature  of  the  disease  is  still  ob- 
scure, hilt  the  ueuro-trophic  theory  meets  very  many  of  the  facts.    Females 
■dw  iinire  liable  to  the  disease  than  males.     In  Archibald  K.  (larrod's  table 
iif  MiO  cases  there  were  411  females  and  89  males.     It  most  comrnotily  sets 
in  lictwei'ii  the  ages  of  twenty  aiid  tliirty,  but  it  may  begin  as  late  as  tifty. 
Ii  iircms  mIso  ill  children;  within  the  past  live  years  there  have  been  at 
my  clinics  four  cases  in  children  under  twelve.     'I'he  degree  of  deformity 
may  be  extreme  even  at  this  early  age.     Hereditary  influences  are  not 
uiiroiiimoii.     In  (iarrod's cases  there  were  in  2]()  instances  a  family  history 
oi'  joint  disease.     Seguin  has  reported  the  occurrence  of  three  cases  in 
rliildicn  of  the  same  family.     It  is  stated  that  the  disease  is  more  common 
in  fainilios  wi.'i  i^lit'iisical  history.     It  seems  to  be  more  fre<|uent  in  women 
wlio  have  '.    ;    •■;;•  i,m  and  uterine  trouble,  or  who  are  sterile.     In  this 
country  aiu       !.  Mu-vtism  or  gout  in  the  forebears  is  rare.     ^lental  worry, 
prii'f,  and  anxn;  v  .  .\r.m  frequent  antecedents.     It  is  an  atTe(,'tion  quite  as 
(■imuiion  in  the  ric''.  id  in  the  poorer  classes,  though  in  Knghind  and  the 
Continent  the  latter  seem  more  prone  to  the  disease.    'IMiough  often  uttrib- 
iitod  t(  .  iild  or  damp,  and  occasionally  to  injury,  there  is  tu>  evidence  that 
these  are  ctVicient  causes. 

Morbid  Anatomy. — The  changes  in  the  joints  dider  es.sentially 
fioiu  tliose  of  gout  in  the  absence  of  deposits  of  urate  of  soda,  and  from 
'hiunic  riii'iimatism  by  the  existence  of  extensive  structural  alterations, 
piirticuiin,  in  the  cartilages.  We  are  largely  indebted  to  the  magnificent 
*vorkoi.\H  •!•]  for  our  knowledge  of  the  anatomy  of  this  disease.  The 
f'Hanges  bt-giu  in  the  cartilages  and  synovial  membranes,  tlie   cells  of 


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306 


CONSTITUTIONAL   DISEASES. 


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which  pntliforate.  Tho  cartilage  covering  tlio  joint  nnrlergnos  u  pepuliiiv 
librilhition,  becomes  soft,  and  is  either  al)sorl)0(l  or  gradnally  tliimuil  l,v 
attrition,  tlius  hiving  bare  iho  ends  of  tlie  bone,  whicli  beconu?  sniootli, 
polished,  und  eburnated.  At  tlic  margins,  wliero  the  pressure  is  less,  the 
proliferating  elements  may  develo])  into  irregular  nodules,  which  os-ifv 
and  enlarge  the  heads  of  the  boTies,  forming  osteophytes  which  cdinplotclv 
lock  the  joint.  'I'he  j)eriosteum  may  also  form  new  bone.  There  i.s  iisii- 
ally  great  tliickening  of  the  ligaments,  and  tinally  complete  aiicli\i(i>;. 
results.  'J'his  is  rarely,  however,  a  true  anchylosis,  but  is  caused  bv  tlif 
osteophytes  and  thickened  ligaments.  There  are  often  hyperostosis  and 
increase  in  the  articular  ends  of  the  bone  in  length  and  thiekuc'ss,  In 
long-standing  cases  and  in  old  persons  there  nuiy,  on  the  other  liand.  W 
great  atrophy  of  the  heads  of  the  affected  bones.  The  spongy  siibstiiin. 
becomes  friable,  and  in  the  hip-joint  the  wasting  nuiy  reach  such  a;. 
extreme  grade  that  iho  articulating  surface  lies  between  tho  trocliantcr.v 
This  is  sometimes  cai'.j'  n-  rbus  coxm  senilis.  The  anatomical  cliaiiL'i- 
may  lead  to  great  def(.  .      The  metacarpal  joints  are  enhugcil  iiini 

thickened,  and  the  fingers  ..^e  deHected  toward  the  ulnar  side.  The  tncj 
often  show  a  similar  deflection.  The  nodosities  at  the  joints  are  known  as 
Ilaygarth's  nodosities. 

The  muscles  become  atro])hied,  and  in  some  cases  the  wasting  roacliH 
a  high  grade.  Neuritis  has  been  demonstrated  in  the  nerves  about  tlie 
joints. 

Symptoms. — Charcot  makes  a  convenient  division  of  the  cases  inm 
TTeberden's  nodosities,  the  general  progressive  form,  ami  the  partial  ir 
mono-articular  form. 

Heberden's  Nodes. — In  this  form  the-tlngers  are  affected,  ami  "liui' 
hard  knobs"  develop  gradually  at  the  sides  of  tho  distal  |)haLiiig(>.  Tiny 
are  much  more  common  in  women  than  in  men.  They  begin  usiiiiliy 
between  the  thirtieth  and  fortieth  year.  The  subjects  nuiy  have  Iw'i 
digestive  troubles  or  gout,  lleberden,  however,  says  "  they  have  no  ccii- 
nectiou  with  gout,  being  found  in  ])ers(uis  who  never  had  it."'  In  tiK 
early  stage  the  joints  may  be  swollen,  tender,  and  slightly  red,  partieiilariv 
when  knocked.  The  attacks  of  pain  ami  swelling  may  come  en  in  ti;'' 
joints  at  long  intervals  or  follow  indiscretion  in  diet.  The  little  tuberdr 
at  the  sides  of  the  dorsal  surface  of  the  secoiul  phalanx  increase  in  size, 
and  give  the  characteristic  appearance  to  tlr  affection.  The  eartiliii.'^ 
also  become  soft,  and  the  ends  of  the  bones  eburnated.  Urate  ef  soda  i; 
never  deposited  (Charcot).  The  condition  is  not  curable;  but  there i> 
this  hopeful  feature — the  subjects  of  these  nodosities  rarely  have  involve- 
ment of  the  larger  joints.  They  have  been  regarded,  too,  as  an  iinlicatiiii 
of  longevity.  Charcot  states  that  in  women  with  these  nodes  cancer  seem- 
more  frequent. 

General  Progressive  Form. — This  occurs  In  two  varieties,  acute  am 
chronic.     The  acute  form  may  resemble,  at  its  outset,  ordinary  urticiilar 


ARTHRITIS  DEFORMANS. 


307 


ilie:iMiati.-!ii.  Tlicre  are  involvenunit  of  iiiiuiy  joints;  swollinpr,  particularly 
of  tlie  >viii)vial  .sliuaths  ami  l)ursas  not  often  rt'diioss;  hut  tlicro  is  iiiod- 
crutt'  ffViT.  Howard  describes  tliis  condition  as  most  frccpicnt  in  young 
women  fioni  twenty  to  thirty  years  of  ajje,  often  in  eonno(;tion  witli  rect!nt 
ilclivcrv,  lactation,  or  raj)id  child-bearin<r.  Acute  cases  may  develoj)  at 
the  iiie]io|>iiuse.  It  may  also  conic  on  in  children.  "These  patients  sulTer 
ill  their  mineral  health,  heeomo  weak,  pale,  depressed  in  spirits,  and  lose 
iK'sli.  Ill  .-cvcral  cases  of  this  form  marked  intervals  of  improvement  have 
uepurred;  the  local  disease  has  ceased  to  [irogress,  and  toleral)le  comfort 
has  been  experienced  perhaps  until  pregnancy,  delivery,  or  lactation  again 
lieteriiiiiie  a  fresh  outbreak  of  the  disease." 

'J'he  rliriinic  form  is  by  far  the  most  common.  The  joints  are  usually 
involved  symmetrically.  The  first  symptoms  are  pain  on  movement  and 
sli<f|it  swelling,  which  may  bo  iu  the  joint  itself  or  in  the  peri-articular 
sheatlis.  In  some  cases  the  effusion  is  marked,  in  others  slight.  The 
Ideal  coiulitions  vary  greatly,  and  periods  of  improvement  alternate  with 
attacks  of  swelling,  redness,  and  pain.  At  first  only  one  or  two  joints  are 
alTected ;  usually  the  joints  of  the  hands,  then  the  knees  and  feet ;  gradu- 
ally otlier  articulations  are  involved,  and  in  extreme  cases  every  articula- 
tion in  the  body  is  affected.  Pain  is  an  extri'inely  varialih;  symiitom. 
Some  cases  proceed  to  the  most  extreme  deformity  without  jjain  ;  ia 
ethers  the  sutfering  is  very  groat,  iiarticiilarly  at  night  and  during  the 
exaeerliatiuiis  of  the  disease.  There  are  cases  in  wliicdi  pain  of  an  agoniz- 
ing character  is  an  almost  constant  symptom,  rerpiiring  for  years  the  use 
of  iiiorpliiu. 

Gradually  the  shape  of  the  joints  is  greatly  altered,  partly  hy  the  pros- 
enee  of  osteojihytes,  partly  by  the  groat  thickening  of  the  cajisular  liga- 
ments, and  still  more  by  the  retraction  of  the  muscles.  In  moving  the 
aiTeeted  joint  crepitation  can  be  felt,  due  to  the  eburnation  of  the  articular 
siufuees.  Ultimately  the  joints  become  completely  locked,  not  by  a  true 
lioiiY  anchylosis,  but  by  the  osteophytes  M'hich  form  around  the  articular 
sui'faeos,  like  ring-bone  in  horses.  T'here  is  al-o  a  spurious  anchylosis, 
i-M\m\  by  the  thickening  of  the  cajisular  ligaments  and  fibrous  adhesions. 
The  muscles  about  the  joints  undergo  important  changes.  Atrophy  from 
ilisus(  gnidiiidly  sii})ervenos,  and  contractures  tend  to  fiex  the  thigh  upon 
the  abiliiiiieii  and  the  leg  upon  the  thigh.  There  are  cases  with  rajiid 
uuLspiilar  wasting,  symmetrical  involvement  of  the  joints,  and  trophic 
t'lianrres  which  strongly  suggest  a  central  origin.  Numbness,  tingling, 
I'igineiitatiun  or  glossiness  of  the  skin,  and  onychia  may  be  present.  In 
extreme  cases  the  patient  is  completely  helpless,  and  lies  on  one  side  with 
'1h'  Icl's  drawn  up,  the  arms  lixecl,  and  all  tlio  articulations  of  the  extremi- 
ties loekeil.  Fortunately,  it  often  happens  in  these  severe  gonorul  cases 
that  the  joints  of  the  hand  are  not  so  much  alTected,  and  the  patient  may 
be  able  to  knit  or  to  write,  though  unable  to  walk  or  to  use  the  arms.  It 
IS  surprising  indeed  how  much  certain  patients  with  advanced  arthritis 


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308 


CONSTITUTIONAL  DISEASES, 


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deformans  can  acooniitlisli.  No  one  who  IkuI  seen  thci  boauUfu'l  inoilols 
and  n)ic,i-os(',oj)io  iJi-cpJiralions  of  tlio  late  11.  1).  Schmidt,  of  New  OiKjui?, 
coiihl  imairiiio  that  lie  liad  been  afflieted  for  years  with  a  most,  cxtroiiio 
gnide  of  this  terribk)  disease.  In  iiumy  cases,  after  involvinj,^  two  or 
tliree  joints,  the  disease  becomes  arrested,  and  no  fnrthor  devcloinucm 
occurs.  It  may  be  limited  to  tlic  wrists,  or  to  tlic  knees  and  wrists, or 
to  tiie  knees  and  aiikh'S.  A  majority  of  the  patients  tinally  rcacli  a 
quiescent  staj^e,  in  whicli  tliey  aie  free  from  [mn  and  enjoy  excellent 
health,  suffering  only  from  the  inconvenience  and  cripi)ling  ncccssiirilv 
associated  with  the  disease. 

Coincident  alTcctions  are  not  nncommon.  In  the  active  stagt' the  pii- 
tionts  are  often  amumic  aiul  sntYer  from  dysjiepsia,  which  may  recur  at 
intervals.     Tiiere  is  no  tendency  to  involvement  of  tlie  heart. 

1'he  partial  or  mono-articular  form  atfects  chieHy  old  persons,  aiul  \< 
seen  particularly  in  the  hip,  the  knee,  th((  sjjinal  column,  or  shoulder,  it 
is,  in  its  anatomical  feature.--  identical  with  the  general  disease.  In  tlic 
liip  and  shoulder  the  muscles  early  show  wasting,  and  in  the  hip  the  con- 
dition ultimately  becomes  that  already  described  as  morbus  co.iw  nciiilis. 
These  cases  seem  not  infrequently  to  follow  an  injury.  They  dilTer  from 
the  polyarticular  form  in  occurring  chietly  in  men  and  at  a  later  pcrind  of 
life.  One  of  the  most  interesting  forms  affects  the  vertebra',  coiiqilctt'lv 
locdving  the  articulations,  and  producing  the  condition  known  n^  .^■jihiuIii- 
litis  clcfoDniuis.  Wlien  the  cervical  spine  is  involved  the  head  caiiiHt 
be  moved  up  and  down,  but  is  carried  stitliy.  Usually  rotation  can  ln' 
elTccted,  The  dorsal  and  lumbar  sjdues  nuiy  also  oe  involved,  and  t!; 
body  cannot  be  flexed  in  the  slightest  degree.  No  other  joints  may  In 
alTected. 

L)iagnosis. — Arthritis  defornnms  can' rarely  be  mistaken  for  eitlur 
rheumatism  or  gout.  It  is  i  uportant  to  distinguish  from  the  mono-articu- 
lar form  the  local  arthritis  of  the  shoulder-joint  which  is  characterized  k 
})ain,  thickening  of  the  capsule  and  of  the  ligaments,  wasting  (if  \w 
shoulder-girdle  muscles,  and  sometimes  by  neuritis.  This  is  an  alu'C'tion 
wdiich  is  quite  distinct  from  arthritis  deformans,  and  is,  moreover,  in  v. 
majority  of  cases  curable. 

Treatment. — Arthritis  deformans  is  an  incurable  disease.  In  maiiy 
cases,  after  involvement  of  two  or  three  joints,  the  progress  is  arresied. 
Too  often  it  invades  sucoessively  all  the  articulations,  and  in  ten,  Hftcoii. 
or  twenty  years  the  crippling  becomes  general  and  permanent. 

The  best  that  can  be  ho])ed  for  is  a  gradual  arrest.  It  is  useless  to 
saturate  the  patients  with  iodide  of  potassium,  salicylates,  or  ([uiiniu'. 
Arsenic  seems  to  do  good  as  a  general  tonic.  The  improvement  may  Ir 
marked  if  large  doses  of  it  are  givcMi.  Iron  should  be  used  freely,  if 
there  is  amiMuia.  An  old  recipe,  called  the  "  Chelsea  Pensioner,"  cdntain- 
ing  sulphur  3  j,  cream  of  tartar  3  j,  rhubarb  3  iv,  gum  guaiaciim  3j' 
honey  1  xvj  (Sig. :   1  j  night  and  morning),  iu  Avarm  wine,  was  formerly 


GOUT. 


309 


iniicli  ii>i  il.  Careful  attention  to  tlio  (liijoistion,  plenty  of  j^ood  food,  and 
frt'sli  iiir  are  important  measures.  Hydrotherapy,  with  carefidiy  per- 
formed iiias,>a;xe,  is  best  for  the  alleviation  of  the  jiairi,  and  may  possii)ly 
ivstrain  the  jiroirress  of  tlie  aiTertion.  In  early  eases  local  improvement 
jinil  iiftcii  .irri'at;  gain  in  the  general  strength  follow  a  prolonged  treat- 
inonl  at  the  hot  mineral  baths;  but  the  practitioner  should  exercise  care 
ill  rccoinnieiuling  this  mode  of  treatment,  wliich  is  of  very  doidjtful  value 
when  the  disease  is  well  established.  I  have  repeatedly  known  eases  to  bo 
iviidcrcd  iiuich  worsu  by  residence  at  these  institutions.  When  good 
ivsuits,  it  is  largely  from  change  of  scene  aiul  climate,  and  the  careful 
n'i(iilati()ii  of  the  diet.  The  local  treatment  is  of  bcnelit  in  arresting  the 
iii'oiiivss.  When  there  are  much  heat  an<l  j)ain  the  liml)  should  be  at  rest, 
cold  compresses  ajjplied  at  night,  the  joints  wrapped  in  oiIe(l  silk,  and  in 
tliu  niorniiig  thoroughly  massaged.  It  is  surprising  how  much  can  be 
(ionu  hv  carefully  apjjlied  friction  to  reduce  the  thickening,  to  promote 
iihsorption  of  elTiisioii,  and  to  restore  mobility.  Massage  is  also  of  special 
bonelit  in  n)aiiitiiining  the  nutrition  of  the  muscles,  which  early  tend  to 
utroiiliy.  In  the  case  of  the  knees  this  nutilc  of  trcMliiient  will  sometimes 
prevent  the  retraction  of  the  muscles  and  the  gradual  lii'xion  of  the  legs 
on  tlio  thighs.     No  benefit  can  be  expected  from  electricity. 


VI.    GOUT    (I'od„!/ra). 

Definition.— A  nutritional  disorder,  one  factor  of  which  is  an  exoess- 
ivi>  i'oriiialiiiii  of  uric  acid,  characterized  clinically  by  attai-ks  of  acute 
arthritis,  by  the  gradual  dei)()sition  of  urate  of  soda  in  and  about  the  joints, 
and  liy  iliu  occurrence  of  irregular  constitutional  symptoms. 

Etiology. — The  precise  T.ature  of  the  disturbance  in  metabolism  is 
;iot  known.  There  is  probably  defective  oxidation  of  the  foodstiilTs,  com- 
IjiiU'd  with  imperfect  elimination  of  the  waste  produi'ts  of  the  body. 

Among  important  etiological  factors  in  gout  are  tlio  following: 

('/)  llircditdnj  Iiifluc/irrs. — Statistics  show  that  in  from  fifty  to  sixty 
per  cent  of  all  cases  the  disease  existed  in  the  parents  or  grandparents. 
The  transmission  is  su})[)oscd  to  be  more  marked  from  the  male  side. 
''asi's  with  a  strong  hereditary  taint  have  been  known  to  develop  before 
puborty.  The  disease  has  been  seen  even  in  infants  at  th(>  I)rcast.  Males 
are  more  subject  to  the  disease  than  females.  It  rar(dy  develops  before 
the  thirtieth  year,  and  in  a  large  majority  of  the  cases  the  first  manifes- 
tations appear  before  the  age  of  fifty.  (/>)  Alnihol  is  the  most  })oi:ent 
fai'tor  in  the  etiology  of  the  disease.  Fermented  liquors  favor  its  develop- 
ii'-iit  iiuicli  more  than  distilled  sjiirits,  and  it  prevails  most  extensively  in 
'luintries  like  England  and  (iermany,  which  consume  the  most  beer  and 
iio.  The  lighter  beers  used  in  this  country  are  much  less  liable  to  produce 
^"Hit  tliiiii  the  heavier  English  and  Scotch  ales,  (c)  Food  plays  a  rfilc  ecpial 
111  importance  to  that  of  alcohol.     Overeating  without  active  bodily  oxer- 


^';    I'll 


f.  *■ 


810 


CONSTITUTIONAL    DISEASES. 


ciso  is  roijanlod  as  ;i  vory  special  ])ro(lispnsing  causo.  A  f()rm  of  jjontv 
dysptipsia  lias  hccii  dcscrilx'tl.  A  rohiist  and  a<'tivo  dif^ostioii  is,  lidwcvcr 
often  met  in  tronty  {icrsoiis.  (iout  is  by  no  moans  confined  to  llic  rid), 
In  En<?laiid  ttie  conihination  of  poor  food,  defective  hyj^iene,  and  an  excess- 
ive eonsiiniption  of  malt  liijuors  makes  tlu^  "poor  man's  g()nt"a  niiiiiiK,;) 
alfection.  (^/)  Lead.  (Jarrod  luus  shown  that  workers  in  lead  are  spcrjallv 
prone  to  gout.  In  tliirty  per  cent  of  the  hospital  eases  the  patients  liml 
been  painters  or  workers  in  lead.  The  ussooiiition  is  probably  to  i)e  souiriit 
in  th((  production  by  this  poison  of  arterio-sc^lerosis  and  chronic;  nejilirjti,. 
Sometliing  in  addition  is  necessary,  or  certainly  in  this  country  we  slinnlil 
more  frecpiently  see  eases  of  the  kind  so  common  in  liOndon  hospitals. 
Chronic  lead-[)oisonin<f  is  here  frequently  associated  with  arterio-selurosis 
and  contracted  kidneys,  but  acute  arthritis  is  rare,  (iouty  (h'posits  are. 
however,  to  be  found  in  the  big-toe  joint  and  in  tlie  kidneys  in  these 
cases. 

The  nature  of  gout  is  unknown.  That  tliere  is  faulty  metabolism,  as- 
sociated in  some  very  special  way  witli  tlie  chemistry  of  uric  aeid,  we 
know,  but  notliing  more.  The  remainder  is  theory,  awaiting  refiUution 
or  confirmation.  The  conditions  of  life  favorable  to  the  devel(i]iiiuiit  nf 
gout  are  thus  well  drawn  by  a  careful  student  of  tlie  disease  ((i.  \V.  Bal- 
four). After  speaking  of  the  increasing  disi)osition  to  "  venosity  "  of  tlie 
blood  as  years  advance  with  conseriuent  diminished  oxidation,  he  says: 

"  Add  to  this  that  in  a  state  of  civilization  man  is  always  sujjplied  with 
a  superfluity  of  foods  and  drinks,  which  the  habits  of  society  ami  tlu 
anxiety  of  his  friends  tempt  liini,  if  they  do  not  actually  compel  liiiii,tii 
partake  of  four  or  even  five  times  a  day. 

"  Moreover,  as  the  bulibling  energy  of  youth  fails,  the  mere  pleasure  of 
it  no  longer  incites  us  to  violent  exertions  ;  the  needs  of  civilization  do  iie: 
require  such  exertions  from  us,  and  the  many  luxurious  apiiliaiiccs  uf 
civilized  life  aid  ami  abet  the  natural  indolence  that  grows  upon  man  ii> 
age  advances,  and  largely  preclude  the  need  for  any  but  the  most  trilling 
bodily  exertion. 

"  Hence  this  less  highly  oxygenated  blood  is  flooded  with  a  redinidanev 
of  nutritive  nniterial  far  in  exi'ess  of  the  rcfiuirementsof  theframe. wliiili 
can  neither  be  used  up  in  any  of  its  ordinary  appropriations,  imr  fully 
oxidated  in  any  other  way,  and  so  excreted.  The  general  metabolism  is 
thus  impaired,  every  function  of  the  body  impeded,  every  secretion  tie 
teriorated  ;  all  the  organs  sulfer. 

"Thus  we  have  the  gouty  diathesis  fully  developed  ;  a  diathesis— Iialm 
of  bod\' — present  in  each  one  of  us  after  middle  life,  and  which  Illodilil^ 
the  orgatiic  metabolism  of  each  one  of  us,  both  in  health  and  in  disease. 
The  gouty  diathesis  is  only  a  comj)r(diensivc  term  for  all  those  eliaiiges  in 
the  character  and  eoinjiositiou  of  the  blood  induced  by  the  evils  of  civiliza- 
tion— deficient  exercise  and  excess  of  nutriment.  .  .  .  Gout,  on  the  dtlier 
hand,  is  the  mime  given  to  all  tho.so  modifications  of  our  metabulism 


OOUT. 


311 


oaiised  bv  the  ,a:oiity  diathesis,  as  well  as  to  all  the  sympt(  ms  to  which 
those  niotlitications  give  rise." 

The  views  regarding  uric  acid   and   its   relation   to  gout  are  very 

(iiirnid  lioltls  that  with  lessened  alkalinity  of  the  blood  there  is  an  in- 
eroiiHe  in  the  uric  acid,  due  chiefly  to  diminished  elimination.  He  attrib- 
utes the  deposition  of  the  urate  of  soda  to  the  diminished  alkalinity  of  the 
iilusiua,  which  is  unable  to  hold  it  in  solution.  In  an  acute  paroxysm 
tlu'i'e  is  ;ui  ucciinndation  of  tlie  urates  in  the  blood,  and  the  inflamnuition 
is  ciiUfed  1)V  their  sudden  (lei)osit  in  crystalline  form  about  the  joint. 

Iliiig  thinks  that  there  is  no  increased  formation  of  uric  acid  in  gout, 
Imt  tliiit  the  blood  is  less  alkaline  than  normal,  and  less  able  to  hold  the 
uric  acid  or  its  salts  in  solution. 

Roberts  (Sir  William),  in  the  Croonian  Lectures,  1893,  has  advance<l  a 
new  view  with  reference  to  the  chemistry  of  gout.  The  chalk-like  deposits 
lire  formed  of  tiie  crystalline  biurate  of  sodium,  and  "  the  arthritic  inci- 
iknits  of  gout  may  be  said,  not  improi)erly,  to  be  simply  incidents  pertain- 
iiiir  to  the  precipitation  of  these  crystals  in  the  structures  of  the  joints.'' 
The  factor  of  capital  importance  in  the  pathology  of  the  disease  relates  to 
the  cliemical  properties  of  this  insoluble  biurate. 

Ill  the  metabolism  of  the  healthy  body  uric  acid  and  the  neutral  and 
iiciil  urates  play  a  very  minor  part.  They  are  in  the  form,  in  reality,  of  a 
ijUinhiuratc,  svhicli,  unlike  the  biurate,  is  easily  soluble  in  the  blood-serum, 
iiiul  it  is  in  this  form  that  the  uric  acid  circulates  in  the  blood  and  is  ex- 
creted by  the  kidneys.  "  In  perfect  health  the  elimination  of  the  quadri- 
uriite  proceeds  with  suflficiont  speed  and  completeness  to  prevent  any  undue 
ileteiitioii  or  any  accumulation  of  it  in  the  blood;  but  in  the  gouty  state 
this  traiifpiil  process  is  interrupted,  either  from  deficient  action  of  the 
kidneys  or  fror>i  excessive  introduction  of  urates  into  the  circulation,  or 
from  sonio  other  cause,  and  the  quadriurate  lingers  unduly  in  the  blood 
and  accumulates  therein.  The  detained  quadriurate,  circulating  in  a 
medium  which  is  rich  in  sodium  carbonate,  gradually  takes  up  ai»  addi- 
tional atom  of  base,  and  is  thereby  transformed  into  biurate.  This  trans- 
formation alters  the  phy.siological  problem.  The  uric  acid,  or,  rather,  a 
pm'tion  of  it,  circulates  nc  longer  as  the  more  soluble  and  presumably 
'iisily  secreted  quadriurate,  out  as  biurate,  which  is  less  soluble, and  proba- 
bly also— either  for  that  reason  or  because  it  is  a  comi)oiitid  foreign  to  the 
nornud  economy— less  easy  of  removal  by  the  kidneys.  The  biurate  thus 
produced  exists  at  first  in  the  gelatinous  modifications,  but  with  the  lapse 
"f  tiuu'  ami  increasing  accumulation  it  j)asses  on  into  the  almost  insoluble 
' nstalliiie  condition,  and  then  j)recipitation  becomes  imminent,  or  actu- 
ally takes  place."  The  precipitation  is  particularly  apt  to  occur  in  certain 
parts  of  the  body  where  circulation  is  feeble  and  the  temperature  low, 
iiiul  in  regions  where  the  lym])h  contains  a  relatively  high  percentage  of 
sodium  chloride,  as  in  the  synovial  sheaths. 
21 


^'.  \m 


312 


CONSTITUTIOXAF.    DISK  ASKS. 


I .' 


Levison  (Die  IIiirMsiiiircdiiitlioso,  Hcrliii,  180.'J)  nocoi)ts  the  qnadriiirate 
theory  of  Uoherts,  ii(ioj)tin<^  at  tlio  sumc  tiiim  Horhjiczcw.ski's  vicwH  that  the 
uric  JU'id  is  related  es[)eeially  to  the  nueleiiis  of  tlic  body,  atid  is  derived  in 
great  part  from  the  de-triictioii  of  the  white  blood-corpiiscdes,  the  cxcn- 
tion  incroasiri;; /yrf// /*rr.v,v»  witli  the  intensity  of  the  leiieocytosis.  AVhilr 
tlii.s  is  true  in  niaiiy  diseiisos,  as  in  pneumonia,  Hicliter,  in  ii  recent  (•iircfnl 
dtudy,  lias  shown  tliat  there  ant  important  exet'ptinns. 

P'ibstein  tliinivs  that  tlio  lirst  cluui^e  is  a  niitritivo-f  issue  distiirlaiuc, 
which  h'ads  to  necrosis,  and  in  tlui  necrotic  areas  tiie  urates  are  depositid 
— a  view  wlu(di  lias  been  modified  by  von  Noorden,  who  holds  that  a  spe- 
cial ferment  leads  to  the  tissue  change,  to  which  the  deposit  of  the  urates 
is  secondary. 

Ciillen  held  that  gout  was  prinuirily  an  affection  of  the  nervous  system. 
On  this  nervous  theory  of  gout  there  is  a  basic,  arthritic  stock — u  diatiietir 
habit,  of  which  gout  and  rheumatism  are  two  distinct  branches.  The 
gouty  diathesis  is  expressed  in  (rr)  a  neurosis  of  the  nerve-centres,  whidi 
may  be  iiiherit(!d  or  acrpiired  ;  and  {/>)  "a  pecuiliar  incapacity  for  norniiil 
elaboration  within  the  whole  body,  not  merely  in  the  liver  or  in  one  or  two 
organs,  of  food,  whereby  uric  acid  is  formed  at  times  in  excess,  oris  in- 
capable of  being  duly  transformed  into  more  soluble  and  less  noxious 
products  "  (Duckwortli).  The  explosive  neuroses  and  the  inlhieneo  of  de- 
pressing circumstiiuces,  ])hysicn',  or  "uental,  ])oint  strongly  to  thu  part 
played  by  the  ner\ous  system  mi  the  disease. 

Morbid  Anatomy. — The  blonu  shows  an  excess  of  uric  arid,  as 
proved  originallv  by  (Jarrod.  The  ur'.c  acid  may  bo  obtaiiu-d  fnnii  the 
blood-serum  by  the  nu'thod  known  a;;  uric-acid  thread  experiment,  or  fnnn 
the  seruii  obtained  from  a  blister.  To  3  i.i  of  serum  add  in  v-vj  of  aceti'^ 
acid  in  a  watch-glass.  A  thread  immers'ed  in  this  will  show  in  a  fe«' 
hours  an  incrustation  of  uric  acid.  This  is  not,  however,  peculiar  tocnti:. 
but  occurs  in  leukaemia  and  chlorosis.  The  important  changes  are  in  the 
articular  tissues.  The  first  joint  of  the  great  toe  is  most  fre(|iioiit'  •  in- 
volved ;  then  the  ankles,  knees,  and  the  small  joints  of  the  hands  ami 
wrists.  The  deposits  may  be  in  all  the  joints  of  the  lower  limbs  ami 
absent  froiti  those  of  the  upper  limbs  (Norman  Moore).  If  (leiitli  take? 
place  during  an  acute  paroxysm,  there  are  signs  of  inflammation,  liypeiie- 
mia,  swelling  of  the  liganuMitous  tissues,  aiul  of  effusion  into  the  joint. 
The  primary  change,  according  to  Ebstein,  is  a  local  necrosis,  duo  to  the 
presence  of  an  excess  of  urates  in  the  blood.  This  is  seen  in  the  eartihee 
and  other  articular  tissues  in  which  the  nutritional  currents  are  slow.  In 
these  areas  of  coagulation  necrosis  the  reaction  is  always  acid  and  the 
neutral  urates  are  ileposited  in  crystalline  form,  as  insoluble  acid  iinitw 
The  articular  cartilages  are  first  involved.  The  gouty  deposit  nuiy  be  uni- 
form, or  in  small  areas.  Though  it  looks  superficial,  the  deposit  is  in- 
variably interstitial  and  covered  by  a  thin  himina  of  cartilage.  Tlie  de- 
posit is  thickest  at  the  part  most  distant  from  the  circulation.    The  ligii- 


si^^n 


GOUT. 


313 


inoiits  iiiul  fibro-cartilfigo  ultimately  become  involved  and  are  infiltrati'd 
with  clialky  deposits,  the  so-called  chalk-stones,  or  tophi.  Tiieso  are  usu- 
allv  covcied  by  skin ;  but  in  some  cases,  particularly  in  tiie  nietacarpo- 
liliiiliiiij,'i'iil  urticidalions,  this  ulcerates  and  the  clialk-sloties  appear  ex- 
toriiiillv.  The  synovial  lliiid  nuiy  also  contain  crystals.  In  very  lonjj- 
s;i!i(ling  cases,  owing  to  an  excessive  deposit,  the  joint  becomes  ininiobile. 
The  iiiiirglMal  outgrowths  in  gouty  arthritis  are  true  exostoses  (Wynne). 
The  ciu'tiiiigo  of  the  car  may  contain  to])hi,  which  are  seen  as  wiiilish 
ii(iihiU'!<  at  the  margin  of  tlie  helix.  The  cartilages  of  the  nose,  eyelids, 
ami  larynx  are  less  frequently  affected. 

Of  changes  in  the  internal  organs,  those  in  the  rejial  and  vascular  sys- 
tems are  the  most  imiiortant.  The  kidney  changes  believed  to  be  charac- 
teristic of  gout  are :  {//)  A  deposit  of  urates  chielly  in  the  region  of  the 
[laiiilhe.  Tliis  is  a  less  common  change,  however,  than  is  usually  sui)- 
pusi'd.  Nornuin  Moore  found  it  in  only  twelve  out  of  eighty  cases.  The 
\[\>u\'S  of  the  pyramids  show  lines  of  whitish  deposit.  On  microscojjical 
cxaiiiiiiation  the  material  is  seen  to  be  largely  in  tiie  intertubular  tissue. 
In  siimr  instances,  however,  the  deposit  seems  to  be  both  in  the  ti^oue  and 
in  the  tiil)ides.  Ebstcin,  in  bis  monograph,  has  described  and  figured 
aivas  of  necrosis  in  both  cortex  and  medulla,  in  the  interior  of  which  were 
I'l'vstalliiu'  deposits  of  urate  of  soda.  The  presence  of  these  uratic  con- 
iR'tions  at  the  apices  of  the  pyramids  is  not  a  positive  indication  of  gout. 
Tlit'V  are  not  infrequent  in  this  country,  in  which  gout  is  rare.  {/>)  An 
interstitial  nephritis,  either  the  ordinary  "contracted  kidney"  or  the 
ai'tcrio-sclerotic  form,  neither  of  which  are  in  any  way  distinctive.  It  is 
not  possible  to  say  in  a  given  case  that  the  condition  has  been  due  to  gout 
unless  marked  evidences  of  the  disease  coexist. 

The  inetatarso-phalangeal  joint  of  the  big  toe  should  be  carefully  ex- 
iuninoil,  as  it  may  show  typical  lesions  of  gout  without  any  outward  token 
yf  arthritis. 

Arterio-sclerosis  is  a  very  constant  lesion.  "With  it  the  heart,  particu- 
larly the  left  ventricle,  is  found  hypertro;^^'ied.  According  to  some  au- 
thors, concretions  of  urate  of  soda  may  occur  on  the  valves.  « 

Changes  in  the  respiratory  system  are  rare.  Deposits  have  been  found 
in  the  vocal  cords,  and  uric-acid  crystals  have  been  !net  in  the  sputa  of  a 
gouty  patient  (J.  W.  Moore).  Emphysema  is  a  very  constant  condition 
in  olil  cases. 

Symptoms. — Gout  is  usually  divided  into  acute,  chronic,  and  irregu- 
lar forms. 

Acute  Gout. — Premonitory  symptoms  are  common — twinges  of  pain 
111  the  small  joints  of  the  hands  or  feet,  nocturnal  restlessness,  irrita- 
bility of  temper,  and  dyspepsia.  The  urine  is  acid,  scanty,  and  high- 
"ilorcfl.  It  deposits  urates  on  cooling,  and  there  may  be,  according  to 
'lU'i'od,  transient  albuminuria.  There  may  be  traces  of  sugar  (gouty  gly- 
^'isiiria).    Before  an  attack  the  output  of  uric  acid  is  low  and  is  also  di- 


^ 


wm^ 


'uy  '\ 


8U 


CONSTITl'TIOXA L    DISF-'.ASKS. 


niinislicd  in  iho.  oarly  part  of  tho  pjiroxysm.  In  sotno  itistuncos  tlic  tliiunt 
is  sore,  iiiid  there  may  ho  astlinmtic  attacks.  Tlie  attack  sets  in  usiiiiHy 
in  tlie  early  niorninj^  hours,  Tlie* patient  is  aroused  l)y  a  severe  |i;mi  jn 
the  nietatarso-phahini^'cal  articnhition  of  the  hi<^'  toe,  and  more  coihiikmiIv 
on  th(!  risijht  tlian  on  the  left  side.  The  puin  i.s  agonizinj;,  tho  joint  swells 
rapidly,  and  becomes  hot,  tense,  and  shiny.  'I'ho  sensitiveness  is  oxtrciin', 
and  the  patient  describes  the  j)aiji  as  if  the  joint  were  hein<:f  ]iross('(l  in  n 
vise.  There  is  fever,  and  the  temiu'rature  may  rise  to  10^°  or  WW 
Toward  morning  tho  severity  of  tlio  symptoms  subsides,  an(l,  althniitrh  tlio 
joint  remaitis  swollen,  the  day  may  he  passed  in  comparative  cmnfiirt. 
The  symptoms  recnr  the  next  niglit,  and  the  tit,  as  it  is  called,  nsiially  !;i>ts 
for  from  live  to  eight  days,  the  severity  of  the  symptoms  gradually  abating. 
Occasionally  other  joints  are  involved,  particularly  the  big  too  of  tlic  op- 
posite foot.  Tho  innamnnition,  however  intense,  never  goes  on  to  rii|i]iii- 
ration.  With  the  subsidence  of  the  swelling  tho  skin  desfiiuimatos.  Aftn- 
the  attack  the  general  health  may  be  much  improved.  Itecurroiiccs  iiiv 
frequent.  Some  i)atients  have  three  or  four  attacks  in  tiyear;  others  at 
longer  intervals.  liecorche  has  shown  that  the  amount  of  uric  acid  is 
reduced  prior  to  an  attactk,  diminishes  during  the  first  two  days,  then  in- 
creases very  !nu(!h  and  falls  toward  the  close. 

The  term  rctrnrvdcnt  or  suppressed  gout  is  applied  to  serious  inteniiil 
symptoms,  coincident  with  a  ra])id  disappearance  or  improvement  of  \\iv 
local  signs.  Very  remarkable  numifestations  may  occur  uiuler  these  cir- 
cumstances. The  patient  may  have  severe  gastro-intestinal  syniptonis- 
pain,  vomiting,  diarrhcea,  and  great  depression — ami  death  may  oinir 
during  such  an  attack.  Or  there  may  be  cardiac  manifestations — (lysjniu;!, 
])ain,  and  irregular  action  of  the  heart.  In  some  instances  in  wliieh  tlir 
gout  is  said  to  attack  the  heart,  an  acute  pericarditis  develops  and  proves 
fatal.  So,  too,  there  may  be  nuirked  cerebral  numifestations— delirium 
and  coma,  and  even  apoplexy — but  in  a  nuijority  of  these  instaiiecs  tk 
symptoms  are,  in  all  probability,  nrr  mic. 

Aoute  gout  is  a  rare  disease  in  America,  particularly  in  hospital  prac- 
tice. .  Among  the  well-to-do,  and  even  among  club-men — a  class  partifii- 
lai'ly  liable — it  is  infrequent,  in  comparison  with  tho  jirevaleiiee  in  tlie 
corresponding  classes  in  Englatul.  Men  in  large  family  ijractiee  may 
pass  a  year  or  more  without  seeing  a  case.  It  luis  become  more  coinni'm, 
however,  during  the  past  twenty-five  years. 

Chronic  Gout. — With  increased  frequency  in  the  attacks,  tho  nrtieiilur 
symptoms  persist  for  a  longer  time,  and  gradually  many  joints  beooim' 
alTected,  Deposits  of  urates  take  place,  at  first  in  the  articular  eartiliiir<' 
and  then  in  the  ligaments  and  capsular  tissues;  so  that  in  tho  course "' 
years  the  joints  become  swollen,  irregular,  and  deformed.  The  foct  aro 
usually  first  affected,  then  the  hands.  In  severe  cases  there  may  be  exten- 
sive concretions  about  the  elbows  and  knees  and  along  tho  tciuleiis  and  m 
the  bursas.     The  tophi  appear  in  the  ears.     Finally,  a  unique  cliniial  pie- 


(JOUT. 


.';i5 


lie  llirnal, 
II  usn;illy 
?,  \mn  ill 

(lIllllKilllv 

lint  swclU 
f  iwlrciiii', 
ossod  ill  ;i 
or  lii:r. 
hniijrli  tlic 

i  ColiifdH. 
nisilly  liistj 
ly  iil)iitiiig, 

of   till'  op- 

1  to  suinm- 

t08.     AfttT 

rroiKt's  art' 
;  others  at 
iric  acid  is 
ys,  tliuii  in- 

)us  intoriKiI 
lOllt  of  tlio 
r  tlicsc  cir- 
ytnptonis- 
niay  occur 
— (lyspnu'ii, 
which  tlif 

111(1  pl'(•Vl•^ 

ilcliriiim 
tiuices  the 

-pi till  prao- 
:iss  piirtii'ii- 
■luv  in  tlie 
nctioo  m;iy 
re  coninicii, 


11 


1,'  (irficiiuir 

its  bccoiiif 

r  ciirlilairts 

i(<  cmirsont 

w  foct  iif 

ly  lie  CXtill- 

(l(iiis  ami  in 
clinical  pio- 


tiirp  i^  iirmliicod  whicli  caimot  l)o  mistaken  for  any  otlitM"  alTc'(!li()ii.  'V\w 
skill  over  tlio  tu])lii  may  rupluro  or  iihioratc,  and  alxtiit  tlio  kiiiU'kh'M  the 
clmlk-stonos  may  bo  freely  exposed.  Patients  witli  elironie  gout  are  iisii- 
allv  (Ivspt'ptie,  often  of  a  sallow  eomplexion,  and  show  signs  of  arterio- 
MJcrnsis.  Tlie  puists  tension  is  increased,  the  vessels  are  stilT,  and  the  left 
vfiitriele  is  hypertrophied.  'I'ho  urine  is  inerease<l  in  amount,  is  of  low 
specilie  gravity,  and  usinUly  contains  a  slight  amount  of  albumin,  wit'  a 
ftw  livaliiio  easts.  Intercurrent  attacks  of  acute  polyarthritis  may  deveh  i, 
ill  wliieh  the  joints  become  inflamed,  and  the  temperature  ranges  from 
lor  to  in:r ;  but  even  with  slight  fever  the  condition  is  a{)t  to  be  dan- 
jicroii",  as  unemia,  pleurisy,  pericarditis  or,  in  some  instaJices,  menijigitis 
niiiy  .supervene.  Patients  with  chronic  gout  may  show  renuirkable  nuuital 
and  even  bodily  vigor.  Certain  of  tlie  most  distinguished  mend)ers  of  our 
profession  have  been  terrible  sufferers  from  this  disease,  notably  the  elder 
Scalijier,  .lerome  Cardan,  and  Sydeidiam,  whose  statement  that  "  more 
wise  nun  than  fools  are  victims  of  the  affection  "  still  holds  good. 

Irregular  Gout. — This  is  a  motley,  ill-defined  group  of  symptoms, 
manifeslatioiis  of  a  condition  of  disordered  nutrition,  to  which  the  terms 
ijiiuli/  (liaf/ii'sis  or  lUh(Pviic  state  have  been  given.  Cases  are  seen  in  mem- 
bers of  gouty  families,  who  may  never  themselves  have  suffered  from  the 
acute  disease,  and  in  persons  who  have  lived  not  wisely  but  too  well,  who 
liave  eaten  and  drunk  largely,  lived  sedentary  lives,  and  yet  havi  been  for- 
*Mnate  enough  to  escape  an  acute  attack.  It  is  interesting  to  note  the 
nous  manifestations  of  the  disease  in  a  family  with  marked  hereditary 
position.  The  daughters  often  escape,  while  one  son  may  have  gouty 
attacks  of  great  severity,  even  though  he  lives  a  temperate  life  and  tries 
ill  every  way  to  avoid  the  conditions  favoring  the  disorder.  Another  son 
lias,  perhaps,  oidy  the  irregular  manifestations  and  never  the  acute  art;icu- 
lar  atleetion.  While  the  irregular  features  are  perhaj)s  more  often  met 
witli  in  the  hereditary  affection,  they  are  by  no  means  infrequent  in  per- 
sons who  appear  to  have  acquired  the  disease.  The  tendency  in  some 
families  is  to  call  every  affection  gouty.  Even  infantile  complaints,  such 
as  scald-head,  naso-pharyngeal  vegetations,  and  enuresis,  are  often  re- 
^'arded,  without  sufficient  grounds,  I  believe,  as  evidences  of  the  family 
aihiieiit.  Among  the  commonest  manifestations  of  irregular  gout  are  the 
followiiijT : 

{(i)  ('/(f(i)icons  Ernptions. — Garrod  and  others  liave  called  special  at- 
tention to  the  frefjuent  association  of  eczema  with  the  gouty  habit.  The 
Ircnch  in  particular  insist  upon  the  special  liability  of  gouty  persons  to 
-^kin  alfections,  the  arthritides,  as  they  call  them. 

(/')  U astro-intestinal  Disorders. — Attacks  of  what  is  termed  bilious- 
ness, in  which  the  tongue  is  furred,  the  breath  foul,  the  bowels  consti- 
piited,  and  the  action  of  the  liver  torpid,  are  not  uncommon  in  gouty 
persons.    A  gouty  parotitis  is  described. 

(c)  Vardio-vascnlar  Symptoms. — With  the  lithiemia,  arterio-sclerosis 


Y    * 


li 


ivi?. -^ 


si  it* 


316 


CONSTITrTIONAL   DISKASES. 


is  frcqueiitlv  aspr  niiited.  The  blood  tension  is  persistently  high,  the  vo!;!:ol 
walls  become  stiff,  and  cardiac  and  renal  changes  gradnady  develop.  1|, 
this  condition  the  manifestations  may  be  renal,  as  when  the  albiiniiniiria 
becomes  more  marked,  or  dropsical  symptoms  supervene.  The  niaiiifosta- 
tions  may  be  cardiac,  when  the  hypertrophy  of  the  left  ventrich'  fails  aini 
there  are  paljiitation,  irregular  action,  and  ultimately  a  condition  of  asys- 
tole. Or,  finally,  the  manifestations  may  be  vascular,  and  throuil)o.sis  of 
the  coronary  arteries  may  cause  sudden  death.  Aneurism  may  develop 
and  prove  fatal,  or,  as  most  frequently  happens,  a  blood-vessel  gives  wav 
in  the  brain,  and  the  patient  dies  of  apoplexy.  It  makes  but  little  (litltr- 
ence  whether  we  regard  this  condition  as  primarily  an  arterio-selerosis.  (ir 
as  a  gouty  nephritis ;  the  point  to  be  remembered  is  that  the  nutritional  dis- 
order with  which  an  excess  of  uric  acid  is  associated  induces  in  time  in- 
creased tension,  arterio-sclerosis,  chronic  interstitial  nephritis,  and  chansrcs 
in  the  myocardium.  Pericarditis  is  not  infrequent  in  connection  with  the 
granular  kidney  met  with  in  gout. 

(d)  Nervous  M(iin'fesfn/ions. — Headache  is  frequent.  Ilaig  lias  callnl 
special  attention  to  the  association  of  this  symptom  with  retention  of  iirii 
acid  in  the  system.  Neuralgias  are  not  uncommon  ;  sciatica  and  para'S- 
thesias  may  develop.  A  common  gouty  manifestation,  upon  which  Duck- 
worth has  laid  stress,  is  the  occurrence  of  hot  or  itching  feet  at  niglit. 
I  notice  in  Plutarch  that  Strabo  called  this  symptom  "the  lispi!i<rof  the 
gout."  C'ramps  in  the  legs  may  also  be  very  troublesome,  lliitchiiison 
has  Ciilled  attention  to  hot  and  itching  eyeballs  as  a  frequent  siijii  nf 
masked  gout.  More  serious  cerebral  manifestations  result  from  a  condi- 
tion of  arterio-sclerosis.  Apoplexy  is  a  common  tennination  of  guiit. 
Meiiingitis  may  develop,  usually  basilar. 

(e)  rrivnry  PLwrdcrs. — The  urine  is  'highly  acid  and  higli-coloifl. 
and  may  deposit  on  standing  crystals  of  lithic  acid.  Transient  and  tem- 
porary increase  in  tliis  ingredient  cannot  be  regarded  as  serious.  In  many 
cases  of  chronic  gout  the  amount  may  be  diminished,  and  oJily  iiu'ivasiil 
at  certain  periods,  forming  the  so-called  uric-acid  showers.  E.  I'fiilTir"- 
investigations  on  the  urine  in  gout  are  of  interest,  and  are  hflicvcd  to 
have  some  diagnostic  sigrificance :  "On  passing  100  c.  e.  of  the  day's 
urine  through  a  filter  charged  with  from  0-3  to  0'5  grains  of  pure  urii 
acid,  there  is  less  uric  acid  (precipitable  by  hydrochloric  acid)  in  tlie  fil- 
trate than  in  the  unfiltered  urine.  The  difference  is  represented  by  what 
he  calls  '  easily  separable '  or  '  free '  uric  acid.  Applying  this  test  to  gouty 
urine,  he  found  (1)  that  during  and  just  after  an  acute  attack  there 
is  none,  or  almost  none,  of  this  'easily  separable'  uric  acid  present,  ati'l 
(2)  that  in  the  intervals  between  the  attacks  and  in  clironic  gout  neariy 
all  of  the  uric  acid  of  the  urine  (precipitable  by  IICl)  is  of  tliis 'easily 
separable'  variety.  It  is  to  be  no  cd  that  healthy  urine  loses  by  filtration 
through  0-3  grains  of  uric  acid  rarely  more  than  35  per  cent  of  the  ainmint 
which  can  be  preci]>itated  by  hydrochloric  acid."     Sugar  is  found  inter- 


GOUT. 


317 


mittently  in  the  urine  of  gouty  persons — gouty  glycosuria.  It  may  pass 
into  triu'  diabetes,  but  is  usually  very  amenable  to  treatment.  Oxaluria 
niav  also  be  present.  Gouty  persons  are  specially  projie  to  calouli,  Jerome 
Cariliui  to  the  contrary,  who  reckoned  freedom  from  stone  among  the  chief 
(if  the  doiut  paildf/rw.  Minute  quantities  of  albumi.i  are  very  common  in 
iicrsoiKS  of  gouty  dyscrasia,  and,  when  the  reiud  changes  are  well  estab- 
li.-lu'd,  tube  casts.  Urethi'itis,  accompanied  with  a  well-marked  purulent 
iiis(:li!trge,  may  develop,  so  it  is  stated,  usually  at  the  end  of  an  attack.  It 
may  occur  spontaneously,  or  follow  a  pure  connection. 

( /■)  PiihiioiKir!/  Disorders. — Tliere  are  lu)  characteristic  changes,  but, 
as  Greeiihow  has  pointed  out,  chronic  bronchitis  occurs  with  great  fre- 
quoiu'V  in  persous  of  a  gouty  habit. 

((/)  Of  eye  alTcctions,  iritis,  glauconui,  luvmorrhagic  retinitis,  aiul  sup- 
purative iiatiopthaluiitis  have  been  described. 

Treatment.  —  Jfi/i/imir. — Iiulividuals  who  have  inherited  a  tendency 
to  gout,  or  wiio  have  shown  any  manifestations  of  it,  should  live  temper- 
ately, alistaiii  from  alcohol,  aiul  eat  moderately.  An  open-air  life,  with 
pK'iity  of  exercise  and  regular  hours,  does  much  to  counteract  an  inl)orn 
teiuleiicy  to  the  disease.  Tlie  skin  should  be  kept  active  :  if  the  patient  is 
robust,  by  the  morning  cold  bath  with  friction  after  it;  hut  if  he  is  weak 
or  (lel)ihtated  the  evening  warm  bath  should  be  substituted.  An  occa- 
sional Tiirkisli  l)ath  with  active  shauij)Ooiiig  is  very  advantageous,  'i'lie 
patient  sliotdd  dress  warmly,  avoid  rapid  alterations  in  tenii)erature,  and 
beearefid  not  to  ha\('  tlu>  skin  suddenly  chilled. 

IHdiiir. — With  few  exceptions,  persons  over  forty  eat  too  much,  and 
the  lirst  injunction  loa  gouty  person  is  to  keep  his  appetite  within  reason- 
able hounds,  to  eat  at  .stated  hours,  and  to  ti*ke  plenty  of  time  at  his  meals. 
In  the  matter  of  food,  (piantity  is  a  factor  of  more  importance  than  qual- 
ity with  many  gouty  persons.  As  Sir  William  Koberts  well  says,  "  Nowhere 
perhaps  is  it  more  necessary  than  in  gout  to  consider  the  nuin  as  well  as 
the  ailiiu'iit,  and  very  often  more  the  num  than  the  ailment.'" 

Very  renuu'kable  dilTerences  of  ojiinion  exist  as  to  the  most  suitable 
diet  in  this  disease,  some  urging  warmly  a  vegt'table  diet,  others  allowing 
;i  very  liberal  amount  of  meat.  Ou  the  one  hand,  the  author  just  quoted 
!=ays:  "The  most  trustworthy  experiments  indicate  that  fat,  starch,  and 
Jiiiiar  have  not  the  least  direct  influence  on  the  production  of  uric  acid ; 
but  as  the  free  consumption  of  these  articles  naturally  operates  ;■•  restrict 
the  intake  o  the  nitrogenous  food,  their  use  has  iiulirectly  flie  eitect  of 
•liiiiinishiMt'  the  average  production  of  uric  acid."  On  the  other  hand, 
»>.  II.  l>r!»  )er  says:  "The  conversion  of  azotized  food  is  more  complete 
«'ith  a  m'  limum  of  carbohydrates  than  it  is  with  an  excess  of  them ;  in 
oilier  wo  ,1s,  one  of  the  best  means  of  avoitling  tlie  accumulation  of  lithic 
aeui  in  the  blood  ia  to  diminish  the  carbohydrates  rather  than  the  azotized 
loo'ls."  The  weight  of  opinion  leans  to  the  use  of  a  modified  nitrogefioua 
diet,  without  excess  in  starchy  uud  saccharine  articles  of  food.    Fresh  vege- 


'\ 


ill 


i 


i 


m 


»  ,1 

vy\m. 


.>(S 


*  m 


518 


CONSTITUTIONAL   DISEASES. 


lA' 


\i 


1>/ 


tables  and  fruits  may  be  used  freely,  but  among  the  latter  strawberries  aud 
bananas  sliould  be  avoided. 

Ebstein  urges  strongly  the  use  of  fat  in  the  form  of  good  fresli  butter, 
from  2^  to  3J-  ounces  in  the  day.  Jle  says  that  stout  gouty  subjwts  m 
only  do  not  increase  in  weight  with  plenty  of  fat  in  the  food,  but  tlmt  tlicv 
actually  become  thin  and  the  general  condition  improves  very  much.  Hut 
bread  of  all  sorts  and  the  various  articles  of  food  prepared  from  Imlian 
corn  should,  as  a  rule,  be  avoided.  Roberts  advises  gouty  ])ati('iits  to  re- 
strict as  far  as  practicable  the  use  of  common  salt  with  their  meals,  tiiiice 
the  sodium  biurato  very  readily  crystallizes  out  in  tissues  with  a  high  per- 
centage of  sodium  salts. 

In  this  nuitter  of  diet  each  individual  case  must  receive  separate  con- 
sideration. 

There  are  very  few  conditions  in  the  gouty  in  which  stimuliints  of 
any  sort  are  required.  Whenever  itulicated,  whisky  will  be  found  per- 
haps the  most  serviceable.  While  all  are  injurious  to  these  patients, somt; 
are  much  more  so  than  others,  particularly  malted  liquors,  champagne, 
port,  and  a  very  large  proportion  of  all  the  light  wines. 

Mineral  Wat  em. — All  forms  may  be  said  to  be  beneficial  in  gout,  iis 
the  main  element  is  the  water,  and  the  ingredients  are  usually  indiffer- 
ent. Much  of  the  humbuggery  in  the  profession  still  lingers  about  min- 
eral waters,  more  particularly  about  the  so-called  lithia  waters.  Therein 
not  the  slightest  evidence  that  the  carbonate  of  lithium  has  any  intluenee 
whatever  in  promoting  the  sol 'ibility  of  uric  acid.  Fortunately,  they  all 
contain  the  essential  ingredient,  ;<nd  one  perhaps  cannot  overlook,  even  in 
the  gouty,  the  influence  of  suggestion.  The  water  should  be  drunk  when 
the  stomach  is  empty.  Three,  four,  or  five  glasses  a  day  sufllee.  ami  in 
the  early  morning  it  nuiy  be  taken  hot. 

The  question  of  the  utility  of  alkalies  in  the  treatment  of  gout  is 
closely  connected  with  this  ^abject  of  mineral  waters.  This  (leop-rnoted 
belief  in  the  profession  was  rudely  shaken  a  few  years  ago  by  Sir  William 
Koberts,  who  claims  to  have  shown  conclusively  that  alkalescence  as  smli 
has  no  innnence  whatever  on  the  sodium  biurato.  The  sodium  salts  are 
believed  bv  this  author  to  be  particularly  harmful.  In  Yeo's  Manual  of 
Clinical  .  catment  the  cfticacy  of  the  alkalies  is  nuiintained;  and  as  he 
well  says,  in  spite  of  all  the  theoretical  denunciation  of  tlie  use  of  the 
sodium  salts  in  gout,  the  gou.ty  from  all  parts  of  tlie  world  flock  to  those 
very  Continental  springs  in  which  these  salts  are  most  ])redoniinant. 

Of  the  mineral  springs  best  suited  for  the  gouty  may  be  mcntioneii, 
in  this  country,  those  of  Saratoga,  Bedford,  and  the  White  Siilplnir; 
Buxton  and  Bath,  in  England  ;  in  France,  Aix-les-Bains  and  t'oiitreve- 
villa;  and  in  Germany,  Carlsbad,  Wildbad,  and  Homburg. 

The  efficacy  in  reality  is  in  the  M-aters,  in  the  way  they  are  taken, 
on  'an  empty  stomach  and  in  large  quantities ;  and,  as  every  one  knows, 
the  important  accessories  in   the  modified  diet,  proper  hours,  regular 


GOUT. 


319 


exercise,  with  baths,  douches,  etc.,  play  a  very  irnjiortant  role  in  tlie 
••cure." 

Mf'iliriiKil  Trentincnt. — In  an  acute  attack  the  limb  should  be  elevated 
mill  the  atTocted  joint  wrapped  in  cotton- wool.  Warm  fomentations,  or 
I'ullcrs  lotion,  may  be  used.  Steaming  the  joint  is  sometimes  beneficial. 
A  brisk  mercurial  j)urge  is  always  advantageous  at  the  mitst't.  The  wine 
or  tincture  of  colcliicum,  in  doses  of  twenty  to  thirty  minims,  may  be 
given  every  four  hours  in  combituition  with  the  citrate  of  potash  or  the 
eitnite  uf  lithium.  The  action  of  the  colcliicum  should  be  carefully 
wiitelk'd.  It  has,  in  a  majority  of  the  cases,  a  powerful  inlluence  over 
the  symptoms — relieving  the  pain,  and  reducing,  sometimes  with  great 
rupiditv,  the  swelling  and  redness.  It  should  be  promptly  stopped  so 
soon  as  it  has  relieved  the  pain.  In  cases  in  which  the  pain  and  sleep- 
lessness are  distressing  and  do  not  yield  to  colcliicum,  morphia  is  neces- 
sary, The  ])atient  should  be  placed  on  a  diet  chiefly  of  milk  and  barley- 
water,  but  if  there  is  any  debility,  strong  broths  may  be  given,  or  eggs. 
It  is  occasionally  necessary  to  give  small  quantities  of  stimulants.  During 
convalescence  meats  and  fish  and  game  may  be  taken,  and  gradually  the 
patient  may  resume  the  diet  previously  laid  down. 

In  sdiiie  of  the  subacute  intercurrent  attacks  of  arthritis  in  old,  de- 
formed joints  the  sodium  salicylate  is  occasionally  useful,  but  its  adminis- 
tration must  be  watched  in  cases  of  cardiac  and  renal  insutlicieiicy.  Ic  is 
also  mueli  advocated  by  Ilaig  in  the  uric-acid  habit. 

The  chronic  and  irregular  forms  of  gout  are  best  treated  by  the  dietetic 
and  hygienic  measures  already  referred  to.  Iodide  of  i>otassium  is  some- 
times useful,  and  jireparations  of  guaiacum,  quinine,  and  the  bitter  tonics 
coinliined  with  alkalies  are  undoubtedly  of  benefit. 

Piperazin  has  been  much  lauded  as  an  efficient  aid  in  tlio  solution  of 
uric  acid.  The  clinical  results,  however,  are  very  discordan'  li  may  be 
employed  in  doses  of  from  fifteen  to  thirty  grains  in  the  d.iv,  and  is 
conveniently  given  in  aerated  water  containing  live  grains  to  the  tum- 
blerful. 


''•I; 


320 


CONSTITUTIONAL  DISKASES. 


VII.  DIABETES   MELLITUS. 

Definition. — A  disorder  of  nutrition,  in  wliieli  sujjiir  appuiiiiilates 
in  the  blot, J  iind  is  excreted  in  the  urine,  the  daily  uniount  of  which  ij 
greatly  increased. 

Etiology. — Hereditary  inthiences  play  an  important  role,  and  nm 
are  on  rec'ord  of  it.s  occurrence  in  many  members  of  the  same  familv, 
There  are  instances  of  the  coexistence  of  the  disease  in  husl)aiul  ainl 
wife.  Men  are  more  frequently  alfeeted  than  women.  It  is  a  distat^c  of 
adult  life  ;  a  nuijority  of  the  cases  occur  from  the  third  to  the  sixtli  decade. 
It  is  rare  in  childlio'xl,  but  cases  are  on  record  in  children  under  one  voar 
of  age.  Persons  of  a  neurotic  teinjierament  are  often  affected.  It  is  a 
disease  of  the  higher  classes.  Hebrews  seem  especially  prone  to  it;  mc 
fourth  of  Frerichs'  ])atients  were  of  the  Semitic  race.  In  a  consitlcraldc 
proportion  of  tlie  cases  of  diabetes  the  subjects  have  been  excessively  fat 
at  the  beginning  of,  or  prior  to,  the  onset  of  the  disease.  A  slight  traru 
of  sugar  is  not  very  uncommon  in  obese  persons.  This  so-called  lipoircnir 
glycosuria  is  not  of  grave  signiticauce,  and  is  oidy  occasionally  t'olloHtil 
by  true  diabetes.  On  the  other  hand,  as  von  Noortlen  has  shown,  there 
may  be  a  "diabetogenous  obesity,"  in  which  diabetes  and  obesity  develfip 
in  early  life,  and  these  cases  are  very  unfavorable.  There  are  instamr-- 
on  record  in  wdiich  obesity  with  diabetes  has  occurred  in  three  genera- 
tions. Diabetes  is  more  common  in  cities  than  in  country  districts.  (Joiit, 
syphilis,  and  malaria  have  been  regarded  a^  predisposing  causes.  Moiitil 
shock,  severe  nervous  strain,  and  worry  precede  many  cases.  'J'lie  eonilii- 
nation  of  intense  application  to  business,  over-indidgence  in  food  im\ 
drink,  with  a  sedentary  I'fe,  seem  particularly  prone  to  induce  the  disoa.* 
It  may  .set  in  during  pregnancy,  and  in  rare  instances  may  only  occur  ;it 
this  period.  Injury  to  or  disease  of  the  spinal  cord  or  brain  lias  Imh 
followed  by  diabetes.  In  the  carefully  analyzed  cases  of  Frerichs  there 
were  thirty  instances  of  organic  disease  nf  these  parts.  The  medulla  i? 
not  always  involved.  In  only  four  of  bis  r:i-r<,  which  showed  organic  ihv 
ease,  was  there  sclerosis  or  other  anomaly  of  this  part.  An  irritative  lesion 
of  Bernard's  diabetic  centre  in  the  medulla  is  an  (KH'asional  cause.  I  saw 
with  Riess,  at  the  Friedrichshain,  Berlin,  a  wonnui  who  had  anolnalllll^ 
cerebral  symptoms  and  diabetes,  and  in  whom  there  was  found  pust  iiiMr- 
tern  a  cysticercus  in  the  fourth  ventricle. 

The  disease   has  occasiomilly  followed  the  infectious  fevers.    A  fi» 
cases  have  followed  injury  without  involvement  of  the  brain  or  cord. 

In  comparison  with  European  countries  diabetes  i    a  rare  diseased 
America.     The  lust  census  gave  only  'Z-8  per  one  hundred  thuusiind  w' 


DIABETES   MELLITUS. 


821 


popiiliition,  against  a  ratio  of  from  five  to  nine  in  tlio  former.  In  tliis 
ivinon  the  incidence  of  tlie  disease  may  be  gathered  from  the  fact  that 
aiiioii;:  thirty-five  tliousand  patients  under  treatment  at  the  .Jolms  Hop- 
kins Hospital  and  Dispensary  there  were  only  ten  eases. 

Wo  are  ignorant  of  tiie  nature  of  tlio  disease.  Normally  the  earbo- 
hvih'iitos  taken  with  the  food  are  stored  in  the  liver  and  in  the  muscles  as 
('ivoogon,  and  then  utilized  as  needed  by  the  system.  Glycogen  can  also 
be  forniod  from  the  proteids  of  the  food,  and  under  certiiin  circumstances 
suirar  niav  l)e  directly  formed  from  the  body  proteids.  Whenever  the 
sii!:;;ii'  ill  the  systemic  blood  exceeds  a  definite  amount  (a!)out  0  'i  per  cent) 
it  is  (iiscliiirged  by  the  kidneys,  producing  glycosuria.  Tlieoretically  dia- 
betes iiiiiy  iie  supposed  to  be  induced  by : 

((f)  The  ingestion  of  a  larger  quantity  of  carbohydrates  and  peptones 
than  can  be  warehoused,  so  to  speak,  in  the  liver  as  glycogen,  so  that  jiart 
has  to  pass  over  into  the  hepatic  blood.  Some  of  the  instances  of  lii)ogeuic 
or  dietetic  glycosuria  are  of  this  nature. 

(b)  Disturbances  of  the  liver  function:  (1)  Changes  in  the  circula- 
tion uiiiler  nervous  influences.  Puncture  of  the  medulla,  lesions  of  the 
conl,  and  centrid  irritation  of  various  kinds  are  followed  by  glycosuria, 
which  is  attributed  to  a  vaso-motor  paralysis  (more  rajud  blood-llow)  in- 
duced by  these  causes.  On  this  view  the  disease  is  a  neurosis,  {'i)  In- 
stability of  the  glycogen,  owing  either  to  imperfect  formation  or  to  con- 
ditions of  the  cells  which  render  it  less  stable.  Phloridzin  and  other 
siibstaiK^cs  which  cause  diabetes  very  probably  act  in  this  way,  though 
phloridzin  is  said  to  act  primarily  tn  the  renal  e])ithelium,  destroying  its 
power  of  keeping  back  the  sugar. 

{(■)  Defective  assimilation  of  the  glucose  in  the  system.  How  and 
under  what  normal  circumstances  the  sugar  is  utilized  we  do  not  yet 
know.    Theoreticaliy  faulty  metabolism  would  explain  the  condition. 

Interesting  observations  have  of  late  made  it  probable  that  the  jiancreas 
may  in  some  cases  be  the  seat  of  tbe  trouble.  Lesions  of  this  organ  are 
met  with  in  about  .")()  per  cent  of  the  cases  (Hansemann).  Von  Meriiig 
and  Miid<()wski  have  shown  tluit  extir|)ation  of  the  gland  in  dogs  is  fol- 
lowed by  glycosuria,  but,  if  a  small  portion  remains,  sugar  does  not  appear 
in  the  urine,  facts  which  have  been  confirmed  by  Lepin(>  and  others.  The 
pancreas,  on  this  view,  has,  like  the  liver,  a  double  secretion — an  extornal, 
which  is  [)oured  into  the  intestines,  and  an  internal,  which  jiasses  into 
the  blood.  Tliis  latter  is  suppo.sed  to  be  of  the  nature  of  a  ferment,  in 
tlie  presence  of  whi('h  alone  the  normal  assimilative  processes  can  take 
place  with  the  glycogen.  I)isea.se  of  the  pancreas  causes  diabetes  by 
preventing  the  formation  of  the  glycolytic  ferment.  Kven  when,  as  in  a 
majority  of  instances  of  diabetes,  tlie  organ  is  apparently  nornuil,  a  func- 
tional trouble  may  disturb  the  formation  of  this  ferment.  The  fact  that 
if  a  small  jtortion  of  the  gland  is  left,  in  the  experiments  upon  dogs,  dia- 
betes dois  not  occur,  is  analogous  to  the  remarkable  circumstance  that  a 


!l 


f      > 


,  r'VH   ■'^^'^ 


! 


1«    s1 


yi. 


"Hi    1 


322 


CONSTITUTIONAL  DISEASES. 


small  fragment  of  the  thyroid  is  sutricient  to  prevent  the  development  of 
artificial  myxa?dema. 

Morbid  Anatomy. — Saundby*  has  recently  analyzed  the  cluiiiges 
which  occur  in  this  disejise. 

The  nervous  sysfem  shows  no  constant  lesions.  In  a  few  instances 
there  have  been  tumors  or  sclerosis  in  the  medulla,  or,  as  in  the  case  above 
mentioned,  a  cysticercus  has  pressed  on  the  floor.  Cysts  have  been  mot 
with  in  the  white  matter  of  the  cerebrum  and  perivascular  changes  have 
been  described.  Glycogen  has  been  found  in  the  spinal  cord.  In  the 
pcriplieral  nervous  system  there  are  instances  in  which  tumors  liavo  been 
found  pressing  on  the  vagus.  A  secondary  multiple  neuritis  is  not  rare, 
and  to  it  the  so-called  diabetic  tabes  is  probably  due.  R.  T.  Wiliiumson 
has  found  chai\ges  in  the  posterior  columns  of  the  cord  similar  to  those 
which  occur  in  pernicious  antxjmia. 

In  the  sympathetic  system  the  ganglia  have  been  enlarged  and  in  some 
instances  sclerosed,  but  there  is  nothing  peculiar  in  these  changes.  The 
blood  may  contain  as  high  as  0'4  per  cent  of  sugar  instead  of  O'lr)  per  cent. 
The  plasma  is  usually  loaded  with  fat,  the  molecules  of  which  may  be  seen 
as  fine  particles.  When  drawn,  a  white  creamy  layer  coats  the  eoajrnlinii, 
and  there  may  be  lipajmic  clots  in  the  small  vessels.  There  are  no  special 
changes  in  the  red  or  white  corpuscles.  Gabritschewsky  has  shown  thut 
the  polynuclear  leucocytes  in  diabetes  contain  glycogen.  Glycogen  eaii 
occur  in  normal  blood,  but  it  is  here  extra-cellular.  It  has  boon  aUo 
found  in  the  polynuclear  leucocytes  in  leukaemia.  The  Jtcnrf  is  liyper- 
trophied  in  some  cases.  Endocarditis  is  very  rare.  Artorio-sclerosis  \i 
common.  The  luiif/s  show  important  changes.  Acute  bronclid-piuii- 
monia  or  croupous  pneumonia  (either  of  which  may  terminate  in  pin- 
grene)  and  tuberculosis  are  common.  The'  so-called  diabetic  ])lithi:;is  is 
always  tuberculous  and  results  from  a  caseating  broncho-pneuinoniii.  In 
rare  cases  there  is  a  chronic  interstitial  pneumonia,  non-tuberculons.  Fat 
embolism  of  the  pulmonary  vessels  has  been  described  in  connection  \vith 
diabetic  coma. 

The  lii'er  is  usually  enlarged,  fatty  degeneration  is  common,  ami 
French  writers  have  described  a  form  of  cirrhosis.  Letulle,  who  has  de- 
scribed remarkable  examples  of  this  so-called  diabetic  cirrhosis— tlie  rir- 
rhose  pigmentaire — thinks  the  change  is  due  to  abnormal  destruction  of 
the  blood-cells.     It  may  be  associated  with  bronzing  of  the  skin. 

The  pancreas^  as  pointed  out  by  Lancereaux,  shows  important  chantres. 
IIansemann,t  in  forty  eases  of  pancreatic  disease  with  diabetes,  f omul  sim- 
ple atrophy  in  thirty-six ;  and  he  gives  a  table  of  seventy-two  cases  from 
the  literature. 


*  IJradtihaw  Lecture,  Royal  College  of  Physicians  of  London,  1890 ;  and  LecturcsoD 
Diabetes,  E.  B.  Treat,  New  York,  1891. 
t  Zfitsehrift  f.  klin.  Med.,  Bd.  26. 


DIABETES   MELLITUS. 


823 


V  ! ,: 


A  patient  of  W.  T.  Bull  died  of  diabetes  after  extirpation  of  the  pan- 
creiis.  In  some  instances  there  is  a  pigmentary  cirrliosis  analogous  to  that 
which  occurs  in  the  liver,  and  this  induration  seems  to  be  an  important 
chaiigt'.  Cancer  and  calculi  have  been  met  with  ;  and  Longstreth  found, 
in  one  instance,  cystic  disease  of  the  organ.  Fat  necrosis  of  the  pancreas 
has  also  been  found.     Dilatation  of  the  stonuich  is  common. 

Tlie  kidndjx  show  usually  a  diffuse  nephritis  with  fatty  degeneration. 
A  liyaline  cluuige  occurs  in  the  tubal  epithelium,  particularly  of  the  de- 
BLiiidiug  limb  of  the  loop  of  Ilenle,  and  also  in  the  capillary  vessels  of  the 

IllftS. 

Symptoms. — Acute  and  chronic  forms  arc  recognized,  but  then  's 
no  esseiiliul  diireroiice  between  them,  except  that  in  the  former  the  pr 
tieiits  are  younger,  the   course  more    rapid,  and    the  emaciation   more 
marked. 

It.  is  also  possible  to  divide  the  cases  into  (I)  hpofjrnic  or  dietetic,  which 
iiu'hiiles  the  transient  glycosuria  of  stout  persons;  ['i)  neurotic,  dnc  to 
injiu'ies or  fnnctioiud  disorders  of  the  nervous  system;  and  (13)  pttiiciratic, 
ill  whicli  tlierc  is  a  lesion  of  the  pancreas.  It  is,  however,  by  no  means 
easy  to  discriminate  in  all  cases  between  these  forms.  Of  late  attempts 
have  been  made  to  separate  a  clinical  variety  analogous  to  experimental 
pancreatic  diabetes.  Ilirschfeld,  from  fJuttmann's  clinic,  has  described 
cases  running  a  rapid  and  severe  course  usually  in  young  and  middle-aged 
jHrsons.  The  polyuria  is  less  common  or  even  absent,  and  there  is  a  strik- 
ing defect  in  the  assimilation  of  the  albuminoids  and  fats,  as  shown  by 
the  examination  of  the  faeces  and  urine.  In  four  of  seven  cases  autopsies 
wore  made  and  the  pancreas  was  found  atrophic  in  two,  cancerous  in  one, 
and  in  the  fourth  exceedingly  soft. 

The  onset  of  the  disease  is  gradual  and  cither  fre([ucnt  micturition  or 
inordinate  thirst  first  attracts  attention.  Very  rarely  it  sets  in  rai)idly, 
after  a  sudden  emotion,  an  injury,  or  after  a  severe  chill.  When  ftdly 
established  the  disease  is  characterized  by  great  thirst,  the  passage  of  large 
quantities  of  saccharine  urine,  a  voracious  appetite,  and,  as  a  rule,  pro- 
gressive emaciation. 

The  Urine. — The  amount  varies  from  six  or  eight  pints  in  mild  cases 
to  tliirty  or  forty  pints  in  very  severe  cases.  In  rare  instances  the  quan- 
tity of  urine  is  not  much  increased.  Under  strict  diet  the  amount  is 
nuicli  lessened,  and  in  intercurrent  febrile  affections  it  may  be  reduced  to 
tiornial.  The  specific  gravity  is  high,  ranging  from  I'O'^o  to  1'04.");  bnt 
ill  except  ional  cases  it  may  be  low,  1-(>1;3  to  1-020.  The  urine  is  pale  in 
color,  ahiiost  like  water,  and  has  a  sweeti.sh  odor  and  a  distinctly  sweetish 
taste.  The  reaction  is  acid.  Sugar  is  present  in  varying  amounts.  In 
mihl  cases  it  does  not  exceed  one  and  a  half  or  two  per  cent,  but  it  may 
reach  from  live  to  ten  percent.  The  total  amount  excreted  in  the  twenty- 
four  iiours  may  range  from  ten  to  twenty  ounces,  and  in  exceptional  cases 
from  one  to  two  pounds.     The  following  are  the  most  satisfactory  tests  : 


imiA 


324 


CONSTITUTIONAL   DISKASES. 


>t 


Fi'hUnrfs  Tost. — The  solution  consists  of  sulphate  of  copper  (jjrs.  00]), 
noiitnil  tartrate  of  ])otasli  (^^rs.  .'?(!4),  solution  of  eaustie  soda  (tl.  nz^,  4), 
sind  distilled  water  to  make  uj)  six  ouneos.  Put  adraehin  of  this  in  u  test- 
tube  and  boil  (to  test  the  reagent) ;  add  an  equal  quantity  of  urine  and  bull 
a<(ain,  when,  if  sugar  is  present,  the  yellow  suboxide  of  copper  is  thrown 
down.     The  solution  must  be  freshly  prejjared,  as  it  is  apt  to  decoiniioH'. 

Tromnwr's  Tvst. — 'i'o  a  drachm  of  urine  in  a  test-tube  add  a  few  ([n\<i 
of  a  dilute  sulphate-of-copper  solution  and  then  as  much  liquor  pa/aKsw 
as  urine.  On  boiling,  the  copper  is  reduced  if  sugar  bo  present,  fonniii;' 
the  yellow  or  orange-red  suboxide.  There  are  certain  fallacies  in  the  cop- 
per tests.  Thus,  a  substance  called  glycuronic  acid  is  met  with  in  the 
urine  after  the  uso  of  certain  drugs— chloral,  idienacetin,  morphia,  cliloni- 
form,  etc. — which  reducjes  copper.  Glycosuria  acid  or  ulcapton  may  also 
prove  a  source  of  error  (see  page  777). 

Fermentdtidu  Test. — Tins  is  free  from  all  doubt.     Place  a  small  fra"'- 

n 

ment  of  yeast  in  a  test-tube  full  of  urine,  which  is  then  inverted  over  a 
glass  ves.sel  containing  the  same  fluid.  If  sugar  is  i)resent,  fermentation 
goes  on  with  the  formation  of  carbon  dioxide,  which  accumulates  iu  the 
upper  part  of  the  tube  and  gradually  expels  the  urine.  In  doubtful  caacs  a 
control  test  should  always  be  used. 

Of  other  ingredients  in  the  urine,  the  urea  is  increased,  the  uric  acid 
does  not  show  special  changes,  and  the  phospliates  may  be  greatly  iu  ex- 
cess. Ealfe  has  described  a  great  increase  in  the  phosphates,  and  in  .-oiiie 
of  these  cases,  with  an  excessive  excretion,  the  symptoms  may  be  very 
similar  to  those  of  diabetes,  though  the  sugar  nniy  not  be  constantly  pre;- 
ent.  The  term  phos])hatic  diabetes  has  sometimes  been  applied  to  tliLiii, 
Acetone  and  acetone-forming  substances  are  not  infrequently  present.  Le 
Xobel's  test  for  acetone  is  as  follows :  "  Po'ur  an  ounce  of  urine  into  a 
urine  glass;  add  a  drachm  or  two  of  nitro-prusside  of  sodium  (live  grains 
to  one  ounce)  and  a  few  drops  of  strong  liquor  ammonite.  After  standinjr 
a  few  minutes  a  rose-violet  color  is  developed,  which,  if  much  acetone  is 
present,  may  require  diluting  with  water  in  order  to  bring  out  the  bril- 
liancy of  its  color  "  (Saundby). 

(il)iro(i>'n  has  also  been  described  as  present  in  the  urine. 

AUiuiniii  is  not  infrequent.  It  occuirred  in  nearly  thirty-seven  per  cent 
of  the  examinations  nuide  by  Lippman  at  Carlsbad. 

Pneumatnria,  the  formation  of  gas  in  the  urine,  due  to  fermentative 
processes  in  the  bladder,  is  occasionally  met  with. 

Fat  may  be  passed  in  the  urine  in  the  form  of  a  fine  einul'-ioii 
(lipnria). 

Among  the  genend  symptoms  of  the  disease  thirst  is  one  of  the  most 
distressing,  A  very  large  amount  of  water  is  required  to  keep  the  siijiar 
in  solution  and  for  its  oxcn^tion  in  the  urine.  The  amount  of  water  con 
sumeil  will  be  found  to  bear  a  definite  ratio  to  the  quantity  excretoil.  In- 
stances, however,  are  not  uncommon  of  pronounced  diabetes  in  which  the 


DIABETES  MELLITUS. 


325 


tliirst  is  not  excessive;  but  in  such  cases  the  amount  of  urino  passed  is 
TicMT  liir;,^'.  'I'lic  thirst  id  most  intense  an  hour  or  two  after  meals.  As 
a  rule,  tiio  iliiicstion  is  jj^ood  and  the  apju'tito  inordinate.  A  story  is  told 
of  ii  iiuiii  wilh  iliabcti's  who  was  paid  to  stay  away  from  a  certain  restau- 
rant at  whii'li  dinners  were  given  at  lixed  j)riees.  It  is  sometimes  impos- 
sible to  satiate  the  raven(»us  ai)petite  of  u  diabetic  patient.  The  condition 
is  sdiiiciiiiii'S  termed  buUiitia  or  poli/phdf/ in. 

TliL'  toiiL.MU'  is  usually  dry,  red,  and  glazed,  aiul  the  saliva  scanty.  The 
CIU11.S  may  licfome  swollen,  and  in  the  later  stages  a])hthous  slouuititis  is 
c'oiimidii.     Constipation  is  the  rule. 

Ill  -[liii'  of  the  enormous  amount  of  food  consumed  a  patient  may  be- 
come ra|iiilly  emaciated.  This  loss  of  llesh  bears  some  ratio  to  the  poly- 
uria, ami  when,  under  suitable  diet,  the  sugar  is  reduced,  the  patient  may 
(luickly  gain  in  llesli.  The  .skin  is  dry  and  harsh,  and  j)erspirations  rarely 
occur,  exeept  wli'.'ii  phthisis  coexists.  Drenching  sweats  have  been  known 
to  allcriiate  with  excessive  polyuria.  The  temperature  is  often  subnor- 
mal ;  the  j)uls(!  is  usually  f recpient,  ami  the  tension  increased.  Many  dia- 
betics, liuwever,  do  not  show  marked  emaciation.  Patients  past  the  mid- 
(llo  jipriod  of  life  may  have  the  disease  for  years  without  much  disturbance 
of  tlic  liealtli,  and  nuiy  reuuiin  well  nourished.  The.se  are  the  cases  of  the 
diahi'te  ijr((s  in  contradistinction  to  lUahvte  iiuii^/rc. 

Diabetes  in  Children. — lACcently  Stern  has  analyzed  117  cases  in  chil- 
dren. Tliey  usually  occur  among  the  better  classes.  Six  were  under  one 
year  of  age.  Hereditary  influences  were  marked.  The  course  of  the  dis- 
ease is,  as  a  rule,  much  more  rapid  than  in  adults.  The  shortest  duration 
was  two  (lays.  In  'seven  cases  it  did  imt  last  a  month.  One  ca.<e  is  men- 
tioned of  a  cluld  apparently  born  Avith  the  glycosuria,  who  recovered  in 
eight  months. 

Complications. — {(()  Cutaneous. — Boils  and  carbuncles  are  extreme- 
ly eonniion.  Eczema  is  also  met  with  and  at  times  an  int(derablc  itching. 
Ill  women  the  irritation  of  the  urine  may  cause  the  most  intense  i)ruritu8 
pr.ileiuli,  and  in  men  a  balanitis.  Rarer  affections  are  xanthonui  and  pur- 
pura, (iangrene  is  not  uncommon.  William  Hunt  has  analyzed  04  cases. 
In  oU  the  localities  were  as  follows  :  Feet  and  legs,  37  ;  thigh  and  buttock, 
■■.*;  nuclia,  2;  external  geidtals,  1;  lung.s,  3;  fingers,  3;  back,  1;  eyes,  1. 
Perforating  ulcer  of  the  foot  may  occur. 

(5)  Pulmonary. — The  patients  are  not  infrequently  carried  off  by  acute 
piicKiHoiiid,  which  may  be  lobar  or  lobular.  (Utuijn'itc  is  very  ajit  to 
siiiXM'vcne,  but  the  breath  does  not  necessarily  have  the  foul  odor  of  ordi- 
iiary  gangrene. 

Tiibcrriihnis  hniucho-jmeumonia  is  very  common.  It  was  formerly 
thought,  from  its  rapid  cour.se  ami  the  limitation  of  the  disease  to  the 
huig,  that  this  was  not  a  true  tuberculous  alfection  ;  but  in  the  cases  which 
have  como  inuler  my  notice  bacilli  have  been  present,  and  the  condition  is 
now  generally  I'cgarded  as  tuberculous. 


320 


CONSTITUTIONAL  DISEASES, 


>'  n 


(r)  Renal. — Alhuminnria  i.s  a  tolcmbly  frequent  complioatidn.  Tlip 
amount  varies  greatly,  and,  when  sliglit,  docs  not  seem  to  be  of  miicli  hid. 
nient.  It  is  sometimes  associated  with  arterio-sclerosis.  It  oeciisidimllv 
})rece(h's  the  development  of  llio  diabetic  coma.  Occasionally  cystitis 
dcvelcjps. 

{d)  Nervous  System. — (I)  Diubvtic  coma,  first  studied  by  Kusstnaiil, j, 
the  most  serious  complication  of  the  disease,  and  carries  olf  a  con.-sidoialile 
proportion  of  all  cases,  ])articularly  in  the  young.  It  may  occur  when 
dialjetes  is  unsuspected,  as  in  two  cases  recently  reported  by  Francis 
Minot.  Frerichs  recognized  three  groups  of  cases:  (a)  'Those  in  which 
after  exertion  the  patieuts  were  suddeidy  attacked  with  weakness,  syiico|ic, 
somnolence,  and  gradually  deepening  unconsciousness;  death  occiuTiiii; 
in  a  few  hours.  (/3)  Cases  with  preliminary  gastric  disturbance,  siuh  as 
nausea  and  vomiting,  or  some  local  aiTection,  as  ])haryngitis,  phlegmon, dr 
a  pulmonary  complicatiou.  In  such  cases  the  attack  begins  with  head- 
ache, delirium,  great  distress,  and  dyspn(ea,  alfecting  both  inspiration  ainl 
expiration,  a  condition  calh'd  by  Kussnuiul  (iir-/inii;/<'r.  Cyanosis  mayor 
may  not  be  present.  If  it  is,  the  pulse  becomes  rapid  and  weak  and  tlic 
patient  gradually  sinks  into  coma;  the  attack  lasting  from  one  to  live 
days.  There  may  be  a  very  heavy,  sweetish  odor  of  the  breath,  due  to  the 
presence  of  acetone,  (y)  Cases  in  which,  without  any  previous  dyspima 
or  distress,  the  patient  is  attacked  with  headache  and  a  feeling  of  intoxi- 
cation, and  rapidly  falls  into  a  deep  and  fatal  coma. 

There  has  been  much  dispute  as  to  the  nature  of  these  symptoms,  but 
our  knowledge  of  the  disease  is  not  yet  sufficiently  advanced  to  give  a 
ratioiud  explaiuition.  The  character  of  the  attack  and  the  similarity,  in 
many  instances,  to  ura'mia  would  indicate  that  it  de])ended  upon  sonic 
toxic  agcut  in  the  blood.  The  theory  mo'st  commonly  held,  that  this 
nuiterial  is  acetone,  is  supported  by  the  presence  of  the  acetone  reaction  in 
tlie  urine  and  its  odor  in  the  breath.  Stad<'lmann  believes  that  the  con- 
dition is  not  acetonaMuia,  but  that  the  poisonous  agent  is  an  intermediate 
product  between  the  sugar  and  acetone,  an  oxy-butyric  acid. 

Saunders  and  Hamilton  have  described  cases  in  which  the  lung  capil- 
laries were  blocked  with  fat.  They  attributed  the  symjjtoms  to  fat  cnd)o- 
lism,  but  there  ai-e  many  cases  on  record  in  which  this  condition  was  not 
found,  though  lipa^mia  is  by  no  means  infrecjiient  in  diabetes. 

The  symptoms  have  been  attributed  to  uraemia,  and  albuminuria  fre- 
quently precedes  or  accomj)anies  the  attack. 

(2)  Periphernl  Neuritis. — The  neurahjins,  numbness,  and  tinjrling, 
which  are  lutt  uncommon  symptoms  in  diabetes,  are  probably  minor  neu- 
ritic  manifestations. 

Diobciic  Tabrs  (so  called). — This  is  a  peripheral  neuritis,  characterized 
by  lightning  pains  in  the  legs,  loss  of  knee-jerk — which  may  ocenr  with- 
out the  other  symptoms — and  a  loss  of  power  in  the  extensors  of  the  foet. 
The  gait  is  the  characteristic  siepjjciffe,  as  in  arsenical,  alcoholic,  aad  other 


4 


niAHKTFIS   MKLLITUS. 


327 


form?  of  iiiMiritic  parulysis.  Clian'ot  sfjifos  tlint  tlioro  iniiy  hp  atrophy  of 
tlu'dptir  ti.i-vi's.  ('Imiig((sin  tlic  posterior  coltiiniis  of  tlii*  cord  liiivc  Im'cii 
foiiiid. 

Diitliilir  I'(ini/)lf'(/ifi. — This  is  also  in  all  prohahility  (liu;  to  neuritis. 
Tliciv  iiiv  iMscs  ill  which  power  has  been  lost  in  both  arms  aiul  le<,'s. 

(;{)  Mnihtl  Siiniplinits. — The  patients  are  often  morose,  and   there  is  a 

striiiij,'  teiideiiey  to  heectine  liv) hondriacal.     (Jenerai  paralysis  has  been 

kiiDttii  to  develop.  Some  i)ationts  display  uu  extraordinary  de;,nve  of  rost- 
li'isiiL'SS  and  anxiety. 

(4)  Sjiiridl  SfHsrs. — Oataraet  is  liable  to  occur,  and  may  develop  with 
nipidity  ill  yoiiiii,' ])ersons.  Diabetic  retinitis  (;losely  resenil)lei:  the  all)U- 
iiiiiiiiiir  form.  Ha'niorrlia;.(es  are  common.  Suddeti  amaurosis,  similar 
to  that  which  occurs  in  ura'inia,  may  oi'ciir.  Paralysis  of  tlii^  muscles  of 
art'onimodation  may  be  present;  and  lastly  atrophy  of  the  optic  nerves. 
Aural  syiiipfoiiis  may  come  on  with  fjrcat  rapidity,  either  an  otitis  media, 
or  in  sonic  instances  inflammation  of  the  ma>itoid  cells. 

(5)  Sexual  Function. — Impotence  is  common,  and  may  be  an  early 
synijitoin. 

Course. — In  children  tlio  disease  is  rapidly  progressive,  and  may  prove 
fatal  ill  a  t'cw  days.  It  may  be  stated,  as  a  general  rule,  that  the  oldtn*  the 
piitiriitat  the  time  of  onset  the  slower  the  course.  Cases  without  hered- 
iiary  inlliuiiccs  are  the  most  favorable.  Iti  stout,  elderly  men  diabetes 
is  a  much  more  hopeful  disease  than  it  is  in  thin  persons.  ^liddlc-aged 
patients  may  live  for  many  years,  and  jiersons  are  met  with  who  have  had 
the  iliscasc  for  ten,  twelve,  or  even  lifteen  years. 

Diagnosis. — (llycosuria,  which  to  all  intents  and  purposes  is  a  mild 
fiii'in  cf  tlic  disease,  is  to  be  distinguished  only  by  its  transient  character. 
Tiiero  is  no  other  disease  with  which  true  diabetes  can  be  confounded. 
Thore  are  cases  in  which  the  diabetes  presents  a  remarkable  intermittency, 
and  sugar  may  be  absent  for  weeks  or  months  at  a  time.  It  must  not  be 
forgnttoii  that  hysterical  women  sometimes  put  sugar  in  the  urine  for  the 
purpiiscs  of  deception. 

Prognosis.— I Ji  true  diabetes  instances  of  cure  are  rare.  On  the 
"tlicf  liaiiil.  the  transient  or  intermittent  glycosuria,  met  with  in  stout 
'ivorfocder !,  or  in  jiersons  who  have  utidergone  a  severe  mental  strain,  is 
^iry  amenable  to  treatment.  Not  a  few  of  the  cases  of  reputed  cures  be- 
i'liir  to  this  division.  Practically,  in  cases  under  forty  years  of  age  the 
"iitlook  is  had  ;  in  older  persons  the  disease  is  less  serious  and  much  more 
amenable  to  treatment.  It  is  a  good  plan  at  the  outset  to  determine 
whetluT  the  urine  of  a  patient  contains  sugar  or  not  on  a  diet  absolutely 
five  frnni  carbohydrates.  In  mild  cases  the  sugar  disappears;  in  the 
Severer  easi's  it  continues  to  be  formed  from  the  proteids. 

Treatment. — In  families  with  a  marked  predisposition  to  the  disease 
tlie  use  of  starchy  and  saccharine  articles  of  diet  should  be  restricted. 

The  personal  hygiene  of  a  diabetic  patiefit  is  of  the  first  importance. 
23 


I 


I    •i' 


'F 


328 


CONSTrn'TIONAL  DISRASKS?. 


4 


Sonnies  of  worry  hIiouM  Itc  uvoidcd,  and  ho  wliould  loud  an  even,  quiet 
lift',  if  posHiblo  in  an  c'<iiialiUi  I'liiiiati'.  Flaiiiu'l  or  .silk  hIiouM  lio  worn 
lu^xt  to  till!  skin,  and  tlit;  {^Tcatcsl  care  siuudd  \>v  taken  to  piiitnotc  in 
action.  A  liikowarni,  or  it'  lolcralily  robust,  a  cold  balli,  sliould  Ix-  takin 
everyday.  An  oeeasional  'i'nrkisii  bath  is  usernl.  Systeinalie,  iiiiiijcim,, 
t'Xt'rci.so  should  bo  taken.  When  tiiis  is  iidt  feasibli',  mu.ssaye  slioulj  Li' 
given. 

Pirf. — Our  injunotions  t(»-day  are  those;  of  Sydenham  :  "  lict  tiic  patient 
e.it  food  of  easy  (ii;,'estioii,  such  as  veal,  mutton,  and  the  like,  aiul  aUtum 
from  all  sorts  of  fruit  and  j^arden  stulT." 

The  (•(tr/xi/iifi/nilcn  in  the  food  should  be  reduced  to  a  ininiiiinm, 
Under  a  stricit  hydro('arbona(!eons  and  nitrogenous  reginu-n  all  I'liscsare 
benefited  and  some  are  eured  'I'lie  most  minute  and  speeific^  instructions 
shoidd  ho  given  in  each  case,  and  the  dietary  arrangi'd  with  .>;cni|uil(iii> 
care.  It  is  of  the  first  importance  to  givo  tho  patient  variety  in  tlic  im], 
otherwise  the  loathing  of  certain  essential  articles  becomes  intoKMal)l(',iui(i 
t<»o  often  the  i)atient  gives  up  in  disgust  or  despair.  It  is  well,  iH'rliii[i>, 
not  to  attempt  the  al)solute  exclusion  of  the  cari)oliydrates,  but  to  iillnw 
u  small  proportion  of  ordinary  bread,  or,  better  still,  as  coiitaiiiiiij.'  ha 
starch,  potatoes.  It  is  best  gradually  to  enforce  a  rigid  system,  <Miitiii{rnil 
one  article  after  atiother.  The  following  is  u  list  of  articles  which  (liubi'tic 
patients  may  fake ; 

Licpiids :  Soups  —  ox-tail,  turtle,  bouillon,  and  other  clear  B(iii[^ 
Lemonade,  colTee,  tea,  chocolate,  and  cocoa;  these  to  bo  taken  wiilidiii 
sugar,  but  tliey  may  bo  sweetened  with  saccharin.  Potash  or  suda  water, 
and  Ajjollinaris,  or  the  Saratf)ga-Vichy,  and  milk  in  moderation,  nmy  If 
used. 

Of  animal  food  :  Fish  of  all  sorts,  includiTig  crabs,  lobsters,  and  1}  ■ 
ters  ;  salt  and  fresh  butcher's  meat  (with  the  exception  of  liver),  poultry, 
and  game.     Kggs,  butter,  buttermilk,  curds,  and  cream  cheese. 

Of  bread  :  (llnten  and  bran  bread,  and  ahuond  and  coc^oanut  hisJciiit-. 

Of  vegetables:  Lettuce,  tomatoes,  spinach,  chicory,  sorrel,  radislns 
asparagus,  wat(;r-cress,  mustaril  and  cress,  cucumbers,  celery,  and  eiulivtv. 
Pickles  of  various  sorts. 

Fruits  :  Lemons  and  oranges.  Currants,  plums,  cherries,  pears.  appl« 
(tart),  melons,  raspberries  and  8trawl)errie8  may  be  taken  in  iiKuleration. 
Nuts  are,  as  a  rule,  allowid)le. 

Amous^  prnhibik'd  nriicle,^  are  the  following:  Thick  soups  and  livor, 

Ordinary  bread  of  all  sorts  (in  quantity) :  rye,  wheaten,  brown,  or 
white.  All  farinac^eous  preparations,  such  as  hominy,  rice,  tapioca,  poni'i- 
lina,  arrowroot,  sago,  and  vermicelli. 

Of  vegetables:  Potatoes,  turnips, parsnips,  squashes,  vegetable  iimrrnff 
of  all  kinds,  beets,  corn,  artichokes. 

Of  liquids :  Beer,  sparkling  wine  of  all  sorts,  and  the  sweet  aerateii 
drinks. 


ill  ;::i^?;::r 
3;.iil;it.'J:1 


I   , 


DiAHi-yrKs  iMKi.Lrrus. 


32t) 


The 'Jii'f 'lif^''i'l*y  in  iirraii<^iii<(  the  daily  mrtiii  of  a  diuhptif  patient 
lUhc  Itii'inl.  ami  for  it  various  siih.stituU'.s  have  hccri  advised — i)raii  bread, 
aliiU'ii  iMcad,  iind  ulinolid  biscuits.  Most  of  tlicse  are  iiiiiialatable,  and 
iiiiiiiv  are  frauds.  A  friend,  ii  distinguished  physician,  wlio  has,  unfortu- 
iKiti'lv,  liiitl  to  make  trial  of  a  j^i'eat  many  of  them,  writes:  " 'I'liat  iiiado 
from  Hhin.:"'  Hour  is  usually  so  heavy  and  indiifestil)le  that  il  I'un  only  bo 
iisrd  to  II  limited  extent.  (Huten  Hour  ol)tained  ii  I'aris  or  London  coii- 
taiiis  iil)oiii  !."i  per  eent  of  the  ordinary  amount  of  stareh  and  can  bo  vvoll 
iiM'il,  The  ,rliiten  Hour  obtained  in  this  country  has  from  ;}."»  to  4")  per 
iviit  (if  starch,!  lul  can  bo  used  successfully  in  mild  but  n^.t  in  severe  forma 
iif  (iialii'tcs." 

I'lili'ss  a  satisfactory  and  palutablo  gluten  bread  can  be  obtained,  it  is 
lititci'  to  iillow  the  patient  a  few  ounces  of  ordinary  iiread  daily.  The 
"SdVii"  hnail  is  not  any  better  than  that  nuide  from  the  Itest  Lrliiteii  flour. 
A.' 11  substitute  for  sugar,  saccharin  is  very  useful,  and  is  perfectly  harni- 
li«8.  (ilyeerin  nuiy  also  boused  for  this  purpose.  Levulose,  fruit  sugar, 
\<  rciidily  ,i  siunlated,  and  seems  to  bo  not  oidy  harmless  in  diabetes,  but 
\rry  bciu'liceiit.  It  nuiy  bo  used  for  sweetening  purjtoses  in  nutdenite 
iiiiiiinuts  ( Hale  White). 

It  is  well  to  begin  tho  treatment  by  cutting  (dT  article  after  artiolo 
until  file  sugar  disappears  from  the  urine.  Within  a  month  or  tw(t  tho 
imtii'iit  may  gradually  bo  allowed  a  mon'  liberal  ri'giinen.  An  exclusively 
milk  diet,  either  skimmed  milk,  buttermilk,  or  koumyss,  has  been  reconi- 
iiiiiiiicd  by  Duiikiu  and  others.  Certain  cases  seem  to  impntve  on  it,  but 
It  i<  not,  on  I'lo  whole,  to  be  recoinnu'iided. 

Medic'i;)!  Treatment.-  -  r';is  is  most  unsatisfactory,  and  no  one  drug 
;ili|it;ii's  to  iiave  u  directly  curative  inlluence.  Opium  alone  stands  tho 
ttstof  ex|)('rieiice  as  a  remedy  capable  of  limiting  t!u'  progress  of  the  dis- 
i';i>f.  l)i;ilH'tic  j)atients  seem  to  have  a  special  tolerance  for  this  drug. 
(iiilfia  is  preferred  by  I'avy,  and  has  the  advuntag(M)f  being  le.ss  consti- 
jutiiiir  than  morphia.  A  patient  may  begin  with  half  a  grain  three  times 
a  day,  \v]ii(di  may  bo  gradually  iiu-reased  to  six  or  eight  grains  in  the 
tuinty-fonr  hours.  Not  much  effect  is  noticed  ludcss  the  patient  is  on  ii 
i'i|.'id  diet.  When  the  sugar  is  reduced  to  a  ndnimum,  or  is  absent,  the 
'<\mn  should  be  gradually  withdrawn.  The  patients  not  only  bear  well 
t'i.M' large  doses  of  rnor|)liia,  but  they  stand  its  gradual  reduction.  Po- 
!;i-sium  bronnde  is  often  a  useful  adjunet.  'I'he  arsenitc  of  bromine,  a 
siiliitii)n  of  arsenious  acid  with  bromine  in  glycerin  (dose,  three  to  five  min- 
ium after  meals),  Ims  been  very  highly  recommended,  but  it  is  by  no  means 
I  SMcrtain  us  opiimi.    Ar.senic  alone  may  be  used.    Anti|iyrin  may  be  given 

do*,s  of  ten  grains  three  times  a  day,  and  in  cases  with  a  marked  neu- 
[■■"tic  constitution  is  sometimes  satisfactory.     'J'he  salicylates,   iodoform, 
"'"'"rb ''fill,  jambul,  lithium  suits,  strychnine,  creasote,  and  lactic  acid 
have  been  ein|)loyo.d. 

J  I'l'imraiious  of  the  pancreas  (glycerin  extract,  dried  and  fresh  ghmd) 


K« 


,    >»-- 


'M   1 


'yy 


U-:l 


330 


CONSTITUTIONAL   DISEASKS. 


Imvc  been  usod  in  tlio  hope  that  they  would  supply  the  interriiil  sccrotimi 
nec'os.siiry  to  norrnul  sugur  iiu'taboliaiii.  Tlio  success  luis  not,  liowivcr, 
been  in  any  way  comparable  with  the  use  of  the  thyroid  extract  in  rnvx- 
crdoma.  Lopine  has  isolated  a  glycolytic  ferment  from  the  paiicicasaiHl 
also  from  malt  diastase,  and  has  used  it  with  some  success  in  four  cases. 

Uf  the  eonii)lications,  tlie  ;>;-/n'//».s  and  eczema  are  best  treated  hycon]. 
ing  lotions  of  bcjric  acid  or  hyposulphite  of  soda  (1  ounce;  waur,  1 
quart),  or  the  use  of  ichthyol  and  lanolin  ointment. 

The  coina  is  an  almost  liojx'less  complication.  Iidialations  of  o.xv- 
gen  have  been  recommended,  and  the  intravenous  injections  of  a  saliiif 
solution,  as  practised  by  Hilton  Fagge.  The  three  pi^r  cent  soliiiidii  i»f  tin. 
sodium  bicarltonatJ  has  generally  been  employed.  The  treatmeiii  has  iiti, 
however,  been  satisfactory.  Of  seventeen  cases,  collected  by  CJliadhournc, 
in  oidy  one  was  it  successful ,  in  seven  there  was  temporary  impidvcnitiit; 
and  the  best  that  can  l)e  said  for  it  is  that  it  nuiy  give  the  ])ati(iit  a  fm 
liours  of  complete  consciousness.  Injections  should  be  made  as  souu  aa 
possible  after  the  appearance  of  the  coma. 


VIM.  DIABETES   INSIPIDUS. 

Definition. — A  chronica  alTcction  characterized  by  the  passage  nf 
large  <iuaiitities  of  normal  urine  of  low  specillc  gravity. 

The  condition  is  to  i)e  distii\guished  from  tliuresis  or  polyuria,  wiiirli 
is  a  rrc(piciit  sympt(»in  in  hysteria,  in  liright's  disease,  and  (M'(iK<ii';i;il!} 
in  cerebral  or  other  alTections.  Willis,  in  l(i74,  first  rco«jgnize(|  the  di- 
tiiu'tion  between  a  saccharine  and  non-saccharijie  form  of  diai)etos. 

Etiology. — 'I'hc  disease  is  most  common  in  young  ])ersoiis  Of  ih' 
8.*)  cases  collected  by  Strauss,  !>  \vcie  under  five  years;  \'l  between  iivoarl 
ten  years;  ;J(!  between  ten  and  twenty-five  years.  Midts  ai  •  in  (ire  fre- 
quently attacked  than  females.  The  alfecfion  nniy  be  poitgciiital.  A 
hereditary  tendeiUT  has  been  note<l  in  many  cases,  the  most  <  xtiaoniiiiiirv 
of  which  has  l)een  rcportc(l  ])y  Weil.  Of  Ml  members  in  four  gciicratinii-. 
'^\)  had  persistent  polyuria  without  any  d<?terioratioji  in  health.  Iiijnn  ti 
the  nervous  system  has  been  present  in  certain  instances,  and  tlic  (!i>ra-i' 
has  followed  sunstroke,  or  a  violent  emotion,  su  h  as  fright.  Traiiiiiati-ni 
has  occasionally  been  the  c.\cifing  'aus(>.  The  injury  may  have  Ih'i'II  t' 
the  head,  but  in  other  casea  Hie  lesion  has  ),een  1  )  flie  trunk  or  to  tlie 
limbs.  The  <lisease  has  followed  rapidly  the  copious  drinkiiif,'  of  c"!'' 
water,  or  a  drinking-bout;  or  lias  set  in  during  the  convalescoiicc  from  an 
acute  disease.  Tumors  of  the  b.-ain  and  lesions  of  the  medulla  have  Ikih 
met  with  in  a  few  iiislanc-s.  Cases  of  polyuria  have  been  accoinpaTiii"!  V 
para  »sis  of  the  sixth  nerve.  Maguire  has  seen  an  instance  after  iiu"-' 
gitis  in  which  paralysis  of  the  sixth  pair  occurred  with  it.  ({crnard.it 
will  be  remembered,  discovered  a  spot  in  the  floor  of  the  fourth  veutnae 


DIABETES  INSIPIDUS. 


331 


of  iininiiils  wliich,  when  pun(;tured,  produood  polyuria.  Lesions  of  the 
(.r!.'iiiii!  of  tilt)  abdomen  may  bo  associated  with  an  excessive  flow  of  urine, 
wliicli,  however,  should  not  bo  regarded  as  true  diabeles  iiisipidus.  Dick- 
inson iiifiitions  its  occurrence  in  abdominal  tumors;  Halfe,  in  abdominal 
iim'iirisiii.     1  liave  noted  it  in  several  cases  of  tuberculous  peritonitis. 

Tho  nature  of  the  disease  is  unknown.  It  is,  doubtless,  of  nervous 
nriiriii-  I  lit'  most  reasojiable  view  is  that  it  results  from  a  vaso-motor  dis- 
tiirbiince  of  the  renal  vessels,  due  either  to  local  irritatit)n,  as  in  a  ease  of 
;ilii|i)iiiiii;d  tumor,  or  to  centra!  ilisturbaiuio  in  cases  of  brain-lesion,  or  to 
iViictiuiial  irritation  of  the  centre  in  the  medulla,  giving  rise  to  continu- 
ous renal  congestion. 

Morbid  Anatomy. — There  are  no  constant  anatomical  lesions. 
Till'  kidiirjis  liave  been  fountl  enlarged  and  congested.  The  bladder  has 
!«rii  foiDiil  liypcrtrophied.  Dilatation  of  the  ureters  antl  of  the  pelves  of 
the  kidiit'vs  has  been  present.  Dt^ath  has  not  infretpicntly  resulted  from 
(liionic  pubiiunary  disease.  Very  varied  lesions  have  been  met  with  iu 
tlie  iiervoiH  system. 

Symptoms. — The  disease  may  come  on  rapidly,  as  after  a  fright  or 
iiii  injiiiy.  More  commonly  it  develops  slowly.  A  copious  secretion  of 
i,:im',  with  increased  thirst,  are  the  jirominent  features  of  the  disease. 
Tlio  amount  of  urine  in  tho  twenty-four  hours  may  range  from  twenty  to 
furiy  pints,  or  even  more.  The  specific  gravity  is  low,  1-()(H  to  I'OO.");  tho 
lolor  is  extremely  pale  and  watery.  The  tt)tal  soliil  constituents  may  not 
lif  I'l'iiiii'ctl.  Tlu)  amount  of  urea  has  sometinu's  been  ftmntl  in  excess. 
Abnormal  ingredients  are  rare.  M  usc^le  sugar,  inosite,  h's  been  occasionally 
fiiMil.  Alliii/iiin  is  rare.  Traces  of  sugar  have  been  met  with.  Naturally, 
wiih  tlif  passage  of  such  euoniious  quantities  of  urine,  thert^  is  a  propor- 
tii'iiiitc  tliirst,  antl  the  only  inconvenience  of  tho  disease  is  the  necessity 
f'T  frctpHMit  iiiicturititm  antl  frequent  driid<ing.  The  appetite  is  usually 
,L''«i(l,  rni'cl)  excessive  as  in  tliabetes  nu'llitu.s.  The  jiatients  may  be  well 
ii'iiirisJH'il  and  healthy-lot)king.  The  disease  iji  many  instajices  lioes  not 
iippcar  to  interfere  in  any  way  with  the  gencial  health.  The  pers|iiratit)n 
i«  iiatunjly  sliuht  and  the  skin  is  harsh.  The  amount  tif  saliva  is  snudl 
"'!  the  iniiuth  usually  dry.  Cases  have  been  tiescril)etl  in  which  the  toler- 
ance cf  mIcoIkiI  has  been  remarkalde,  and  jiaii'uts  have  bt;en  knt)wn  to 
tiike  a  cduple  of  pints  of  braiulv,  or  a  dt)zen  or  more  bottles  of  w^ine,  in 
till'  .lay. 

The  conrso  of  the  disease  depends  entiuly  upoji  the  nature  of  the  pri- 
'iiMiv  tio!ihli..  S.iiuetimes,  with  tirganic  disease,  either  cerebral  nr  abdomi- 
'■'1.  tlic  general  health  is  much  impaired;  the  jjatient  bec^omes  thin,  ami 
niiiiilly  Insi's  strejigth.  In  the  essential  t>r  iiliopathic  cases,  got^l  health 
iiiiy  he  inaintaiiu'tl  for  an  imlefinite  perit)il,- and  the  aiTectic::  has  been 
h'li'wn  to  jKTsist  for  fifty  years.  Death  usually  results  from  some  inter- 
'iincnt  alTei'tit)n.     Spontatieous  cure  may  take  place. 

•Diagnosis.—  A  low  speeifie  gravity  r.nd  the  absence  of  sugar  in  the 


332 


CONSTITUTIONAL  DISEASES, 


li 


ill 


urine  distiiiguisli  the  disease  from  diabetes  mollitus.  Ilystoriual  iiolvuria 
iiiiiy  somctiiiies  siimilate  it  very  closely.  The  uiuouiit  of  iiriin'  (.'xtTotiii 
may  he  enormous,  and  only  the  development  of  other  hysterical  iiianift'v 
talions  may  enable  the  diagnosis  to  be  made.  This  eondilion  is,  liu\vc\ir, 
always  transitory. 

In  certain  cases  of  chronic  Hright's  disease  a  very  large  ainount  <,[ 
urine  of  low  specille  gravity  may  be  j)assed,  l)ut  the  presence  <>[  alhiiiii;ii 
ami  of  hyaline  easts,  and  the  existence  of  lieightened  arterial  leiisiun,  snil 
vessels,  and  hypertro})hied  left  ventricle  make  the  diagnosis  eiu<y. 

Treatment.— The  treatment  is  not  satisfactory.  >io  attempt  slionM 
be  made  to  reduce  the  amount  of  liipiid.  Opium  is  highly  reconinioiuiiM, 
but  is  of  doubtful  service.  The  j)reparati()ns  of  vali'rian  may  he  tritil; 
either  the  powdered  root,  beginning  with  live  grains  three  times  a  (liu.iu:! 
increasing  until  two  draclims  are  taken  in  the  day,  or  the  valiiiimatfcf 
zinc,  in  lifteen-grain  doses,  gradually  increased  to  thirty  grains,  three  tiini'> 
a  day.  Ergot,  ergotin,  antipyrin,  the  salicylates,  arsenic,  strychiiinp.  tur- 
pentine, and  the  bromides  have  been  recommended.  Eiectrieity  may  In 
used. 


r' 


f  ^"'i  *  '■ 
J«'^  -if'! 


■■I 


IX.    HICKETS. 

Definition. — A  disease  of  infants,  characterized  by  impaired  mitrit;  : 
and  alterations  in  the  growing  bones. 

Cilisson,  the  anatomist  of  the  liver,  described  the  disease  accurateh  in 
the  seventeenth  century. 

Etiology. — 'J'he  disease  exists  in  all  parts  of  tlu' world,  !)iit  is  pai- 
ticularly  marked  among  the  poor  of  the  larger  cities,  who  are  liaillylKMi.vil 
and  ill  fed.  It  is  iinich  more  common  in  Europe  than  in  AintriLii.  in 
Vienna  and  London  from  oO  to  SO  per  cent  of  all  the  ehihhvii  at  ti: 
clinics  present  signs  of  rickets.  Jt  is  a  comj)aratively  rare  discaff  in 
Canada.  In  the  cities  of  this  continent  it  is  very  prevalent,  pai'ticiilar.i 
among  the  children  of  the  negro  and  of  the  Italian  races.  Want  "l 
suidight  and  impure  air  are  important  facitors.  A  starchy  diet,  tiMi  iiiikli 
cow's  milk,  and  the  indiscriminate  feeding  so  common  in  the  iliiMriii'f 
the  poor,  are  important  agents;  but  something  is  recpiired  beyniui  tlun. 
for  children  of  healthy  parents,  who  have  an  am)»le  (piantity  of  tlii'  pniiiff 
food,  may  become  rickety.  It  seems  ])robal)h',  however,  that  the  coinlii- 
mition  of  dcfi'ctive  food  and  bad  air  plays  the  most  important  nl!':  I'l" 
longed  lactation  or  suckling  a  child  during  pregnanes  are  aeeeshory  tii"- 
logical  fjictors. 

'I'here  is  no  evidence  that  the  disia.«e  is  hereditary,  but  there  is  pi"!- 
ably  a  form  of  fetal  rickets.  It  is  doubtful,  however,  whether  the  eliaiip' 
met  with  in  this  iirc  identical  with  the  post-natal  disease.  In  these hal'i- 
which  are  geiu'ially  stiil-l)orn,  the  limbs  are  short,  the  curves  nt'  the  !»"'•'■ 
are  exaggerated,  and  at  the  junction  of  the  ej)ipliyses  there  is  im  |iiiMKr- 
ttting  zone  of  cartilage.     This  eoudition  is  called  by  Parrot  ac/«'inli'"I'^"^!'' 


li^ 


RICKETS. 


333 


and  rhondrndij atrophia  ffrfnh's  V)y  Kanfnmiin,  wlio  has  writton  a  nioiio- 
s:r;i]ili  111!  iIh'  subject  (lH!i"2).  In  the  chililron  wliicli  siirvivi',  tho  <i;rowtli, 
paiticiiliirly  of  tlie  limbs,  is  stunted,  and  they  form  au  important  group 
(microniciia)  of  the  dwarfs. 

liickits  iilTirts  male  and  female  children  equally.  It  is  a  disease  of  the 
first  ami  -I'cond  years  of  life,  rarely  beginning  before  the  sixth  month. 
.It'iiMcr  lias  described  a  late  rickets,  in  which  form  the  disease  may  not  ap- 
pear until  the  ninth  or  even  until  the  twelfth  year.  It  has  been  licld  that 
rii'kots  is  only  a  manifestation  of  cojigenital  syphilis  (I'arnjt),  but  this  is 
(rrtainly  not  correi^t.  Syphilitic  bones  rarely,  if  ever,  present  the  spongy 
tis.«in'  peculiar  to  rickets,  and  racliitic  bones  never  show  the  midtiple  oste- 
ophvtcs  nf  syphilis. 

Morbid  Anatomy. — 'I'ho  bones  show  the  most  important  changes, 
partiriilariy  the  ends  of  the  long  boiu-s  and  the  ril)s.  Bt'tweeii  the  shaft 
and  epiphyses  a  sliglit  bulging  is  ajijiarent,  aiul  on  section  the  zone  of  pro- 
liftMiHidM,  which  normally  is  represented  by  two  narrow  bands,  is  greatly 
tbickciicd,  bluish  in  ccdor,  nuire  irregtdar  in  outline,  and  very  much 
.-(ifti'r.  'i'lie  width  of  this  cushion  of  cartilage  varies  from  live  to  fifteen 
Miilliiiictres.  The  line  of  ossification  is  also  irregular  and  more  spongv 
am!  V,  sfidar  than  nortnal.  The  jieriosteum  .strips  olT  very  readily  from 
till'  sliaft,  and  beneath  it  there  nuiy  l)e  a  spojigioiil  tissue  not  nidrke  de- 
lah'ifii'il  hone.  The  practical  ontctmie  of  thes  chiiiiges  is  a  delay  in.  ami 
iiiipcrfi'cr  performance  of,  tlu!  ossilicatioii,  so  that  the  bone  has  iieithcr 
the  iiataral  rate  of  growth  nor  the  normal  firmness.  In  the  crMui-um 
ilioro  may  he  large  areas,  particulaidy  in  the  ]iarieto-occipital  region,  iti 
which  the  <issilication  is  delayed,  jtroducing  the  so-called  cranio-talies.  .so 
that  the  bone  yields  reaiHly  to  pre.s.^ure  with  the  finger.  'I'liere  are  local- 
ized ilepressed  .sjiots  of  atrophy,  which,  on  j»re.s,«ure,  give  the  .so-calh'd 
"pareliiiieut  crackling."  Flat  liyperostoses  develop  from  the  outer  table, 
particularly  on  the  frontal  and  parietal  bone.s,  ami  produce  the  charaeter- 
i>iie  hi i  foi'chead  with  prominent  frontal  eminenees,  u  condition  some- 
times mistaken  for  hydrocH'phalus. 

The  chemical  amilysis  of  rickety  >>ones  shows  a  marked  diminutiom  in 
the  ealenreous  .salts,  whi(di  mav  be  as  low  as  from  '.'.")  to  :{."»  per  cent. 

The  liver  and  spleen  are  usually  etdarged,  and  .sometimes  the  i!i»».sen- 
terie  glands.  As  (Jee  suirirests,  thes(»  conditions  {»rohably  residt  from  the 
jreiieral  state  of  the  health  associati'd  with  rickets.  It  is  rnteresting  to 
imte  (hat  I'encke  describes  a  relative  increase  in  the  size  of  the  arteries  in 
riekets. 

Kas<ii\vitz,  the  leading  anthorrty  on  the  anatomy  of  rickets,  rpg«rds 
the  hypera-mia  of  the  jieriosteum,  the  nuirrow,  the  cartilage,  and  of  the 
lionc  itself  as  the  primary  lesion,  out  of  which  all  the  olbers  develop. 
Ihis  (li>iiirhs  the  normid  developi'ient  of  the  growing  bone  and  ex- 
eites  changes  in  the  hone  already  formed.  The  cartilage  cells  in  conse- 
||iU'iiee  proliferate,  the  matrix  is  softer,  and  as  u  result   the  bone  which  is 


-J^ 


nh 


1  :*>  ? 


fi  '■.% 


884 


CONSTITUTIONAL   DISEASES, 


formed  from  this  imhealtliy  cartilage  is  lacking  in  firmness  and  Koliditv. 
In  the  bono  already  formed  tliis  excessive  vascularity  favors  tln'  iioniiul 
processes  of  absorption,  so  that  tiie  relation  between  removal  and  lU-jiosi. 
tion  is  disturbed,  absorption  taking  place  more  rapidly.  The  new  inatrriiil 
is  })oor  in  lime  salts.  Kassowilz  seems  to  have  proved  experiuuntalh 
that  hyperrt!mia  of  bone  results  in  defective  deposition  of  lime  sails.  Bar- 
low and  Bury*  have  given  an  elaborate  analysis  of  the  changes  desoribui 
by  this  author.  It  is  interesting  to  nolt^  that  (ilisson  attributed  rickets t. 
disturbed  nutrition  by  arterial  blood,  anil  believed  the  changes  in  the  loiip' 
bones  to  bi^  due  to  excessive  vascularity. 

Symptoms. — 'rho  disease  comes  on  insidiously  about  the  jicridil  (,:' 
dentition,  before  the  child  begins  to  walk.  In  many  ca.ses  digestive  ili-- 
turbances  precede  the  api)earance  of  the  characteristic  lesions,  ami  the 
nutrition  of  the  child  is  markedly  im]iaired.  There  is  usually  s^lij;iu 
fever,  the  child  is  irritable  anil  restless,  and  sleeps  badly.  If  the  cliilii 
has  already  walkeil,  it  shows  a  marked  disinclination  to  do  so,  and  .seein- 
feeble  and  unsteady  in  its  gait.  Sir  William  .Jenner  has  called  atleiitidn 
to  three  general  symptoms  which  are  present  in  many  cases  of  riekei.v 
There  is  first  a  dilfusc  soreness  of  the  body,  so  that  the  child  cries  when 
an  attemj)t  is  made  to  move  it,  and  j)ri'fers  to  keep  i)erfectly  still.  Tin- 
tenderness  is  often  a  marked  and  suggestive  symptom.  Associated  wiili 
this  are  slight  fever  and  a  tendency  at  night  to  throw  f)ir  the  bcdclnllKs. 
This  may  be  partly  due  to  the  fact  that  the  general  sensitiveness  is  siuii 
that  even  their  weight  may  be  distres.sing.  And,  third,  there  is  sudi 
profuse  sweating,  particularly  about  the  head  and  neck,  that  in  the  iiunii- 
ing  the  pillow  is  found  soaked  with  perspiration. 

The  tissues  become  soft  aiul  llal)by  ;  the  skin  is  pale ;  cUni  from  a 
healthy,  jdumj)  condition,  the  child  becomes  puny  and  feeble.  It  is  in 
this  stage  of  the  disease  that  we  sometimes  find  such  a  degree  of  disaliiliiy 
in  the  muscles,  particidarly  of  the  legs,  that  paralysis  may  be  siis|)eeti(l. 
This  so-called  pseudo- paresis  of  rickets  residts  in  part  from  the  flabliy. 
weak  condition  of  the  legs  and  in  part  from  the  |)ain  associated  with  tlir 
movements.  Such  cases  are  by  no  means  uncommon,  but  they  are  readilv 
distinguished  from  infantile  paralysis.  Coincident  with,  or  followiii;: 
closely  upon,  the  general  symptoms  the  characteristic  skeletal  lesions  an' 
observed.  Among  the  lirs!  of  these  to  appear  are  the  chaiigi's  in  the  rihs 
at  the  junidion  of  the  bone  with  the  cartilage,  forming  the  so-eallnl 
rickety  rosary.  When  the  child  is  thin  these  nodules  may  be  ilistiiietlv 
seen,  and  in  any  case  can  be  easily  nuule  out  by  touch.  They  very  nirolv 
U[)pear  before  the  third  mouth.  They  nuiy  increase  in  size  u[)  to  theses 
ond  year,  aiul  are  rarely  seen  after  the  fifth  year.  The  thorax  uiiileff:<i("< 
important  changes.  Just  outside  the  junction  of  the  cartilages  with  tli'- 
ribs  there  is  an  oliliipus  shallow  depression  extending  downward  uiul  out- 

*  ('ycloj)H'(liii  of  the  Diseases  <if  Children,  vol.  ii. 


RICKKTS. 


835 


ward.  A  transverse  curvo,  soinotiinos  ciilli'd  Harrison's  groove,  passes  out- 
wanl  fnmi  ilie  luvel  of  tlio  ensii'onu  cartilage  toward  tiie  axilla  and  may 
bo  (kviifiii  d  at  eaidi  ins]iiralion.  It  is  rendered  more  })roniinent  by  the 
ovi'isiiiii  and  j)rominenee  of  the  costal  border.  'J  he  stermim  projects, 
pai'tiriilarl\  in  its  h)wer  half,  forming  the  so-calU'd  j)igeon  or  chicken 
liivast.  These  changes  in  tht!  thorax  are  not  jiecidiar,  however,  to  rickets, 
and  are  iiiindi  more  commonly  as.sociated  wiih  hypertroiihy  of  the  tonsils, 
(ir  any  trouble  which  interferes  with  the  free  entrance  of  air  into  the 
lung!).  I'listcriorly  the  s[iine  is  nsiially  curved,  the  processes  are  ]tromi- 
uont,  and  lateral  curvatuie  may  be  j)roduccd. 

The  licad  of  a  rickety  child  usiudly  looks  large,  ajid  the  fontaiielles 
rt'inaiii  <4irn  for  a  long  time.  There  are  areas,  particularly  in  the  paricto- 
in'ciiiital  regions,  in  which  ossilication  is  imperfect;  and  the  bone  may 
\iild  to  the  pressure  of  the  linger,  a  condition  to  which  the  term  cranio- 
tiihdi  lias  l)een  given.  The  ndation  of  this  condition  to  rickets  is  still 
(ioniewliat  doubtful,  as  it  is  very  often  associated  with  syphilis— 'in  47  of 
1 1 II I  eases  recently  studied  l)y  (ieorgo  Carpenter.  Coincideiitly  with  this, 
liyprrplasia  [iroceeds  in  the  frontal  and  jiarietal  emiiu-nces,  so  that  these 
iHiriions  (if  the  skull  increase!  in  thickness,  and  jnay  form  irregular  hos.'ies. 
In  (iiie  type  the  skull  nuiy  be  large  and  cdoiigated,  with  the  top  coiisidera- 
lily  ilatteiied.  in  another,  ami  j)erhaj)s  more  common  case,  the  shape  <if 
till'  skull,  when  seen  from  above,  is  rectangular — the  ('((put  (/iiailrtifin/i. 
The  skidl  looks  large*  in  jtroporlion  to  the  face.  The  forehead  is  broad 
and  siinare,  and  the  frontal  eminences  marked.  The  anterior  fontauelle 
i>  late  in  (dosing  and  may  remain  open  nntil  the  third  or  fourth  year. 
Tiie  -kill  is  thin,  the  vtdns  are  percei)tible,  and  the  hair  is  (d'tcn  riil)bc(l 
from  the  hack  of  the  skull.  In  contradistinction  to  the  cranio-tabes  is 
till' Condition  of  crunio-scderosis,  wliicdi  has  also  liccn  ascribed  to  ricktds. 

Oil  phudng  the  ear  over  the  antciior  fontamdlc,  or  in  the  temporal 
rt'^Moji,  a  syst(dic  murmur  may  frequently  l)e  beard.  This  condition,  first 
do>pril)e(l  by  Fisher,  of  IJoston,  was  bidicveil  by  him  to  be  ])cculiar  to 
rii'kets.  Whih'  unquestionably  beard  with  the  greatest  frequency  in  this 
disease, its  presence  and  persistence  in  ptifcctly  healthy  infants  have  been 
iiinply  demonstrated.*  The  murmur  is  rarely  lu'ard  after  the  fifth  year. 
A  knowledge  of  the  I'xistenee  of  this  systidic  l)rain  niiirniiir  may  prevent 
errors.  A  case  in  whiidi  it  was  w(dl  marked  was  nqiorted  as  an  instance 
"f  siippesed  gummy  tumor  of  the  brain,  in  wliiidi  the  murmur  Mas  thought 
to  1)('  di\!'  lo  pressure  on  the  vessels  at  the  base. 

Changes  oeiMir  in  the  hones  of  the  face,  childly  in  the  niaxille,  whii  h 
are  ri'diiced  in  size.  The  normal  ])roeess  of  dentition  is  muidi  disturbed  ; 
iiid;'ed,  lile  teidliing  is  one  of  the  markeil  features  in  rickets.  The  teeth 
«liiidi  ajijiear  mav  be  small  and  badiv  formed. 


*OsI,.r.  On  tho  Systolic  Bruin  Jluriniir  of  I'liihlreii,  Itoston  Medical  und  Surgical 
■'"iiniiil,  I'iso, 


'It 


^l 


■'1 


i'-^-      ■:       f 


»     } 


hi 


p-  -I 


\    . 


fV    M 


I'l  ' 


+  «-    fa 


iUi 


III 


336 


CONSTITUTIONAL   DISEASES. 


In  the  upper  ]inil)S  changes  in  the  setipnliR  are  not  common.  Tlic 
chvviclo  may  ho  tliickenod  at  the  sternal  eml,  and  there  may  be  tliirkc'ninr 
iicar  the  attachment  of  tlic  sterno-clei(h}  muscle.  The  nu)st  iiotieeable 
changes  are  at  the  lower  ends  of  the  radius  ami  ulna.  The  eiilai^omom 
is  at  the  juiiftion-arca  of  the  sliaft  and  epiphysis.  Jioss  evident  cdliiii't'. 
ments  may  occur  at  the  lower  end  of  the  humerus.  In  severe  cases  tlit 
natural  shai)e  of  the  bones  of  the  arm  nuiy  be  much  altered,  liavini:  to 
support  the  weight  of  the  child  in  crawling  on  the  floor.  The  chanj.'cs  iii 
the  i)elvis  are  of  special  importance,  ])articular]y  in  fenude  chihhvii,  a.s  ii, 
ex trenu!  cases  they  lead  to  great  deformity  and  narrowing  of  the  (nitlrt. 
In  the  legs,  the  lower  CTul  of  the  tibia  lirst  becomes  enlarged;  and  m 
slight  cases  it  may  alone  be  atTected.  In  the  severe  forms  the  upper  tii'l 
of  the  bone,  the  corres])onding  parts  of  tlie  fibula,  and  the  lower  eml  of 
the  femur  become  greatly  thickciu'd.  If  the  child  walks,  slight  liowiiii- 
of  the  tibia'  inevitably  results.  In  more  advanced  cases  the  tibia-  iiiii 
even  the  femora  may  be  arched  forward.  In  other  cases  the  condition  of 
knock-knee  occurs.  Unquestionably  the  chief  cause  of  these  defuniii- 
ties  is  the  weight  of  the  body  in  walking,  but  muscular  action  take- 
part  in  it.  The  green-stick  fracture  is  not  uncommon  in  the  soft  boiu? 
of  rickets. 

These  cluuigcs  in  the  skeleton  ])roceed  slowly,  and  the  general  symp- 
toms vary  a  good  deal  with  their  }>rogress.  The  child  becomes  inorc  or 
less  emaciated,  though  "  fat  rickets"  is  by  no  means  uiu'ommon.  IVvri 
is  not  constant,  but  in  actively  jtrogressing  changes  in  the  bone  there  i- 
usually  a  slight  pyrexia.  The  abdomen  is  large,  due  partly  to  llatiilci;! 
distention,  partly  to  enlargenujnt  of  the  liver,  and  in  severe  eases  ii 
diminution  of  the  volume  of  the  thorax.  The  spleen  is  often  eidarged  ainl 
readily  pidpal)le.  The  urine  is  stated  to  contain  an  excess  of  lime  salt-. 
but  Jacobi  and  IJarlow  say  this  has  lujt  been  proved.  Ko  speeial  vr 
peculiar  changes,  indeed,  have  as  yet  been  described.  j\[any  rickety  cliil- 
dren  show  marked  nervous  symptoms  ;  irritability,  peevishness,  and  sleep- 
lessne.ss  ar(>  constantly  present.  Jeiiner  called  attention  to  the  close  rela- 
tionship whi(!h  existed  between  rickets  and  infantile  conviilsion.s,  par- 
ticularly to  the  tits  which  occur  after  the  sixth  month.  Tetiiny  is  by  \\" 
means  uncommon.  It  ijivolves  most  frequently  the  arms  and  haiuKs;  ee- 
casionallv  the  legs  as  well.  Laryngismus  stridulus  is  a  common  eoniitliea- 
tion,  and  though  not,  iis  some  state,  invariably  associated  with  this  disea.* 
y(>t  it  is  certainly  mucdi  more  frc(pu'nt  in  rickety  than  in  other  chililreii. 
Severe  ricketi^  interfere  .seriously  with  the  growth  of  a  child.  K.xtreim 
examples  of  rickety  dwarfs  are  TU)t  uiu^ommon.  The  disease  known  a.< 
acute  rickets  is  in  reality  a  manifestation  of  scurvy  and  will  be  desoribcd 
willi  thiit  disease. 

Prognosis. — The  disease  is  never  in  itself  fatal,  but  the  condition 
of  the  child  is  such  that  it  is  readily  carried  off  by  intercurrent  alTeetioii.-. 
particularly  those  of  the  respiratory  organs.     Sptism  of  the  l;ii  vnx  and 


SCURVY. 


887 


convulsions  occasionally  cause  (loath.  In  females  the  rleformity  of  tho 
iti'Uis  i-  serious,  as  it  may  U'ad  to  ditliculties  in  parturitidn. 

Treatment. — Tlio  l)etter  tlie  condition  of  tlie  mother  during  jireg- 
iiiini'V  tlie  less  likelihood  is  there  of  the  devi'lopment  of  rickets  in  the 
cliiltl.  Uajiidly  repeated  pre<fnan(Mes  and  suckling  a  child  during  preg- 
iiiiiiuv  sci'Mi  im])ortaiit  factors  in  the  production  of  the  diseases  ()!  the 
;:('iu'ral  treatment,  attention  to  the  feeding  of  the  ciiild  is  the  first  con- 
siiK'iiition.  If  the  mother  is  unhealthy,  or  cannot  from  any  cause  nurse 
the  cliild,  a  suital>le  wet-nurse  should  he  provided,  (»r  the  (^hild  must  bo 
iirtitirially  fed.  Cows'  milk,  diluted  according  to  the  age  of  the  child, 
slimilil  constitute  the  chief  food.  Care  should  he  taken  to  examine  the 
ciMiilition  of  the  stools,  and  if  curds  art!  present  the  child  is  taking  too 
niiicli,  or  it  is  not  sulliciently  diluted.  Barley-water  or  carefully  strained 
ami  \v(ll-l)oiled  oatmeal  gruel  form  excellent  additions  to  the  milk. 

The  chilli  should  he  warndy  clad  and  should  he  in  the  fresh  air  and 
muisliiue  the  great(!r  })art  of  the  day.  It  is  a  "  vidgar  error  "  to  suppose  that 
(Iflicute  children  cannot  stand,  when  carefully  wrai)ped  u]),  an  even  low  tem- 
lu'ratiiic.  The  child  should  be  bathed  daily  in  warm  water.  Careful  friction 
with  sweet  oil  is  very  advantageous,  and,  if  projierly  performed,  allays  rather 
than  aggravates  the  sensitiveness.  Special  care  should  he  taken  to  pre- 
vciil  ilcformity.  The  child  should  not  be  allowed  to  walk,  and  for  this 
purpose  splints  applied  so  as  to  extend  beyond  the  feet  are  very  etTective. 
Of  iiK'dicines,  i)hosphoru8  has  been  warmly  recommended  by  Kassowitz, 
1111(1  its  use  is  also  advised  by  Jacobi.  The  child  nuiy  l)e  given  gr.  ^Jj- 
two  or  three  times  a  day,  dissolved  in  olive  oil.  Cod-liver  oil,  in  doses 
of  fniiu  a  half  to  one  teasjioonful,  is  very  advantageous.  The  .syrup  of  the 
ioilidc  of  iron  may  be  given  with  the  oil.  The  digestive  disturbances, 
together  with  the  respiratory  antl  nervous  complications,  should  receive 
appropriate  treatment. 


X.   SCURVY  (Scorbutm), 

Definition. — \  constitutional  disease  characterized  by  great  debility, 
with  aiiieiiiia,  a  s])ongy  comlition  of  the  gums,  and  a  tendency  to  luKmor- 
rliages. 

Etiology. — The  disease  has  been  known  from  the  earliest  times,  and 
liii>  jiivvailed  particularly  in  armies  in  the  field  and  among  sailors  on  long 
voya.ut's. 

From  the  early  part  of  this  century,  owing  largely  to  the  cfTorts  of 
liiiul  and  to  a  knowledge  of  the  conditions  upon  which  the  disease  de- 
pt'ii'ls.  scurvy  has  gradually  disajipeared  from  the  naval  .service.  In  the 
iiurcaiitile  marine,  cases  still  occasionally  occur,  owing  to  neglect  of  ])roper 
and  siiital)le  food. 

The  disease  develops  whenever  individuals  have  subsisted  for  pro- 


ii: 


1..  i. 


%■' 


ill  '»    ^         1. 


H    'I 


iflf 


iftl 


II 


? 


Jj 


338 


CONSTITUTION  A  li   DISK  ASRS. 


longed  periods  upon  a  diet  in  which  fresh  vegetables  or  their  sulistituto.^ 
are  liiel\ing.  An  iiisiiflicieiit  diet  ajipears  to  he  an  essential  element  ii 
the  disiiast;,  and  all  observers  are  now  nnaninious  tliat  it  is  tiie  absiiicc  d. 
those  ingri'dicnls  in  the  food  which  are  supplied  by  fresh  vcgcialili's. 
Wliat  these  constituents  are  has  not  yet  been  definitely  deteriniiu'd.  (lar- 
rod  holds  that  tlie  defect  is  in  tlie  abseiui  of  the  potassie  salts.  (Itluis 
believe  that  the  essential  factor  is  the  absence  of  the  organic  salts  picstnt 
in  fruits  and  vegetables.  Kalfe,  who  lias  made  a  very  carefid  stndy  of  tlio 
subject,  believes  that  tin;  abseiiei!  from  the  food  of  the  malates,  citrates, 
and  lactates  re<luces  the  alkalinity  ui  the  blood,  which  depends  upon  tlio 
carbonate  directly  derived  from  these  salts.  This  diminished  alkalinity, 
gradually  produced  in  the  scurvy  patients,  is,  he  believes,  identical  with 
the  elTect  which  can  be  artilicially  produced  in  animals  by  feeding  tliciii 
with  an  excess  (if  acid  salts;  the  nutrition  is  impaired,  there  are  ecchynnws, 
and  ])rofound  alterations  in  the  characters  of  the  blood.  The  acidity  (if 
the  urine  is  greatly  reduced  and  the  alkaline  phosphates  are  diminishcil 
in  amount. 

In  opi»osition  to  this  chemical  view  it  has  been  urged  that  the  disoasp 
really  depends  upon  a  spccilic  (as  yet  unknown)  micro-organism. 

In  comparison  with  foruur  times  it  is  iu)w  a  rare  disease.  In  seaport 
towns  sailors  sutfering  with  the  disease  are  now  and  then  admitteil  \i> 
hospitals.  In  large  almshouses,  during  tiie  winter,  cases  are  sonietiiius 
seen.  On  several  occasions  in  I'hiladclphia  characteristic;  examples  were 
admitted  to  my  wards  from  the  almshouse.  Some  years  ago  it  was  iief 
very  uncommon  among  the  himbernu'u  in  the  winter  camps  in  theOtiawn 
^'alley.  Aiming  the  Hungarian,  Bohendan,  and  Italian  nunei-s  in  I'eiiii- 
sylvania  the  disease  is  not  infrtHpient.  This  so-called  land  scurvy  ilitfers 
in  no  particular  from  the  disease  in  sailors.     ■ 

Tiui  only  case  of  scurvy  admitted  to  the  Johns  Hopkins  Hospital  in 
six  years  was  a  well-to-do  woimm  with  chronic  dyspepsia,  who  had  liveil 
for  nuiny  months  on  tea  aiul  bread. 

In  parts  of  Russia  scurvy  is  endejuic,  at  certain  seasons  reacliiiiir  e|ii- 
demic  proportions;  and  the  leading  authorities  upon  the  disorder,  now  in 
that  country,  are  almost  uiuiiunu)us,  according  to  HolTnuinn,*  in  regard- 
ing it  as  infectious. 

Other  factors  play  an  important  ]>art  in  the  disease,  ])articularly  ])liys- 
ieal  and  nu>ral  inllueiu'cs — overcrowdijig,  dwelling  in  cold,  liamp  <|iiarters. 
ami  prolonged  fatigue  under  depressing  influences,  as  during  the  retreat 
of  an  army.  Among  prisoners,  nu-ntal  depression  plays  an  iiiipnrtaiil 
roli:  It  is  staled  that  eitidemics  of  the  disease  have  broken  out  in  liif 
French  convict-ships  /■//  ran/r  to  New  Caledonia  even  when  tin;  di(  t  wn- 
amply  suflicient.     Nostalgia  is  sometimes  an  important  eletnent.     li  i» '"' 


*  IjflirlMU'fi  (ler  ('(iiistiliUioiisl<raiiklieiteii.  F.  A.  HofTmiinn  (1803),  a  worl<  t'<  which 
the  sUuleat  is  referred  for  ihe  best  modern  exposition  of  tills  group  of  disorder?. 


I 


SCURVY. 


330 


intorostincf  fivrt.  that  prolonged  starvation  in  itself  (loos  not  nocossarily 
I'iiiist'  scurvy.  Not  one  of  tlio  ])rofi'ssional  fasti-rs  of  lato  yours  lias  tlis- 
jiliivcil  any  soorbntic  symptom.  Tlio  ilisoaso  attacks  all  agos,  but  the  old 
arc  Minrt'  siiscoptiljlo  to  it.  Sox  has  no  s])ecial  inlhionco,  but  during  the 
.<i(';.'(' of  I'aris  it  was  noted  that  llio  males  attacked  were  greatly  in  excesa 
(if  till'  fi'inalos.     Infantile  scurvy  will  he  considered  in  a  soecial  note. 

Morbid  Anatomy. — Tho  anatomical  changes  are  marked,  though 
liv  iiu  imaiis  sjiecilic,  and  are  chiefly  those  associated  with  ha'inorrliage. 
Tlic  1i1(hh1  is  dark  and  fluid.  The  niicroscoi)ical  alterations  are  those  of  a 
si'vcrc  iiiueniia,  without  loucocytosis.  The  bacteriologieal  examination  has 
not  vieldeti  anything  very  positive.  Practically  tliei-  are  no  changes  in 
tilt'  blood,  either  anatomical  or  chemical,  which  can  bo  regarded  as  pecul- 
iai  to  tile  (iisoaso.  Tlio  skin  shows  the  ecchunosos  evident  during  life. 
'i'licfe  are  lia'morrhagos  itito  the  muscles,  and  occasionally  about  or  even 
into  the  joints.  JlaMiiorrhagos  occur  in  the  internal  organs,  ))articularly 
on  the  serous  membranes  aJid  in  the  kidneys  and  bladder.  The  gums  are 
MVdlleii  and  sometimes  ulcerated,  so  that  in  advance(l  ea.ses  the  teeth  arc 
liio.se  and  have  even  fallen  out.  Ulcers  are  occasionally  met  with  in  the 
ilciiiii  and  colon,  lla'inorrhiigos  are  extremely  common  into  the  mucous 
iiu'iiiliiaiies.  'J'he  spleen  is  enlarged  and  soft.  Parenchymatous  changes 
iire  constant  in  the  liver,  kidneys,  and  heart. 

Symptoms. — 'i'he  di.soaso  is  insidious  in  its  onset.  Early  symptoms 
iuv  lo,-s  in  weight,  ju'ogressivoly  developing  wi'akness,  and  jiallor.  Very 
siKiii  the  gums  are  noticed  to  be  swollen  and  spongy,  to  bleed  easily,  and 
ill  extreme  cases  to  j)resent  a  fungous  ajijtearanco.  These  ehangos,  re- 
iranied  as  characteristic,  are  sometimes  absent.  The  teeth  may  become 
Iniise  and  even  fall  out.  Actual  necrosis  of  the  jaw  is  not  common.  The 
Itii'Mtli  is  excessively  foul.  The  tongue  is  swollen,  but  may  be  red  and 
lint  iiiuch  furred.  The  salivary  glands  are  occasionally  enlarged.  Ila-m- 
iiirhages  beneath  the  mncous  membranes  of  the  mouth  are  common. 
Tlif  >kiii  be<!omes  dry  and  rough,  and  ecchynioses  soon  ajipear,  lirst  on 
the  h'lrs  and  then  on  the  arms  and  trunk,  and  j)artieiilarly  into  and  about 
the  hiiir-folliclos.  They  are  petechial,  but  may  become  larger,  and  when 
siihriitaneous  may  cause  distinct  swellings.  In  severe  ea.ses,  partieularly 
in  the  legs,  there  nuiy  be  effusion  between  the  periosteum  and  the  bono, 
turiiiiiig  irregular  nodes,  which,  in  the  case  of  u  sailor  from  a  whaliTig 
vtsstl  who  canio  under  my  observation,  had  broken  down  and  formed 
foiil-loiiking  sores.  The  slightest  bruise  or  injury  causes  luemorrhage 
into  the  injured  part.  (Kdema  about  the  ankles  is  common.  The  "scurvy 
seli'id.sis,"  se(!n  oftenest  in  the  legs,  is  a  remarkable  infiltration  of  the  sidj- 
eiitiuieoiis  tissues  and  muscles,  forming  a  brawny  induration,  the  skin  over 
which  may  Ijo  blood-stained.  Ilamiorrhages  from  the  mucous  membranes 
alt'  less  eonstant  8ym[)toms;  epistaxis  is,  however,  frequent.  Haemop- 
tysis and  luematemesis  are  uncommon,  llaematuria  and  bleeding  from 
the  bowels  may  be  preseut  in  very  severe  cases. 


»' 


ft) 


**'■ 


340 


OONSTITrTIONAIi   DISKASKS. 


m4 


'9. 


I';il|>itati(in  of  the  lu'iirt  and  fccldcnoss  aii<l  irregularity  of  the  iiiijuilso 
arc  iiroiiiiiiciit  synii)toiiis.  A  lui'iiiic  miiniiur  can  usually  lie  hcaril  ;it  the 
l)usi'.  Ila'm(irrlia,i,'i('  iiifarctinu  of  tlic  Iwwj^s  and  spleen  lias  heeii  dfyi'iiliod. 
I{i'S|iiratory  syiMjftoMis  are  not  eoniiiioii.     'Tlie  appetite  is  impaired,  and 

uwiu!^  to  tile  sort-ness  of  the  [rums  tlie  patient  is  uiudde  to  chew  tlic  f |. 

Constipation  is  more  frequent  than  diarrlm-ii.  'i'he  urine  is  ofttn  ;ill,ii. 
minous.  The  changes  in  the  eomi)osition  of  the  urine  arc  not  ((iii^tiint ; 
the  specillc  gravity  is  high  ;  the  color  is  deeper  ;  and  the  pliosphaic-i  me 
increased.  The  statements  with  reference  to  the  inorganic  consiitiuMits 
are  contradictory.  Some  say  the  idiosjjhates  and  potash  are  detieiunt; 
others  that  they  are  increased. 

There  are  mental  depression,  indilTerejice,  in  some  cases  lioadaclie,  and 
in  the  later  stages  didirium.  Cases  of  convidsions,  of  hemiplegia,  aiul  nf 
meningeal  ha'inorrhage  have  heen  descrihed.  Hemarkalde  ocular  symp- 
toms are  occasionally  met  with,  such  as  idght-hlindness  or  day-hjind. 
ncss. 

In  advanced  cases  necrosis  of  tin;  hones  may  occur,  and  iti  yoniiir  per- 
sons  even  separation  of  the  epiphyses,  'i'here  are  instances  in  which  the 
cartilages  have  se[)arated  from  the  sternum.  The  callus  of  a  recently 
repaired  fracture  has  been  known  to  undergo  destruction.  Fever  is  ikji 
present,  except  in  the  later  stages,  or  when  secondary  inflammatidiis  in 
the  internal  organs  appear.  The  temperature  mav.  indeed,  he  sonictiims 
below  normal.     Acute  arthritis  is  an  occasional  co.    ,ilication. 

Diagnosis.  —  No  dinieulty  is  met  in  the  recognition  of  scurvy  when 
a  number  of  pensons  are  affected  together.  In  isolated  cases,  however,  the 
disease  is  distinguished  with  ditliculty  from  certain  forms  of  )iur|)iirii. 
The  association  with  manifest  insutliciency  in  diet,  and  the  rapid  amel- 
ioration with  suitable  food,  ure  points  by  which  the  diagnosis  can  be  read- 
ily settled. 

Prognosis. — The  outlook  is  good,  unless  the  disease  is  far  advanced 
and  the  conditions  persist  wdiich  lead  to  its  development,  'i'he  niortulity 
now  is  rarely  great.  During  the  civil  war  the  death-rate  was  l(j  per  cent. 
Death  results  from  gradual  heart-failure,  occasionally  from  smlden  syncope. 
^leningeal  ha'morrhage,  extravasation  into  the  serous  cavities,  entero-coli- 
tis.  and  other  intercurrent  affections  may  {irove  fatal. 

Prophylaxis. — The  regulations  of  the  Hoard  of  Trade  refpiire  that  a 
siifficient  suj)ply  of  antiscorbutic  articles  of  diet  be  taken  on  each  ship;  .<n 
that  now,  exce})t  as  the  result  of  accident,  the  occurrence  of  scurvy  is  litre 
in  sailors. 

Treatment. — Tlu;  juice  of  two  or  three  lemons  daily  and  a  varied  diet, 
with  ])lenty  of  fresh  vegetables,  suffice  to  cure  all  cases  of  scurvy,  inilps.^ 
far  advanced.  When  the  stomach  is  much  disordered,  small  fpiantities  of 
scraped  meat  and  milk  should  be  given  at  short  intervals,  and  the  lemon- 
juiee  in  gradually  increasing  quantities.  A  bitter  tonic,  or  a  steel  and  tjark 
mixture,  may  be  given.    As  the  jMitient  gains  in  strength,  the  diet  may  be 


if- 


SCUltVY. 


341 


more  liliriiil,  utid  lio  riuiy  out  fivrly  of  point ocs,  (.'iihlia^ro,  wiitor-civssi's,  unil 
l,.tiiiri.  Tlie  stoiimtilis  is  tlio  Hyiiiptoin  wliicli  causes  tlio  jfrt-iiU'st  (lihtrcsd. 
Tilt' pc'i'iii!iii}.'imrtte  of  potiish  or  iHliitc*  curbolic  aii<l  forms  tlio  best  inoiith- 
wiisli.  I'riirilliiig  the  swollen  i^niius  willi  a  toh  ral)ly  slroiifx  solution  of 
iii;nil('  III'  -ilviT  is  vt'ry  useful.  'I'lie  solution  is  lielter  tlian  tlie  solid  stic'k, 
;i.- it  rciulies  to  tlio  crcviees  between  the  ^'ramilatioiis.  The  e(Mislipati<iii 
wliicli  is  so  eoiinuon  is  best  treated  with  lai>;e  eneiniita.  For  otlu  r  eon- 
(litieiis,  such  us  lubMiorrhages  and  ulcerations,  suitable  measures  must  bo 
finitloyod. 

INFANTII.i:  SCURVY  {riarlow'x  Disease). 

As  in  adults,  scurvy  may  occur  in  children  in  coiisefpioncc  of  imperfect 
food  sii|i|ily.  A  few  years  ago  I  saw  n  well-marked  ease  in  a  <  liild  of  four, 
whoso  diet  had  been  chietly  "  grits  "  and  jiotatoeH.  Tlie  complexion  was 
iiiiiildy,  the  gums  spongy,  ami  there  was  a  j)urj»uiie  rash  on  the  legs. 

\V.  M.  Cheadle  and  (ice,  in  London,  have  described  in  very  young 
cliildrcu  a  caeliexia  associated  with  ha-mnrrliagc.  Cheadle  regarded  the 
cases  as  scurvy  ingrafted  on  a  rickety  stock.  Gee  called  liis  cases  periosteal 
fiiclii'xia.     Cases  ha<l  previously  been  regardeil  as  acute  rii'kets. 

A  few  years  later  Harlow  made  an  exhaustive  study  of  the  condition 
with  careful  anatomical  observations.  The  aiTecti<m  is  now  recognized  as 
iiifiuitile  scurvy,  and  in  (Jermany  is  culled  Harlow's  Disease.  The  alTection 
is  vi'iT  imich  more  frecpicnt  in  this  country  than  has  lieen  supposeil.* 
Till' cliildren  attacked  are  almost  invariably  those  wlii(di  liavt;  lieen  fetl 
iipoii  condensed  milk,  and  the  jiroprietary  and  preserved  foods  for  chil- 
'Inii ;  -nine  instances,  too,  have  followed  the  use  of  sterilized  milk.  Tho 
cast's  are  met  with  at  any  period  after  the  age  of  four  months,  but  they 
arc  most  common  in  the  second  jieriod  of  infancy,  from  the  ninth  to  the 
I'ightfciitli  nionlhs.  Tiie  child  may  look  well  nourished,  but  is  jiallid  and 
has  ti  muddy  complexion.  There  are  very  often  signs  of  rickets.  If  the 
tcctii  have  appeared,  the  gums  Tnay  be  spongy  or  there  may  bo  luemor- 
rliagc-  oil  the  mucous  membrant^s. 

Tlic  following  is  a  general  clinical  summary,  taken  from  Harlow's  Hrad- 
shaw  Lecture,  1S!)4  : 

"So  long  as  it  is  left  alone  tho  child  is  tolerably  quiet;  tho  lower 
limlis  lire  kept  drawn  up  and  still;  but  when  plact^d  in  its  bath  or  other- 
wise moved  there  is  contimious  crying,  and  it  soon  becomes  clear  that  the 
pain  is  coiiiiceted  with  tho  lower  limbs.  At  this  period  the  upper  limbs 
may  l)c  touched  with  impunity,  but  any  attomjit  to  move  the  logs  or  thighs 
f-'ives  rise  to  screams.  Next,  some  obscure  swelling  may  be  detected,  first 
on  oiH'  Idwer  limb,  then  on  the  other,  though  it  is  not  ai)solutoly  symmet- 
ni'ul.  .  .  .  The  swelling  is  ill-defined,  but  is  suggestive  of  thickening 
round  tlic  shafts  of  tho  bones,  beginning  above  the  o{)ij)hyseal  junctions. 


;i  n 


J>: 


r'Ni 


Northrup  luid  Cruiulall,  New  York  Medical  Journal,  1894,  i. 


842 


COXSTlTrTIONAL   DISKASES. 


ll 


A 'I 


i 


;  J 


(JriKliiiilly  tlio  ])iilk  of  tlic  liiiihs  iilTt'ctcd  lu'comcs  visihly  inorpnscd,  .  .  , 
'Pile  position  of  till"  liiiihs  Ih-coiiics  soiiu'wliiit  diUVrnnl  fnnii  what  it  was  at 
tl»o  oiitrtt't.  Iiistfjul  of  liciii;^  Hexed  they  lie  evei'te(l  und  rniiiiolulc,  in  ^ 
state  of  pseudo-paralysis.  .  .  .  Ahoiit  this  time,  if  not  hefore,  ^Tciit  wrA- 
tiess  of  the  Itaek  liecoines  inaiiifest.  A  little  swelliii,!,'  of  one  or  Ixith  scin,. 
uiii'  may  appear,  and  the  upper  limhs  may  show  ehan^^es.  These  are  niii|\ 
80  iioiisidefaltle  as  the  altei-ations  in  the  lower  limits.  'There  may  he  sHtll- 
ini,'  uhove  the  wrists,  exlentlini,'  for  a  short  distanre  up  the  foreann,  mul 
some  swelliiij;  in  the  nei^hhorho<td  of  the  epiphyses  of  the  liiuiifni<. 
TliercMs  symmetry  of  lesions,  hut  it  is  not  ahsolnle;  und  the  liiiili  iilTir- 
tion  is  jrenerally  eonseeniive,  thouj^h  the  involvement  of  one  linili  I'nlldw. 
very  close  upon  another,  'i'he  joints  are  fret*.  In  severe  eases  allot  her  s\iii|i. 
tom  may  now  be  found — namely,  crepitus  in  the  re<rions  adjacent  to  tin 
junctions  of  the  shafts  with  the  ei)iphyses.  The  upju-r  and  lower  extrcirii- 
ties  of  the  femur,  and  the  ujjper  extremity  of  tiie  tihia,  are  the  coaniun: 
sites  of  such  fractures;  but  the  ui)per  etid  <»f  tlio  liumerus  may  also  be  mi 
ulTeeted.  ...  A  very  startling?  ai)j)earance  may  be  observed  at  this  \)miu\ 
in  the  front  of  the  chest.  'I'he  sternum,  with  the  adjacent  costal  ciuti- 
hij^es  ami  a  small  portion  of  the!  contiyiutus  ribs,  sei'ins  to  have  sunk  Imi!- 
ily  back,  f/t  hhir,  as  though  it  had  been  subjected  to  some  violence  wliii  i: 
liad  fractured  several  ribs  in  the  front  and  driven  them  back.  ()e(ii:«i(iii- 
ally  thickeniuL:^  of  varyin<r  extent  may  lie  f<iund  on  the  exterior  of  \\v 
vault  of  the  .skull,  or  even  on  some  cf  the  bones  of  the  faci'.  .  .  .  Hen 
also  must  be  mentiom-d  a  remarkable  eye  phenomenon.  There  (levtlnp- 
u  rather  sudden  proptosis  of  one  eyeball,  with  pulVnicss  and  verv  >liu'iii 
stainini,'  of  the  upper  lid.  Within  a  day  or  two  the  other  eye  pri'.H'iii? 
similar  appearances,  thou<.fh  they  may  he  of  less  severity.  The  ocidur  cnii- 
jiinctiva  may  show  a  little  ecchyniosis,  or  may  be  ((uite  free.  With  rt's|K'i; 
to  the  constitutional  symptoms  accompanying  the  above  series  nf  evciit- 
tlie  most  important  feature  is  the  iirofouml  amvinia  \vhi(di  is  divcl- 
oped.  .  .  .  'i'he  amemia  is  j)roi)ortional  to  tlie  amount  of  lindi  itivulvr- 
nient.  As  the  case  jtrot'eeds,  there  is  a  certain  earthy-colore(i  vv  .>iillii« 
tint,  which  is  noteworthy  in  severe  cases,  and  when  once  this  is  c.tab- 
lishod  bruise-like  ecchymoses  imiy  ajjpear,  and  more  rarely  small  pin|nini. 
Euniciation  is  not  a  marked  feature,  but  asthenia  is  extreme  ami  siil'- 
geslive  of  muscular  failure.  The  temperature  is  very  «'rratic ;  it  is  dftcn 
raised  for  a  day  or  two,  when  successive  limbs  are  involved,  es|ii'ii:ill} 
during  the  tense  stage,  but  is  rarely  above  101"  or  102°.  At  other  tiiiir 
it  nuiy  be  nornuil  or  subnormal." 

'J'lie  essential  lesion  is  a  subperiosteal  blood  extravasation,  Avliicli 
causes  the  thickening  and  tenderness  in  the  shafts  of  the  bones.  In  ■iuiiii 
instances  there  is  biemorrhage  in  the  intramu.scular  tissue. 

The  prophylaxis  is  most  important.  The  various  proprietary  fornix  of 
condensed  milk  and  preserved  foods  for  infants  should  not  be  usnl.  Tl'^' 
fresh  cow's  milk  should  be  substituted,  and  u  teuspoonful  of  iiniit-jiiirt 


''13!'; 


rrui'iuA. 


i\V.\ 


(irjfTiivv  miiv  l>o  pivoTi  with  a  littlo  sicvctl  potato.  A  little  oraii^ro-jiiici'  i>v 
liiiinii-jiiii'i'  limy  uIho  l)c  given   in  walri'.      I'ecovery  is  usually  prompt  and 

•iilisfai'tory. 

XI.    PURPURA. 

Strictly  speakin?,  purpura  is  a  syMiptiuu,  not  n  disease;  hut  under  this 

Icrni  ar mveniently  arran^'ecl  a  nurnifer  nf  alTedions  rduiraetcri/.eil  hy 

r\n'!ivii,-iitiniis  of  tlie  hlodd  into  the  skin.  In  the  present  state  of  our 
kiiii«l(Ml;:re  a  satisfai'lory  elassitieation  canmit  he  made.  M\iludiiig  synip- 
iiiiiMtir  purpura,  \V.  Koeli  ynnips  all  fnrnis,  iiududiuLT  ha'iuophilia, 
i;iii|cr  tin- di'^ii^nation  /Kt'iiKirr/Hn/ir  (//(//Ar>/.v,  hclievini;  that  intcriMrdiiite 
fniMis  link  the  tnild  purpura  simplex  and  the  most  intense  purpura  haan- 
nrrlmirii'a ;  while  V.  \.  HolTnumn  e()nsiders  them  all  (except  ha'inophilia) 
rii  iiT  the  lu'ndini,'  iimr/itis  iiuk-iiIosiis.  'I'he  purpuric  spots  vary  fi'mn  oni> 
!u  tliree  or  four  nullimetres  in  diami-ter.  When  small  and  pin-point-like 
liny  arc  ridled  petechia';  when  lai'ge,  they  are  known  as  (•(■(diyiiu)ses.  At 
lii>t  liri,i,dil  red  in  c(dor,  they  heeome  darker,  and  gradually  fade  to  hrown- 
i-ii  .xtaius.     'I'hey  ilo  not  disappear  on  prcssuic. 

The  following  is  ii  provisional  grouping  of  the  eases: 

Symptomatic  Purpura.— ('0  Infections.-  In  pyamia.  se])tiea-nna, 
iii;iliL,'iiaiii  endocarditis  (particularly  in  the  latter  alTeetictn),  eccliynio.ses 
iiiiiy  lie  very  ahundant.  In  typhus  fever  the  rash  is  always  purpuric. 
M';i>l('s,  scarlet  fever,  and  more  pai'ticularly  small-j»ox,  have  ea(di  a  \ariciy 
rliiinicterized  hy  an  extensive  purpuric  rash. 

(/')  Toxic. — 'The  virus  of  snakes  jtroduces  with  great  rapidity  cxtrava- 
•Mtinii  (if  l)l(H)d — a  eondition  which  has  heeii  very  carefully  studied  hy 
Wiir  .Mitchell.  Certain  medicines,  particularly  copaiha,  (piinine,  hella- 
'i"iiiia,  luerciiry,  ergot,  and  the  iodides  oectisionally,  tire  f(dlowed  hy  a 
liihi'lii;d  rash.  Purpura  may  follow  thi'  use  of  comparatively  small  doses 
"f  iniljile  of  potassium.  It  i.s  not  a  very  common  occurrence,  considering 
ilip  jrivat  frei|iicncy  with  wdiieh  the  drug  is  employed.  A  fatal  event  may 
litMaiiseil  hy  a  small  amount,  as  in  a  case  reported  hy  Stephen  Mackenzie 
"fa  child  which  died  iifter  a  dose  of  two  and  a  ludf  griiins.  An  erythema 
may  precede  the  ha-morrhage.  It  is  not  always  a  simple  purpura,  hut  may 
'>••  iiii  acute  fehrile  erii])lion  of  gretit  intensity.  In  Scptcndier,  iS'.tl,  a 
iiiaii  aired  forty-eight  was  admitted  under  my  care  with  arterio-sclerosis 
''"'1 'hepsy.  The  latter  yielded  rapi<lly  to  digitalis  and  diiirctin.  When 
"i!iv;ilt.si.,.iit  he  was  ordered  iodide  of  potassium  in  ten-grain  doses  three 
'i'lii"'  a  day,  and  took  in  fourteen  days  4:.*0  grains.  lie  had  high  fever, 
"Tyx.a,  .swelling  of  the  throiit,  and  the  most  extensive  purpura  over  the 
"linli'  lidiiy.  Fnder  tliis  division,  too,  comes  the  purpura  so  often  as.so- 
™tc(i  with  jatindico. 

('■)  Cachectic. — Tender  this  lieading  are  best  described  tlu>  instances  of 
I'lirpi'i'ii  which  develop  in  the  constitutional  disturbance  of  cancer,  tul)er- 
i;iilosis,  llodgkiii's  disease,  Bright's  disease,  scurvy,  and  in  the  debility  of 


ii;    1. 


34i 


CONSTITUTIONAL  DISEASES. 


i.« 


old  ago.  Ill  tlioso  cases  the  spots  are  usually  confined  to  the  extroiiiitio,!. 
Tliey  may  be  very  aliumlaiit  in  the  l.wer  linil)s  and  about  tlie  \vii>i..  iinl 
hands.  'I'liis  eon.stitutes,  probably,  tlu;  commonest  variety  of  the  iliscayi', 
and  many  examples  cif  it  can  be  seen  in  the  warils  of  any  large  hosjiiial. 

{(I)  Neurotic. — One  variety  is  met  with  in  eas(s  of  organic  discasf. 
It  is  tlie  so-called  myelopnthic  purp'ua,  which  is  seen  oecasidiiullv  in 
locomotor  ataxia,  particularly  following  attacks  of  the  lightniu;:  paiii, 
and,  as  a  rule,  involving  the  area  of  the  skin  in  which  the  pains  liiivc  lucn 
nu)st  intense.  Cases  have  been  met  wiln  also  in  acute  iiiyelitis  ami  in 
transverse  myelitis,  iiiid  occasionally  in  seven-  neuralgia,  anollicr  fdrrn 
is  the  remarkal)le  hysterical  condition  iv  wiiich  stignuita,  or  bl'.'ciliiii.' 
points,  appear  upon  the  skin. 

(')  Mechanical.  'I'liis  variety  is  most  frequently  seen  in  veiKnis  s!a,-is 
of  any  fdrin,  as  in  the  jiaroxysms  of  whooping-cough  and  in  epile|iM. 

Arthritic. — This  form  is  characterized  by  invoivement  of  the  jdiiits. 
It  is  usually  known,  tlierefore,  as  rheumatic,  though  in  reality  the  cvi 
deiu!e  upon  wliicli  this  view  is  based  is  not  conclusive.  For  the  \\w>v\r 
it  seems  more  satisfactory  to  usi-  the  dcsijrnation  arthritic.  Three  ",\\m\< 
of  cases  may  be  recognizi  "  : 

{ii)  A  mild  form,  often  kiu)wn  as  Purpura  simplex,  seen  nin.st  I'diii- 
moldy  in  children,  in  whom,  with  or  without  articid:ir  pain,  a  cni]i  "f 
pi!ri)iirie  spots  appi'ars  upon  the  legs,  less  comnu)nly  upon  the  trunk  aini 
arms.  As  pointed  out  by  (iraves,  this  form  i;;  not  infrequently  iissticiatwi 
with  diai'rlio'a.  The  disease  is  si-ldom  severe.  'I'here  may  be  loss  ef  ap- 
petite, ami  slight  ana-nda.  Fever  is  not,  as  a  rule,  present,  and  the  pa- 
tients  get  well  in  a  week  or  ten  days.  'I'hese  cases  are  usually  ivjianlwl 
as  rlu'iimatic,  and  are  eertaiidy  associateil,  in  .><om(!  instances,  with  un- 
doubted rheumatic  matdfestations  ;  yet  in  a' majority  of  the  patients  whi^li 
I  have  seen  the  arthritis  was  slighter  than  in  the  ordinary  rheiiMiutisiii  nf 
children,  and  no  other  nuiiufestations  were  present. 

{/))  Peliosis  rheumatica  {Sr/ilinlphi\'<  Discftsc). — This  remarkatileaffrc- 
tion  is  characterized  by  tuidtiple  arthritis,  and  an  eruption  which  varir 
greatly  in  character,  sometimes /;/^/7<// /•/>•,  more  coinimiidy  associarid  with 
loiicttriit  or  with  cri/f/i<'/ii(i  r.riiil(ilirinii.  The  di.sease  is  most  coiimiim  in 
nudes  between  the*  ages  of  twenty  and  thirty,  it  not  infrequently  i^cts  in 
with  sore  throat,  a  fever  from  Kll"  to  lO)}",  and  articular  p.iins.  Tin 
rash,  which  makes  its  appearance  iirst  on  the  legs  or  about  the  alTcili'l 
joints,  nniy  be  a  simple  purpuru  or  ordinaiy  urticarial  wheals.  In  etlur 
instances  there  are  nodtdar  iidiltrations,  not  to  l»e  distinguish. il  fpua 
erythenui  m)dosum.  The  combination  <»f  wheals  and  purpiuii,  thr  pur- 
pura urfinuiK,  is  very  distinctive.  Much  more  rarely  vesication  is  imi 
with,  the  so-called  pniiji/iii/in't/  juir/mrtr.  'I'he  amount  of  (cdenia  i.- van- 
abli' ;  occasionally  i"  is  excessive.  In  one  case,  which  I  saw  in  Meiitiviii 
with  Molson,  the  chin  and  lower  lip  wire  enctrmously  swollen,  tciifv, 
glazed,  and  deeply  ecchymotic.     The  cyelidd  were  swollen  and  |nnpiiri'. 


PUJiPURA. 


345 


while  si;ittorP(l  over  the  dioeks  and  about  tlio  joints  were  numerous  sf  ota 
(if  liur|iiiiii  urticans.  'I'hese  are  the  cases  wliicli  have  been  described  us 
fcbrilr  purpuric  wdcinn.  'I'ho  teini)erature  rangi",  in  mild  cases,  is  not 
iiiirh,  hut  tuay  reach  Wi"  or  lO.T. 

Till'  urine  is  sometimes  reduced  in  amoui\t  and  may  l)e  albuminous. 
I'liu  joint  alTeclious  are  usually  slight,  tliough  associated  with  much  pain, 
|);irli(Milarly  as  the  rash  comes  out.  Kelapses  nuiy  occur  and  the  iliseaso 
iiiiiv  ret  mil  at  the  same  time  for  several  years  in  succession. 

Thr  (liagiu)sis  of  Sciirtidein's  disease  olTers  no  dillicidty.  The  associa- 
tion (if  niiiltiple  arthritis  with  i)ur[)ura  and  urticaria  is  very  characteristic. 
Ill  II  (I  .iiich  1  saw  with  Musser  there  was  endo-pericarditis,  and  the 
ijiu'stioii  at  lirst  arose  whether  the  patient  had  malignant  endocarditis 
with  cxlciisivc  cutaneous  infantts. 

Schiiiili'iirs  peliosis  is  tiiought  by  most  writers  to  bo  of  rheumatic 
iiriLjiii,  and  certainly  many  of  the  cases  have  the  ch;.i;iv'tcrs  of  ordinary 
liitimiatic  fever,  jiliis  fuiriiiira.  Jiy  many,  however,  it  is  regarded  as  a 
siiiriiil  all'ection,  of  wiiich  the  arthritis  is  a  iiumifestatiijn  analogous  to 
thiit  wiiieli  occurs  in  liaMuophilia  and  in  scurvy.  'I'he  frefjueney  with 
wliicli  sore  throat  precedes  the  attack,  and  the  occasional  occurrence  of  eii- 
ilmarditis  (!r  pericarditis,  are  certainly  very  suggestive  of  true  rheumatism. 

The  cases  usua'ly  do  well,  and  a  fatal  event  is  ext'vmely  rare.  The 
threat  symptoms  n-ay  [x-rsist  and  give  trouble.  In  two  instances  I  have 
seen  iiecrnsis  and  :<loiighing  of  a  portion  of  the  uvula. 

(')  Henoch's  Purpura.— This  variety,  seen  chiefly  in  children,  is  cliar- 
;i'';,  i/ei|  liy  ( 1)  relapses  or  recurrences,  often  extending  over  several  years; 
('.')  liiiiiieoiis  lesions,  which  are  those  of  erythema  multiforme  rather  than 
iif  simple  purpura;  (."{)  gastro-intcstiual  criscs--paii>,  vomiting,  and  iliar- 
ilui'a;  (4)  joint  pains  or  s\>;'lling.  often  trilling;  (."»)  Iiiciiiorrliages  from 
the  iimcoiis  membranes.  When  froju  the  kidney,  an  intensi-  ha'morrliagic 
nephritis  may  su|»ervene,  wdiieh  proved  fatal,  with  the  .symptoms  of  acute 
lliii,'lit's  (lisea.se,  in  one  of  my  cases,  and  became  chroni<'  in  a  case  of 
I'  W.  rreiitiss.  Any  one  or  two  of  the  above  .symptoms  nuiy  be  .)'is  iit; 
tiif  intestinal  crises  with  enlargement  of  the  spleen  may  be  present  and 
''•'I'lir  fur  months  before  the  trui-  ntilurc  of  the  trouble  bccrmies  iiianil'est. 
llii-  t'uiiii  has  an  iuttM-esting  (ionnection  with  the  angio-iieiirotic  (cdema, 
wliii  h  is  also  characterized  by  severe  gastro-intesunal  crises.  The  prog- 
nosis is  good;  but  one  of  the  nine  cases  wliiidi  have  come  under  my  (are 
'li''il.  A  series  of  cases  has  been  collecte(|  by  von  Deiisch  and  lioehe,* 
''II'  'lii-  t'oriii  is  very  much  more-  conumjn  than  their  study  of  it  would 
iiulicate.  • 

Purpura  Hebmorrhagica. -ruder  thi.-^  heading  nuiy  be  consid- 
T'''!  the  ra,>es  of  Very  severe  purpura  with  liaMuorrhages  from  the  mucous 
iiifinhniiies.     The  alFection,  known  as  the  nuivlnis  itniculihsus  of  Werlhof, 


f    'H 


^' 


•  ( t 


♦  Fislsrhiiff  llerni  Kdouiird  lleiioeh,  itcrlin,  IH!)0. 


il 


-"1 


¥i 


340 


CONSTITUTIONAL   DISKASES. 


is  most  commonly  mot  witli  in  yoiinj'  and  doliciito  individuals,  p;utiou. 
lady  in  girls;  but  cuse8  uru  described  iu  which  the  disease  has  aiucked 


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ItCAN  mOII«. 
NUM("  or 

OOHruKlH 


BLACK,  RED  CORPUSCLES.  RED,  HAEMAGLOBIN.  BLUE,  COLaHUSS  COHPUSCUl. 

(iiAUT  Xlll.— Illii>trati<  the    riipidity  with   which  aniPiiiia  is  produci^d   in  I'lirjiurs 
ha'tiiorrhagicii  iiiiil  I  he  grn<hial  rt'i'overy. 

adult.s  ill  full  vi^ror.  After  u  few  days  of  weakness  and  debility.  |iiir|iur; 
spots  appear  on  the  skin  and  rapidly  intirease  in  numbers  and  size,  lilci 
in,t(  from  the  mucous  surfaces  .s(!ts  in,  and  the  epista.xis,  hannatiiria,  iiiiil 
ha'inoptysis  may  cau.se  profound  ana'mia.  Ciiart  ,\  III  illustrates  ili''  riipiil- 
ity  with  which  aiuemia  is  produced  and  the  gradual  recovery.  Death  may 
take  place  from  loss  of  lilood,  or  from  iui'morriiago  into  the  brain.  Slii'lit 
fever  u.viially  accompanies  the  disease.  In  favorable  cases  the  iilTcotion 
terminates  in  from  ten  days  to  two  weeks.  'I'liere  are  ijistances  of  purpura 
luemorrhagica  of  great  malignancy,  which  may  jirove  fatal  within  iwciily- 
four  hours— ;>H/7>;/ra  fiilihiiKuix.  This  form  is  most  commoidy  iint  with 
in  children,  and  is  characterized  by  cutaneous  hrt'morrhagea,  whieli  ilcvdop 
with  great  rapidity.  Death  may  occur  before  any  bleeding  tak  -  plin''' 
from  the  mucous  membranes. 

In  the  diii(]iinsis  of  purpura  hajmorrhagica  it  is  important  l"  cxi'lude 
scurvy,  which  may  be  done  by  the  consideration  of  tho  previous  health. 


J' 


PURPURA. 


347 


the  drfumstances  under  which  the  disease  develops,  and  hy  the  absence 
,.f  sttrlliiii:  "f  tlie  gmiis.  'I'hr  iii:ili<(imiit  forms  of  the  fevors,  juirtiouhirly 
small-iKix  and  measles,  are  distinyished  by  the  proilrdiiie.s  and  the  higher 
tciiipcratiin'. 

Treatment.— In  symptomatic,  purjnira  attention  slioidd  be  j)aid  to 
the  I'diKJitioiis  iukUm"  which  it  deveh)ps,  and  measures  .shouM  ]>v  employed 
to  iiuTcaso  the  strejij^tii  and  to  restore  a  noruud  blo(»d  condition.  Tonics, 
;.'(iii(l  fiioii,  and  fn'sh  air  meet  these  indications.  In  tiic  simple  j)urpura  of 
ihililreii,  or  that  associated  witii  slight  articular  trou!)le,  ai'scnic  in  full 
iliKcs  should  Ik'  <,Mven.  No  good  is  obtained  from  the  small  doses,  but  the 
{•'(iwIit's  .-nhitinii  shoulil  be  pusiied  freely  unlii  iih\sii)l(igir;tl  efl'ecls  are 
iilttaiiied.  In  peliosis  rheumatica  thesotlium  salicvlates  may  be  given,  but 
with  liiscreiion.  I  confess  not  to  have  seen  any  sju'cial  control  of  the  ha-m- 
nniiaircs  by  this  remedy.  \Vt  are  still  wiihniit  a  trustworthy  medicine 
"Aliii'h  i';u\  ;dwuys  be  relied  upoi.  to  control  purpura. 

.\romatic  sulphuric  acid,  ergot,  turpentine,  acetate  of  lead,  or  tannic 
Hill  pilh''  acids,  may  be  used,  and  in  some  instaiK'cs  they  .seefn  to  check 
ilie  hleiiliiig.  In  other  cases  tlie  whole  series  of  ha.-mostatics  may  be  tried 
in  .succession  without  anv  benefit. 


l!.KM()I{RnA(JI('    I)ISF'L\SKS   i)V   THE   XKW-BoHN. 

!.  Syphilis  Haemorrhagica  Neonatorum.— The  child  may  Ik-  born 
in-ahhv,  nr  there  nniy  be  signs  of  ha'uiorrhage  at  birtii.  'I'hiu  in  a  few 
'i.a- there  are  extensive  cutaneous  extrava.sations  and  bleeding  from  tin- 
mucous  surfaces  ,ind  from  the  navel.  Tlie  chiM  may  liecomc  deeply 
jaiiiuliccd.  The  p'i«t-uu>rtem  sIdws  luunerous  extravasations  in  the  inter- 
nal nr:r;m>  and  exietisive  syphiliiii'  (diaiiges  in  the  liver  and  other  organs. 

".'  Epidemic  HaBmoglobinuria  ( ir///rXv7',v  /^/wrsr).— Ila-moglobiiuiria 
ill  llie  iii'u-horn.  vvhieli  occasiiuudly  ilevelops  in  epidemic  fiu'm  in  lying-in 
iii-t!tiitiiins,  is  a  very  fatal  alTection,  which  sets  in  usually  aliout  the  fourth 
'lay  iif  lifi'.  The  child  becomes  jaundiced,  and  there  arc  markeil  gastro- 
uitcstiiiiil  >yniptotus,  with  fever,  jaundice,  rapid  resiiiratiiui,  and  sometimes 

i.vaiKwis.      The   urine   cojitains   albumin    ami    Id l-cidoriug    matter — 

iiit'thii'tii<i;:hiliiu.  'i'lif  di.sea.se  luis  to  lie  distinguished  from  the  simple 
utiTUs  lu'iiiiatoruni,  with  wni(di  there  may  souu'linies  lie  lilood  or  blood- 
"||"iin,ir  matter  in  the  uriiu'.  Tlu'  post-mortem  shows  an  al>sence  of  any 
H'|rtii'  ciiiidition  of  the  umbilical  ves.sels,  but  the  spleen  is  swollen,  and 
tluT:' are  |iiirietif(trn»  luemorrhages  in  ditfereut  parts.  Sonu'  cases  have 
dinwii  ill  ;i  marl  I'll  degree  ucuto  fatty  degeneration  of  the  internal  organs 
-til.'  sn-i';il!,..|  Uiilil's  disease. 

•'•  Morbus  M.vculosus  Neonatorum  .i»art  from  the  common  visceral 
liaiii()rili;i;'i's.  ihi  result  of  injuries  at  birth  (see  p.  •.••;i),  bit-eding  from 
"I"  Ml' iiinie  ,,f  ti,^.  g^rfacea  is  a  not  uncommon  eveiit  in  the  new-born, 
l'arti(  iiliirly  in  ho.spi^al  practiw.     Forty-live  ca.se3  occurred  in  f;,T(i(i  deliv- 


f 


-'U:.'^. 


ti.A 


f 


348 


CONSTITrnONAli   DISEASES, 


cries  (('.  \V.  Townsriul).  Tlic  lilccdiiii,'  may  l)i;  rroiii  tlio  navel  aloiic,  bm 
more  coiniiioiily  it  is  ireiicrai.  Of  '["(jwiiscnd's  '»(>  cases,  in  '^0  the  IiIcmh] 
caiiu'  fniiii  the  liowels  [iiiiht'ini  nriiiiafunnii),  in  11  I'ldiii  tht!  stmnaili,  in 
14  from  the  )iii)iilh,  in  l"-.*  from  the  nose,  in  IS  from  tiie  navel,  in  :i  frnm 
the  navel  alone.  Tim  Ijleeilini:  heirins  within  the  lirst  week,  hut  in  imv 
inslances  is  (lelaved  to  the  seeond  or  ihii'd.  Thirty-one  of  the  (m-is  djii! 
and  r.)  recovered.  The  discii.^e  is  usually  of  brief  duratio!>,  (K ath  occur- 
rhi'j;  in  from  one  lo  sc\en  da\.s,  '!"1k'  temperature  is  often  clcv;it,'i, 
'I'he  nature  of  the  disease  is  unknown.  As  a  rule,  notliinir  ahiiunmil 
is  found  jjost  morleP'.  The  j^'eneral  and  not  local  nature  of  the  alTo- 
tion,  its  self-limited  cduiracter,  the  presence  of  fever,  and  the  i:ivat(r 
prevalence  of  the  disease  in  hospitals,  siijiffest  an  iid'cctious  orij^in  (Tnun. 
send).  The  hleedim;  may  he  a.-^-sociated  with  inteiisi'  ha'tnato^fcuoii-  jaii'. 
dice.  Not  every  case  of  hlccdini,''  from  stomacii  or  itowels  IicIoults  in  ti  - 
eatejiory.  I'lcers  of  the  (esophai,nis.  stomach,  and  duodetiutn  have  l.i.;. 
found  in  the  new-horn  dead  of  jncldint  in'oiiiitoruiii.  The  chihl  may  ilia.i 
tiiii  blood  from  the  lircast  and  subsc(|iicntiy  vomit  it.  in  the  ircalrnri,' 
the  e.\ternal  warmth  must  be  maintaiiu'il,  and  in  feeble  infants  the  m, 
rnisc  maybe  used.  Camphor  is  recommended  and  ergotin  hv[)U(lcnii;: 
allv. 


X!!     H/EMOPHILIA. 


**-, ' 


m 


Definition.  — An  iiercditary,  constitutional  fault,  cliaractcri/.ed  In  a 
ti-ndency  to  uncnntrollalilc  lilei'ilinj,%  either  spontaneous  or  fidiii  .^liii, 
wounds.     It  is  sometimes  associated  with  a  form  of  arthritis. 

J'larly  in  the  ceniury  .-several  physicians  of  this  country  called  atU'iili'O 
to  the  occurreiu'i'  of  profuse  haemorrhage  'from  slight  causes.  TIk  fa  ■ 
that  fatal  ha'morrhage  might  occur  from  slight,  trilling  wounds  liaii  lii': 
known  for  centuries.  The  recognition  of  the  family  miture  of  thcilJMa- 
is  duo  to  the  writings  of  lUiel,  Otto,  Hay,  Coatcs,  and  otheis  in  tliisidiin- 
try.  'I'he  disease  has  been  elaborately  treated  in  the  monogriiplis  of  Lc: 
and  (I'randidier. 

Etiology.  —  In  a  majority  of  cases  tlie  disposition  is  hereditary.  Tli- 
fatdt  nuiy  bo  acquired,  however,  but  nothing  is  known  of  flic  coiKliiinii- 
iinder  which  the  disease  may  thus  arise  in  healthy  stock. 

The  hereditary  transmission  in  this  disease  is  remarkaliK'.  In  tin' 
Applcton-Sviiin  family,  of  lieading,  Mass.,  there  have  l)een  eases  for 
nearly  two  centuries;  and  l'\  !•'.  Urown,  of  that  town,  Iclls  nic  that  in- 
stances have  already  occurred  in  the  seventh  genenition.  The  usual  iiKii- 
of  transmission  is  through  the  moflier,  who  is  not  herself  a  Itlcciir,  in;' 
the  daughter  of  one  Atavism  through  the  fi-malc  alone  is  almost  ili' 
rule,  and  the  daugiitt-rs  of  a  bleeder,  though  lieallhy  and  free  from  mi; 
tendency,  arc-  almost  certain  to  transmit  the  disposition  to  the  iiiiik'  "1^ 
spring.     'J'iie  affection  is  much  more  common  in  males  than  in  (I'mal- 


ILEMOPIIILIA. 


349 


thf  proportion  boinji  o.stimiitod  iit  clfvcn  to  nno,  or  ovon  tliirtooii  to  oiio. 
The  U'IhIcik;}'  usuiilly  iippcjirs  williin  tlu'  first  two  ycnrs  of  lilV.  It  \a  raw 
fur  rnaiiii'cstiitioiis  to  luMlclavcd  imtil  tlio  ti'titli  or  twclflli  yciir.  l-'iiiiiilios 
III  iill  ciiiKJitioiis  of  lift'  arc  alTcctcd.  'i'iic  Itlicilcr  fjmiilics  arc  usually 
hiiL'c.    'i"!i<:  luciiilx-rs  arc  licaltliy-lodking,  and  have  line,  soft  si<iiis. 

Morbid  Anatomy.  — No  special  peculiarilies  have  hecn  described. 
Ill  -oiih'  iii'laucctf  cli'inifes  have  hecti  found  in  the  sni;dlcr  vessels ;  but 
iiMillii'i's  I'iireful  studies  have  been  ncsrativc.  An  uuusiia!  ihinnoss  of  the 
w-.'l-  has  been  noted.  lla'inorrhaL'cs  have  ln'cn  found  in  and  about  the 
i:m-iilt's  of  llu!  joints,  iind  in  a  few  instances  inlljiniriiation  of  the  synovial 
•iirfiiccs.  The  luiturc  of  the  disc.'ssc  is  undetermined,  and  we  do  jiot  yet 
KiMW  whctiicr  it  depends  upon  a  pcculiai' frailty  of  the  biood-v  .-sels  or 
sDiiU'  ]M'cnliarity  ii\  tlu"  constitution  of  the  blood,  which  pri'V"iits  Ihc  nor- 
mal ilii'diiihii-  i'oriiKition  in  a  wound. 

Symptoms.  —  I'sually  luenionhilia  is  uc  t  noteil  in  the  child  unlil  a 
iiilliiiL;  'lit  is  fiillowed  by  serious  or  uiu-ontrollalile  ha'inorrliatre.  or  spon- 
taiii'MiH  lijccdinij  occurs  aiitl  presents  insupci'alilc  dilVicnltii's  in  its  arrest. 
Till' symptoms  may  be  (grouped  under  three  divisions  :  external  bleediiifr.s, 
MiiiiitiiiKMtus  and  traumatic;  interstitial  blecdiuLrs.  petechia'  i  nd  ecchy- 
imisi-:;  and  llu*  joint,  alVections.  The  external  lilccdinLTs  may  I)e  spon- 
i;!iii'(iiis,  liiii  more  commonly  they  follow  cuts  an  I  wounds.  In  :5:54  cases 
iLiaudiilicr)  the  chief  blcediuLrs  were  cpist.axis,  1  C'.i ;  from  the  month,  4.'5 ; 
•itoinacli,  1.") ;  bowels,  ;j(i ;  urethra,  KJ ;  lunjj.s,  \]  ;  aiid  in  a  few  instance,^ 
lili'i'ilitiL:  from  the  skin  of  tlu!  head,  the  tonij^ue,  tiiiLTcr-tip-:.  tear-papilla, 
iwljils.  external  ear,  vulva,  navel,  iiml  scrotum. 

Tiaimiatic  hlcedini,'  may  result  from  blows,  cuts,  scratches,  etc.,  and 
ihi' lilitmi  may  lie  dilTused  into  I  he  tissues  or  dischar',''ed  externally,  '['riviaj 
njii'iatieiw  have  proved  fatal,  such  as  the  e\|riiclion  of  teeth, circumcision, 
ni' VfiicsiM'tiou.  It  i.s  possible  that  there  may  lie  local  defects  wliich  make 
Mcdlinu'  from  certain  ])arts  if  the  lioily  more  danircrous.  \).  liayes  .\i,mu'w 
iiiriiliiiiiinl  to  me  the  case  if  a  bleeder  who  had  al\<a\s  bled  from  cuts  and 
liriiixs  iihdvc  tlit^  neck,  uevi'r  from  those  below,  'Che  bleedinir  i.s  a capil- 
hii'v  (iii/.iuir.  li,  iiiay  las'  foi-  hoin's,  or  even  nmny  days.  Kpistaxis  nuiy 
Iinivi-  fatal  in  twenty-four  hours.  In  the  slow  iileedin<r  from  the  mucous 
siirfaci's  larire  blood  tumors  may  form  aiul  project  from  the  imse  oi' 
moiuli,  fdrudiiL.'  remarkalile-|ooi\im,'  .slnictures,  and  showiiii,'  that  the 
Mi'oil  lian  the  power  of  coaLTulation.  The  interstitial  ha-morrhaires  may 
III'  ^iviu'aiKoi.s  ■',•  inay  result  from  injury.  Petechia'  or  larire  I'xtrava.sii- 
ti'itis-lia'niatoniaia— nuiy  occur,  th"  latter  usually  followini;  blows. 

r..i  jiniit  alTectiotis  of  ha'mo|il  lia  are  I'dmnkahli'.  There  may  simply 
''•' l»;ii!i  :  ■.^u■  vlueli  eoine  on  siiddeidy  with  fever,  and  clo.sely  resem- 
"'''  ■  .iu'iimatism,  Tlu' larijer  joints  art' usually  alTectcd.  .Arthritis 
iiiiiv    ;1ii.r  ii,  ,in  attack  of  ha'morrhau'e. 

•^"  ':ii'  a--  ft  (.  e\;iit>iiiation  of  the  blood  (.'ocm,  no  changes  of  special 
"I'lini'iii  lia\o  t  en  noted.     When  the  bleedini;  has  been  severe  it  is  thin 


f   'i 


w,^  ■■' V-^ 


350 


CONSTITUTIONAL   DISEASES. 


,"'  'W 


if  M 


and  watery,  but  at  the  borjinning  of  the  blouding  the  blood  is  rich  in 
corpuscles  and  cnaj^ndiites  tirtuly. 

Diagnosis. —  lu  tlie  diagnosis  of  the  condition  the  family  tiiHlcnov 
is  iinportant.  A  single  unfontroUabie  ha'Mu>rrhage  in  child  or  ;iiuili  is 
not  to  be  ranked  as  ha-nioitliilia ;  but  il  is  only  wlieii  a  j)ers()ii  sIkpwsu 
marked  tendency  to  niullii»le  luemorrhages,  sjionlaneous  or  trinimuiic, 
which  tendency  is  not  transitory  but  jtersists,  particularly  if  thi  ro  haw 
been  joint  affections,  that  we  nuiy  consider  the  condition  ii:iiiio[iliiiia, 
Peliosis  rheutnatica  is  an  affection  whicii  touches  luenuiphilia  \crv  chisclv. 
particularly  in  tlu'  relation  of  the  joint  swelling.  It  may  also  show  jtsilf 
in  several  members  of  a  family.  The  diagnosis  from  the  various  forms 
of  i»urpura  is  usually  easy. 

Progfnosis. — 'I'lie  j)atients  rarely  die  in  the  first  bleediuf.'.  The 
younger  the  individual  tlie  worse  is  the  outlook,  tiiougli  it  is  rarely  fatal 
in  the  first  year,  (irandidicr  states  that  of  Ift'-l  boy  subjects,  HI  died  lufuri' 
the  termiiuition  of  the  seventh  year.  The  longer  the  bleeder  survives  tlie 
greater  the  chance  of  his  outliving  the  tendeiu'y ;  but  it  may  persist  tn 
old  age,  as  shown  in  the  case  of  Oliver  Applet*. u,  the  first  rejxjrted  Ameri- 
can bleeder,  who  died  at  an  advanced  age  of  hieuiorrhage  from  a  hed-seri' 
and  from  the  urethra.  The  prognosis  is  graver  in  a  boy  than  in  ii  jrirj. 
In  the  latter  menstruation  is  sometimes  early  and  excessive, but  fortunalf- 
ly,  in  the  female  nuMnbers  of  ha'moplulic  families,  neither  this  fuiu'tinn 
nor  tiic  act  of  i)arturition  brings  with  it  sj)ecial  dangers. 

Treatment. — .Meml)ers  of  a  bleeder's  family,  particularly  the  hey?, 
should  be  guarilcd  from  injury,  and  operations  of  all  sorts  should  1* 
aM)i(le(l.  The  daughters  shoukl  not  nuirry,  as  it  is  througli  them  that  tlic 
tendency  is  pi'opagated. 

When  an  injury  or  wound  has  occurred,' absolute  rest  and  coiiipresMiii 
should  first  be  tried,  and  if  these  fail  the  styptics  may  be  used.  In  epis- 
taxis  ice,  tannin,  and  gallic  arid  maybe  tried  before  resorting  to  plugL'inL'. 
Internally  ergot  seems  to  have  done  good  in  several  cases.  Legir  advi-is 
the  ])erchloride  of  iron  in  ha!f-dra(dim  doses  ev<'ry  two  hours  with  a 
purge  of  sul])liate  (»f  soda.  Venesection  has  been  tried  in  several  i'ast'>. 
Transfusion  has  been  employed,  but  without  success.  During  couvales- 
cence,  iron  aiul  arsenic  should  be  freely  used. 


SECTION   III. 


DISEASES   OF  THE   DIOESTIVE   SYSTEM. 


I.  DISEASES   OF  THE   MOUTH. 
STOMATITIS. 

(1)  Acute  Stomatitis. — Simple  or  frvtlu'iimtons  stomatitis,  the  cotn- 
iiiiiiii'^l  rnriii  (if  iiillaiiimatioii  (if  tlm  iiioiitli,  results  fnini  tlic  action  of 
iiriliiiits  iif  various  sorts,  it  is  fn'(|U('iit  at  all  a^t's.  In  children  it  is 
iifttii  assiiciated  with  (lentitioii  aud  with  j^'astro-iutestiual  disturhaui'e, 
|iaiticnliirly  in  ill-nourished,  unhealthy  suijjects.  In  adults  it  follows  the 
iivmisc  nf  toiiacco  and  the  use  of  too  liot  or  too  liighly  seasoned  food.  It 
i<  a  fifijiifiit  eoneoinitant  of  indigestion,  and  is  met  with  in  the  ucute  sj)e- 
"ilic  I't'vcrs. 

Tilt'  atrt'ction  may  he  limited  to  the  gums  and  lips  or  may  extend  over 
•he  wlnile  surface  of  the  mouth  and  include  the  tongue.  There  is  at  tirst 
«ii|H'rti(ial  rcdiu'ss  and  dryness  of  the  memhrane,  followed  by  ii\creased 
M'ci'ctiuii  and  swelling  of  the  tongue,  which  is  fiirreil,  and  indented  by  the 
ti'i'tli.  There  is  rarely  any  constitutional  distnrliance,  hut  in  children 
ilifiv  may  1m.'  slight  elevation  of  temperature.  Tlu'  condition  is  >iilticient 
t'Miiiise  coiisiderahle  disi\omfort,  sometimes  amounting  to  actual  distress 
ainl  |i;iin.  particularly  in  mastication. 

Ill  infants  the  mouth  should  he  carefully  sponged  after  eacii  feeding. 
A  iiKiiitli-wash  of  borax  or  the  glycerine  of  borax  may  be  used,  and  in  se- 
vere cases,  which  tend  to  become  chronic,  a  dilute  solution  of  nitrate  of 
>ihvr  (ihrcc  or  four  grains  to  the  ounce)  may  be  applied. 

(■')  Aphthous  Stomatitis.— This  form,  also  kwimix  UA  foil irnhtr  or  re- 
wtiht)  >lniiiiititis,  is  characterized  by  the  presence  of  snuill,  slightly  raised 
^l"its,  fiuiu  two  to  four  millimetres  in  diameter,  surrouiuled  by  reddened 
ariiila..  'I'li,.  spots  a|)poar  first  as  vesicles,  which  ruptur",  leaving  small 
'il"'i''<  v>iih  grayish  bases  and  l)right-red  margins.  They  are  seen  most 
fivi|iicntly  (in  the  inner  surfaces  of  the  lips,  the  edges  of  the  tongue,  and 
till' ihiiks.  Tliey  are  seldom  present  on  the  mucous  membrane  of  the 
imarynx.  This  form  is  met  with  most  often  in  children  uiuler  three  years. 
It  may  mciir  either  as  an  independent  alfeetiou  or  in  association  with  any 


-^-      s  ;  ,?i 


r*  !j 


1 

1 

I  >'     ' 

I 


3.V2 


PISKASKS   OF  '11  IK   DKiKSTIVK  SYSTKM. 


V 


W^ 


one  1)1'  the   fi'lirilc  <lisc;ist's  of  cliildlniiKl  or  witli  iiii  attii<  k  of  iiidi^'citi,,),, 
'I'lic  (•!■(  |>  of    vesicles  coincs    out    willi    ^MMiit    riipitlitv  iilid    tl:e    little  ulirr. 
may  lie  I'lillv  t'oriiied   williiii  1\vent\-ronr  hours.     'I'lie  child  coiii|iIaiii< , 
>sort'iH'ss  of  the  iiioutii  iiiid  takes  food  with   reluctance.     'i"he  luiceal  st'cn- 
tioiis  arc  im-reascd,  iiiid  the  Iti'cath  is  lieavv,  Imt,  iiol  fold.     The  ediisti:,;. 
tiuiial  syrii|»toiiis  arc  usually  those  of  tlic  (liseasc  with  which  the  apliili 
arc  associatcil.     'The  disease   mii~l    not    he  eoiifomiilcd  with   thi'ii-h.     \ 
.ipccial  paiasitc  has  hceu  found  in  connciMioii  with  it.      It.  is  not  a  MMini, 
coiidilion,  and  heals  rapidly  with   the  irn|iro\cnient  of  the  c<insliiulii.ii:,. 
stiito.     Ill   severe  cases  it    may  extend   to  tlu?   pillars  of   the  fauces  ainl  i- 
the  pharynx,  and    jiroduce    ulcers   which    are    irritating  luid  dillieuli  ; 
heal. 

Kach  ulcer  should  he  IoucImmI  with  nitrate  of  isilvcr  and  the  iiininii 
should  he  thoroughly  cleansed  after  taking  food.  A  wash  of  chloratcnf 
potash,  or  of  l)orax  and  glycerine,  may  he  used.  'I'he  constitutional  svimi- 
toms  should  receive  cai'cful  attention.  Here  may  he  mcntioiicil  a  cin:,,  . 
alToction  which  has  hceii  ohservcd  chiclly  in  southern  Italy,  and  whidi  - 
characterized  hy  a  pearly-colored  iiienilnane  with  induration,  imiMciliati  ,\ 
lieneath  the  tiuigue  on  the  fi'a'niini  (  Riga's  disease).  There  may  lie  iiiiKii 
imUiratioii  and  ultimalcly  ulceration,  it  occurs  in  hoth  healthy  aii'i 
cuclu'tif;  children,  usually  ahout  '.ne  time  of  the  eruption  of  the  lir.st  li'i:, 
Jt  is  sometimes  epidemic. 

(;{)  Ulcerative  Stomatitis.  -This  form,  which  i.s  also  known  l>y  tl,.- 
names  of  frhd  s/miiii/i/is,  o,  /ni/ri'l  .v/zv  uKuif/i,  occurs  particularly  in 
children  aft, M'  the  hrsi  dentition.  It  may  prevail  as  a  wide-spread  ciii- 
demic  in  institutions  in  which  the  sanitary  conditions  are  defeelivc  It 
has  heeii  met:  with  in  j;iils  and  cam|»s.  Insullicient  and  unwInli'MOi' 
food,  impi'oper  veiililatioii,  and  prolonged-  damp,  cold  weather  si'ciii  ' 
be  special  predispo-iug  causes.  La.k  of  cleaidiiu'ss  of  the  nmiiin.  th. 
prcsonee  of  c.irious  leeih,  and  the  collection  of  tartar  around  tluiii  finii' 
the  developiiii'ut  of  the  di.sease.  The  all'cction  spreads  like  a  speiilii' lii- 
ease,  hu^  the  microhe  has  i.ot  yet  hecn  isolatetl.  It  has  been  licld  tlini 
the  disease  i-;  the  same  as  the  foot-and-mouth  disease  of  eattle,  and  tli;i! 
it  is  conv<'yed  hy  the  milk.  Imt  there  is  no  p(*silive  evidence  eii  lln" 
points.  I'avne  suggests  that  the  virus  is  identical  with  that  of  lontj 
gioiis  impetigo. 

The  nn)rhid   ju-ocess  begins  at  the  maigiu  of  the  gums,  which  lit m 

swcdien  and  red,  and  l)leed  I'cadily.  Ulcers  form,  tb.e  bases  of  wliidi  ap 
Covered  with  a  grayish-white,  firmly  adherent  mend)r.iiu'.  In  scviTc  i"W- 
the  teeth  may  beooiiie  loosened  and  necrosis  of  the  alveolar  prnciss  iiia; 
ocpur.  The  ulcers  extend  along  the  gum-line  of  the  npper  and  low.r 
jaws;  the  tongue,  lips,  and  mucosa  of  the  cheeks  ar(>  usually  swelleii.  bii' 
rarely  nleorated.  There  is  salivation,  tlio  breath  is  foul,  and  ma-tii-atioii 
is  painful.  Tlie  submaxilhu'y  lymph  glands  are  enlarged.  An  cxantlici! 
often  develops   and   may  be   mistaken  for  measles.     The  con>tiuitii.iii;'. 


fe--:^ii 'bik  *, 


STOMATITIS. 


•)-  <> 


^vmiititni-i  arc  rtftoii  pcvorr.  iiii.l  in  iiistitiilioiis  death  sonu'timc.-!  ro.-iiilts  in 
ill,,  cast'  I'f  ilcltilitatt'il  (•liiiiircii. 

la  the  ii'i'iitiiu'iit  fit'  liiis  fnrni  of  stoinatitirt  cliloruti'  <if  imtiisli  lias  hccii 
I  ,;iii,l  I,,  lie  almost  spccitic.  It  sIkmiM  Ik-  irivcii  in  iht^'^  of  ten  irniiiis, 
tlnir  liiii>-s  a  (lay,  to  a  cliild,  ami  to  an  adult  doiihic  thai  aiiioiiiit. 
l/iiallv  ii  iiiav  Itc  used  as  a  nioiilli-wasli.  or  tlii'  powdcrt'd  salt  may  Ih'  ap- 
iiliid  liu'ri'tlv  to  till'  iilccratci]  surface-.  Wlicii  there  is  nuicli  fetor  a  |)cr- 
iii;iii;,'iiii;iic-(ir-poia-h  wash  may  he  tiscd,  ami  an  ap[ilii'ation  (if  nitrate  of 
.il\ir  iii;i\  hr  made  to  the  idccrs. 

Tiicrc  arc  several  of/irr  nirirtirx  of  tdcerutivc  son*  inontli,  wliieh  dilTcr 
riitiiclv  from  this  form.  I'lecrs  of  the  month  arc;  common  in  nnrsin^ 
Mdiiii'ii.  and  are  usually  seen  on  the  mucous  membrane  (d"  the  lips  an<l 
liii'i'ks.  'I'iiey  ilcvclop  from  tiie  mueoiis  follicles,  and  are  from  three  to 
live  inillimel res  in  diameter.  'They  may  cau.se  little  or  no  inconvciueiicc; 
!i;it  in  some  instances  they  are  very  painful  and  inti'rfcre  seriously  with 
•:ii>  takiuir  of  food  aiul  its  lUiistication.  .\s  a  ride  they  heal  readily  after 
;in  ii|i|ilii  iiliiiii  of  nitrate  of  silver,  and  the  condition  is  an  indication  f».ir 
■luii  •:.  I'l'csh  air,  and  a  better  diet. 

lifcurriii^^  outbreaks  of  an  herpetic,  even   pemphiiroid,  eruption  are 

n  ill  iiciinitic  individuals   [sl-nitttilis  ni  i/rn/lcd  r/irmiicd,  .lacobi).     in 

•'.iin  cases  it  is  as.sociiitod  with  an  erytluiimi  multiforme. 

I'.u'rot  d(>.'ril)cs  the  (x-cjisioiuil  appearance  in  the  new-boi'ii  of  small 
iilriT.s  .symiaetrically  placed  on  tlii'  liard  ])alatc  on  either  side  of  the  middle 
liiir.  They  are  nu't  with  in  very  debilitated  eliildreti.  The  idcers  I'arcly 
inal;  usually  they  tend  to  inci'ease  in  size,  and  may  involve  the  bone. 

i'lnliiar's  aphth;e  consist  (d"  small  patches  and  ulcers  on  the  hard  palate, 
laiisid  as  a  rule  in  youiiL,^  infants  by  theartilicial  nipple  or  the  nunse's  lln}.;er. 

(1)  Parasitic  Stomatitis  (Thnisk ;  Sdoi- :  .Vn'/m/). — 'I'his  a(Tectioi\, 
nio>t  i(.ii,nionl\  seen  in  (diildreii,  is  dependcMit  tipou  a  fuuLrns,  the  unc- 
ihiirxinijKs  iilliiniiis,  v;\\\v{\  by  iiobiii  [\w  irnlitun  dlhicitits.  It  lielon<rs  to 
till' (, I'll, inf  yea<t  funL;i,and  consists  of  lii'aiicliim.''  tilanient<.  from  the  ends 
"f  whiili  ovoid  torula  cells  develop,  'i'ho  di.sea.se  does  not  ari.se  appar- 
•'iitly  ill  a  iici'iual  mucosa.  The  usc^  (d'  an  improper  diet,  uncleanliness  of 
till'  iiiiiii!!),  (li(.  jii'i,!  fermentation  (d'  rcrnnaiits  of  I'ood,  or  the  dc\el  ipmeiit, 
tT'iiii  any  i  aiisc,  of  catai'i'hal  stomatitis  predispose  to  the  growth  of  the 
liniL'ii>.  ill  institutions  it  is  rre(pientl\  transmilted  by  iini'han  fccdini(- 
Ijiillli-,  spill, us,  etc.  It  is  not  coiilined  to  children,  but  is  met  with  in 
iiiliilts  ill  the  (iual  stajres  (d'  fever,  ii\  chronic  tuberculosis,  diaiu  tes,  and  in 
'aijit'iiii  ,-tali'S.  'I'lic  para.iite  dev(do|)s  in  the  upper  layers  (d"  the  mucosa, 
:iiiilllii.  lilaiiiriits  fui'ui  a  dense  felt-work  aiiioiiLr  the  c|iithclial  cells.  The 
ili-rasf  liruins  on  the  tonj^ue  and  is  seen  in  the  form  of  sliiihtly  raised, 
I'l'^Mlv-wliiie  spots,  which  iiicrcaso  in  si/e  and  j^radiially  coalesce.  The 
iiit'iiiliraiir  thus  i'oi'incd  can  be  readily  scrajied  <df,  leaviiij(  ai!  itilact  mu- 
'"■"ii,  I'V.  il   the  j)roce.s,s  extends  deeply,  a  l)leedin<,',  sli;j;hlly  ulcerated  sur- 


I 


i'    *  •  ^ 


it.; 


^i 

M 


m 


i: 


vH'. 


ff  ^W 


irl: 


354 


MSKASKS  OF   TIIK   DKiKSTlVK  SVSTKM. 


fiiiM".  Tlic  tlisoiise  sprciidH  to  the  checks,  lijw,  uiid  litird  paliitc,  aihl  nmv 
involve!  till)  tonsils  iiiid  jiliarvnx.  In  v(!ry  severe  eases  the  eiiliiv  Imcoai 
niucosii  is  covered  hy  the  ^fniyish- white  ineinhraiie.  It  may  i-vin  (xtcii.l 
into  the  (I'sojdiaj^iis  and,  according  to  I'arrot,  to  thi^  stomach  and  ({I'diin. 
It  is  occasionally  met  with  on  the  vucul  cords.  Uohnst,  \vt'll-iiiiiiii,|i,.|| 
ciiildren  are  sometimes  alTected,  but  it  is  nsiially  met  with  in  ciifirlili'ii, 
emaciated  infaids  with  di;,'esliv(!  or  intestinal  troubles.  In  such  cuscs  ihc 
liiscase  may  persist  for  months. 

The  alTection  is  readily  reco<;[inzed,  and  must  not  he  confoiinili'd  with 
aphthous  stomatitis,  in  whi(di  tlu!  ulcers,  prcccdi'd  by  tin-  I'uriiKiiion  ,,f 
vesicles,  are  j»erfectly  <listinctive.  In  thrush  llii'  microscopical  cxaiiiina- 
tion  shows  the  jircscnce  of  (he  cliaractcristicr  funijns  throuf^diout  liic  nicm- 
brane.  In  this  condition,  too,  the  month  is  usually  tiry — a  striking  ((iiitra-t 
to  the  salivation  accompanyin£f  aphtha'. 

'riirush  is  more  readily  jtrevented  than  venn)vcd.  The  child's  iikhiiIi 
sliould  be  kept  scrupulously  dean,  and,  if  artiilcially  feel,  the  ImiuIc 
should  be  tliorouijhly  sterilized.  Lime-water  or  any  other  alkaline  lliiiil, 
such  as  the  bicarbonate  of  soda  (a  draidim  to  a  tundder  of  water),  nmy  W 
employed.  When  the  ])at(dies  are  lU'cscnt  thecc  alkaline  moiitli-ua«lH- 
may  be  eontimu'd  after  cacdi  feeding.  A  spray  of  borax  or  of  Mil|iliiu 
of  soda  (a  drachm  to  the  ouiu'c)  or  the  black  wash  with  ^dycci'liie  iiiny 
be  employed.  The  periiian<,Mnate  of  jiotassium  is  also  nscful.  TIicimh- 
stitutional  treatment  is  of  cipial  inijiortance,  and  it  will  often  be  fininl 
that  the  thrush  persists,  in  sjiite  of  all  local  measures,  nntil  the  j^ciirral 
liealth  of  the  infant  is  improved  by  (dian<:e  of  air  or  tiic  relief  of  the  (liar- 
rho'a,  or,  in  obstinate  cases,  the  substitution  of  a  natural  for  the  artiliiiil 
diet. 


I  in 


(.">)  Gangrenous  Stomatitis  {fmii-nnir  Oris ;  Xomu). — .\n  alTccti 
cliaractcri/c(l  by  a  ra]iiilly  proj^rcssin^' jran^'reiu',  startiii",'  on  the  iriiins  m' 
cheeks,  and  leadinj^  to  extensive  slou^hinjf  and  destruction.  Tlii-  tcni!'!'' 
bnt  fortunately  rare  disease  is  seen  only  in  children  under  very  i)i-iiiiitarv 
conditions  or  diirin;,'  convalescence  from  the  acute  fevers.  1:  is  iii"' 
common  in  girls  than  in  boys.  It  is  met  with  betwi'cn  the  .ips  of  tU" 
and  five  years.  In  at  least  one  half  of  the  cases  the  disease  has  (lcvcl(i|)el 
during  convalescence  from  measles.  Cases  have  bc«'n  seen  also  after  srar- 
let  fever  and  typhoid.  The  mneons  membrane  is  lirst  alTected,  ii.-ualh  "f 
the  gnms  or  (d'  one  cheek.  It  begins  insidiously,  and  when  first  seen  tlure 
is  a  sloughing  nicer  of  the  mucous  membrane,  whicdi  spreads  rapidly  mil 
leads  to  l)rawny  induration  of  the  skin  and  adjacent  parts.  The  slinij.'li!ii.' 
extends,  and  in  severe  cases  the  (dieck  is  ju-rforatcd.  The  disease  may  spnail 
to  the  tongue  and  (bin  ;  it  may  invade  the  bones  of  the  jaws  and  e\rii  r  • 
volve  the  eyelids  and  ear.s.  In  mild  eases  un  nli'cr  forms  on  I  he  iin'tr 
surface  of  the  cheek,  wdii(di  heals  or  may  jK-rforate  and  leave  Ji  listiilni'- 
opening.  Matui'ally  in  smdi  a  severe  alTcction  the  constitutional  (li.-tiirl'- 
ance  is  very  great,  the  pulse  is  rai)id,  the  prostration  extreme,  and  (Iw''^ 


Irliif      ';■';)■ 


STOMATITIS. 


355 


usuiilly  tiikos  place  within  ii  week  or  ton  diiVH.  Tlic  tciiipcriitiirf  ruav  reach 
In;;'  (ir  lii4".  niarrhd'ii  is  usually  prt'srnt,  and  aspiraticui  pni'Uiiiuiiiu 
often  lU'Vi'liips.  II.  U.  Wiiartdii  iuis  (Icscrihi-d  ii  case  in  which  tiuTc  \\ii.s 
(XttMisivc  colitis.  Iiinj,'ai'd  has  foiiinl  in  cases  of  nmna  a  tiiread-likc 
iiacilliis  Itiit  its  precise  relation  to  []n>  disease  is  doubtful.  '\'\\v  hi;,ddy 
nfriu'tik'  bodies  iloscribed  hy  Sansoin  in  tim  blood  wcro  probably  blood- 
phitc.'*. 

The  treatuuMit  of  (he  disease  is  unsatisfactory.  In  many  cases  the 
(Miifut  is  so  insidious  that  tluTci  is  ati  extensive  slou^rhin;;  sore  when  the  case 
lirst  coiups  under  ol)servation.  Destruction  of  the  sore  l)y  the  cautery. 
liilur  ilic  Paipieliu  or  fuming  nitrii;  acid,  is  the  most  etreetinil.  Antisep- 
lir  ii|i|ili(atioiis  should  he  nuide  to  destroy  the  fetor.  The  child  should 
lie  ranfiilly  iinurished  and  stinudanls  ;;iven  freely. 

(ti)  Mercurial  Stomatitis  (/'/i/>i/i/<ni).—.\]i  inllanimation  of  the  mouth 
ami  siili\ary  irlands  caused  by  mercury,  which  occur.;  cbiclly  in  persons  who 
!;;i\c  11  >|iccial  susceptibility,  and  rarely  now  as  a  residt  of  the  excessive 
tiM' (pf  the  dru;r.  It  is  met  with  also  in  persons  whose  occupalinu  neces- 
Mtalcs  the  lonstant  handling  of  mercury.  It  often  follows  the  adminis- 
trutiiiii  of  repeated  small  doses.  Thus,  a  jtatit'Ut  with  heart  disease  wlio 
was  mill  red  an  eighth  of  a  grain  lA'  calonud  every  thri'e  hours  for  diu- 
ntii'  |iurposes  had,  after  taking  eight  or  ten  doses,  a  severe  stonuititis, 
Hiiii'li  |itrsisted  for  sevi'ral  week>.  1  have  known  it  to  follow  also  the  adinin- 
i.-U'iitioii  of  small  doses  of  gi'ay  powder.  Tlu'  patient  complains  lirst  of  a 
iintiillic  la.-te  in  the  mouth,  the  gums  become  sw(dlen,  reil,  and  sore,  nuis- 
licaliipii  is  dillicult,  and  soon  there  is  a  great  increase  in  the  secretion  of 
liif  saliva,  which  Hows  freely  from  the  mouth.  Tin-  tongue  is  swollen, 
till' lii'cath  has  a  foul  odor,  and,  if  the  all'i'ction  ](rogre.sses,  there  may  be 
iilii'i-atioii  nf  the  mucosa,  and,  in  rare  instances,  necrosis  of  the  jaw.  Al- 
ilniuirli  Iroulilesome  and  distressing,  the  disease  is  rarely  serious,  and  re- 
ii'Vcry  ii.Mially  takes  place  in  a  couple  of  weeks.  lii>tances  in  which  the 
tntli  hccoiiie  lodsened  or  detached  or  in  which  the  inllamimition  extends 
til  tlic  |iiiaryn\  and  Kustaehian  (ui)es  arc  rarely  seen  now. 

Till'  .idniini.-tration  of  mer<'iiry  >liould  lie  suspended  so  soon  as  the 
,:.'iniis  are  "touched. "  .Mild  cases  of  thi'  all'e(;tion  subside  within  a  fi-w 
'lays  ami  refniirc  only  a  simple  mouth-wash.  In  severi'r  cases  tlu'  chlorate 
"f  |Mitasli  may  be  given  internally  and  used  to  rinse  the  mouth.  The 
li"«tls  .-lidiild  lie  freely  openi'd ;  the  patient  should  take  a  hot  hath  every 
'Wiiiiii:  and  should  drink  plentifully  of  alkaline  mineral  waters.  Atropine 
i-sipiiu'tinies  serviceable,  ami  nuiy  be  given  in  doses  of  one  one  hundredth 
"f  iigniiii  twice  a  day.  Iodine  is  also  recommended.  When  the  salivation 
i*  severe  and  protracted  the  patient  beeonu's  much  debilitated,  amemiade- 
^'■I't^iiiid  a  supporting  trcitiiunt  is  indieatid.  The  diet  is  iieccssarilv 
'"iiii'U'"!'  the  patient  finds  th  •  chiel  lilliculty  in  taking  food.  If  the  paiii 
i-M'Vciva  Dover  powder  may  I  ■   viveii  at  night. 

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23  WEST  MAIN  STREET 

WEBSTER,  N.Y.  14580 

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350 


DISEASES  OF  THE   DIGESTIVE  SYSTEM. 


tiouliirly  tho  morcurial  form,  upon  tlie  fk'volniiiunf  troth  of  fliildrcii.  Tlii^ 
coiu]iti(jn  known  as  erosion^  in  which  tho  ti'oth  iiro  hnnoycoinboil  or 
])itto(l  owing  to  dofuctive  formation  of  enainol,  is  indioativo  as  m  riilcof 
iiifaiit'lo  sloniatitiH.  Siicli  tooth  must  bo  distinjj;uisluMl  carorunv  from 
those  of  oougonilal  syphilis,  wliicli  may  of  eoiirso  cooxi-st,  Ijiit  tin?  two 
conditions  are  distinct.  Tho  honeycombing  is  frorpiontly  soon  on  the 
iiicisors;  but,  according  to  Jonatlnin  Hutchinson,  the  tost  tooth  (if  iiifm,. 
tilo  stomatitis  are  tho  first  pornuinont  molars,  tlion  tho  incisors,  "  which  arc 
almost  as  constantly  jiittod,  eroded,  and  of  bad  color,  often  sliowiii^'  tin 
transverse  furrow  which  crosses  all  the  teeth  at  the  same  lovt'l."  Mai^iti.: 
regards  these  transverse  fiii-rows  as  the  result  of  infantile  convulsions  or 
of  severe  illness  during  early  Ufo.  Ho  thinks  they  are  anah)gous  to  tli" 
furrows  on  tlio  nails  which  so  often  follow  a  serious  disease. 

(T)  Eczema  of  the  Tongue  {(Imijniphirdl  T(i>/(juc).—\  romarkalilr 
de.s(puuiuition  of  tho  supca-licial  epithelium  of  tho  tongue  in  circiiiatc 
patches,  which  spread  wliilo  tho  central  portions  heal,  l-'usion  uf  ]iat(li(> 
h'ads  to  areas  with  sinuous  outlines.  When  extensive  the  tongue  maybe 
covered  with  those  areas,  like  a  goograjihieal  map.  The  afTection  eaiisisa 
good  deal  of  itcliing  and  heat,  and  nui}  be  a  source  of  much  mental  wnrrv 
to  the  patients,  who  often  dread  lest  it  may  be  a  commencing  cancer. 

'J'he  etiology  of  tho  disease  is  unknown.  It  occurs  in  infants  iiiiii 
children,  ajul  it  is  not  very  infrofpient  in  adults.  It  has  been  regiu'iKd  ;i> 
a  gouty  nuinifestation,  and  transient  attacks  may  accompany  indigestinn. 
It  is  very  liable  to  rela})so.  In  adults  it  may  prove  very  obstinate,  and  1 
know  of  Olio  instance  in  which  the  disease  persisted  in  spite  of  all  tiva;- 
r-ont  for  more  than  two  years.  Scjlutions  of  nitrate  of  silver  give  tlii' 
most  satisfactory  results  in  I'olieving  the  iiit(>nse  burning. 

(8)  Leukoplakia  buccalis. — Samuel  Plumbe  described  the  eondiiinii 
as  iff/i//osis  li/if/iKthr.  It  has  also  been  called  hucnd  psoriasis  and  kmilimf 
iiiii'-dsd'  (iris.  There  are  unsymmetrical  patches  of  various  shajies.  uliiii,-l; 
or  often  pearly  white  in  color,  smooth,  and  without  any  teiideiiev  t" 
ul.'orato.  They  have  been  called  lingual  corns.  The  intensity  of  t!i' 
ojiaqiio  white  color  depends  upon  the  thickness  of  the  epidermis.  Tii' 
I)atches  may  extend  and  become  slightly  papillomatous,  'i'la  ic  are  in- 
stances in  which  genuine  epithelioma  has  devt'loiiod  from  tiuiii.  '1!.' 
<'ondition  is  met  with  most  commonly  in  heavy  smokers,  and  is  soiaeli'in- 
known  as  tho  smoker's  tongue.  An  interesting  ([uostion  is  the  relation!" 
.<ypliilis.  While  .somewhat  similar  patches  develop  in  '.afocted  porsoii". 
the  true  syphilitic  glossitis  rarely  iiresonts  tho  same  oi)a(pio  white,  smonni 
appearance.  It  is  more  commonly  at  tho  edge  and  tho  point  of  the  Unvp' 
than  on  tho  dorsum,  and  yields  promptly  to  specific  treatment. 

Leukoplakia  is  a  very  obstinate  alleclion  and  resists  as  a  ml'  all  fmiii- 
of  treatment.  All  irritants,  such  as  smoke  and  very  hot  food,  slioiiU  k 
avoide<l.  Local  treatment  with  ono-half-j)or-cent  corrosive  siibliinateora 
one-per-cent  chromic-acid  solution  has  boon  recommended.    'I'lie  jn'oprKt} 


DISEASES  OF  THE   PHARYNX. 


35Y 


of  active  local  treatment  is  doubtful.  Tlio  appearance  of  anytliing  like 
piipilloiiiutoiisj  outgrowths  should  be  regarded  as  an  indication  for  surgical 
intervention. 


II.  DISEASES  OF  THE   SALIVARY   GLA:XDS. 


1.  Hypersecretion  {P/j/alism). — The  normal  amount  of  saliva  varies 
from  two  to  tiircc  ])ints  in  the  twenty-four  hours.  Tlie  secretion  is  in- 
crciist'd  (hiring  the  taking  of  food  and  in  the  pliysiological  ])rocesses  of 
ih'iititioii.  A  great  increase,  to  which  the  h'vm  j)/ij(tlisin  is  applied,  is  met 
with  iiinlcr  many  circumstances.  It  occurs  occasifmally  in  mental  and 
iKM-vdiis  alVections  and  in  rabies.  Occasionally  it  is  seen  in  the  acute 
fcvi'rs,  [larticulurly  in  small-pox.  It  has  been  met  with  during  gestation, 
usually  early,  tluiugh  it  may  persist  throughout  the  entire  course.  It  has 
liirii  kiHiwn  to  ot'cur  at  each  menstrual  ])eriod  ;  and,  lastly,  it  is  a  com- 
UKiii  I'lVicl  of  certain  drugs.  i\rereury,  gold,  copper,  the  iodine  com- 
|i(»uiuls,  and  (among  vegetable  remedies)  jaborandi,  muscarin,  and  t()])ac(!o 
excite  the  salivary  secretion.  Of  these  we  Tuost  frequently  see  the  ellVct 
of  mercury  in  producing  ])tyulism.  The  salivation  may  be  present  with- 
out any  inllamnuition  of  the  mouth. 

■I.  Xerostomia  {Arrcsl  of  the  Salirarj/  and  Biicral  Srrrrtions  ;  Dry 
Mnolli). — In  this  coiulition,  first  described  l)y  Jonathan  Hutchinson,  the 
socivtidiis  of  the  mouth  and  salivary  glands  are  su])pressed.  The  tongue 
is  red.  sniiictimes  cracked,  and  (pntedry;  the  mucous  membrane  of  the 
clioeks  and  of  the  ]ialate  i-^  smooth,  shining,  and  dry;  and  nuistication, 
ilcLdutitioii,  and  articulation  are  very  ditlicult.  The  condition  is  not  com- 
mon. A  majority  of  the  cases  are  in  women,  and  in  several  instances  have 
Wn  associated  with  nervous  jdienomena.  The  general  health,  as  a  rule, 
is  uiiiinpairod.  Iladden  suggests  tha^.  it  is  due  to  involvement  of  some 
(•('iitrv'  which  controls  the  secretion  of  the  salivary  and  buccal  gliiiuls.  A 
Mt'll-inarked  case  came  under  my  observation  in  a  man  aged  thirty-two, 
who  was  sent  to  me  by  Donald  Baynes  on  account  of  a  peculiar  growth 
along  ti.!'  gums.  This  proved  to  be  the  remnants  of  food  which,  owing  to 
tlie  al)scnc('  of  any  salivary  or  buccal  secretions,  collected  along  the  gums, 
hfoanio  hardened,  and  adhered  to  them.  The  condition  lasted  for  three 
weeks,  and  was  cured  by  the  galvanic  current.* 

'!■  Inflammation  of  the  Salivary  Glands. 

(ff)  Specijir  Parotiiis.     (See  Mumps.) 

(h)  Si/inp/omatic  parofiiis  ov parotid  buho  occurs: 

(1)  In  the  course  of  the  infectious  fevers— typhus,  typhoid,  pneumo- 
'iiii<  pyaemia,  etc.  In  ordinary  practice  it  occurs  oftenest,  perhaps,  in  typhoid 
h'vcr.    It  is  the  result  either  of  septic  infection  througli  the  blood,  or  the  in- 


^'-•. 


P    i\ 


f  '■,. 


*  Canada  Medical  and  Surgical  Journal,  vol.  v,  p.  439,  1877. 


358 


DISEASES  OF  THE   DIGESTIVE  SYSTEM. 


'I 


fliimmation,  in  many  cases,  passes  np  the  salivary  duet,  and  so  reailios  tlie 
gland.  The  process  is  usually  very  intense  and  leads  i'ai)idly  to  suppura- 
tion. It  is,  as  a  rule,  an  unfavorable  indication  in  the  course  of  ;i  fever. 
I  have  seen  recently  parotitis  in  secondary  sypliilis. 

(2)  In  connection  with  injury  or  disease  of  the  abdomen  or  ])('lvis. a 
condition  to  which  Stephen  Paget  has  called  special  attention.  Of  iiii 
cases  of  this  kind,  "  10  followed  injury  or  disease  of  the  urinary  traet, 
18  wer^  due  to  injury  or  disease  of  the  alimentary  canal,  and  '2-i  wen;  due 
to  injury  or  disease  of  the  abdominal  wall,  the  peritoiiiinim,  or  the  pehie 
cellular  tissue.  The  reniaining  aO  were  due  to  injury,  disease,  or  tciiipu- 
rary  derangement  of  the  genital  orgar.s."  By  temporary  derangenieiit  is 
meant  slight  injuries  or  natural  processes — a  slight  blow  on  the  testis,  the 
introduction  of  a  ])essary,  menstruation,  or  pregnancy.  The  etiology  of  this 
form  of  parotitis  is  obscure.     Many  of  the  cases  are  undoubtedly  septic, 

(3)  In  association  with  facial  paralysis,  as  in  a  case  of  fatal  peri[ilieral 
neuritis  described  by  Gowers. 

In  the  treatment  of  parotid  bubo  the  application  of  half  a  dozen 
leeches  will  sometimes  reduce  the  inflammation  and  promote  rosolution. 
When  suppuration  seems  inevitable  hot  fomentations  should  be  applied. 
A  free  iiu::ision  should  be  made  erirli/. 

(c)  Chronie  parotitis,  a  condition  in  which  the  glands  arc  enlarged, 
sometimes  painful,  has  been  described,  following  in  one  case  inflaiiiniation 
of  the  throat,  in  another  mum2)S.  Salivation  may  be  present.  It  may 
be  due  to  lead  or  mercury.  It  is  met  with  occasionally  in  chronic  Uriglit's 
disease.  I  have  under  my  care  at  present  a  young  girl,  aged  thirteen,  with 
hereditary  sypliilis,  who  has  had  for  nearly  a  year  enlargement  of  all  the 
salivary  glands,  the  lachrymal  glands,  the  buccal  mucous  glands,  and  the 
spleen. 


III.  DISEASES  OF  THE  PHARYNX. 

(1)  Circulatory  Disturbances.— ('0  Ifi/percemia  is  a  common  condition 
in  acute  and  chronic  alfoctions  of  the  throat,  and  is  frequently  seen  as  a 
result  of  the  irritation  of  tobacco  sjnoke.  Vcjious  stasis  is  seen  in  valvular 
disease  of  the  heart,  and  in  mechanical  obstruction  of  the  sni)erior  vena 
cava  by  tumor  or  aneurisnj.  In  aortic  insufficiency  the  cajnllary  pi'lsf 
may  sometimes  be  scon  and  the  intense  throbbing  of  the  internal  ccrotid 
may  bo  mistaken  for  aneurism. 

{h)  Ilu'inorrhai/e  is  found  in  association  with  bleeding  from  other 
mucous  surfaces,  or  it  is  due  to  local  causes  in  tho  pharynx  itself,  lu 
the  latter  case  it  may  be  mistaken  for  Innemorrhage  from  the  lungs  or 
stomach.  The  bleeding  nuiy  como  from  granulations  or  vegetations  m 
the  naso-phary)ix.  Sometimes  the  patient  finds  the  pillow  stained  in  the 
morning  with  bloody  secretion.     The  condition  is  ^arely  serious,  and  ouly 


DISEASES  OP  THE  PHARYNX. 


359 


roquiros  suitable  local  treatment  of  the  ])liarynx.  Oecasionally  a  ha^mor- 
rhii'^o  takf>  jilaco  into  the  mucosa,  producing  a  pharyngeal  hi«matoma.  I 
have  tlii'iit'  seen  a  cotidition  of  the  uvula  resenil)ling  haemorrhagic  infarc- 
tion. One  was  in  a  patient  with  acute  rheumatism,  to  whom  large  doses 
(if  Hiilicylii'  acid  had  been  given;  the  other  two  were  instances  of  peliosis 
rluiuimticii,  in  botli  of  which  ])artial  sloughing  of  the  uvula  took  place. 

(,')  (Ijh'ina. — An  infiltrated  a>dematous  condition  of  the  uvula  and 
adjacoiit  parts  is  not  very  uncommon  in  conditions  of  debility,  in  pro- 
fmind  aiiii'iiiia,  and  in  Bright's  disease.  The  uvula  is  sometimes  from  this 
(■aiisu  ciioniiously  en.argcd,  and  may  lead  to  diflficulty  in  swallowing  or  in 
bmitliing. 

[i)  Acute  Pharyngitis  {Sure  Throat;  An(jina  SinijAc.c). — The  entire 
liliiirviigcal  structures,  often  v '  '  the  tonsils,  are  involved.  The  condi- 
tiiiii  may  follow  cold  or  exposure.  In  other  instances  it  is  associated  with 
ciiiistitutioiial  states,  such  as  rheumatism  or  gout,  or  with  digestive  dis- 
(inlcrs.  Tlie  ])atient  complains  of  uneasiness  and  soreness  in  swallowing, 
(if  a  tVcHug  of  tickling  and  dryness  in  the  throat,  together  with  a  con- 
stant desire  to  hawk  and  cough.  Frequently  the  inflammation  extends 
into  the  larynx  and  produces  hoarseness.  Xot  uncommonly  it  is  only 
part  of  a  general  miso-])haryngeal  catarrh.  The  process  may  pass  into 
tlie  Eustachian  tubes  and  cause  slight  deafness.  There  is  stiffness  c  f 
the  neck,  the  lymph  glands  of  Avhicli  may  be  enlarged  and  painful.  Th> 
coiistittitioiKd  symptoms  ai'c  rarely  severe.  The  disease  sets  in  Avith  a 
cliiHy  foeling  and  slight  fever,  and  the  pulse  is  increased  in  frequency. 
Occasionally  tlie  febrile  symptoms  are  more  severe,  particularly  if  the 
tonsils  are  specially  involved.  The  examination  of  the  throat  shows  gcn- 
i^ral  congestion  of  the  mucous  membrane,  which  is  diy  and  glistening, 
and  in  plaee.5  covered  Avith  sticky  secretion.  The  uvula  may  be  much 
swollen. 

Acute  pliaryngitis  lasts  only  a  few  days  and  requires  mild  measures. 
If  the  tonsils  are  involved  and  the  fever  is  high,  aconite  or  sodium  salicylate 
may  be  given.  Ciuaiacum  also  is  beneficial;  but  in  a  nuijority  of  the 
eases  a  calomel  ])urge  or  a  saline  aperient  and  inhalations  with  steam 
meet  tlii^  indications. 

(3)  Chronic  Pharyngitis.— This  may  follow  repeated  acut':!  attacks.  It 
is  very  coininon  in  persons  who  smoke  or  drink  to  excess,  and  in  those 
who  use  the  voice  very  much,  such  as  clergymen,  hucksters,  and  others. 
It  is  fnH(uently  met  Avith  in  chronic  nasal  catarrh.  The  miso-iiharynx 
ami  the  posterior  Avail  are  the  parts  most  frequently  afTected.  The 
■inicous  nicnibrane  is  relaxed,  the  venules  are  dilated,  and  roundish 
liodios,  from  two  to  four  millimetres  in  diameter,  reddish  in  color,  pro- 
joc't  to  a  variable  distance  beyond  the  mucous  membrane.  These  repre- 
sent the  jtroliferations  of  lymph  tissue  about  the  mucous  glands.  They 
may  be  very  abundant,  forming  elongated  roAVS  in  the  lateral  Avails 
^f  the  pharynx.     With  this  there  may  be  a  dry  glistening  state  of  th» 


T^^^n^^F 


n 


360 


DISEASES  OP  TJIE   DIGESTIVE  SYSTEM. 


t!';* 


pharyngcnil  imico<!i,  poniotirnes  known  as  phtrumjilis  .sicca.  The  pillar 
of  tli(3  fiiiK'cs,  and  tlio  uvula  are  often  niucli  relaxed.  The  si'crctiiiii 
forms  at  the  back  of  the  pharynx  and  the  jiatient  may  feel  it  dropdnMii 
from  the  vault,  or  it  i.s  teiuieioiis  and  adliercnt,  and  is  only  removed  by  re- 
peated efforts  at  hawkini;. 

In  tlui  /rei/fiiif'/i/,  special  attention  must  be  paid  to  the  general  licultli, 
If  jiossible,  tiie  cause  should  he  ascertained.  The  condition  is  ahiios! 
constant  in  smokers,  and  cannot  bo  cured  without  stop])ing  the  nso  of 
bjbaeco.  The  use  of  food  either  too  hot  or  too  much  spiced  should  he  fur- 
hidden.  AVlieii  it  depends  upon  excessive  exercise  of  the  voice,  i\-t should 
be  enjoiiu'd.  In  many  of  these  cases  change  of  air  and  tonics  help  vcrv 
miu'h.  In  the  local  treatiiuMit  of  the  throat  gargles,  washes,  and  pastilk- 
of  various  sorts  give  tem[)orary  relitd',  but  when  the  hypertrophie  condi- 
tion is  marked  the  spots  should  he  thoroughly  destroyed  by  the  galviiim- 
eautery.  In  many  instances  this  atfords  great  and  permanent  relief,  Imt 
in  others  the  condition  ])ersists,  and  as  it  is  not  uid)earable,  the  patitiu 
gives  up  all  hope  of  ])ermaiu'nt  relief. 

(4)  Ulceration  of  the  Pharynx.— (r/)  Follicular.  The  ulcers  arc  usu- 
ally small,  su])erlicial,  and  generally  associated  with  chronic  catarrh. 

(Z()  Syphilitic  ulcers  are  usually  painless,  and  most  fre([uently  situated 
on  the  ])osterior  wall  of  the  pharynx.  They  occur  in  the  secondary  sfairc 
as  small,  shallow  excavations  M'ith  the  mucous  patches.  In  the  tertiary 
stage  the  ulcers  are  due  to  erosion  of  gunumita,  and  in  healing  they  leavi; 
whitish  cicatrices. 

(r)  'I'nberculous  ulceration  is  not  very  uncommon  in  advanced  case? 
of  phthisis,  and,  if  extensive,  is  one  of  the  most  distressing  features  of  the 
later  stages  of  the  disease.  The  ulcers  are  irregular,  with  ill-deliuod  cd^'e? 
and  grayisli-yelloAV  bases.  The  posterior  wall  of  the  phaiynx  may  haveim 
eroded,  worm-eaten  appearance.  These  ulcers  are,  as  a  rule,  intensely 
painful. 

{(I)  Ulcers  occur  in  connection  with  psoudo-mendiranous  inflamma- 
tion, i^rticularly  the  diphtheritic.  In  cancer  and  in  lupus  ulcers  are  also 
presen^. 

((')  Ulcers  are  met  with  in  certain  of  the  fevers,  particularly  in  typlioid. 

In  many  instaiu'cs  the  diagnosis  of  the  natui'e  of  pharyngeal  ulcers  is 
very  dithcult.  The  tuberculous  and  cancerous  varieties  are  readily  recug- 
nized,  but  it  happens  m)t  infrequently  that  a  doubt  arises  as  to  the 
syphilitic  character  of  an  ulcer.  In  mnny  instances  the  local  condi- 
tions may  he  uncertain.  Then  othc*  evidences  of  syphilis  slioulil  '"' 
sought  for,  and  the  patient  should  be  placed  on  mercury  and  iiulideot 
potassium,  under  which  remedies  syphilitic  ulcers  usually  heal  with  great 
rapidity. 

(5)  Acute  Infectious  Phlegmon  of  the  Pharynx. — Under  this  term 
Senator  has  described  cases  in  Avhich,  along  with  difficulty  in  swallowing. 
soreness  of  the  throat,  and  sometimes  hoarseness,  the  neck  enlarges,  the 


I'      ,<    • 


h 


ACUTK  TONSIIiLITIS, 


301 


plinrvnKC'iil  mucosa  becomes  swollen  uiul  iiijectx'd,  the  fever  is  higli,  tlio 
niiistiliitiniial  syin])toms  are  severe,  iuul  the  iiitlumniiitiou  passes  on  rap- 
idly to  su[)|)iiratiou.  The  symptoiiis  are  very  intense.  Tlie  swelling  of  the 
nliiii'viigoal  tissues  early  reaches  such  a  grade  as  to  impede  respiration.  Veiy 
similar  symptoms  may  be  {)roduced  by  foreign  bodies  in  the  pharynx. 

(il)  Retro-pharyngeal  abscess  occurs  :  (1)  In  healthy  cliildren  between 
six  months  and  two  years.  The  child  becomes  restless,  the  voice  changes 
ami  is  nasal  or  metallic  in  tone,  and  there  are  pain  and  difficulty  in 
swallouiiig.  Inspection  of  the  jjharynx  reveals  a  projecting  tumor  in  the 
iiiidiilo  line,  or  it  may  not  be  visible,  but  is  readily  felt  on  })alpation  pro- 
jtctiiig  from  the  posterior  wall.  This  form  has  been  carefully  described  by 
Koplik.  (;.')  As  a  not  infrcrpient  sequel  of  the  fevers,  })articularly  of  scarlet 
ft'Vt'r  and  diplitiieria.    {'.})  In  caries  of  the  bodies  of  the  cervical  vertebra?. 

The  diagnosis  is  readily  made,  as  the  projecting  tumor  can  be  seen,  and 
full  ttitli  the  linger  on  the  posterior  wall  of  the  pliarynx. 

(T)  Angina  Ludovici  {LndwUfH  AiKjina ;  CeUnUtis  of  the  .Vt'c^-).— In 
medical  ]»ractice  this  is  seen  as  a  secondary  inflammation  in  the  specific 
fevers,  particularly  diphtlieria  and  scarlet  fever.  It  may,  however,  occur 
idiopatliieallv  or  result  from  trauma.  It  is  probably  always  a  stre])tococcus 
infection  win  'i  spreads  rajiidly  from  tlie  glands.  The  swelling  at  first  is 
must  marked  i,  the  subnuixillary  region  of  one  side.  The  symptoms  are, 
as  a  rule,  intense,  and,  unless  early  and  thorough  surgical  measures  are  em- 
ployed, there  is  great  risk  of  systemic  infection.  Felix  Semon  holds  that 
the  various  acute  septic  inflammations  of  the  throat — acute  anlema  of 
the  larynx,  i)hlegmon  of  the  pharynx  and  larynx,  and  angina  Ludovici — 
■•  represent  degrees  varying  in  virulence  of  one  and  the  same  process." 


lY.     DISEASES   OF  THE  TOXSILS. 
ACUTE  TONSILLITIS. 

(1)  Follicular  or  Lacunar  Tonsillitis. — For  practical  purposes,  under 
tliis  name  may  be  described  the  various  forms  which  have  been  called  ca- 
tiinlial,  erythematous,  ulcero-membranous,  and  herpetic. 

Etiology. — The  disease  is  met  with  most  fi'cquently  in  young  per- 
sons, but  in  children  under  ten  it  is  less  connnon  than  the  chronic  form. 
It  is  rare  in  infants.  Sex  has  no  special  influence.  Exposure  to  wet  and 
eold,  and  bad  hygienic  surroundings  appear  to  have  a  direct  etiological 
eonuection  with  the  disease.  In  so  many  instances  defective  drainage  has 
heen  fouml  associated  with  outbreaks  of  follicular  tonsillitis  that  sewer-gas 
ij  regarded  as  a  common  exciting  cause.  One  attack  renders  a  patient 
liiore  liable  to  subsequent  infection.  Special  stress  is  laid  by  some  writers 
I'l'i'ii  llie  coexistence  of  tonsillitis  with  rheumatism.  Cheadle  describes  it 
''■*  one  of  the  phases  of  rheumatism  in  childhood  with  which  articular  at- 
tiieks  may  alternate.  I  cannot  say  that,  in  my  experience,  the  connection 
24 


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302 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


between  the  two  alTc'ctions  has  Vjoen  very  striking,  except  in  one  point,  viz, 
that  an  atta(3k  of  acute  rlicumatism  is  not  infrequently  precedod  hv  jn- 
flanirnation  of  the  tonsils.  The  existence  of  jtains  in  the  lijuhs  is  no  cvi- 
dencc  of  the  connection  of  the  ;i.'fection  with  rheumatism.  A  discast'  so 
common  and  wide-spread  as  acute  tonsillitis  necessarily  attacks  nianv  [m- 
sons  in  whose  families  rheumatism  prevails  or  who  may  themselves  have 
had  acute  attacks. 

Mackenzie  jxives  a  table  showing  that  m  four  successive  years  mnre 
cases  occurred  in  September  than  in  any  other  month ;  in  October  nnirlv 
as  many,  with  July,  August,  and  Xovember  next.  In  this  country  it  soi'ins 
more  prevalent  in  the  spring.  So  many  cases  develop  Avithin  a  short  time 
that  the  disease  may  be  almost  epidemic.  It  spreads  through  a  family  in 
such  a  way  tiiat  it  must  be  regarded  as  contagious. 

An  old  notion  prevails  that  there  is  a  definito  relation  between  the 
tonsils  and  the  testes  and  ovaries.  F.  J.  Shepherd  has  called  attention  to 
the  circumstance  that  acute  tonsillitis  is  a  very  common  affection  in  newly 
married  persons.  That  view  is  prol)ab1y  correct  which  regards  tonsilliti« 
as  a  local  disease  with  severe  constitutional  manifestations,  althougli  tlic 
fever  is  often  high  in  proportion  to  the  local  symptoms.  The  eoiunume?t 
organism  found  in  tonsillitis  is  a  streptococcus.  Staphylococci  also  ocriir. 
In  some  cases  the  haciUuH  lUplttltprhp,  of  Loeffler  have  been  found.  Imt 
they  do  not  always  possess  the  full  virulence  (see  Atypical  Forms  of  l>ijili- 
theria). 

Morbid  Anatomy. — The  lacunre  of  the  tonsils  become  filled  with 
exudation  products,  which  form  cheesy-looking  masses,  projecting  from 
the  orifices  of  the  crypts.  \ot  infrerpicjitly  the  exudations  of  conti!j;uoiis 
lacuna?  coalesce.  The  intervening  mucosa  is  usually  swollen,  deep-ml  in 
color,  and  may  present  heri)etic  vesicles  or,  ii\  some  instances,  even  mem- 
branous exudation,  in  which  ca.se  it  may  be  difiicult  to  distinguish  the 
condition  from  diphtheria..  The  creamy  contents  of  the  crypt  are  luude 
up  of  microcorci  and  e{)ithelial  (Jvhrh. 

Symptoms.— Chilly  feelings,  or  even  a  definite  chill,  and  aoliing 
pains  in  the  back  and  limbs  may  precede  the  onset.  The  fever  rises  iiiii- 
idly,  and  in  the  case  of  a  young  child  may  reach  105°  on  the  evenin.?  ff 
the  first  day.  I'he  patient  complaitis  of  sorenesr.  of  the  throat  <ind  diffi- 
culty in  swallowing.  On  examination,  the  toTisils  are  seen  to  he  swollen 
and  the  crypts  pn^sent  the  charact?ristic  creamy  exudate.  The  tongtic  i-' 
furred,  the  breath  is  heavy  and  foul,  and  the  urine  is  highly  colored  mi'l 
loaded  with  urates.  In  children  the  respirations  are  usually  very  hiirric'l. 
and  the  pulse  is  greatly  incn  ased  in  rapidity.  SwalloAving  is  j)aiiif"l,  lui'l 
the  voice  often  becomes  nasal.  Sli'jfiit  swelling  of  the  cervical  ghnul.*  is 
present.  In  severe  cases  the  symptoms  increase  and  the  tonsils  become 
still  more  swollen.  The  inflammation  gradually  subsides,  and,  as  a  nile, 
within  a  week  the  fever  departs  and  the  local  symptoms  greatly  improve 
The  tonsils,  however,  remain  somewhat  swollen.     The  prostratiuu  and 


,1  i-'i'A;^h' 


ACUTE  TONSILLITIS. 


363 


constitutional  disturbance  are  often  out  of  proportion  to  the  intensity  of 
tho  local  disease. 

Then' are  complications  which  occasionally  excite  uneasiness.  Febrile 
iilbiiiniiuu'ia  is  not  uncommon,  as  llaig-lirown  has  pointed  out.  Cases  of 
I'lidocanlitis  or  pericarditis  have  been  found.  It  is  to  be  borne  in  mind 
that  in  ehildren  an  apex  systolic  murmur  i  by  no  means  uncommon  at 
the  height  of  any  fevj^r.  The  disease  may  extend  to  the  middle  ear. 
The  development  of  paralytic  symptoms,  local  or  general,  after  an  attack 
which  has  been  regarded  as  foliicidar  tonsillitis  indicates  an  error  in  diag- 
nosis.   A  diffuse  erythema  may  develop,  simulating  scarlet  fever. 

Diagnosis. — It  may  bo  difficult  to  distinguish  follicular  tonsillitis 
from  dii)htheri;!.  It  would  seem,  indeed,  as  if  there  were  intermediate 
tVirnis  between  the  mildest  lacunar  and  the  severer  pseudo-mend)ranous 
tonsilliti.-.  In  the  follicular  form  the  iiulividual  yellowish-gray  masses, 
<e[iiii'atod  liy  the  reddish  tonsillar  tissue,  are  very  characteristic ;  whereas 
in  di[ihtli('ria  the  membrane  is  of  ashy  gray,  and  uniform,  not  patchy.  A 
1-oint  (if  the  greatest  importance  in  diphtheria  is  that  the  membrane  is  not 
liinite  1  to  the  tonsils,  but  creeps  up  the  pillars  of  the  fauces  or  appears  on 
dif  uvula.  The  di])htheritic  membrane  when  removed  leaves  a  bleeding, 
1  rodcd  surface ;  whereas  the  exudation  of  lacunar  tonsillitis  is  easily  sepa- 
iiitcd.  and  there  is  no  erosion  beneath  it.  In  all  doubtful  cases  cultures 
>liiMild,  if  ii()ssil)le,  be  nuide  to  determine  the  presence  of  Loeffler's  bacillus. 

{•I)  Suppurative  Tonsillitis. 

Etiology. — This  arises  under  conditions  very  similar  to  those  men- 
tioned in  the  lacunar  form.  It  nuiy  follow  exposure  to  cold  or  wet,  and  is 
p;u'ticularly  liable  to  recur.  It  is  most  common  in  adolescence.  The  in- 
llamniation  is  here  more  deeply  seated.  It  involves  the  stroma,  and  tends 
tngo  on  to  suppuration. 

Symptoms. — The  constitutional  disturliance  is  very  great.  The 
temperature  rises  to  104°  or  10."")°,  and  the  pulse  ranges  from  110  to  130. 
Xoetunial  dcdirium  is  not  uncommon.  The  prostration  may  be  extreme. 
TluM'c  i>  110  local  disease  of  similar  extent  which  so  rajiidly  exhausts  the 
Nivngth  (if  a  patient.  Soreness  and  dryness  of  the  throat,  with  pajn  in 
■^wallowing,  are  the  symptoms  of  which  the  patient  first  complains.  One 
nr  both  tonsils  may  be  involved.  They  are  enlarged,  firm  to  the  touch, 
'lusky  rod  and  cedomatous,  and  the  contiguous  parts  are  also  much  swol- 
liii.  Tlu>  swelling  of  the  glands  may  be  so  great  that  they  meet  in  the 
iiiiddlc  lino,  or  one  tonsil  may  even  push  the  uvula  aside  and  almost  touch 
the  other  gland.  The  salivary  and  buccal  secretions  are  increased.  The 
,:'!andj;  of  the  neck  enlarge,  the  lower  jaw  is  fixed,  and  the  patient  is  un- 
uhle  to  ojien  his  mouth.  In  from  two  to  four  days  the  enlarged  gland 
I'lerome.*  softer,  and  fluctuation  can  be  distinctly  felt  by  placing  one  finger 
f'li  the  tonsil  and  the  other  al  the  angle  of  the  Jaw.  The  abscess  usually 
points  toward  the  mouth,  but  it  may  point  toward  the  pharynx.  It  may 
burst  spontaneously,  affording  instant  and  great  relief.      Suffocation  haa 


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364 


PISRASES  OF  THE  PldKSTIVR  SYSTEM. 


followed  tliP  ru})tiirc  of  a  liirffo  abscess  and  the  entrance  of  the  pus  into  tlif 
larynx.  When  the  siippnration  is  ju'ritonsillar  and  extensive,  tlic  iiiliTiml 
carnt  id  ai'tcrv  may  he  (ipcncil ;  l)iit  these  are,  fortunately,  very  rare  accidents, 

Treatment.— In  the  folHcnlar  form  aconite  may  he  iriven  in  I'lili'ddvc;, 
It  acts  very  hcnelicially  in  eliiMren.  'Die  saHcylate.-;,  jriven  freely  at  tin 
outset,  are  rej,'arded  hy  some  as  specific,  Imt  I  have  si'cn  no  evidence  (if 
siudi  2)rompt  and  decisive  action.  At  nit;;ht,  a  full  dos(i  of  Dover's  pow- 
der may  ho  jjiven.  'I'iie  use  of  gnaiacnm,  in  the  form  of  two-jj^riiin  Id?. 
enj;jes,  is  ■\vannly  recommended.  Ii'on  and  (piinim^  shoidd  be  re>crvnl 
until  the  fever  has  sultsided.  A  i)ad  of  si)on<,no-piline  or  thick  llaniiil 
di[»ped  in  ice-e(dd  water  may  he  ap])licd  around  the  neck  and  eDvend 
with  oiled  silk.  !>rore  convenient  still  is  a  small  ice-hag.  T.ocallv  the 
tonsils  may  he  treated  with  the  dry  sodium  hicarhonale.  The  iiioi.^teniil 
linger-tii)  is  dipped  into  the  soda,  whi(di  is  then  ruhhed  gently  on  tlii' 
gland  and  repeated  every  hour.  Astringent  preparations,  suidi  as  inm 
and  glyceriiu",  alum,  zinc,  and  nitrate  of  silv(!r,  may  he  tried.  To  clcan^i' 
and  disinfect  the  throat,  solutions  of  borax  or  thymol  in  glycerine  ami 
water  nuiy  ho  used.      //y.'      '      •>  •■■'■) 

In  suppurative  tonsillitis  hot  applications  in  the  form  of  poultices  anil 
fomentations  are  more  comfortable  and  better  thau  tlio  ice-ha;:.  Thf 
gland  should  be  f(dt — it  cannot  always  he  seen — from  time  to  time,  and 
should  he  opened  when  lliictiuitioii  is  distinct,  '^i'he  progress  of  the  div 
ease  nuiy  he  shortened  and  the  ])atient  spared  several  days  of  great  sutfir- 
j  the  gland  is  scarilied  early.     '!Phe  curved  bistoury,  guarded  nearly 

^  point  with  plaster  or  cotton,  is  the  most  satisfactory  iiistrununt, 

Tiiu  incision  should  l)e  made  from  above  downward,  })arallcl  with  tlio  an- 
terior pillar.  There  are  cases  in  which,  before  su2)puration  takes  place, 
the  parenchynuitous  swelling  is  so  great  that  the  patient  is  thi'oatonid 
with  sulfocation.  In  such  instances  the  tonsil  must  either  he  excised  or 
tracheotomy  or,  possildy,  intubation  performed.  Delavan  retVi's  to  two 
eases  in  which  lus  states  that  tracheotomy  would,  under  those  circum- 
stances, have  saved  life.  Patients  with  this  alfi'ction  require  a  nouriihiug 
liquid  diet,  and  during  convalescence  iron  in  full  doses. 


CHRONIC  TONSILLITIS. 

{Chronic  Naso-pharyngeal  Obstruclion  ;  JHoulh-Breathing  ;  Aproaexia.) 

Under  this  heading  will  he  considered  also  hypertrophy  of  the  adenoid 
tissue  in  the  vault  of  the  pharynx,  sometimes  known  as  the  pliaryM^rciil 
tonsil,  as  the  alfection  usually  involves  both  the  tonsils  jjrijpiT  and  this 
tissue,  and  the  symjitoms  are  not  to  be  differentiated. 

Chronic  eidargcmeut  of  the  tonsillar  tissues  is  an  affection  of  groat  nn- 
portance,  and  nuiy  influence  in  an  extraordinary  way  the  mental  and  boJilj 
development  of  children. 


CHRONIC  TONSILLITIS. 


865 


Etiology. — llyiHTtnijiliy  of  tho  toTisillur  structures  is  occasionally 
i,'(iii;,'('iii':il.  Cases  are  perjuiiis  most  I'reciueut  in  children,  iluriuf^  tho  third 
lii'iiii-tlfciiile.  The  condition  also  occun'  in  y<»un^'  adtdts,  more  rarely  in 
tlic  iiiiiidlt-ai^ed  'J'hu  ei)lar;^enieMt  may  follow  di|)iitlicria  (»r  the  eruptive 
lV\fi's.  The  l'rei{ueney  of  the  oeeiirreiice  of  adenoid  growths  in  thy  naso- 
[iliaiyiix  has  hei'U  variously  stated.  ^Meyer,  to  whom  tho  i)rofession  ia  in- 
iKlitiil  lor  (idling  attention  to  the  suhjeet,  found  them  in  ahout  one  per 
cuiit  (if  tho  children  in  ('oiienhageii,  wiule  C'hapj)ell  found  sixty  cases  in 
ihu  exiimiuation  Oi  two  tiiousand  children  in  New  York.  These  ligures 
;:iv(!  !i  very  moderate  estimate  of  tiio  pri^valenee  of  the  trouhle.  It  occurs 
(i|iiidly  ill  l)iiys  and  girls,  according  to  soiiio  writers  with  greater  preva- 
k'lK'u  ill  tiio  former. 

Morbid  Anatomy. — The  tonsils  proper  present  a  condition  of 
(•lininif  hypcrtr(jpliy,  duo  to  multiplication  of  all  the  coiistituents  of  tho 
irliimls.  The  lym]ihoid  eleinonts  nuiy  l)o  chielly  involved  without  much 
(Kv('lii|iin(iit  of  the  stroma.  Jii  other  instances  the  lihroiis  matrix  is  in- 
civiiscd,  iiiid  the  organ  is  then  harder,  smaller,  lirmer,  and  is  cut  with 
miR'li  greater  dilliculty. 

Tlie  a(lenoi<l  growths,  ■wliich  spring  from  tho  vault  of  tho  pharynx, 
fiii'iu  masses  varying  in  size  from  a  small  })oa  to  an  almond.  T hoy  may 
be  sessile,  with  hroad  bases,  or  pedunculated.  They  arc  reddish  in  color, 
of  iiKKlerate  firmness,  and  contain  numerous  l»lo(»d-vessels.  "  Abundant, 
as  a  rule,  over  the  vault,  on  a  line  with  the  fossa  of  the  Eustachian  tube, 
tlu!  growths  may  lie  posterior  to  the  fossii — namely,  in  the  dei)rossion 
kiuiwii  as  the  fossa  of  Kosenmiiller,  or  upon  the  jiarts  wliich  are  parallel 
to  the  posterior  wall  of  the  jdiarynx.  The  growths  appear  to  spring  in 
tliL'  main  from  the  mucous  memhrane  covering  tho  localities  whore  tho 
coiiiioctive  tissue  fills  in  the  inequalities  of  the  base  of  tho  skull"  (Har- 
rison Allen).  The  growths  aro  most  fre(piently  papillomatous  Avith  a 
lyiiiphdid  inirenchyma.  Hypertrophy  of  tho  pharyngeal  adenoid  tissue 
iiiiiy  he  present  without  great  enlargement  of  tho  tonsils  proper.  Chronic 
ciitarrh  of  the  nose  usually  coexists. 

Symptoms. — The  direct  effect  of  chronic  tonsillar  hypertrophy  is 
the  OBtaWisliment  of  mouth-breathing.  The  indirect  effects  are  deforma- 
tion of  tho  thorax,  clTanges  in  the  facial  expression,  sometimes  marked 
iilterati'iu  in  the  mental  condition,  and  in  certain  cases  stunting  of  the 
growth.  Woods  Hutchinson  has  suggested  that  the  embryological  rela- 
tion of  these  structures  with  the  pituitary  body  may  account  for  the  in- 
terforeiiee  with  development.  The  establishment  of  mouth-hreathing  is 
ilio  symptom  Avhich  llrst  ;i,ttracts  the  attention.  It  is  not  so  noticeable  by 
ility,  ulthinigh  the  child  may  present  the  vacant  expression  characteristic 
of  this  eoiulition.  At  night  the  child's  sleep  is  greatly  disturbed  ;  the 
ri'spirations  are  loud  and  snorting,  and  „nore  are  sometimes  prolonged 
pauses,  f(jllowed  by  deep,  noisy  inspirations.  The  pulse  may  vary  strangely 
^hiring  tliese  attacks,  and  in  the  prolonged  intervals  may  be  slow,  to  in- 


1'  mtft 


366 


DISKASKS  OF  TIIK   DKiKSTIVK  SYSTKM. 


IM'    fil 


croiisf)  prcatly  with  tlio  forced  inspirations.  Tlu'  iila-  nasi  slioiiM 
served  during,'  llii-  .slccit  of  tho  child,  as  tlicy  ari'  gonietiriu's  nuich  irtiartcil 
diirinj,'  inspiration,  dno  to  a  laxity  of  tho  walls,  a  condition  readily  rcnio- 
died  by  the  nse  of  a  soft  win-  dilator.  Nij,'lit  terrors  ari'  coninidii.  Tlie 
child  nuiy  wake  up  in  a  pafoxysni  of  shortness  of  Invulh.  Some  of  iIk-i' 
noctnrnal  attacks  nniy  bo  dne  to  rellex  sjiasin  of  the  glottis.  Dnriiij,' tin- 
day  there  nuiy  be  chokinj,'  fits  when  oaling. 

When  the  niont1i-brt'athin<.'  has  persisted  for  a  long  time  (lufinitc 
chatigcH  are  brouglit  abont  i.i  the  face,  mouth,  and  chest.  The  facits  is 
.so  peculiar  and  distinctive  that  the  condition  nuiy  l)e  evident  at  a  jrluiico. 
The  ex]iroa8ion  is  dull,  heavy,  and  apathetic,  due  in  jiart  to  the  fad  tlmt 
tho  niontli  is  habitually  k'ft  ojx'n.  In  long-standing  cases  the  cliilil  Is 
very  stupid-looking,  responds  slowly  to  (|uestions,  and  nuiy  be  sullen  ihhI 
cross.  Tho  lips  are  thick,  tlie  nasal  orifices  sjnall  and  pinche(l-in  lookini:, 
and  tlio  superior  dental  arch  is  narrowed  and  the  roof  of  tlu;  nmnlli  fun. 
eiderably  raised. 

The  remarkable  alterations  in  the  shape  of  the  chest  in  coninctidii 
with  enlarged  tonsils  were  first  carefully  studied  by  Dupuytreii  (ls-^,s), 
who  evidently  fully  appreciited  the  great  iinportaiico  of  the  condition. 
lie  noted  "a  lateral  depressi'..  .  of  the  parietes  of  the  cliest  consisting  of  u 
de])rossion,  more  or  less  great,  of  the  ribs  on  each  side,  and  a  proportidiiatc 
protrn.sion  of  tlie  Kternuin  in  front."  J.  Masctn  Warren  (Medical  Kxaiii- 
incr,  lS3i))  gave  an  admirable  description  of  the  constitutional  .syni|itoiii^ 
and  the  thoracic  deformities  induced  by  enlarged  tonsils.  Tlicsc,  witli 
the  memoir  of  Lambron  (1801),  constitute  the  most  importajit  contribu- 
tions to  our  knowledge  on  the  subject.  Three  types  of  deformity  may  Ic 
recognized  : 

(a)  The  Pigeon  or  Chicken  Breast,  by  far  the  most  common  ffirm,  in 
which  the  sternum  is  prominent  and  there  is  a  circular  depression  in  tlu 
lateral  zone  (Harrison's  groove),  corresponding  to  the  attachment  of  the 
diaphragm.  The  ribs  are  jinaninont  anteriorly  and  the  sternum  i;  anL'ii- 
lated  forward  at  the  manubrio  gladiolar  junction.  As  a  mouth-l)r(athor 
is  watched  during  sleep,  one  can  see  the  lower  and  lateral  thoracic  regions 
retracted  during  inspiration  by  the  action  of  the  diaphragm. 

{/))  Barrel  Chest. — Some  diildren,  the  subject  of  chronic  naso  pliarvn- 
geal  obstruction,  have  recurring  attacks  of  asthma,  and  the  chest  may  be 
gradually  deformed,  becoming  rounded  and  barrel-shaped,  the  neck  short, 
and  the  shoulders  and  back  bowed.  A  child  of  ton  or  eleven  may  luive 
the  thoracic  conformation  of  an  old  man  with  emphysema. 

(r)  The  Funnel  Breast  ( Trichier-bnts().—Thk  remarkable  deformity, 
in  which  there  is  a  deep  depression  at  the  lower  sternum,  has  o.xrited 
much  controversy  as  to  its  mode  of  origin.  I  believe  that  in  soiiu'  in- 
stances, at  least,  it  is  dne  to  the  obstructed  breathing  in  connection  wiili 
adenoid  vegetations.  Within  the  past  three  years  I  have  seen  two  cases  in 
children,  in  which  the  condition  was  in  process  of  development.    During 


CllUON'lC  TONSILLITIS. 


307 


in^iiinitinn  tlio  lower  Htcrnum  was  foivil)Iy  rotnictod,  so  inuoli  so  tliiit  at 
till'  luiji'it  tliu  (k'pressioii  convspoiulfd  lo  ii  wcll-inurkuci  "  frit/i/rr-Orusl." 
While  ill  repose  tho  lower  steriml  region  was  distiiietly  exeiivuted. 

The  voice  is  altered  and  ae(|;iires  u  nasal  (|iialilv.  The  i)roniin('iation 
of  I'crtiiin  Iette"s  is  ehaiij^ed,  and  tiiere  is  inability  to  ]tronouii('e  the  nasal 
loiisotiiuits  n  and  in.  Hhich,  in  his  inondgraph,*  lays  great  stress  npon 
the  assdciation  of  niouth-hreatiiing  with  stnttering. 

The  hearing  is  impaired,  nsually  owing  to  the  extension  oi  intlainina- 
tioii  along  the  Knstaehian  tubes  and  the  obstruction  with  mucus  or  tiie 
iiiiiTowing  of  their  oridees  by  pressure  of  the  adenoid  vegetations.  In  some 
instiiiici'S  it  may  be  due  to  retraction  of  tiie  drums,  as  the  upper  pharynx 
is  insiilliciently  supplied  with  air.  Naturally  the  3en.ses  of  taste  and  smell 
aro  iiiiiih  impaired.  With  tliese  symptoms  there  may  be  little  or  no  nasal 
ciitarrii  or  discharge,  but  tlic  pharyngeal  secretion  of  mucus  is  always  in- 
oi'ca.^eil.  Children,  however,  do  not  notice  this,  as  the  mucus  is  usually 
swallowed,  l)ut  older  persons  expe(!tt)rate  it  wiih  dillicults. 

Among  other  symptoms  may  be  mentioned  hciulache,  w  inch  is  by  no 
imaiis  uncommon,  general  listlessucss,  and  an  iiulisposiiiou  for  physical 
or  iiieiital  exertion,  llahit-spasm  of  tho  face  has  been  described  iu  cou- 
nt'i'tiou  with  it.  I  have  known  several  instances  in  whicii  permanent 
relief  has  been  afforded  by  tin;  removal  of  the  adenoid  vegetations.  Enu- 
resis is  occasionally  an  associated  symptom.  The  intlnonce  upon  the  men- 
tal development  is  striking.  Mouth-breathers  are  usually  didl,  stupid, 
aiul  backward.  It  is  impossible  for  them  to  tix  the  attention  for  long  at  a 
time, and  to  this  impairment  of  the  mental  function  (Juye,  of  Amsterdam, 
has  given  the  name  itpruse.ria.  Headaches,  forgetfulness,  inability  to 
study  without  discomfort,  are  frequent  symptoms  of  this  condition  in  stu- 
dents. There  is  more  than  a  grain  of  truth  in  the  aphorism  s/nif  i/unr 
imnillt  tiKil  save  i/our  lift',  which  is  found  on  the  title-page  of  Captain 
Catliu's  celebrated  pamphlet  on  mouth-breathing. 

A  symptom  specially  associated  with  enlarged  tonsils  is  fetor  of  the 
breath.  In  the  tonsillar  crypts  tho  in.si)issated  secretion  undergoes  de- 
eoinposition  and  an  odor  not  unlike  that  of  IJochofort  or  Limburger  cheese 
is  produced.  The  little  chee.sy  masses  may  sometimes  be  squeezed  from 
the  crypts  of  the  tonsils.  Though  the  odor  may  not  apparently  be  very 
strong,  yet  if  the  ma.ss  be  squeezed  between  the  fingers  its  intensity  will  at 
once  be  appreciated.  In  some  cases  of  chronic  enlargement  the  cheesy 
masses  may  be  deep  in  the  tonsillar  crypts ;  and  if  they  remain  for  a 
prolonged  period  lime  salts  are  deposited  and  a  tonsillar  calculus  in  this 
way  produced. 

Children  with  enlarged  tonsils  are  especially  prone  to  take  cold  and  to 
riX'urring  attacks  of  follicular  disease.  They  are  also  more  liable  to  diph- 
theria, and  in  them  the  anginal  featni'es  in  scarlet  fever  are  always  more 


*  Die  Pathologic  und  Therapie  der  Mundathmung.     Wiesbaden,  1889. 


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868 


DISEASES  OP  THE   DIGESTIVE  SYSTEM. 


serious.  The  ultimate  re.«alts  of  untreated  adenoid  liypertrophy  are  im- 
portant. In  some  cases  the  vegetations  disappear,  leaving  an  at'iphjc 
condition  of  the  vault  of  the  pharynx.  Xeglect  may  also  lead  to  the  so- 
called  Tliori  v/aldt's  disease,  in  which  there  is  a  cystic  condition  of  tin- 
pharyngeal  tonsil  and  constant  secretion  of  mueo-pus. 

Diagnosis. — The  f.icial  aspect  is  usually  distinctive.  Enlargt'd  ton- 
sils are  readily  seen  on  inspection  of  the  pharynx.  There  may  be  no  priat 
enlargenu'iit  of  the  tonsils  and  nothing  ai)parent  at  tiie  back  of  the  throiit 
even  when  the  naso-pharynx  is  completely  blocked  with  adenoid  vpore- 
tations.  In  children  the  rhinoscopic  examination  is  rarely  i)raclieal)li'. 
Digital  examination  is  the  most  satisfactory.  IMie  growths  can  then 
be  felt  either  as  small,  flat  bodies  or,  if  ext^.'usive,  as  velvety,  grapo-like 
papillomata. 

Treatment. — If  the  tonsils  are  large  and  the  general  state  is  evi- 
dently influenced  by  them  they  should  be  at  once  removed.  Applieatiuii* 
of  iodine  and  iron,  or  pencilling  the  crypts  with  nitrate  of  silver,  arc  of 
service  m  tV',-3  vnilder  grades,  but  it  is  waste  of  time  to  apply  them  in  verv 
enlarged  g'an'is.  There  is  a  condition  in  which  the  toiisils  are  not  imich 
enlarged,  but  the  crypts  are  constantly  filled  with  cheesy  secretions  am! 
cause  a  very  bad  odor  in  the  breath.  In  such  instances  the  removal  of 
the  secretion  and  thorough  pencilling  of  the  crypts  with  chromic  acid 
may  be  practised.  The  galvano-cautery  is  of  great  service  in  many  cajij 
of  enlarged  tonsils  when  there  is  any  objection  to  the  more  radical  snip- 
cal  procedure. 

The  treatment  of  the  adenoid  growths  in  the  pharynx  is  of  the  great- 
est importance,  and  should  be  thoroughly  carried  out.  Parents  slioiiM 
be  frankly  told  that  the  afTection  is  serious,  one  which  impairs  the  iiion- 
tal  not  less  than  the  bodily  development' of  the  child.  In  spite  of  tin- 
thorough  ventilation  of  this  subject  by  specialists,  practitioners  do  nut 
appear  to  have  grasped  as  yet  the  full  importance  of  this  disease.  Tliey 
are  far  too  apt  to  temporize  and  uniiecessai'ily  to  postpone  radical  meiu- 
ures.  The  child  must  be  etheri7.ed,  when  the  growths  can  be  roinovid 
either  with  the  flnger-nail,  which  in  most  instances  is  sufficient,  or  with 
a  suitable  curette.  Considerable  haemorrhage  may  follow,  but  it  is  ustially 
checked  quickly.  The  good  ctTects  of  the  operatioji  are  often  apparent 
within  a  few  days,  and  the  child  begins  to  breathe  through  the  nose.  In 
some  instances  the  habit  of  mouth-breathing  persists.  As  soon  as  tlie 
child  goes  to  sleep  the  lower  jaw  drops  and  the  air  is  drawn  into  the 
mouth.  In  these  cases  a  chin  strap  can  be  readily  adjusted,  wliieli  the 
child  may  wear  at  night.  In  severe  cases  it  may  take  months  of  earefiil 
training  before  the  child  can  speak  properly. 

Throughout  the  entire  treatment  attention  should  be  paid  to  hy;:ioiie 
and  diet,  and  cod-liver  oil  and  the  iodide  of  iron  may  be  administered 
with  benefit. 


'  ■"'  ii;,^'b,t!fr.- 


ACUTE  CESOPIIAGITIS. 


369 


Y.  DISEASES  OF  THE  (ESOPIIAGUS. 


I.  ACUTE  CESOPHAGiTIS. 


Etiology. — Acute  infliiiniuation  occurs  (a)  in  the  catarrhal  processes 
of  tlio  spei'itic  fevers;  more  rarely  as  an  exteusidu  from  catarrh  of  the 
iiliaryiix.  {/')  As  a  result  of  intense  mechanical  cr  chemical  irritation, 
priMliiL'LHl  by  I'oreijfn  hodies,  ])y  very  hot  hcjuids,  or  by  stron^j^  corrosives. 
(.)  Ill  tlie  form  of  i)seu(io-membranous  inilammation  in  diphtlieria,  anil 
(x'c'iisioiiully  in  pneumonia,  typhoid  fever,  and  pyjemia.  {d)  As  a  pustular 
iiitlaiuniatiou  in  small-pox,  and,  according  to  Laennec,  as  a  result  of  a  pro- 
luii"C(l  :uhiiinistri'-tion  of  tartar  enu'tic.  (c)  In  connection  Avith  local  dis- 
ease, inirtiriilarly  cancer  eitlier  of  tlic  tul)e  itself  or  extension  to  it  from. 
witlnnit.  Anil,  lastly,  acute  cesophagitis,  occasionally  M'itli  ulceration,  may 
(KTiir  s|K)iitaiu'ously  in  sucklings. 

Morbid  Anatomy. — It  is  extremely  rare  to  ?ee  redness  of  the 
muiiwu  except  when  cliemical  irritants  have  been  swallowed.  More  com- 
iiiniily  the  eiiitliehum  is  tliickened  and  lias  desquamated,  so  that  the  sur- 
fair  is  Cdvi'ivd  witli  a  fine  granular  substance.  The  mucous  follicles  arc 
swiilk'u  and  occasionally  there  maybe  seen  small  erosions.  In  the  pseudo- 
MioiubrMnous  inflam.i  ation  tlu're  is  a  gn.yish  croupous  exudate,  usu;  lly 
limited  in  extent,  at  the  ujiper  portion  of  the  gullet.  This  must  not  be 
(■niif.iui\ded  with  the  grayish-wliite  deposit  of  thrush  in  childr.'n.  Tiio 
imstular  disease  is  very  rare  in  small-pox.  In  the  phlegmonous  inflamma- 
tion llie  nuicous  membrane  is  greatly  swoUe;.,  and  there  is  purulent  infil- 
tration in  the  submucosa.  This  may  be  limiti'(l  as  about  a  foreign  body, 
IT  oxtreniely  diffuse.  It  may  even  extend  throughont  a  large  part  of  the 
gullet.  Gangrene  occasionally  supervenes.  Birch-IIirschfeld  describes  a 
remarkable  case  in  an  hysterical  woman,  who  vomited  a  long  membranous 
tubfi  which  proved,  on  examination,  to  bo  the  detached  epithelial  lining  of 
the  (os(ii)hagus.  Practically,  in  post-mortem  work,  there  is  no  [lortion  of 
the  alimentary  canal  which  more  rarely  shows  signs  of  disease. 

Symptoms. — Pain  in  deglutition  is  always  present  in  severe  inflam- 
mation (if  the  o'sophagus,  and  in  the  form  which  ioV  z  the  swallowing 
of  stronsr  irritants  may  prevent  the  taking  of  food.  A  dull  ])ain  beneath 
the  sternmn  is  also  present.  In  the  niilder  forms  of  catarrhal  inflamma- 
tion there  are  usually  no  symptoms.  The  presence  of  a  foreign  body  is 
indicated  by  dyspl.  '.gia  ami  sjiasm  with  the  regurgitation  of  portions  of 
the  food.  Later,  blood  and  pus  may  be  ejected,  it  is  surprising  how  ex- 
ttiijivo  the  disease  may  be  in  the  ivsophagiis  without  producing  much  pain 
or  groat  discomfort,  except  in  swallowing.  The  intense  iiillainmatiou 
^vhich  folldws  the  swallowing  of  corrosives,  when  not  fatal,  gradually  sub- 
side?, and  often  leads  to  cicatricial  contraction  and  stricture. 

The  treatment  of  acute  infiammation  of  the  oesophagus  is  extremely 


I 


ll 


i 


370 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


unsatisfactory,  particularly  iu  the  seveior  forms.  The  slight  ciitarrlul 
cases  require  no  special  treatment.  When  tlie  dysphagia  is  intense  it  is 
best  not  to  give  food  by  the  mouth,  hut  to  feed  entirely  by  eneiuutu.  Fra;-- 
ments  of  ice  may  be  given,  and  as  the  pain  and  distress:  subside,  dcinulcviu 
drinks.     External  a]iplioations  of  cold  often  give  relief. 

A  chronic  form  of  cesophagitis  is  described,  but  it  results  usually  fron 
the  prolonged  action  of  the  causes  ■which  produce  the  acute  form. 

Associated  Avith  chronic  heart  disease  and  more  frerpu'iitly  with  the 
senile  and  tlie  cirrhotic  liver,  the  o-sophageal  veins  may  be  enormoiislv 
distended  and  varicof.e,  particularly  toward  the  stomach.  In  these  cafts 
the  mucous  membrane  is  in  a  state  of  chronic  catarrh,  and  the  pationtlias 
frequent  eructations  of  mu(nis.  Rupture  of  tliese  u>sopluigeul  veins  iiiav 
cause  fatal  haimorrhage.  Two  cases  of  the  kiiul  have  occurred  in  my  ex- 
perience. 


11.  SPASM  OF  THE  CES0PHACU8  {(Esophngismus). 

This  so-called  spasmodic  stricture  of  the  gullet  ie  met  with  in  hysteri- 
cal patients  and  hypochondriacs,  also  in  chorea,  epilepsy,  and  espociallv 
hydrophobia.  It  is  sonu>times  associated  also  with  the  lodgment  of 
foreign  bodies.  Tlie  Idiopathic  form  is  found  in  females  of  a  inai'ki'4 
neurotic  habit,  but  may  also  occur  in  elderly  men.  It  iiiiiv  be  prov 
cut  only  during  pregnancy.  Of  three  cases  which  have  come  under  niv 
observation,  two  were  in  7nen,  one  a  hypochondriac  over  sixty  years  if 
ago  who  for  many  months  had  taken  only  liquid  food,  and  with  frrt.;i! 
difficulty,  owing  to  a  spasm  Avhich  accompani'xl  every  attempt  to  swallow, 
Tlie  readiness  with  which  the  bougie  passed  and  the  snbse(|ueTit  historv 
showed  the  true  nature  of  the  case.  The  patient  complains  of  inability  to 
swallow  solid  food,  and  in  extreme  instances  even  liquids  are  rejeetpil, 
The  attack  may  como  on  abruptly,  and  be  associated  with  eniotiDnal  iliv 
turbances  and  with  substernal  pain.  The  bougie,  when  pasi^ed,  may  bf 
arrested  temporarily  at  the  seat  of  the  spasm,  which  gradually  yields,  or  it 
may  slip  through  without  the  slightest  effort.  The  condition  is  rarely  seri- 
ous.    Death  has  however  followed. 

The  diagnosis  is  not  ditficult,  particularly  in  young  persons  witli 
ma  ked  nervous  manifestations.  In  elderly  persons  oesophagisiiius  is  almost 
always  connected  with  hypochondriasis,  but  great  care  must  be  taken  to 
exclude  cancer. 

In  some  cases  a  cure  is  at  once  effected  by  the  passage  of  a  boiigio. 
The  general  neurotic  condition  also  requires  special  attention. 

Paralysis  of  the  cesophagus  scarcely  demands  separate  consideration. 
It  is  a  very  rare  condition,  due  most  often  to  central  disease,  ])articiilarly 
bulbar  paralysis.  It  may  be  peripheral  in  origin  as  in  diphtheritie  paralysis. 
Occasionally  it  occurs  also  in  hysteria.    The  essential  symptom  is  dysjihagia. 


STRICTURE   OF  THE  (ESOPHAGUS. 


371 


III.    STRICTURE  OF  THE  (ESOPHAGUS. 


This  results  from  :  (a)  Congenital  narrowing,  (b)  The  cicatricial  oon- 
tnictidii  of  licak'd  ulcers,  usually  due  to  corrosive  poisons,  occasionally 
t(i  svphilis.  (r)  The  growtli  of  tumors  in  the  walls,  as  in  the  so-called 
eaiieoroiis  stricture.  Occasionally  polypoid  tumors  projec^ting  from  the 
imicDsa  iiroduce  great  narrowing,  {d)  External  pressure  by  aneurism,  en- 
hirircd  lynipli  glands,  enlarged  thyroid,  other  tumors,  and  sometimes  by 
puricunliiil  elTusion. 

The  cicatricial  stricture,  may  occur  anywhere  in  the  gullet,  and  in  ex- 
troiiie  cases  may,  indeed,  involve  the  wliole  tube,  but  in  a  majority  of  in- 
t^taiiees  it  is  found  either  high  np  near  the  pharynx  or  low  down  toward 
tlie  stomach.  The  narrowing  may  be  extreme,  so  that  only  small  qiumti- 
tius  of  food  can  trickle  through,  or  the  obstruction  may  be  quite  slight. 
There  is  usually  no  dilliculty  in  nudving  a  diagnosis  of  the  cicatricial  strict- 
ure, as  the  history  of  mechanical  injury  or  the  swallowing  of  a  corrosive 
I'luid  makes  clear  the  nature  of  the  case.  When  the  stricture  is  low  down 
the  oeso])liagus  is  dilated  and  the  walls  are  usually  much  hypertrophied. 
When  it  is  high  in  the'  gullet  the  food  is  usually  rejected  at  once,  whereas 
it'  h)\v  it  may  be  retained  and  a  considerable  quantity  collects  before  it  is 
ivgurgitated.  Any  doubt  as  to  its  having  reached  the  stomach  is  removed 
liy  tlie  alkalinity  of  the  materials  ejected  and  the  absence  of  the  chavacter- 
\<\K  gastri'  odor.  Auscultation  of  the  oesophagus  may  l)e  practised  and 
is  siiiiu'times  of  service.  The  patient  takes  a  mouthful  of  water  and  the 
auscullator  listens  along  the  left  of  the  spine.  During  deglutition  at  the 
seat  of  the  stricture,  in  place  of  the  nornnd  tesophageal  bruit,  there  will  be 
hoard  a  loud  splashing,  gurgling  sound,  and  the  secondary  murmur,  heard 
as  the  fluid  enters  the  stomach,  may  be  absent.  The  passage  of  the  u'so- 
pliageal  Iwugie  will  determine  more  accurately  the  locality.  Conical  bougies 
att;iehed  to  a  flexible  whalebone  stem  are  the  most  satisfactory,  but  the 
giim-elastic  stomach  tube  may  be  used ;  a  large  one  should  be  tried  first. 
Tlie  patient  shotdd  be  placed  on  a  low  chair  with  the  head  well  thrown 
back.  The  index  linger  of  the  left  hand  is  passed  far  into  the  pharynx, 
and  in  some  instances  this  procedure  alone  may  determine  the  presence  of 
!i  ni'W  growth.  The  bougie  is  passed  beside  the  finger  until  it  touches 
the  posterior  wall  of  the  pharynx,  then  along  it,  more  to  one  side  than  in 
the  middle  line,  and  so  gradually  pushed  into  the  gullet.  It  is  to  be  borne 
in  iiuiid  that  in  passing  the  cricoid  cartilage  there  is  ofteii  a  slight  ob- 
struction, (ireat  gentleness  should  be  used,  as  it  has  happened  more  than 
onee  that  tlie  bougie  has  been  passed  through  a  cancerous  ulcer  into  the 
inediiisUiium  or  through  a  diverticulum.  I  have  known  this  accident  to 
happen  twice — once  in  the  case  of  a  distinguished  surgeon,  who  performed 
a'sophugot(jniy  and  passed  the  tube,  as  he  thought,  into  the  stomach.  The 
post-mortem  on  the  next  day  showed  that  the  tube  had  entered  a  diverticu- 
lum an  I  through  it  the  left  pleura,  in  which  the  milk  injected  through 


!^f 


372 


DISEASES  OP  THE   DIGESTIVE  SYSTEM. 


tho  tube  was  found.  In  the  other  instance  the  tube  passed  tlu'ou"li  a 
cancerous  ulcer  into  the  lung,  which  was  adherent  and  inflanud.  ['o,.. 
tunatoly  those  accidents,  sometimes  unavoidable,  are  extremely  rare,  it 
is  well  always,  as  a  precautionary  measure  before  passing  tho  liducric,  tn 
examine  carefully  for  aneurism,  which  may  produce  all  the  syiniitonii  of 
organic  stricture.  In  cases  in  which  the  stricture  is  extreme  tliore  is  al- 
ways emaciation.     For  treatment,  surgical  works  must  bo  cousultid. 


1,.  ' 


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IV.    CANCER  OF  THE  CESOPHAGUS. 

This  is  usually  epithelioma.  It  is  not  an  uncommon  disease,  and  oc- 
curs more  frequently  in  males  than  in  fenuilcs.  The  common  situation  is 
in  the  upper  third  of  the  tube.  At  first  confined  to  tlie  mucous  mem- 
brane, tho  cancer  gradually  increases  and  soon  ulcerates.  Tlio  lumen  of 
the  tube  is  luirrowed,  but  when  ulceration  is  extensive  in  tho  luloi'  stiigos 
the  stricture  may  be  less  marked.  Dilatation  of  the  tube  and  liyjiertrophy 
of  the  walls  usually  take  place  above  the  cancer.  Tlie  canoorous  nlw 
may  perforate  the  trachea  or  a  bronchus,  the  lung,  the  mediastinum,  the 
aorta  or  one  of  its  larger  branches,  the  i)oricardium,  or  it  may  erndo  tlii' 
vertebral  column.  In  my  experience  perforation  of  the  lung  has  been  tin. 
most  frequent,  producing,  as  a  rule,  local  gangrene. 

SymptoniS. — The  earliest  symptom  is  dysphagia,  which  is  prosro-- 
ive  and  may  become  extreme,  so  that  the  patient  emacintes  rapidly.  Iff 
gurgitation  may  take  place  at  once;  or,  if  the  cancer  is  situated  neiirtlif 
stomach,  it  may  be  deferred  for  ten  or  fifteen  minutes,  or  even  longer  if 
the  tube  is  much  dilated.  The  rejected  materials  may  be  nuxed  witii 
blood  and  may  contain  cancerous  fragments.  In  persons  over  iifty  }oar< 
of  age  persistent  difficulty  in  swallowing  accompanied  by  rapid  einueiatiun 
nsuiuly  indicates  oesophageal  cancer.  The  cervical  lymph-glands  are  fro- 
queutly  enlarged  and  may  give  early  indication  of  the  nature  of  the  trouble. 
Pain  may  be  persistent  or  is  present  only  when  food  is  taken.  In  certain 
instances  the  pain  is  very  great.  I  saw  an  autopsy  on  a  case  of  eiinoer  of 
the  oesophagus  in  which  the  patient  gradually  became  emaciated,  but  hi 
no  special  symptoms  to  call  attention  to  the  disease.  These  latent  cases 
are,  however,  very  rare. 

The  j)rof/nosis  is  hopeless,  and  the  patients  usually  become  pnigres.<ive- 
ly  emaciated,  and  die  either  of  asthenia  or  sudden  perforation  of  the  ulcer. 

In  the  diagnosis  of  the  condition  it  is  important,  in  the  first  i)luce,  to 
exclude  pressure  from  without,  as  by  aneurism  or  other  tumor.  Tlie 
history  enables  us  to  exclude  cicatricial  stricture  and  foreign  bodies.  The 
sound  may  be  passed  and  the  presence  of  the  stricture  determined.  As 
antioned  above,  great  care  should  be  exercised.  Fragments  of  carcinom- 
atous tissue  may  in  some  instances  be  removed  with  the  tube.  Oa  aus- 
cultation along  the  left  side  of  the  spine  the  primary  oesophageal  murimir 
may  be  much  altered  in  quality. 


:Bi.:.r.; 


DILATATIONS  AND  DIVERTICULA. 


373 


Trcdlnwnt. — In  most  cases  milk  and  liquids  can  be  swallowed,  but 
isiippk'iiiciitary  nounslii..ent  should  be  given  by  the  rectum.  It  nuiy  be 
advisiiblf  in  some  instances  to  jiass  a  tube  into  the  stomach  and  attempt 
to  feed  ill  this  way.  If  the  patient  is  willing  to  take  the  risk,  ojsopha- 
"otoray  or  gustrotomy  may  be  performed  in  order  to  pr  'long  life. 


V.  RUPTURE  OF  THE  CESOPHAGUS. 

This  may  occur  in  a  heidthy  organ  as  a  result  of  prolonged  vomiting. 
Boorliiiiive  (lescri))ed  the  first  case  in  Baron  Wassennar,  who  "  broke  asun- 
d'T  tlio  tube  of  the  cesophiigus  near  the  diaphragm,  so  that,  after  the 
most  oxcn\ciati;ig  ])ain,  the  elements  which  he  swallowed  passed,  together 
with  the  uir,  into  the  cavity  of  the  thorax,  and  he  ex])ired  in  twenty-four 
hours."  Fitz  has  reporte  I  a  case  a!id  has  analyzed  the  literature  on  the 
subject  up  to  18T7.  The  accident  has  usually  occurred  during  vomiting 
after  a  full  meal  or  when  intoxicated.     It  is,  of  course,  invariably  fatal. 

iliich  more  common  is  the  post-mortem  digestion  of  the  oesophagus, 
wliirh  was  first  described  by  King,  of  Guy's  Hospital.  It  is  not  very 
infrequent.  In  one  instance  I  found  the  contents  of  the  stomach  in  the 
k'ft  pleura.  The  erosion  is  in  the  posterior  wall,  and  may  be  of  consider- 
able extent. 


VI.    DILATATIONS  AND   DIVERTICULA. 

Steno.«is  of  the  gullet  is  followed  by  secondary  dilatation  of  the  tube 
above  the  constriction  and  great  hypertrophy  of  the  walls.  I'rimary  dila- 
tation is  extremely  rare.  The  tube  may  attain  extraordinary  dime.  1  jus — 
oU  em.  in  circumference  in  Luschka's  case.  Regurgitation  of  food  is  the 
most  common  symptom.  There  may  also  be  difliculty  in  breathing  from 
pressure. 

Diverticula  are  of  two  forms  :  («)  Pressure  diverticula,  which  are  most 
common  at  the  junction  of  the  pharynx  and  gullet,  on  the  posterior  wall. 
Owing  to  weakness  of  the  muscles  at  this  spot,  local  bulging  occurs,  which 
is  gradually  increased  by  the  pressure  of  food,  and  finally  forms  a  saccular 
pouL'li.    [b)  The  traction  diverticula  situated  on  the  anterior  wall  near 
tbe  „    .reation  of  the  trachea,  result,  as  a  rule,  from  the  extension  of 
inilamniation  from  the  lymph  glands  with  adhesion  and  subsequent  cica- 
tricial contraction,  by  which  the  wall  of  the  gullet  is  drawn  out.     Diver- 
ticula liavc  been  successfully  extirpated  by  von  Bergmann  and  by  Mixtcr. 
A  rare  and  remarkable  condition,  of  which  a  case  has  been  recorded 
by  MacLiichlan,  and  of  which  a  second  is  in  attendance  at  my  clinic,  is  the 
ovophago-plouro-cutaneous  fistula.     In  my  })atient  fluids  are  discharged 
:U  uitorvals  through  a  fistula  in  the  right  infra-clavicular  region,  which 
appears  to  communicate  with  a  cavity  in  the  upper  part  of  the  pleura  or 
I'liig.    The  condition  has  persisted  for  more  than  twenty  years. 


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VI.  DISEASES   OF  THE   STOMACH. 

I.    ACUTE   GASTRITIS 

(Simple  Gastritis;  Acute  Gastric  Catarrh;  Acute  Dyspepsia). 

lEtiology. — Acute  gastric  catavrli,  one  of  tlie  most  common  of  com- 
plaints, occurs  at  all  ages,  and  is  usually  traceable  to  errors  in  diet.  It 
may  follow 'the  ingestion  of  more  food  than  the  stomach  can  digest,  or  it 
may  result  from  taking  unsuitable  articles,  which  either  themselves  irritatt 
the  mucosa  or,  remaining  undigested,  decompose,  and  so  excite  an  aeiiti 
d\spci)sia.  A  frequent  cause  is  the  taking  of  food  which  has  begun  tu 
decompose,  particularly  in  hot  weather.  In  children  these  fennentutivi' 
processes  are  very  apt  to  excite  acute  catarrh  of  the  bowels  as  well.  An- 
other very  comnu)n  cause  is  the  abuse  of  alcohol,  and  the  acute  giistriti- 
which  follows  a  drinking-bout  is  one  of  the  most  tyjncal  forms  of  the  dis- 
ease. The  tendency  to  acute  indigestion  varies  very  much  in  (lill'eront 
individuals,  and  indeed  in  families.  "We  recognize  this  in  using  tlic  ex- 
pressions a  "  delicate  stonnich  '  and  a  "  strong  stomach."  Gouty  person- 
are  generally  thought  to  be  more  disposed  to  acute  dyspepsia  than  otlier.-. 
Acute  catarrh  of  the  stomach  occurs  at  the  outset  of  nuiny  of  the  infec- 
tious fevers. 

Lel)ert  described  a  special  infectious  form  of  gastric  catarrh,  oeciirriiig 
in  epidemic  form,  and  only  to  be  distinguished  from  mild  typhoid  fever  by 
tlie  absence  of  rose  sjiots  and  swelling  of  the  spleen.  ^lany  pructitioniij 
still  adhere  to  the  belief  that  there  is  a  form  of  gastric  fever,  but  the  evi- 
dence of  its  existence  is  by  no  means  satisfactory,  and  certainly  a  great 
majority  of  all  cases  in  this  country  are  examples  of  mild  typhoid. 

Morbid  Anatomy. — Beaumont's  study  of  St.  Martin's  stomaeli 
shoAvi'd  that  in  acute  catarrh  the  mucous  membrane  is  i-eddeiied  and 
swollen,  less  gastric  juice  is  secreted,  ami  mucus  covers  the  surface, 
Slight  haemorrhages  may  occur  or  even  small  erosions.  The  subnuieosi 
may  be  somewhat  o'dematous.  !^^icroscopically  the  changes  are  eliiefly 
iioticeabie  in  the  mucous  and  peptic  cells,  which  are  swollen  and  nu'ru 
granular,  and  there  is  an  infiltration  of  the  intertubular  tissue  Avitli  leuco- 
cytes. 

Symptoms. — Tn  mild  cases  the  symptoms  are  those  of  sliglit  "in- 
digestion " — uncomfortable  feeling  in  the  abdomen,  headache,  depression, 


(  UP 


.'V''    1,1       .' 
''^''  ■  'I I'll  •  'i» 


ACUTE  GASTRITIS. 


375 


nausea,  enictations,  and  vomiting,  which  usually  gives  relief.  The  tongue 
U  heavily  coalocl  and  the  saliva  is  increased.  In  cliildren  there  are  intes- 
tinal svniptoms — diarrhcea  and  colicky  pains.  There  is  usually  no  fever. 
The  duration  is  rarely  more  than  tw(!nty-four  hours.  In  the  severer  forms 
the  attack  may  sot  in  with  a  chiil  and  febrile  reaction,  in  which  the  tem- 
perature rises  to  102°  or  10.3°.  The  tongue  is  furred,  the  breath  heavy,  and 
vomiting  is  frequent.  The  ejected  substances,  at  first  mixed  with  food, 
subsequently  contain  much  mucus  and  bile-stained  fluids.  There  may  be 
constipation,  but  very  often  there  is  diarrhu^a.  The  urine  presents  the 
usual  febrile  characteristics,  and  there  is  a  heavy  deposit  of  urates.  The 
abdomen  may  be  somewhat  distended  and  slightly  tender  in  the  epigastric 
region.  nerj)es  may  appear  on  the  lips.  The  attack  may  last  from  one 
to  three  days,  and  occasionally  longer.  The  examination  of  the  vomitus 
shows,  as  a  rule,  absence  of  the  hydrochloric  acid,  jiresence  of  lactic  and 
fatty  acids,  and  marked  increase  in  the  mucus. 

Diagnosis. — The  ordinary  afebrile  gastric  catarrh  is  readily  recog- 
nized. The  acute  febrile  form  is  so  similar  to  the  initial  symptoms  of 
many  of  the  infectious  diseases  that  it  is  impossible  for  a  day  or  two  to 
make  a  delinite  diagnosis,  particularly  in  the  cases  which  have  come  on, 
50  to  speak,  spontaneously  and  independently  of  an  error  in  diet.  Some 
of  these  resemble  closely  an  acute  infection ;  the  symptoms  may  be  very 
intense,  and  if,  as  sometimes  happens,  the  attack  sets  in  with  severe  head- 
ai'l'.o  and  delirium  the  case  may  be  mistaken  for  meningitis.  When  the 
abilomiiial  pains  are  intense  the  attack  may  be  confounded  with  gallstone 
colic.  In  discriminating  between  acute  febrile  gastritis  and  the  abortive 
forms  of  tyidioid  fever  it  is  to  be  borne  in  mind  that  in  the  former  the 
temperature  rises  abruptly,  the  remissions  are  slighter  and  the  drop  is 
nuire  sudden.  The  initial  bronchitis,  the  well-marked  splenic  enlarge- 
ment, and  the  rose  spots  are  not  present.  It  is  a  very  common  error  to 
elass  under  gastric  fever  the  mild  forms  of  the  various  infectious  disorders. 
The  gastric  crises  in  locomotor  ataxia  have  in  many  instances  been  con- 
founded with  a  simple  acute  gastritis,  and  it  is  always  wise  in  adults  to 
test  the  knee-jerks  and  pupillary  reactions. 

Treatment.— ^lild  cases  recover  spontaneously  in  twenty-four  hours, 
and  require  no  treatment  other  than  a  dose  of  castor  oil  in  children  or  of 
bhie  mass  in  adults.  In  the  severer  forms,  if  there  is  much  distress  in  the 
rogiim  of  tlu!  stonuich,  the  vomiting  should  be  iiromoted  by  warm  water 
or  the  sinijile  emetics.  A  full  dose  of  calomel,  eight  to  ten  grains,  should 
''•  jiven,  and  followed  the  next  morning  by  a  dose  of  Ilunyadi-Janos  or 
Cavldjiid  water.  If  there  is  eructation  of  acid  fluid,  bicarbonate  of  soda 
auil  bismuth  may  be  given.  The  stomach  should  have,  if  possible,  al)So- 
bite  rest,  and  it  is  a  good  plan  in  the  case  of  strong  persons,  particularly 
ill  those  addicted  to  alcohol,  to  cut  off  all  food  for  a  day  or  two.  The  pa- 
tient may  1)(>  allowed  soda  water  and  ice  freely.  It  is  well  not  to  attempt 
to  cheek  the  vomiting  unless  it  is  excessive  and  protracted.     Recovery  is 


t 


V    1 

1.      ' 

'it!    , 


376 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


i 


III"  '^ 


I; 


,  llW 


usually  complete,  though  rei)eated  attacks  may  lead  to  subacuio  gastriti> 
or  to  tlie  ostabliHlimoiit  of  chronic  dyspepsia. 

Phlegmonous  Gastritis ;  Acute  Suppurative  Gastritis.— This  k  mi  ex. 

C'ossively  run;  disease,  cliaracterized  l)y  tlie  occurrence  of  suppurative  inii. 
cesses  in  tlie  subiiiucosa.  'J'lie  alTectiou  is  more  common  in  jiicu  tlmii  in 
women.  The  cause  is  seldom  obvious.  It  has  been  met  witli  us  an  iilin. 
patliic  affection,  l)ut  it  has  occurred  also  in  puerperal  fever  and  (illu'i'sip. 
tic  })rocesscs,  and  has  occasionally  followed  trauma.  Anutoiiiically  tlnrc 
a])pear  to  be  two  forms,  a  diffuse  jiurulent  inliltration  and  a  luculizcd  iiL- 
6CCSS  formation,  in  which  case  the  tumor  may  reacli  llic  size  of  an  egg,  ainl 
may  burst  into  the  stoniucli  or  into  the  peritoneal  cavity. 

Tlie  si/iiiploins  arc  variable.  Tlicre  ai'e  usually  pain  in  the  uIkIoiikii, 
fever,  dry  tongue,  unil  symj)toms  of  a  severe  iiifecti\''  process,  dflirium 
and  coma  preceding  deuth.  Juundice  has  been  mec  with  in  some  in- 
stances.  Occasionally,  when  the  abscess  tumor  is  large,  it  has  hwu  Wt 
externully,  in  one  case  forming  a  mass  as  large  as  two  fists.  TluTt'  nw  in- 
stances which  run  a  more  chronic  course,  with  pains  in  the  abiloimn, 
fever,  and  chills. 

The  (/i(it//iosis  is  rarely  possible,  even  when  with  abscess  rui)tiir(.'  in- 
curs, and  the  pus  is  vomited,  as  it  is  not  jiossiblc  to  differentiate  this  cnn- 
dition  from  an  abscess  perforating  into  the  stomach  from  without.  It  i.- 
stated,  however,  that  Chvostek  made  the  diagnosis  in  one  of  his  cases. 

Toxic  Gastritis. — This  most  intense  form  of  inflamniatioii  of  tliu  stom- 
ach is  excited  by  the  swallowing  of  concentrated  mineral  acids  or  strong 
alkalies,  or  by  such  poisons  as  jjliosphorus,  corrosive  sublimate,  uniiiKniiii, 
arsenic,  etc.  In  the  non-corrosive  jioisous,  such  as  phospliorus,  arseiiir, 
and  antimony,  the  process  consists  of  an  acute  degeneration  of  the  glmnl- 
ular  elements,  and  lucmorrhage.  In  the'  powerful  conccntrutcd  \)um\i 
the  mucous  mend)ranG  is  extensively  destroyed,  and  may  be  converted  intii 
a  brownish-black  eschar.  In  the  less  severe  grades  there  may  be  areas  uf 
necrosis  surrounded  by  inflammatory  reaction,  while  the  subnnieoa  is 
lucmorrhagic  and  infiltrated.  The  process  is  of  course  more  intense  at 
the  fundus,  but  the  active  peristalsis  may  drive  the  poison  through  the 
pylorus  into  the  intestine. 

The  symptoms  are  intense  pain  in  the  mouth,  throat,  aiul  stoiiiacli, 
salivation,  great  difliculty  in  swallowing,  and  constant  vomiting,  the  vuiii- 
ited  materials  being  bloody  and  sometimes  containing  portions  of  the 
mucous  membrane.  The  abdomen  is  tender,  distended,  and  })ainful  on 
pressure.  In  the  most  acute  cases  symptoms  of  collapse  supervene;  tlic 
pulse  is  weak,  the  skin  pale  and  covered  with  sweat;  there  is  rcstlcssiuw, 
and  sonietimes  convulsions.  There  may  be  allnnnen  or  blood  in  the  iiniu', 
and  petechitB  may  develop  on  the  skin.  When  the  poison  is  less  iutciise, 
the  sloiiglis  may  separate,  leaving  ulcers,  which  too  often  lead,  in  tin' 
a3sophagus,  to  stricture,  and  iu  the  stomach  to  chronic  atrophy,  and  fiMU}' 
to  death  from  exhaustion. 


CnitONIC   GASTRITIS. 


877 


Tlie  (lifif/nosis  of  toxic  gastritis  is  usually  oasy,  as  inspection  of  tho 
iiioiitli  anil  phai^iix  shows,  in  many  instances,  c^orrosivo  effects,  while  the 
ixiuiiiiuitinii  of  tiio  vomit  may  indicate  the  natniv  of  tho  poison. 

Ill  iKiisoiiiiig  by  acids,  magnesia  should  be  administered  in  milk  or 
with  fUj,'  alltiimeu.  When  strong  alkalies  have  been  taken,  the  dilute  aci<l8 
-liould  Itc  administered.  I'or  the  severe  iullummation  which  follows  the 
swallowiii,:,'  of  tho  stronger  ])oisons  palliative  treatment  is  alone  available, 
ami  iiioi'iiliia  nuiy  be  freely  employed  to  allay  the  ])ain. 

Diphtheritic  or  Membranous  Gastritis.— This  condition  is  met  with 
(Hcasiniiallv  in  diphtheria,  b'lt  more  commonly  as  a  secondary  })rocess  in 
tvplius  (IP  typhoid  fever,  pneumonia,  pyjemia,  small-pox,  and  (H-casionally 
iu  (k'bililated  children.  An  instance  of  it  came  under  my  notice  in  pueu- 
iiiuuia.  The  exudation  may  be  extensive  and  uniform  or  in  jnitches. 
The  condition  is  not  recognizable  during  life,  unless,  as  in  a  case  of  .John 
Tlioiiisoirs,  the  membranes  are  vomited. 

Mycotic  and  Parasitic  Gastritis. — It  oc(;asionally  happens  that  fungi 
(JcVL'liip  iu  the  stomach  and  excite  inllainmation.  One  of  the  most  re- 
[iiaikablc  cases  of  the  kind  is  that  reported  by  Kundrat,  in  which  the 
faviis  fungus  developed  iu  the  stomach  and  intestine. 

In  cancer  and  in  dilatation  of  the  stonuudi  the  sarcime  and  yeast  fungi 
probably  aid  in  maintaining  the  chronic  gastritis.  As  a  rule,  the  gastric 
juice  is  capable  of  killing  the  ordinary  bacteria.  Orth  states  that  the 
aiitlirax  bacilli,  in  certain  cases,  })roduce  swelling  of  the  mucosa  and  ulcer- 
;ition.  Kk'bs  has  described  a  bacillus  gastricus  which  ilevelops  in  the 
lubiiles  and  produces  numerous  spores,  and  Eug.  Fraeukel  has  \\  ported  u 
ca^e  of  acute  emphysematous  gastritis  probably  of  mycotic;  origin.  The 
iarv;e  of  certain  insects  nuiy  excite  gastritis,  as  in  the  cases  reported  by 
(lerhanlt,  Meschede,  and  others.  In  rare  instances  tuberculosis  and  syphi- 
lis attack  the  gastric  mucosa. 

II.    CHRONIC  GASTRITIS 

{Chronic  Catarrh  of  the  Stomach;  Chronic  Dijffpepsia). 

Definition. — A  condition  of  disturbed  digestion  associated  with  in- 
ireased  mucus  formation,  qualitative  or  (pumtitative  changes  in  the  gastric 
jiiiee,  enfeeblement  of  the  muscular  coats,  so  that  the  food  is  retained  for 
iiii  abnormal  time  in  the  stomach ;  and,  linuUy,  with  alterations  in  tho 
.■-tnicture  of  the  nuicosa. 

Etiology. — The  causes  of  chronic  gastriti  •>  may  be  classified  as  fol- 
lows: (1)  Dietetic.  The  use  of  unsuitable  or  impro])erly  prepared  food. 
The  per.ustent  use  of  certain  articles  of  diet,  such  as  very  fat  substances 
nr  f(jo(ls  containing  too  much  of  the  carbohydrates.  The  use  in  excess  of 
tea  or  colTee,  and,  above  all,  alcohol  in  its  various  forms.  Under  this  head- 
ing, too,  may  be  mentioned  the  habits  of  eating  at  irregular  hours  or  too 
rapidly  and  imperfectly  chewing  the  food.     A  common  cause  of  chronic 


j'*''  '^ 


iM/i 


\W 


i        ! 


878 


DISEASES  OF  THE   DlfJESTIVE  SYSTEM. 


ciitarrli  is  driiikiiij;  too  freely  of  ice-wiiter  during  meals,  ii  praetico  wliirh 
j)lays  no  snmil  i)art  in  l\w  prevalence  of  dyspepsia  in  Aiyei'icu.  Aiiotlnr 
frecpient  cause  is  the  altnse  of  tobacco,  (-i)  Constitutional  causes.  .Viiiiinj;, 
chlorosis,  chi'onic.  tul)er(Mdosis,  gout,  diaheles,  and  JJi'ight's  discjisc  mv 
often  as.sociated  witii  chronic  },'astrii^  catarrh.  (;})  Local  coiulitions;  {ii)uf 
the  stomach,  as  in  cancer,  ulcer  and  dilatation,  which  are  iiivaiialiK  nr. 
eompanied  by  catarrh;  (/>)  conditions  of  the  portal  circulation,  ciiuhh' 
chroni('  enf,'orj;cnient  of  the  mucous  meiidiraiu',  as  in  cirrhosis,  clirdiu. 
heart  disease,  and  certain  chronic  lung  alVections. 

Morbid  Anatomy. —Anat(»mieally  two  forms  of  chronic  gustriti 
may  l)e  recogiuzed,  the  simple  and  the  sclerotic. 

(it)  Simple  Chronic  Gastritis —'I'lie  organ  is  nsmdly  enlarged,  tlir 
mucous  miMubranc^  pale  gray  in  color,  and  covered  with  closely  adiicnir. 
tenacious  nuuuis.  The  veins  arc  large,  ]iatches  of  ecchymosis  are  imt  in- 
frcrpiently  seen,  and  in  the  clironie  catarrh  of  jiortal  obstruction  and  ii 
chronic  heart  disease  small  hannorrhagic  erosions.  Toward  the  iivlmi,- 
tho  mucosa  is  not  infre<|uently  irregularly  ])igniented,  and  presents  ii 
rough,  wriid\led,  mammillnted  surface,  the  I'/at  iiudnnuliiiiv  of  the  Fromli. 
a  condition  whitdi  may  sonieti'nes  be  so  prominent  that  writers  liavcdc- 
scribed  it  as  r/as'/ri/ls  pohjjioart.  The  memlirano  may  he  thinner  tlwii 
normal,  and  much  firmer,  tearing  les^  readily  with  the  finger-nail.  YavM 
thus  describes  t)ie  lustological  changes:  The  minute  aiuitoniy  shows  tlh 
picture  of  a  parenchymatous  and  an  interstitial  iiillamniatioii.  Tlii' glaiii 
cells  arc  in  part  eroded  or  show  cloudy  granular  swelling  or  atni|iliy. 
The  distinction  i)etweeu  the  principal  and  marginal  cells  cannot  he  xmvi- 
nizeii,  and  in  many  ])laces,  jiai'ticulaidy  in  the  pyloric  region,  the  tulir- 
have  lost  their  regular  form  and  show  in  many  ])laces  an  atypical  lirani!i- 
ing,  like  the  fingers  of  a  glove.  Tndividm'd  glands  arc  cut  off  toward  \\v 
fundus,  but  appear  at  the  border  of  the*  submucosa  as  cysts,  partly  eiii|ity. 
with  a  smooth  membrane,  partly  fdlcd  with  remnants  of  hyalitie  aiul  iv- 
fractile  epithelium.  An  abundant  small-celled  infiltration  jiivsscs  ajiart 
the  tubules  and  is  particularly  marked  toward  the  surface  of  the  iiuici'ni, 
and  from  the  sidmiucosa  extensions  of  the  connective  tissue  uiaylifHin 
passing  hetween  the  glands.  The  mucoid  transformation  of  the  (rll-ni' 
the  tul)ules  is  a  striking  feature  in  the  process  and  may  extend  to  tlie  vcrv 
fundus  of  the  glands. 

{h)  Sclerotic  Gastritis.— As  a  final  result  of  the  parenchymatous  nwi 
interstitial  changes  the  mucous  membrane  may  undergo  comi)lete  atn)pli,v. 
so  that  but  few  traces  of  secreting  substance  remain.  There  appear  to 
be  two  forms  of  this  sclerotic  atrophy — one  with  thinning  of  the  coats  of 
the  stomach,  ^^7//// /'*•(«  ?r»//-/r»//,  ami  a  retention  or  even  increase  of  taf 
size  of  the  organ ;  the  other  with  enormous  thickening  of  the  coats  aim 
great  reduction  in  the  volume  of  the  organ,  the  condition  whii'li  i^ 
usually  described  as  rlrrlinsis  venfriniU.  Extreme  atrophy  of  the  iiiu- 
cous  membrane  of  the  stomach  has  been  carefully  studied  hy  I-ouwrk. 


CIIRONFC   (iASTIlITIS. 


37!> 


m 


KhmM,  iiiiil  otliors,  iiiul  wo  now  rccojjiii/u  llic  fii>'t  tliat  tlicrc  iiuiy  l)o  such 
,listi'ii('tii)ii  and  <k'gcnoniti()ii  of  the  jflaiuliilar  clciiii'iits  l»y  a  proj^rossivo 
,|rvtl(i|iiii('iit  of  interstitial  tiHsuo  tliut  ultiinatcly  srarcdy  a  trace  of  scerct- 
ill"  ti.ssao  remains.  In  a  clianictcristic  case,  stiidii'd  by  ilciiry  and  inysclf, 
till!  irri'iter  portion  of  tlic  lining  nicnihrano  of  tlic  stotnacii  was  converted 
into  11  perfectly  smooth,  cuticular  structure,  showinj;  no  trace  whatever 
iif  (flaiuhilar  elements,  witli  enormous  iiypertrophy  of  tiie  inuscularis 
imicDSie,  and  here  and  there  formation  of  cysts.  In  the  other  foi-m,  with 
i.lintical  atrophy  and  cyst  formation,  there  is  enormous  int-rease  in  the 
riiiuioctive  ti-sue,  and  the  stonuK'h  may  l)e  so  contracted  that  it  does  not 
Imlil  more  than  a  couple  of  ouiu'cs.  'I'he  walls  may  measure  from  two  to 
tlnve  centimetres;  the  greatest  increase  in  thickness  is  in  the  sulmiucosa, 
hilt  tlio  hypertrojdiy  also  extends  to  the  tnuscular  layers.  A  similar  affec- 
tiiiii  may  coexist  in  the  civcum  and  colon.  The  condition  may  he  ditlicult 
i(»  (listiiigui.'^h  from  dilTuse  carcinoma.  There  may  be  also  proliferative 
luM'itonitis,  with  perihepatitis,  perisidenitis,  und  ascites.  While  one  is  not 
jiistiliod  in  saying  that  all  cases  of  cirrhosis  of  the  stomach  represent  a 
tiiuil  stage  in  the  history  of  a  chronic  catarrh,  it  is  true  that  in  most  cases 
the  jiroi'css  is  associated  with  atroi)hy  of  the  gastric  mucosa,  while  the 
history  indicates  the  existence  of  clironi(!  dyspepsia. 

Symptoms.— The  affection  jjcrsists  for  an  indefinite  period,  and,  as 
is  the  case  with  most  chronic  diseases,  changes  from  time  to  time.  The 
aiipetite  is  variable,  sometimes  greatly  im{)aired,  at  others  very  good. 
Aiiieiig  early  symptoms  are  feelings  of  distress  or  o})pression  after  eating, 
wiiiili  may  become  aggravated  and  amount  to  actual  pain.  When  the 
stiiiuiii'li  is  empty  there  may  also  he  a  painful  feeling.  The  pain  dilTcrs  in 
ilitTtTciit  eases,  and  may  be  trifling  or  of  extreme  severity.  When  local- 
izcil  ami  felt  beneath  the  sternum  or  in  the  prtecordial  region  it  is  known 
lis  hoart-burn  or  sometimes  cardialgia.  There  is  pain  on  jiressure  over 
tlio  stomach,  usually  dilfuse  and  not  severe.  The  tongue  is  coated,  and 
the  piitieiit  complains  of  a  bad  taste  in  tlie  mouth.  The  tip  and  nuirgin 
i)f  the  tongue  are  very  often  red.  Associated  with  this  catarrhal  stomati- 
tis thon^  may  be  an  increase  in  the  salivary  and  pliaryngeal  secretions. 
Xiiiiseu  ■>  an  early  symptom,  and  is  particularly  apt  to  occur  in  the  morn- 
ing'houi's.  It  is  not,  however,  nearly  so  constant  a  symptom  in  ch.-onic 
^'iistritis  as  in  cancer  of  the  stoma(.'h,  and  in  mild  grades  of  the  alTec- 
ti'iii  it  may  not  occur  at  all.  Eructation  of  gas,  which  may  continue  for 
-'Jiiir  hours  after  taking  food,  is  a  very  prominent  feature  in  cases  of  so- 
«illt'il  tlatuient  dyspepsia,  and  there  nniy  be  nnirked  distension  of  the 
iiitcstiius.  With  the  gas,  bitter  fluids  may  be  brought  np.  The  vomit- 
111,^'  tides  not  often  occur  when  the  stomach  is  empty,  but  either  imme- 
'liatfly  after  eating  or  an  hour  or  two  later.  The  vomitus  consists  of  food 
111  various  stages  of  digestion  and  slimy  mucus,  and  the  chemical  examina- 
tion sliows  the  presence  of  abnormal  acids,  such  as  butyric,  or  even  acetic,  in 
iwilition  to  lactic  acid,  while  the  hydrochloric  acid,  if  indeed  it  is  present, 


i 


';-!i;Sf 


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P 


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M 


i 


3S0 


DIHIOASKS  OP  TIIR  DUJKSTIVK  SYsTKM. 


is  mucli  ri'diKH'd  in  (|iiantity.  'riuMli^jcstion  iiiiiy  Ik'  imicli  «lcliiy('(l,  ami 
0)1  wasliiii;^  out  tlio  Htonmcli  us  late  m  hovcu  liourH  afU'i-  catiTij,',  |Mirti„i,s 
of  food  arc  still  |tn'sriif.  'Plic  prolotii^cd  n'tcntioii  favors  di'coin|i(isitiiiii. 
tlu'  stoiiiacli  hccoincs  distended  with  ;;as,  and  tlii.:,  with  the  cjii'diii,- 
catarrh,  may  iiidiieo  <(radiiully  an  atony  of  tlu;  niuseidar  walls.  Tlic  uh. 
sorption  is  slow,  and  iodide  of  potassium,  given  in  eai)sules,  whirh  >li(,|iiii 
noi'jnally  reaeli  the  saliva  within  tifteeii  minutes,  may  not  he  evident  fi.r 
more  than  ha'f  an  hour. 

Constipation  is  usually  jnv.sent,  hut  in  some  instanees  there  is  (iiaiilinn, 
and  undigested  food  pas.ses  rajjidly  through  the  howels.  'I'lie  miiu.  j. 
often  seanty,  high-eolored,  and  deposits  a  lieavy  sediment  of  mates. 

Of  other  symptoms  headaelu'  is  eominon,  and  the  j)atient  feels  eon. 
stantly  out  of  .sorts,  indisposed  for  exertion,  and  low-spirited.  1m  ii!.'!:i;i- 
vated  ea.ses  melaneholia  nuiy  develop.  Trousseau  called  attention  tn  tlir 
oceurrenco  of  vertigo,  a  marke(l  feature  in  certain  cases.  The  jtulsr  j, 
small,  sometimes  slow,  aiul  there  may  he  palpitation  of  tlu^  liearl.  Vv\vr 
does  not  occur.  Cough  is  sometimes  i)resent,  hut  tlic  so-called  stniiiiicli 
cough  of  chronic  dyspeptics  is  in  all  prohability  de[)eiulent  uixm  plmrvn- 
gcul  irritation. 

The  symptoms  of  atrojdiy  of  the  mucous  membrane  of  tlie  stcjiiuicli, 
with  or  without  eo)itracti(»n  of  tlu'  organ,  are  very  complex,  and  caiindt  lie 
said  to  present  a  uniform  ])icture.  The  majority  of  the  cases  ]iresciit  tlic 
syrn[)toms  of  an  aggravated  chronic  dyspepsia,  often  of  such  severity  tlint 
cancer  is  susj)ectod.  In  one  of  the  cases  which  I  examined  the  jHTsi.-liiit 
distress  after  eating,  the  Adunting,  and  tli.i  gradual  loss  of  flesli  iiii'l 
strength,  veiy  naturally  leil  to  this  diagiuisis,  l)ut  the  duration  of  llii 
disease  fur  exc^eeded  that  of  ordinary  carcinoma.  In  the  cirrhotic  torin 
the  tunu)r  mass  may  sometimes  he  felt.  In  atrophy  of  the  stdtiiiirli. 
whetlier  associated  witli  cirrliosis  or  not,  the  clinical  })icture  may  he  t!i;it 
of  pernicious  ana3mi}i.  As  early  as  1800,  Flint  called  attention  to  tlii- 
connection  l)etween  atrophy  of  the  gastric  tnViules  and  aiuvmia,  iui  nlwr- 
vation  which  Fenwick  and  otliers  have  amply  conlirnied. 

Diagnosis. — The  use  of  the  stomach-tube  and  the  chemical  examina- 
tion of  the  contents  of  the  stomach  obtained  in  this  way  have  given  us 
special  information  with  reference  to  tlie  various  forms  of  gastritis  ainl  the 
modus  of  differentiating  them.  The  soft-rubber  stonuich-tube,  jtroviditl 
with  a  funnel-shaped  dilatation,  is  the  most  satisfactory  to  use,  as  it  is  vcn 
readily  2)assed,  and  if  used  by  the  patient  is  not  likely  to  cause  (liiiiuige. 
It  should  be  open  at  the  end  and  possess  one  or  two  lateral  o])eiiin<,'s. 

Ewald  distinguishes  three  forms  of  chronic  gastritis  :  (1)  Siinpk' gas- 
tritis; (2)  mucous  (schlei/nif/e)  gastritis;  (;})  atrophy. 

In  (1)  the  fasting  stomach  contains  only  a  snuill  (piantity  of  n  ?li'i» 
fluid,  while  after  the  test  breakfast  the  IICl  is  diminished  in  quantity  or 
may  be  absent.  Lactic  acid  and  tlie  fat  acids  may  be  present.  Aft*^' 
Buas's  more  rigid  test  meal  the  organic  acids  are  rarely  found. 


fHIlONIC  OASTIUTIS. 


881 


In  (•.')  till'  acidity  '\n  always  sli;,'lit  and  tlic  coiiditictii  ia  (listiii^'iiisliod 
fiiiiii  (!)  chirlly  liy  tlut  lai';;c  aiiiDiint  (if  miiciis  prcsi-nt. 

Ill  (;;)  tlu'  fastiii;,'  Htdiiiaili  is  gciicrully  ciiiiity,  wliilu  after  the  tost 
ljR'iikfu.4  IK'l,  |«.'l>sin,  tiiul  tlio  ciinlliii;^'  IVnnciil  air  wholly  wuiitiiij,'. 

Treatment.  —  Wlicn  possihh*  the  causo  ill  I'ui'h  case  hIiouIiI  lu-  ascor- 
tiiini'il  ji:i<l  all  atlciiiitt  iiiadc;  to  di'tcrniiiui  llic  special  form  of  iiidi- 
psiioii.  I'siially  tlicro  is  no  difUciiIty  in  dilTcrcntialinj^  tlio  ordinary 
nitaiTlial  uiid  the  iiorvous  varietifs.  A  caivfiil  study  of  the  plit'iionu'iiii 
,4'  (liur.^tiuii  ill  the  way  aln-ady  laiil  down,  tlioni,di  not  essential  in 
tvcry  iiistanee,  siioiild  eertainly  he  carrii'd  (jiit  in  tlu^  more  ol)stinat(^  and 
(ilisciire  funns.  Two  important  (piestions  should  he  asked  of  every  dys- 
iK'lilif — first,  as  to  the  time  taken  at  liis  meals;  and,  second,  as  to  tho 
i|iiiiiitily  he  eats.  I'lacticully  u  hir<fo  majority  of  all  cases  of  disturbed 
iIi<(osti(m  come  from  hasty  and  imperfect  mastication  of  tlie  food  and  from 
ovci'ciitiii;^.  Especial  stress  should  he  laid  upon  (he  former  point.  In 
siiiiic  instances  it  will  alone  sullice  to  cure  dyspepsia  if  the  jiaticiit  will 
count  a  certain  niimher  before  swallowing  each  mouthful.  'J'he  seeoiul 
|ii)iiit  is  of  even  greater  importance.  People  luiliitually  eat  too  much,  and 
it  is  proliahly  true  that  a  greater  number  of  maladies  arise  from  excess  in 
catiiiif  than  from  excess  in  drinking.  I'articiilarly  is  this  the  case  iii 
.Viiicrica,  where  the  average  man  is  abstemious  in  the  matti'r  of  alcohol, 
'ml  iiii|)riidcnt  to  a  degree  in  all  matters  relating  to  food.  Moreover,  peo- 
|ili'  liiiv(^  not  had  (imo  to  learn  tho  art  of  cooking,  and  much  of  the  indi- 
pstidii,  partii'ularly  in  tho  country  districts,  may  lu^  cliarged  to  the  bar- 
liariiiis  iiii'tliods  of  preparing  the  food.  The  treatment  may  be  consid- 
I'lvil  uiulcr  the  headings  of  dietetic  and  medicinal. 

{(i)  (Ifurral  mitl  Dietetic. — A  careful  and  systomati(^ally  arranged  di- 
etary is  the  first,  sometimes  the  only  essential  in  the  treatment  of  a  case  of 
'liroinc  dyspepsia.  It  is  imiiossiblo  to  lay  down  rules  applicable  to  all 
ruMS.  Individuals  differ  extraordinarily  in  their  capability  of  digesting 
(litri'iout  articles  of  food,  and  there  is  much  truth  in  the  old  adage,  "  One 
man's  food  is  another  man's  poison."  The  individual  ])references  for  dif- 
IViviit  iu'li(  les  of  food  should  be  permitted  in  the  milder  forms.  Physi- 
I'iaiis  have  jjrobably  been  too  arbitrary  in  this  direction,  and  have  not 
yit'Mcd  siifViciently  to  the  intimations  given  by  the  appetite  and  desires 
ut'tlio  i)atient. 

A  rii;id  milk  diet  may  bo  tried  in  obstinate  cases.  Much  depends 
upiin  wlicther  the  patient  is  able  to  take  and  digest  milk  pro[)erly.  In  the 
loiiiis  associated  with  Bright's  disease  and  chronic  portal  congestion,  as 
^^ell  as  iu  many  instances  in  which  the  dyspepsia  is  part  of  a  neurasthenic 
'"' liystcrical  trouble,  this  plan  in  conjunction  with  rest  is  most  etlicacious. 
It^  milk  is  not  digested  well  it  may  bo  diluted  one  third  with  soda  water 
'>!■  ^  iohy,  or  five  to  ten  grains  of  carbonate  of  soda,  or  a  pinch  of  salt 
"lUY  be  added  to  each  tumblerful.  In  many  cases  the  milk  from  which 
tliu  cnum  has  been  taken  is  better  borne.     Buttermilk  is  particularly 


i'v 


v 


Sti 


m 


ii-iti 


,1 


382 


DISEASES  OF  THE   DIOESTTVE  SYSTEM. 


u 


if! 


^1 


suital)lo,  but  Ciui  rarefy  1)C  tiikoii  for  as  long  a  tinio  alone,  as  iiiiliout> 
tire  of  it  much  more  readily  tlian  thoy  do  of  ordinary  milk.  Xot  oiilv 
can  tlio  goiicnd  nutrition  ho  maintained  on  this  diet,  but  jiatients  sumi'. 
tijncs  increase  in  weight,  aiul  the  unpleasant  gastric,  symptoms  disinipcai 
entirely.  It  should  be  given  at  fixed  hours  and  in  definite  quantities.  \ 
patient  may  take  six  or  eight  ouiu^cs  every  three  hours.  Tlio  aiiiouiit 
necessary  varies  a  good  deal,  but  at  least  lliree  to  live  pints  sIkciIiI  Ir 
given  in  the  twenty-four  houv.s.  This  form  of  diet  is  not,  as  a  rule,  wdl 
borne  Avlutn  there  is  a  tendency  to  dilatation  of  the  stomach.  'JMiu  milk 
may  be  i)reviously  peptonized,  but  it  is  impt)ssible  to  feed  a  chronic  dys- 
peptic in  this  Avay.  Tlie  stools  should  be  caivfuUy  Avatched,  and  if  iiinic 
milk  is  taken  than  can  be  digested  it  is  well  to  s'.ipplenunt  the  dirt  with 
eggs  and  dry  toast  or  biscuits. 

In  a  largo  proportion  of  the  cases  of  chronic  irUigestion  it  i.s  not 
necessary  to  annoy  the  patient  with  such  strict  dietarie,-*.  It  may  lie  qiiiiu 
sufficient  to  cut  off  certain  articles  of  food.  Thus,  if  there  are  acid  itiic- 
tations  or  flatuleiu^v,  the  farinaceous  foods  should  be  restricted,  parliciilnrlv 
potatoes  and  the  coarser  vegehddes.  A  fruitful  source  of  indigcstidii  is 
the  hot  bread  which,  in  different  forms,  is  regarded  as  an  essential  |i;in 
of  an  AmericaJi  breakfast.  This,  as  well  as  the  various  forms  of  pan- 
cakes, pies  and  tarts,  with  heavy  i)astry,  and  fried  articles  of  all  surts, 
should  1)0  strictly  forbidden.  As  a  rule,  white  bread,  toasted,  is  iiioiv 
readily  digested  than  bread  made  from  the  whole  meal.  Persons,  Imu- 
ever,  differ  very  nauch  in  this  ivspect,  and  the  Graham  or  brown  Incad  is 
for  many  people  most  digestible.  Sugar  'v.ul  very  sweet  articles  i<i  fnn] 
should  l)e  taken  in  great  moderation  or  avoided  altogether  by  persons 
Avith  chronic  dyspepsia.  ^lany  instances  of  aggravated  iniligestioii  liavi' 
come  to  my  notice  due  to  the  prevalent  practice  of  eating  largely  of  iiv- 
cream.  One  of  the  most  powerful  enemies  of  the  American  stoiiiaili  in 
the  ]>resent  day  is  the  soda-Avater  fountain,  Avhich  has  usur])ed  so  impor- 
tant a  }ilaco  in  the  apothecary  sh.o]). 

Fats,  Avith  the  exception  of  a  moderate  amount  of  good  butter,  wry 
fat  meats,  and  thick,  greasy  scmps  should  be  avoided.  Iiij'e  tVr.it  iji 
moderation  is  often  advantageous,  particularly  Avhen  cooked,  liaiiaiin- 
are  not,  as  a  rule,  Avell  borne.  Strawberi-ies  are  to  many  ])ersoiia  a  causi 
of  an  iinnual  attack  of  indigestion  and  sore  throat  in  the  spring  nioiitlis. 

As  stated,  in  the  nuitter  of  special  articles  of  food  it  is  inijxissilik'  in 
lay  doAvn  rigid  rules,  and  it  is  the  common  cxpu'rience  that  one  patitiit 
Avith  indigestion  Avill  take  with  im])unity  the  very  articles  which  caiisi' 
the  greatest  distress  to  .mother. 

Another  detail  of  importance  Avhich  nuiy  be  mentioned  in  this  i'"i'- 
nection  is  the  gei\eral  hygienic  management  of  dysj)eptics.  'I'lu'so  pa- 
tients are  often  introspectiA'c,  dwelling  in  a  morbid  manner  on  thtir 
symptoms,  and  much  inclined  to  take  a  despondent  vicAV  of  their  con- 
dition.    Very  little  progress   can   be   made   unless   the   physician  gums 


t'^'-J'^ 


i\M 


C  '\. 


-:';*■•  1 


CHRONIC   GASTRITIS. 


383 


tlair  ooiitiflciK'O  from  tho  out^ot.  1'liL'ir  fe-urs  jiiul  wlilms  should  not  bo 
made  too  light  of  or  ridiculed.  iSysteimitic  exercise,  carefully  res^ultited, 
Kirliiularlv  when,  us  tit  wateriiiif  places,  it  is  cond)ined  with  u  restricted 
■ik't  is  of  special  service.  Change  of  air  and  occupation,  a  prolonged 
via  voyage,  or  a  summer  in  the  mountains  will  sometimes  cure  the  moist 
(ibstiniite  dyspepsia. 

(//)  McdiriiKih — The  special  tlierapeutic  measures  may  be  divided  into 
those  wliicli  attempL  to  rep.lace  in  the  digestive  juices  im[)ortant  elements 
which  are  lacking  and  these  which  stimulate  the  weakened  action  of  t)ie 
,!_';iii.  In  tlie  lirst  group  come  the  hydrochloric  acid  and  ferments, 
wliiili  ai'c  so  freely  employed  in  dys2ie})sia.  The  former  is  the  most  im- 
iiuitaiit.  It  is  the  ingrediont  in  the  gastric  juice  most  commonly  deficient, 
it  is  not  only  necessary  for  its  own  important  actions,  but  its  presence  is 
iiitinuitcly  associated  witli  that  of  the  pepsin,  as  it  is  oidy  in  the  ]»resence 
iif  a  suHicient  quantity  that  the  pepsinogen  is  converted  into  the  active 
iiiL.'i'>iivc  ferment.  It  is  best  given  as  the  dilute  acid  taken  in  somewhat 
larger  quautities  than  are  usually  advised.  Ewald  recommends  large 
i]i,<i.,s_()f  from  1)0  to  100  drops — at  intervals  of  liftceii  mitnites  after  the 
iiii'als.  Lfuhe  and  liiegid  advise  smaller  doses.  Probably  from  15  to  20 
(hops  is  sullicient.  The  jirolonged  use  of  it  docs  not  appear  to  be  in 
;i!iv  wav  hurtful.  The  use,  however,  should  be  restricted  to  cases  of 
ik'iinisis  and  atrojdiy  of  the  nuicous  membrane.  In  actual  gastritis  its 
vahie  is  doubtful. 

Tlio  digestive  ferments:  These  are  extensively  employed  to  strengthen 
il:e  wcakoiied  gastric  and  intestinal  secretions.  The  use  of  jjepsin,  ac- 
I'l'iling  to  Ewald,  may  be  limited  to  the  cases  of  advaiu'cd  mucous 
latai'ih  and  the  instances  of  atrftpby  of  the  stomach,  in  which  it  sliould 
lio  given,  in  doses  of  from  10  to  1.")  grains,  with  dilute  hydrochloric  acid 
i'.  quarter  of  an  hour  after  meals.  It  may  be  used  in  various  dilferent 
forms,  either  as  a  [lowder  or  in  solution  or  given  with  the  acid.  The 
powder  is  much  more  certain.  Pepsin  wine  is  gciu'rally  inert,  as  there  is 
little  of  the  ferment  taken  u])  by  alcohol.  It  is  important  to  use  a  reliable 
iirticle.    Mu<  ii  that  is  in  the  market  is  valueless. 

Paiiereatiii  i.-  of  equal  or  even  greater  value  than  the  j)epsin.  Pains 
should  he  taken  t'  nse  a  good  article,  such  as  that  prepared  by  ^lerck.  It 
should  be  given  in  doses  of  from  15  to  20  grains,  in  (,'ond)ination  with 
hiearhoiiate  of  soda.  It  is  conveniently  administered  in  tablets,  each 
"f  whiiji  tunt,)ins  5  grains  of  tlie  pancreatin  and  the  soda,  and  of  these 
tuo  (ir  tliree  may  be  taken  fifteen  or  twenty  mimites  after  each  meal. 
I'tyaliii  and  diastase  are  particularly  iiulicated  when  the  acid  is  excessive. 
I  ho  action  of  the  former  continues  in  the  stomach  during  normal  diges- 
'011.    Tlu'  malt  diastase  is  often  very  serviceable  given  with  alkalies. 

Of  measures  wliich  stimulate  the  glandular  activity  in  chronic  dys- 
I't'l'^ia  lavage  is  by  far  the  most  important,  parti(ndarly  in  the  forms 
oharuetorixed  by  the  secretion  of  a  large  quantity  of  mucus.     Luke-warm 


10 


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Hlfir 

m'^'''' 

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Hi^-^  ' 

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38-t 


DISEASES  OP  TEE  DIGESTIVE  SYSTEM. 


water  sliould  be  used,  or,  if  there  is  much  mucus,  a  one  per  cent  salt  solu- 
tion, or  a  three  to  five  per  cent  solution  of  bicarbonate  of  soda,  if  tluro 
is  much  fermentation  the  three  per  cent  solution  of  boric  acid  jiiav  ln' 
used,  or  a  dilute  solution  of  carbolic  acid.  It  is  best  employed  in  tl:i' 
morning  on  an  empty  stomach,  or  in  the  evening  some  houiv  afU'r  tlic 
last  meal.  It  is  perhaps  preferaljle  in  the  morning,  ex(!ept  in  those  casos 
in  which  there  is  much  nocturnal  distress  and  flatulency.  Once  u  dav  is. 
as  a  rule,  suflicient,  or,  in  the  case  of  delicate  persons,  every  second  dav. 
The  irrigation  may  be  continued  until  the  water  which  comes  awav  i> 
quite  clear.     It  is  not  necessary  to  remove  all  the  fluid  after  the  inigatiiiii, 

While  perhaps  in  some  hands  this  measure  has  been  carried  to  ex- 
tremes, it  is  one  of  such  extraordiiuiry  value  in  certain  cases  that  it  should 
be  more  widely  employed  by  practitioners.  AVhen  there  is  an  iiisupcralili' 
objection  to  lavage  a  substitute  may  bo  used  in  the  form  of  warm  alkaline 
drinks,  taken  slowly  in  the  early  morning  or  the  hist  thing  at  niirht. 

Of  medicines  which  stimulate  the  gastric  secretion  the  most  important 
are  the  bitter  tonics,  such  as  quassi'i,  gentian,  columbo,  cundurango,  ipecacu- 
anha, strychnia,  and  cardamoms.  These  are  probai)ly  of  more  value  in 
chronic  gastritis  than  the  hydrochloric  acid.  Of  these  strychnia  is  the  nui>t 
powerful,  though  none  of  them  have  probably  any  very  great  stimulating' 
action  on  the  secretion,  and  influeiu;e  rather  the  api)etite  than  the  diijcstimi. 
Of  stomachics  whi(di  are  believed  to  favorably  influence  digestion  the  nmst 
important  are  alcohol  an<l  common  salt.  The  former  would  apjiear  to  mt 
in  moderate  quantities  by  increasing  the  acid  in  the  gastric  juice,  and  wiili 
it  probably  the  pepsin  formation.  Others  hold  that  it  is  not  so  much  the 
secretoi'y  as  the  motor  function  of  the  stomach  which  tlie  alcoliol  stimu- 
lates. In  moderate  quantities  it  has  certaiidy  no  directly  injui-iou.s  influ- 
ence on  the  digestive  processes.  Special  care  should  be  taken,  liowevor,  in 
ordering  alcohol  to  dyspeptics.  If  a  patient  has  been  in  the  hal>it  of  tak- 
ing beer  or  light  wines  or  stimulants  with  his  meals,  the  practiee  may  lie 
continued  if  moderate  quantities  :ire  taken.  Beer,  as  a  rule,  is  not  well 
borne.  A  dry  sherry  or  a  glass  of  claret  is  preferable.  In  the  case  of 
women  with  tiny  form  of  dysi)ei)sia  stimulants  should  be  euii»h)yed  with 
the  greatest  caution,  and  the  practitioner  should  know  his  jiatient  well 
before  ordering  alcohol. 

The  importance  of  salt  in  gastric  digestion  rests  n])on  the  fact  that  its 
presence  is  essential  in  the  formation  of  the  hydrochloric^  arid.  An  in- 
crease in  its  use  may  be  advieed  in  tJ.l  cases  of  chronic  dys])epsia  in  wliiili 
the  a(ud  is  defective. 

Treatment  of  Special  Conditions. — Fermentati(tu  and  ilati- 
Icncy.  ^Vhen  the  digestion  is  slow  or  imperfect,  fermentation  ir^cs  on  m 
the  contents,  with  the  formation  of  gas  and  the  production  cd"  lactic,  bii- 
tyric,  and  acetic  acids.  For  the  treatment  of  this  condition  caivfid  diet- 
ing may  suftice,  particularly  forbidding  such  articles  as  tea,  })astrv,  ami 
the  coarser  vegetables.     It  is  usually  combined  with  pyrosis,  iu  which  the 


NEUROSES  OF  THE  STOMACH. 


385 


acid  flu iil^  ai'c  brought  into  the  mouth.  Bismutli  and  carbonate  of  soda 
,<(iiiu'tiiiii'S  suffice  to  relievo  tlie  condition.  Thymol,  creosote,  and  carbolic 
acid  imiv  be  oiH])loyed.  For  acid  dyspepsia  Sir  William  li(il)erts  recom- 
mends tlio  l)ismuth  lozenge  of  the  British  Pharmacjopo'ia,  the  antacid 
properties  of  ■which  depend  on  chalk  and  l)icarbonate  of  soda.  It  should 
he  tiikoii  an  hour  or  two  after  meals,  and  only  when  the  pain  and  un- 
cu^iiioss  are  present.  Glycerine  in  from  twenty  to  sixty  minim  doses,  the 
essential  oils,  animal  charcoal  alone  or  in  combination  Avith  compound 
ciniiainon  powder,  may  be  tried.  If  there  is  much  j)ain,  chloroform  in 
iwenty-miiiiin  doses  or  a  teaspoonful  of  IIotTinan's  anodyne  may  be  used. 
If  (ibstiiiate,  lavage  is  indicated  and  is  sometimes  striking  in  its  effects. 
Alkidiiie  solutions  may  bo  used. 

Vomiting  is  not  a  feature  which  often  calls  for  treatment  in  chronic 
dYspcjisia ;  sometimes  in  children  it  is  a  iiersistent  symptom.  Creosote 
iind  ciirbolie  acid  in  dro})  doses,  a  few  drops  of  chlorofonn  or  of  dilute  hy- 
drocyanic acid,  cocaine,  Insmuth,  and  oxalate  f)f  cerium  may  be  used.  If 
ubstinato,  the  stonuich  should  be  washed  out  daily. 

Constipation  is  a  frequent  and  troublesome  feature  of  most  forms  of 
indigestion.  Occasionally  small  doses  of  mercury,  i)odoi>hyllin,  the  laxa- 
tive mineral  waters, sulphur, and  cascara  maybe  employed.  (Ilyceriim  sup- 
positories or  the  injection  of  from  half  a  teaspoonful  to  a  teaspoonful  of 
glycerine  is  very  efficacious. 

Many  cases  of  chronic  dyspepsia  are  greatly  beneiited  liy  the  use  of 
mineral  waters,  particularly  a  residence  at  the  springs  with  a  careful  super- 
vision of  the  diet  and  systematic  exercise.  The  strict  rcf/iine  of  certain 
(iermun  Spas  is  particularly  advantageous  in  the  cases  in  which  the 
cln-onic  dyspepsia  has  resulted  from  excess  in  eating  and  in  di-inking. 
Kissingen,  Carlsbad,  Ems,  and  Wiesbaden  are  to  be  specially  recom- 
mended. 

III.  NEUROSES  OF  THE  STOMACH. 

(1)  Gastralgia;  Gastrodynia. — Severe  pains  in  the  epigastrium,  parox- 
ysmul  in  elniractcr,  occur  (a)  as  a  manifestation  of  a  luuctional  neurosis, 
independent  of  organic  disease,  ami  usually  associated  with  otlier  lu'rvous 
symptoms  (it  is  this  form  which  will  here  be  described)  ;  {/>)  in  chronic 
disease  of  tlie  nervous  system,  forming  the  so-called  gastric  crises ;  and 
('■)  in  organic  disease  of  the  stomach,  such  as  ulcer  or  cancer. 

The  functional  neurosis  occurs  chiefly  in  women,  very  commonly  in 
connection  with  disturbed  menstrual  function  or  with  i)ronounced  hys- 
terical symptoms.  The  affection  may  set  in  as  early  as  puberty,  but  it  is 
more  common  at  the  menopause.  Anaemic,  constipated  women  who  have 
worries  and  anxieties  at  home  are  most  prone  to  the  alfcction.  It  is  more 
fiefpieiit  in  brunettes  than  in  blondes.  Attacks  of  it  sometimes  occur  in 
robust,  healthy  men.  More  often  it  is  only  one  feature  in  a  condition  of 
general  neurasthenia  or  a  manifestation  of  that  form  of  nervous  dyspepsia 


\P  ' 


la,    ^iJl^ 


in 


!--4f  f         •fir 

J" 


38(5 


DISEASES  OF  THE   DIGESTIVE  SYSTEM. 


li    f 


in  which  the  gastric  juice  or  hydrochloric  acid  is  secreted  in  excess.    I  um 
very  skeptical  as  to  the  existence  of  a  gastralgia  of  purely  malarial  origin. 

The  syniptoiiis  are  very  characteristic ;  the  patient  is  suddonlv  soizod 
with  agonizing  pains  in  the  epigastrium,  whicli  pass  toward  the  l)ack  ainl 
around  tlic  lower  ribs.  The  attack  is  usually  independent  of  the  takiiiir 
of  food,  and  may  recur  at  definite  intervals,  a  periodicity  which  has  j;iviii 
rise  to  the  supposition  in  some  cases  that  the  affection  is  due  to  inalaiin. 
The  nu)st  marked  })eriodicity,  however,  may  be  in  the  gastralgic  attacks  u( 
ulcer.  They  frerjuently  come  on  at  night.  Vomiting  is  rare;  more  com- 
moidy  the  taking  of  food  relieves  the  pain.  To  this,  however,  there  are 
striking  exceptions.  Pressure  upon  the  epigastrium  commonly  gives  re- 
lief, but  deep  pressure  may  be  painful.  It  seems  scarcely  necessary  to 
separate  the  forms,  as  some  have  done,  into  irritative  and  depressive,  as  the 
cases  insensibly  merge  into  each  other.  Stress  has  been  laid  ujiou  the 
occurrence  of  painful  points,  but  they  are  so  common  in  neurasthenia  thai 
very  little  importance  can  be  attributed  to  them. 

'J'he  (iiaijnosis  offers  many  difficulties.  Organic  disease  either  of  the 
stonuich  or  of  the  nervous  system,  particularly  the  gastric  crises  (if  locn- 
motor  ataxia,  must  be  excluded.  In  the  case  of  ulcer  or  cancer  this  is  imt 
always  easy.  I  well  remember  the  case  of  a  poor  fellow  who  was  disoluugd 
from  tlie  Montreal  (Jeneral  Hospital  as  a  nuUiugerer.  A  week  subscqiiom 
to  his  discharge  he  was  readnntted  with  peritonitis  from  perforation.  Tlu' 
fact  that  tlie  pain  is  most  marked  when  the  stomach -is  empty  and  is  re- 
lieved by  the  taking  of  food  is  sometimes  regarded  as  pathognonuuiie  nf 
sim])le  gastralgia,  but  to  this  there  are  nniny  exce})tions,  and  in  eaneor  the 
pains  nuiy  be  relieved  on  eating.  The  prolonged  intervals  between  tin 
attacks  and  their  independence  of  diet  are  important  features  in  sini[ile 
gastralgia;  but  in  many  instances  it  is  less  the  local  than  the  general 
symptoms  of  the  case  which  enable  us  to  make  the  diagnosis.  It  is  to  be 
remembered  that  in  gall-stone  colic  jaundice  is  fre(iuently  absent,  ami  in 
any  long-standing  case  of  grstralgia,  in  which  the  attacks  recur  at  intervaii 
for  years,  the  question  of  cholelithiasis  should  bo  considered. 

(2)  Nervous  Dyspepsi".. — According  to  Leube,  who  first  separated  it 
from  the  ordinary  gastric  catarrh,  nervous  dyspepsia  is  characterized  by 
sensations  of  distress  and  uneasiness  during  digestion,  and  yet  the  act  k 
accomplished  within  the  physiological  time  limit.  The  studies  of  Ewald, 
Oser,  Rosen])ach,  ami  others  have  greatly  extended  our  knowledge  of  tlie 
condition.  The  cases  are  met  with  most  frequently  in  those  who  liavo 
either  inherited  a  neurotic  constitution  or  have  gradually,  through  indis- 
cretions, brought  about  a  condition  of  nervous  prostration.  All  grades  oc- 
cur, from  the  emaciated,  skeleton-like  subject  of  anorexia  nervosa  to  tlu' 
well-nourished,  healthy-looking,  fresh-complexioned  patient  whose  con- 
stant complaint  is  distress  and  uneasiness  after  eating.  If  in  a  case  of 
dyspepsia  the  stomach  is  found  empty  seven  hours  after  the  test  dinner, 
the  supposition  is  that  the  trouble  is  nervous  (Leube).     The  separation  oi 


NEUROSES  OF  THE  STOMACH. 


38( 


tlip  difToront  forms  can  only  be  made  accurately  by  the  chemical  examina- 
tion of  tilt'  juices. 

Clinical  Forms. — Lonbo  recognizes  three  chief  types,  (a)  Xervous 
(Ivspcpsia  with  normal  soeretion.  There  is  no  dilatation  of  the  stomach, 
no  iiain  <in  pressure,  and  no  change  in  the  condition  of  the  acid.  The 
ti'st  iiu'al  is  digested  Avithin  the  normal  time.  Yet,  despite  the  fact  that 
tluMiHitiir  and  chemical  functi(ms  of  the  organ  are  perfectly  performed, 
there  arc  distress  and  uneasiness  during  the  act  of  digestion.  The  patient 
complains  of  jircssure  and  distention  of  the  stomach;  eructations  occur. 

(i)  The  condition  of  subacid ity  or  inacidity.  Lack  of  tlie  normal 
ammiut  of  acid  is  found  in  chronic  catarrh,  and  particularly  in  cancer. 
According  to  Lcube,  reduction  in  the  normal  amount  of  acid  may  exist 
with  the  inrst  ])ronounced  symptoms  of  nervous  dyspepsia,  and  yet  the 
.-tniiiach  will  bo  free  from  food  witlun  the  regular  time.  A  condition  in 
which  the  gastric  juice  is  entirely  without  acid  may  occur  in  cancer,  in  ex- 
treme sclerosis  of  the  mucous  membrane,  and  as  a  nervous  manifestation 
of  hysteria,  and  occasionally  of  taljcs.  The  most  aggravated  cases  are 
those  asi^ociatcd  with  hysteria  and  neurasthenia.  In  addition  to  the  gen- 
eral symptoms,  there  arc  loss  of  appetite,  sk'e})lessness,  and  gastric  disti'css, 
and  Aviien  the  stomach  is  empty  there  are  uneasy  local  sensations  and  gen- 
eral feelings  of  malaise,  headache,  and  dizziness. 

{(■)  Xcrvous  dyspepsia  with  hyperacidity  of  the  gastric;  juices.  This  is 
p.  form  of  dyspepsia  which  has  long  been  recognized,  but  of  late  has  been 
f|iecially  studied  by  Reichmann  and  others.  Tlie  percentage  of  acid  may 
be  douI)led.  Tiiis  increase  in  the  acid  may  be  an  intermittent  condi- 
tion or  continuous.  The  periodic  form  is  really  a  neurosis  of  secretion — 
fjasiroxi/iisis  of  Rosenbach — which  may  be  quite  independent  of  the  time 
of  dii^estion.  Such  cases  are  rare  and  are  associated  either  with  prcjfound 
iicurastht'nia  or  with  locomotor  ataxia.  The  attack  nuiy  last  for  several 
•lays.  It  usually  sets  in  with  a  gnawing,  unpleasant  sensation  of  the 
stomaih,  severe  headache,  and  shortly  after  the  ])atie]it  vomits  a  clear, 
watery  secretion  of  such  acidity  that  the  tliroat  is  irritated  and  made 
raw  and  sore.  As  mentioned,  the  attacks  may  be  quite  independent  of 
food.  The  chronic  condition  of  hyperacidity  is  more  common.  Digestion 
IS  usually  retarded,  particularly  for  the  starches,  and  there  are  eructations 
itf  acid  lluid  and  gastric  distress.  There  are  instances  also  in  which  when 
the  stomaidi  contains  no  food  there  is  a  secretion  of  a  highly  acid  juice. 
In  these  cases  burning  acid  eructations,  or  even  vomiting,  occurring  during 
the  night  or  early  in  the  morning,  are  quite  characteristic. 

The  relation  of  hyperacidity  to  gastric  ulcer  will  be  considered  later. 

(3)  Nervous  Vomiting ;  Peristaltic  Unrest ;  Rumination.— ((/)  Xem- 
""<  ]  oiiiitinf/  —  a  condition  which  is  not  associated  with  anatomical 
fhanges  in  the  stomach  or  with  any  state  of  the  contents,  but  is  due  to 
nervous  influences  acting  either  directly  or  indirectly  upon  the  centres 
presiding  over  the  act  of  vomiting.     The  patients  are,  as  a  rule,  women — 


■^m 


-'-^«^Sife5^^ 


888 


DISEASES  OF  THE   DIGESTIVE  SYSTEM. 


I     fi 


1 


'!#' 


'im 


i^snally  brunettes — and  the  subject  of  more  or  less  marked  bystericul  mani- 
festations. A  special  feature  of  this  form  is  the  absetice  of  tlic  prclimi. 
nary  nausea  and  of  the  straininjjj  efforts  of  the  ordinary  act  of  vomitiiii'. 
It  is  rather  a  regurgitation,  and  witliout  visible  elfort  and  without  'r^t. 
ging  the  mouth  is  lilled  with  tin;  contents  of  the  stomach,  wliicli  iire  tlun 
spat  out.  It  comes  on,  as  a  rule,  after  eating,  but  may  occur  at  irrcnilar 
intervals.  In  some  cases  the  nutrition  is  not  impaired,  a  feature  whjili 
nuiy  give  a  clew  to  the  true  nature  of  tlie  disease,  as  there  nuiy  be  no  otlur 
hysterical  manifestation  })resent.  As  noted  by  'i'lu'kwell,  it  may  oceiii' jn 
children.  Xervous  vomiting  is  rarely  serious.  Death  may,  however,  fol- 
low,  as  in  the  case  reported  l)y  (Jarland,*  in  which  a  young  woniiin,  a;;i(l 
twenty,  had  had  from  the  age  of  two  attacks  of  vomiting  which  lasted  lor 
twenty-four  hours,  and  which  were  very  ai)t  to  occur  Avhen  the  cliihl  was 
extra  well  ami  vivacious.  She  had  St.  Vitus's  dance  at  eleven.  At  almut 
the  age  of  twenty,  she  luid  excessive  muscular  twitchings,  clonic  iri  tluir- 
acter  and  uncontrollable,  and  amounting  to  violent  motion  of  tlic  luu^clo. 
When  twenty-two  she  had  severe  headache,  gradually  lost  tlcsli,  and  be- 
came low-si)irited.  In  Jamuiry,  1884,  she  bad  headache,  twitcliiugs,  ami 
constant  vomiting,  aiul  died  on  the  loth.  There  was  slight  atrophy  df 
the  mucous  mend)rane  of  the  stomach  and  slight  increase  in  the  lirinmv- 
of  the  kidneys. 

A  type  of  vomiting  is  that  associated  with  certain  diseases  of  the  iicrv- 
ous  system — particularly  loconu)tor  ataxia — forming  part  of  the  gii.-trii 
crises.  Leyden  has  reported  cases  of  prirmiry  periodic  vomiting,  wliich  In 
regards  as  a  neurosis. 

(/>)  Pvrisialtic  Unrest. — This  coiulition,  as  described  by  Kussniaul.  i; 
an  extremely  common  and  distressing  symptom  in  neurasthenia.  Slidrtly 
after  eating  the  peristaltic  movements  of  tlie  stomach  are  increased,  and 
borborygmi  and  gurgling  may  be  heard,  even  at  a  distance.  The  .«nb- 
jective  sensations  are  most  annoying,  and  it  would  appear  as  if  in  llif 
hypera^sthetic  condition  of  the  nervous  .«ystem  the  patient  felt  iionnal 
peristalsis,  just  as  in  these  states  the  usual  beating  of  the  heart  niav 
be  perceptilde  to  liim.  A  further  analogy  is  ad'oi'ded  by  the  fact  tluit 
emotion  increases  this  peristalsis.  It  may  exteiul  to  the  mtestiae.s,  par- 
ticularly to  the  duodenum,  and  on  jialpatiou  over  this  region  the  gur- 
gling is  most  marked.  The  movement  may  be  anti-peristalsis,  iu  wliicli 
the  wave  })asses  from  left  to  right,  a  coiulition  which  may  also  extend  to 
the  intestines.  There  are  cases  on  record  in  which  colored  enciiiata  or 
even  scyliala  have  been  discharged  from  the  mouth. 

{(•)  livminatioii ;  M('ri/cif<inn,s. — In  this  remarkable  and  rare  condi- 
tion the  ])atients  regurgitate  and  chew  the  cud  like  ruminants.  It  oecurj 
in  neurasthenic  or  hysterical  persons,  epileptics,  and  idiots.  Iu  some  in- 
stances it  is  hereditary.     I'here  is  an  instance  iu  which  a  governess  taught 

*  Transuclions  of  tho  Association  of  Ainerican  Physicians,  vol.  iv. 


lit' I 

tkiiilf  ,ii!ii1 43L 


NEUROSES  OF  THE  STOMACH. 


389 


it  to  uvii  cliililrcn.  The  hiibit  may  porsist  for  years,  ami  docs  not  iiocos- 
.■^iiiily  inii)air  tlio  lioalth. 

Here  may  be  mentioned  the  condition  known  as  pica,  met  with  ciiielly 
ill  insanity,  hysteria,  and  cliloi'osis,  in  which  tlie  appetite  is  inordinate 
mill  perverted,  and  in  which  all  sorts  of  non-nutritive  articles  are  eaten. 
(u(ililia,<;i.siii,  earth  or  clay  eating,  prevails  as  a  habit  in  parts  of  the  South- 
ern States. 

Treatment  of  Neuroses  of  the  Stomach. — The  gastralgia,  if 

very  .sevt're,  reipiires  m(»r])hia,  which  is  best  administered  subcutaneously 
ill  eidiibination  with  atro])ia.  In  the  milder  attacks  the  combination  of 
iiiiiriiliia  (gr.  ^)  ■with  cocaine  and  belladonna  is  recommended  by  Ewald. 
The  (jroatest  caution  should,  however,  be  exercised  in  these  cases  in  the 
use  of  the  hypodermic  syringe.  It  is  preferable,  if  opium  is  necessary,  to 
<rive  it  by  the  mouth,  and  not  to  let  the  jjatient  know  the  character  of  the 
dnii;.  Clilorol'orm,  in  from  ten  to  twenty  drop  doses,  or  lIolTmairs  ano- 
(Iviie  will  sDinetimes  allay  the  scA'ore  pains.  The  general  condition  sliDuld 
receive  eareful  attention,  and  in  many  cases  the  attacks  recur  until  the 
lu'jiltli  is  restored  by  change  of  air  with  the  itrolonged  use  of  arsenic.  If 
there  is  aiueniia  iron  may  be  given  freely,  ^'itrate  of  silver  in  doses  of 
i;r.  :|^  to  i  in  a  large  claret-glass  of  water  taken  on  an  empty  stomach  is 
usel'iil  ill  some  cases. 

Many  cases  of  nervous  dyspepsia  with  marked  neurasthenic"  or  hysteri- 
i!il  syiiiptoiiis  do  well  on  the  ^^'eir-.\Iit(•hcll  treatment,  and  in  obstinate 
fnniis  it  should  be  given  a  thorough  trial.  The  most  striking  results 
lire  perhaps  seen  in  the  cases  of  anorexia  nervosa,  which  Avill  be  referred 
to  subse(iiiently.  It  is  also  of  value  in  the  nervous  vomiting.  In  the  dis- 
tressing cases  of  liyp(>racidity,  in  addition  to  the  treatment  of  the  general 
iieurotie  condition,  alkalies  must  be  employed,  either  in  the  form  of  mag- 
nesiii  or  bicarbonate  of  soda.  The  burning  acid  eructations  are  usually 
relieved  in  this  way. 

Limiting  the  patient  to  a  strictly  meat  diet  is  a  valuable  procedure 
ill  many  cases  of  ilyspepsia  associated  with  hyperacidity.  The  meat  should 
be  taken  either  raw  or,  if  an  insuperable  objection  exists  to  this,  very 
>li,i,'htly  cooivod.  It  is  best  given  finely  minced  or  grated  on  stale  bread. 
An  ain|>le  dietary  is  3|-  ounces  (100  grammes)  of  meat,  two  medium 
slices  of  stale  bread,  and  an  ounce  (30  grammes)  of  butter.  This  may 
he  taken  three  times  a  day  with  a  glass  of  A])ollinaris  water,  soda  water, 
'>r.  what  is  just  as  satisfactory,  spring  water.  The  lluid  should  not  be 
taken  too  cold.  S])ecial  care  should  bo  liad  in  the  examination  of  the 
iiieat  to  guard  against  tape-Avorm  infection,  but  suitable  instructions  on 
this  point  can  be  given.  This  is  sufficient  for  an  adult  man,  and  many 
ohstinate  cases  yield  satisfactorily  to  a  month  or  six  weeks  of  this  treat- 
mint,  after  which  time  the  less  readily  digested  articles  of  food  may  bo 
f,'i'iiilually  added  to  the  dietary.  In  other  instances  the  use  of  the  stom- 
ach-tube is  most  effectual. 


300 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


Tliere  are  forms  of  nervous  dyspepsiii  occurring  in  women  who  arc 
often  well  nourished  and  with  a  good  color,  yet  who  suller— |iartiiiilailvat 
night — witii  flatulency  and  ahiloniinal  distress.  The  sleep  may  l.c  oiiiit 
and  undisturbed  for  two  or  tliree  hours,  when  they  are  aroused  with  pain- 
ful sensations  in  the  abdomen  and  eructations.  The  apju'tite  and  iligcs. 
tion  may  appear  to  be  normal.  Constipation  is,  however,  usually  present, 
In  many  of  these  ])atients  the  condition  seems  rather  intestinal  dyspepsia, 
and  the  distress  is  due  to  the  accumulation  of  gases,  the  result  of  excess- 
ive putrefaction.  The  fats,  starches,  and  sugars  should  be  restricted.  \ 
diastase  ferment  is  scjinetimcs  nseful.  The  Ilatuleiu-y  may  be  treateij  hv 
the  methods  above  mentioned.  N'aphthalin,  salicylate  of  bisnnitli,  ami 
salol  have  been  recommended.  Some  of  these  cases  obtain  relief  fium 
thorou<;ii  irrigation  of  the  colon  at  bedtime. 


.    h 


lu.ii 


•     ^   PI 


Ifhi  ^ 


IV.     DILATATION   OF  THE  STOMACH  [On^trecla.is). 

Etiology. — 'I'his  may  occur  either  as  an  acute  or  a  clironie  con- 
dition. 

Acute  diJiitatiiin  is  rarely  seen,  though  it  occurs  whenever  eiKiniKnis 
quantities  of  food  and  drink  are  quickly  ingested.  Occasionally  thisleail. 
to  extreme  paralytic  dilatation,  and  Fagge  has  described  two  case;;  wliiih 
came  on  in  this  way,  one  of  which  proved  fatal. 

Cln'dnir  i/i/(i/ii/iii)i  results  from:  (a)  Narrowing  of  the  jnionis  or  of 
the  duodenum  by  the  cicatrization  of  an  ulcer,  hypertrophic!  stenosis  I'f 
tlie  pyloi'us  (whether  cancerous  (tr  simple),  congenital  stricture,  nr  nica- 
sionally  by  pressure  from  without  of  a  tumor  or  of  a  floating  kiiliicv. 
Without  any  organic  disease  the  jjylorus  niay  be  tilted  up  by  adhesion  to 
the  liver  or  gall-ldaddei'.  or  the  stomacdi  may  be  so  dilated  that,  the  pylnrti? 
is  dragged  down  and  kinked,  {b)  Relative  or  absolute  insuHicieiiey  of  tik- 
muscular  power  of  the  stomach,  due  on  the  one  hand  to  repeated  owr- 
lining  of  the  organ  with  food  and  driidv  {Frhi'nnistirnf/niii/  i/cs  Mimis. 
.Slri'imptdl),  and  on  the  other  to  atony  of  the  coats  induced  by  ebroiiii' 
intlanimation  or  degeneration  or  impaired  nutrition,  the  result  of  consti- 
tutional atfections,  as  cancer,  tuberculosis,  aniumia,  etc. 

The  most  extreme  forms  are  met  with  iu  the  tirst  group,  and  most 
commonly  as  a  sefpience  of  the  cicatricial  contraction  of  an  ulcer.  There 
may  be  considerable  stenosis  without  much  dilatation,  the  obstruction  I)ein2 
compensated  by  iiypertrophy  of  the  muscular  coats.  Consideialde  atieii- 
tion  has  been  directed  in  (Jermany  by  Litten,  Ewald,  and  others  to  tlif 
association  of  dilatation  with  dislocation  of  the  riglit  kidney.  Two  well- 
marked  instances  have  come  under  my  observation  among  a  very  law 
nund)er  of  cases  of  movable  kidney,  but  iu  neither  was  the  dilatation  ex- 
treme. 

In  the  second  group,  due  to  atony  of  the  muscular  coats,  wo  mustili" 
tinguish  between  instances  in  which  the  stomach  is  simply  eidarged  aim 


DILATATION  OF  THE  STOMACH. 


391 


those  uitli  iictiial  dilatutioii,  tlio  ooiiditioiis  wliich  Ewald  olmnictorizcd  as 
iiirfi((.'<lrif  iiml  i/iis/irr/fisis  rcsitoctivoly.  'I'lie  si/c  of  tlio  stoiiuu^li  varies 
trmitlv  ill  (lillVrc'iit  individuals,  and  the  iiiaxiiiiimi  capacity  nf  a  normal 
(iiLMii  Muald  places  at  about  1,<J0()  c.  c.  Moasiirciiiciits  above  this  point 
imlicaic  alisolntc  dilatation. 

Atonic  dilatation  of  the  stomach  may  result  from  weakness  of  the 
coats,  (liu-  to  repealed  overdistention  or  to  ehronic  catarrh  of  the  mucous 
iiicMiliraiie,  or  to  the  «]fencral  muscular  debility  which  is  associated  with 
chroiiii'  wastinjjj  disorders  of  all  sorts.  'I'lie  combination  of  chronic  ^'astric 
ciitarrli  with  overfeeding  and  excessive  drinking  is  om;  of  the  most  fruit- 
ful sources  of  atonic  dilatation,  as  pointed  out  by  Naunyn.  The  condition 
i>  t'nM|uciiily  seen  in  diabetics,  in  the  in>aiu',  ami  in  beer-drinkers.  In 
(IciniMiiy  this  form  is  very  common  in  men  employed  in  the  breweries. 
i'(is>i'hly  muscular  weakness  of  the  coats  may  result  in  some  casi\s  from 
ilisturhed  innervation.  Dilatation  of  the  stomach  is  most  frequent  in 
iiiiildlt'-aged  or  elderly  persons,  but  the  condition  is  not  uncommon  in 
rliiMreii,  especially  in  association  with  rickets. 

Symptoms. — 'J'hese  are  very  variable  and  depend  upon  the  cause  and 
tliedeirive  of  dilatation.  Naturally  the  features  in  cancer  of  the  ])ylorus 
would  tie  very  dill'erent  from  those  met  with  in  an  excessive  drinker. 
Ihiipepsia  is  jiresent  in  nearly  all  cases,  and  there  are  feelings  of  distress 
ainl  uiioasiuess  in  the  region  of  the  stonuieh.  The  ])atient  may  complain 
iniK'h  of  hunger  and  thirst  and  eat  aiul  drink  freely.  The  most  character- 
istic .«yniptom  is  the  vomiting  at  intervals  of  enormous  (pumtities  of  lifpiid 
mill  of  food,  amounting  sometimes  to  four  or  more  litres.  The  material 
is  often  of  a  dark-grayish  color,  with  a  characteristic  sour  odor  diu'  to  the 
oi'iriinic  acids  present,  ami  contains  mucus  and  remnants  of  food.  ()n 
staiuliiig  it  se])iirates  into  three  layers,  the  lowest  ciuisistiug  of  food,  the 
middle  of  a  turbid,  dark-gray  fluid,  and  the  uppermost  of  a  brownish  froth. 
The  uiiei'oscopical  examination  shows  a  large  variety  of  bacteria,  yeast 
fniifri,  and  the  sarcina  ventriculi.  There  may  also  be  cherry  stones,  plum 
stmu's.  and  grape  seeds. 

Tlie  hydrochloric  acid  may  be  absent,  diminished,  normal,  or  in  excess, 
(Ippendiiig  upon  tlie  cause  of  the  dilatation.  The  fernu-ntation  produces 
luetic,  butyric,  and,  possibly,  acetic  acids  and  various  gases. 

In  eonsecjuence  of  the  small  amount  of  fluid  whi(di  passes  from  the 
stomaeli  or  is  absorbed  there  are  constipation,  scanty  iirine,  and  extreme 
ilrynoss  of  the  skin.  I'he  general  nutrition  of  the  patient  suffers  greatly : 
there  is  loss  of  flesh  and  strength,  and  in  some  cases  the  most  extreme 
i-'iimeiiitioii.  A  very  remarkable  sym})tom  which  occnrs  occasionally  is 
tt'tauy.  Ilvst  described  by  Kussmaul. 

Physical  Signs. — hi-yjection. — The  abdomen  may  be  large  and  pronii- 
iipnt,  the  gi'eatest  projection  occurring  below  the  navel  in  the  standing 
posture.  In  some  instances  the  outline  of  the  distended  stomach  can  be 
puiuily  seen,  the  small  curvature  a  couple  of  inches  below  the  ensiform 


'•/  ,'i* 


392 


DISEASES  01-'  THE   DIGESTIVE  SYSTEM. 


M- 


ij!f 


k(. 


Uiu  tw 


*    f . 


cartilage,  aiul  tho  f^rriiter  curvature  passing  ol)li(|uely  from  the  tip  of  ili,, 
teutli  rib  on  the  left  jiidc,  toward  tlie  jtulM's,  and  then  curving  ii|p\viiril  i, 
tho  right  costal  margin.  Too  niucli  stress  cannot  ho  laid  on  tlic  iin|iiir. 
tanco  of  inspection.  In  ten  of  thirteen  cases  of  dilated  stomui  h  in  im 
wards  during  one  year  the  diagnosis  was  nuide  (/e  visit.  Active  poristaisij 
may  be  seen  in  tho  dilated  organ,  the  waves  passing  from  left  to  riirlit. 
Occasionally  anti-[)eristalsis  may  be  seen.  In  cases  of  stricture,  particii 
larly  of  hypertrophic  stenosis,  as  the  peristaltic  wave  reaches  the  pNlonis, 
the  tumor-like  thickening  can  sometimes  be  distinctly  seen  thioii^'li  tln' 
thin  abdominal  wall.  To  stimulate  the  peristalsis  the  abdomen  iimy  Ic 
flipped  with  a  wet  towel,  or  inflation  may  be  practised  with  tartarii'  iiciil 
and  bicarl)onate  of  soda. 

P(iJj)fi/iini. — The  peristalsis  may  be  felt,  and  usually  in  stenosis  the 
tumor  is  evident  at  tlie  ])ylorus.  The  resistan(!e  of  ad  dated  stotiiiieli  i> 
pecidiar,  and  has  been  aptly  compared  to  that  of  an  air  cushion.  Bi- 
manual palpation  elicits  a  splashing  sound — dapofagi' — which  is,  of  eoiiisc, 
not  distinctive,  as  it  can  be  obtained  whenever  there  is  much  li<|ui(l  ainl 
air  in  the  organ,  ])ut  it  cannot  be  obtained  in  a  healthy  jxTSdii  twn or 
three  hours  after  eating.  The  splashing  may  be  very  loud,  and  the  pationt 
may  produce  it  himself  by  suddenly  depressing  the  diajjhragni,  (ir  it  may 
be  readily  obtained  by  shaking  him.  A  tube  passed  into  the  slomacli  may 
be  felt  externally  through  tho  skin,  a  procedure  no  longer  reeoinnu'inleil 
by  Leube,  who  suggested  it.  The  gurgling  of  gas  through  the  pyl(iiii> 
may  be  felt. 

/V/v.7/.v.s/./y/. — 'I'lie  note  is  tympanitic  over  the  greater  portion  of  :i 
dilated  stomach  ;  in  the  dependent  part  the  note  is  dull.  In  the  upridit 
position  the  percussion  should  be  made  from  above  downward,  in  the  left 
parasternal  line,  until  a  change  in  resonan(^e  is  reached.  The  line  of  this 
should  be  marked,  and  the  patient  examined  in  the  recumbent  position, 
when  it  will  be  found  to  have  altered  its  level.  When  this  is  on  a  line 
with  the  navel  or  below  it,  dilatation  of  the  stomach  may  genenilly  bo 
assumed  to  exist.  The  fluid  may  be  withdrawn  from  the  stomach  with  a 
tube,  and  the  dulness  so  made  to  disappear,  or  it  may  be  increased  liy 
pouring  in  more  fluid.  In  cases  of  doubt  tl;e  organ  may  be  artiiicially 
distended  with  carbonic-acid  gas.  A  teaspoonful  of  bicarbonate  of  soda 
is  first  given  in  a  little  water,  and  then  the  same  quantity  of  tartarii'  aci'l. 
The  most  accurate  method  of  determining  the  size  of  the  stomach  is  by 
inflation  through  a  stomach-tube  with  a  Davidson's  syringe,  racanowtki 
has  shown  that  the  greatest  vertical  diameter  of  gastric  resonance  in  the 
normal  stomach  varies  from  10  to  14  cm.  in  the  male  and  is  about  10  cm. 
in  the  fennde. 

Auf<ruUatinn. — The  clapolcment  or  succussion  can  be  obtained  readily. 
Frequently  a  curious  sizzling  sound  is  present,  not  unlike  that  heard  when 
the  ear  is  placed  over  a  soda-water  bottle  when  first  opened.  It  can  be 
heard  naturally,  and  is  usually  evident  when  the  artificial  gus  is  being 


DILATATION  OF  THE  SToMAril. 


a93 


21'Mcrnti'il.  Tlio  lioart  hoimkIs  niiiy  sornotiriicri  ha  triiiLsinittud  with  firoat 
clciiriu'ss  utid  with  ii  im'tiiUic  (itiiility. 

,]li'iisiirii/iiiti  Jiiiiy  1)0  used  hy  piissiu",'  a  hard  sound  into  the  stoniadi 
until  the  u'l'i'iitcr  curvature  is  readied.  Nonnally  it  rarely  passes  more 
tliiiii  (Id  cin.,  measured  from  the;  teeth,  hut  in  eases  of  dilatation  it  may 
m<<  n^  iniict)  as  7(1  cm. 

Diagnosis. --The  diagnosis  can  usually  ho  nuule  without  much  difll- 
ciiltv  by  attention  to  these  methods  of  examituition.  Curious  errors,  how- 
ever, are  on  record,  one  of  the  most  remarkahlc  of  which  was  the  con- 
foiMulint;j  (if  dilated  stomach  with  an  ovarian  cyst;  even  after  tapping 
and  tlio  removal  of  portions  of  food  and  fruit  seeds,  ahdominal  section 
was  performed  and  the  dilated  stomach  opened.  The  prof/nosis  is  liad 
in  eascts  in  winch  there  is  stenosis  of  the  pylorus,  either  simple  or  can- 

I'lTiillS. 

Treatment. — In  the  cases  due  to  atony  carefid  regulation  of  the 
diet  iiiiil  proper  treatment  of  the  associated  catarrh  will  suthce  to  effect  a 
cmv.  Strychnine,  ergot,  and  iron  are  recommended.  Washing  out  the 
.itomiirh  is  of  great  service,  tliough  we  do  not  see  such  striking  and  imme- 
diate rcsidts  in  this  form.  In  cases  of  mechanical  ol)struction  the  stomach 
cliiiiild  In- emptied  and  thorouglily  washed,  either  with  warm  water  or  with 
an  antiseptic  solution.  We  accomplish  in  this  way  three  important  things  : 
Wo  remove  the  weight,  which  helps  to  distend  the  organ  ;  we  remove  the 
iiinciis  iuul  the  stagnating  and  fermenting  material  which  irritates  and  in- 
tlaiMCti  the  stonnich  and  impedes  digestion  ;  and  we  cleanse  the  inner  sur- 
faco  of  the  organ  hy  the  application  of  water  and  medicinal  suhstances. 
The  patient  can  usually  he  taught  to  wash  out  his  own  stomach,  and  in  a 
i-w  of  dilatation  from  simple  stricture  I  have  known  the  practice  to  he 
fullowed  daily  for  three  years  with  great  henetlt.  Tiie  rapid  reduction 
in  the  size  of  the  stomach  is  often  remarkahle,  the  vomiting  ceases,  the 
fitDil  is  taken  readily,  and  in  many  cases  the  general  nutrition  improves 
lafiidly.  As  a  rule,  once  a  day  is  suOicient,  and  it  may  be  jiractised  either 
tlie  tirst  thing  in  the  morning  or  before  going  to  bed.  80  soon  as  the 
fermentative  proces.ses  have  been  checked  lukewarm  water  alone  should 
be  used. 

The  food  should  be  taken  in  small  quantities  at  frequent  intorvuls, 
■iiiil  (ihouhl  consist  of  scraped  beef,  liCube's  beef  solution,  and  tender 
iiieats  of  iill  sorts.  Fatty  and  starchy  articles  of  diet  are  to  be  avoided. 
l-i'|inds  sliould  be  taken  sparingly. 

W  lien  the  condition  becomes  aggravated  a  resort  to  surgery  is  justifi- 
''''le.  Hero  may  be  mentioned  the  recent  statistics  of  gastric  surgery. 
I'ylorie  stenosis  is  the  common  condition.  Dreydorff  has  collected  m 
'■■i>es— lis.s  eases  of  pylorectomy,  mortality  oT'i  per  cent ;  215  gastro-en- 
t'Tostomios,  mortality  43-3  per  cent;  pyloroplasty,  20  cases,  mortality  20-7 
I't'i'  Cent.  Oil  an  average,  after  pylorectomy  the  patient  remained  free 
flora  reeunence  for  a  little  over  a  year. 


Ui 


1:4 


'I'  '      '« 


;}04  DISKASKS  OF  TIIK   DIOKSTIVE  SYSTKM. 

V.  THE  PEPTIC   ULCER-GASTRIC  AND   DUODENAL 

'I'lic  KHiiiil,  iicrrniiiliii^'  or  siiDpli!  ulcer  is  iisiiall_\  .-iii^'lc  and  nirm,  i,, 
till'  stniii.icli  iiiid  ill  the  (liiodi'iiiiiii  u.s  far  as  tlic  jiapilla  l)iiiaria.    Ii  |,ni,. 
alily  I'oIIkws  iiiitritioiiul  distiirl)aiice  in  a  limited    i'e;;i(tn  of  ijic  inn,,,.;, 
whieli  resiills  ill  tiie  liradiial  ileslnielion  of  tiiis  ana  liy  the  <,M.<lric  jni,, 
'i'iie  (■(•iiditidii  is  iisually  associated  with  hyiieracidity. 

Etiology.— CI  ill  ically  the  simple  ulcer  is  not  so  IVe(|uenf  as  llic  sta- 
listiis  oj'  [lost  iiiorteiiis  would  lead  lis  to  expect  ;  Ih^is  in  the  extensive  nv. 
<irds  collected  l)y  Welch,  ulcer,  eicutri/ed  or  open,  was  jireseiit  in  iili,,i,> 
five  per  cent  of  persons  dyiiijf  from  all  causes.  The  scars  are  I'diiinl  m,,!, 
i'reijiiciilly  than  the  ojieii  ulcer. 

Females  are  more  frecpieiitly  ulTected  than  males.  Of  l,(;!il)  cmscs  c,,!. 
Iccted  from  hospital  statistics  Ity  Welch,  and  examined  post  iiini'lnii.  ^m 
]ier  cent  wi'i'e  in  males  and  (Kt  jH'r  cent  were  in  females.  lIc^iviHli 
a;j:e  incidence  in  (lo;  cunes,  of  which  three  fourths  were  distril.iiicjl,,. 
tweeii  the  a^^'es  of  twenty  and  sixty,  with  tolerahle  uniformity  in  tlif  Inii, 
decades,  in  females  the  largest  iiumln'r  of  cases  occurs  lu'lweeii  twciiiv 
and  thirty;  in  niaU's,  hetwoen  thirty  and  forty.  I'lcer  oceasionnllv  i.r- 
I'urs  in  children,  and  (ioodliart  has  reported  a  ease  in  an  infiinl  tliirn 
hours  old.  (iastric  ulcer  is  stated  to  be  less  eonmioii  in  this  coiintr;  thai. 
ill  JMiro[ii'. 

In  women  it  is  freijueiit  among  servant  girls,  and  in  men  uIki  fiillnu 
such  occupations  na  slioo-niaking,  weaving,  and  tailoring,  possibly  ((nimrt- 
od,  as  ilalicrslioii  suggested,  Mith  pressure  on  the  st(»inacli.  This  \i(w 
has  been  developed  by  l{asmussen,  who  holds  that  ()ressiire  of  t lie  costal 
margin,  from  various  causes,  induces  amemia  and  atrophy  of  tlic  iiui(i>ii- 
nieinlirane,  particularly  in  the  region  of  the  smaller  curvatiiic.  Wrv 
rarely  the  disease  originates  from  traumatism  or  the  action  of  (•()i'iii>iu' 
fluids,  (iastric  ulci-r  is  associated  in  a  .s]»eeial  manner  with  certiiiiiiliv 
eases,  in  women  with  ana'iiiia  and  chlorosis  and  with  menstrual  iliHinlcr.-. 
It  is  not  infreipieiitly  met  with  in  tuberculosis.  Such  cases  are  not.  \m- 
ever,  to  be  mistaken  for  the  true  tuberculous  ulcer,  which  may  be  I'diiiiil  in 
the  stomach. 

^fany  cases  have  occnrre<l  i'.  connection  with  disease  of  the  ln';ii't  ir 
of  the  blood-vessi'ls,  a  relation  of  special  interest  in  connection  with  iIt 
embolic  theory  of  its  production. 

The  duodenal  ulcer  is  less  common  than  the  gastric  ulcer,  ami  "ii"'^ 
most  frequently  in  males.  The  combined  statistics  of  Krau-s.  ClivusUk, 
Lebert,  and  Trier  give  171  eases  in  males  and  30  in  females.  In  9  Lasts 
Avhich  have  come  under  my  obsi'rvation  7  were  in  males  and  'Z  in  fi'imiH'S 
one  of  these  was  in  a  lad  of  twelve.  It  has  been  found  in  associiitioii  with 
tuberculosis,  and  may  follow  large  sujierfictial  burns. 

Morbid  Anatomy . — Though  usually  single,  the  ulcers  mayln'imilii- 
pie.   In  none  of  my  cases  were  there  more  than  live,  but  there  is  an  iiistani-t 


Tin:   PKI'TIC   UU'EIl-(}ASTUIC   ANT)   DIIOPKNAL. 


'.»:) 


(Ill  rcfinl  I'f  tliirty-foiir.  The  iilctT  is  sitiintcd  most  roiiuiHUily  on  tlio 
|iii.t(.|i(ir  Willi  oC  the  pyloric  pdftioii  at  or  near  tiic  lesser  eiirvatiire.  It  in 
net  iiiMi'lv  so  rre<|ilent  on  tiu'  aiilerinr  wall.  Oi"  '*('.».')  i-ises  collected  ])y 
U.jrli  t'i'iiii  liospital  stutisticH,  JilSH  wvw  on  tlic  lesser  curvature,  •»':$."»  on 
til,'  |i(i..ierinr  wall,  '.•."»  at  llie  jtyloriis,  ('.!)  oil  tlie  anterior  wall,  TiO  at  tliu 
cMi'iliii,  I".'  lit  tlic  rundiis,  '^]'  on  tlie  j^reater  curs  at  lire,  'i'lie  duodcniil 
nicer  is  usually  witualeil  just  oiitsido  tlio   ring  in   tlio   first  jtortion   of 

lln',i.'llt. 

T!ir  uleev  varics  from  1  to  10  cm.  in  dianu'tcr.  Tt  nuiy  lie  small  and 
iiuiiclieil  niit,  or  it  may  reach  an  enortiious  si/e.  The  larirest  nf  which  I 
li;i\i'  iiiiv  kiiowledirc  is  one  reported  hy  I'eahody,  which  nieasiired  1!»  hy 
loiiii.  and  involved  all  of  the  lesser  curvature  and  spread  over  a  largo 
|iiirt  of  ili(!  aiderior  and  posterior  walls.  The  ideer  is  usually  round  or 
(iviil  in  shape,  hut  may  he  irregular  with  sinuous  horders.  It  is  often  dis- 
tinctly terraced.  In  acute  eases  the  nuicoiis  nu'iid)rane  is  sharply  cut,  us 
if  [iiuu'lied  out  hy  an  instrument.  In  old  cilsos  the  edge  is  indurate<l  and 
loses  the  shaip  margin.  Tho  floor  is  formed  either  l)y  the  suhmiieosa,  hy 
the  nniscular  layers,  or,  not  infriMpiently,  ])y  the  neighhoring  organs,  to 
whii'li  the  stomaidi  has  liecomo  attached.  In  tiu'  healing  of  the  ulcer,  if 
the  iiiitiii-a  is  alone  involved,  the  granulation  tisstie  (levelo])s  from  the  edges 
and  the  Ihior  and  tho  newly  formed  tissue  gradually  contracts  and  nnites 
tlie  iiiaigiiis,  leaving  a  smooth  scar.  In  larger  ulcers  which  have  hecome 
ilce[iiin(i  involved  tho  muscular  coat  the  cicatricial  contraction  may  cause 
H'rious  changes,  the  most  important  of  which  is  narrowing  of  the  i)yloric 
iifitiee  and  conso([uont  dilatation  of  the  stomach.  In  the  case  of  a  girdle 
nicer,  hi iiir-glass  contracition  of  tho  stoinaidi  nuiyhc  produced.  It  is  prob- 
iilile  that  large  ulcers  })orsist  for  years  without  any  attempt  at  healing. 

The  ulcei'  may  deepen  and  penetrate  tho  coats.  Fortunately,  in  a 
majority  of  the  cases,  adlu'sions  form  hetween  the  stonuich  and  adjacent 
iii'piiis,  particularly  with  tho  pancreas,  the  left  lol)e  of  the  liver,  and  tho 
iiineiitiil  tissues  On  the  anterior  surface  of  the  stomach  adhesicm.s  do  not 
fr>  iviiilily  form,  hence  tho  great  danger  of  the  idc(>r  in  this  situation, 
wliiih  iiKiri'  readily  jjorforatos  and  excites  a  ditfuse  ai\d  fatal  peritonitis. 
"a  the  |i()steri(ir  wall  the  ulcer  penetrates  directly  into  the  lesser  pcri- 
t'lneal  cavity,  in  which  case  it  may  produce  an  air-containing  abscess  with 
tliesyiii|>toiiis  of  the  comlition  known  as  suhidirenic  pyo-pneumothorax. 
Ill  ruiv  iustaiiees  adhesions  and  a  gastro-cntaneous  fistula  form,  usually 
"i  the  unihilieal  region.  Fistulous  communication  with  the  colon  may 
also  (Hciir,  or  a  gastro-duodenal  fistula.  There  are  several  instances  on 
I'tidiil  ,ii'  perforatioii  into  tho  pericai'dinm,  and  at  least  two  of  rupture 
iiitci  tho  left  vi'iitriclo.  Perforation  into  the  pleura  may  also  occur.  It  is 
'"  be  ni)U'i\  that  general  emphysema  of  the  subcutaneous  tissues  occasion- 
i'lly  follows  ]ierforation  of  a  gastric  ulcer. 

Oae  of  the  most  serious  effects  of  gastric  ulcer  is  erosion  of  blood-ves- 
s^'ls.    The  lueinorrliage  may  occur  in  the  acutely  formed  ulcer  or  iu  the 


ev. 


! 


'  !i 
i  n 


i 


1 1!  I 


i 


.   I'if^i 


;5t)6 


DISKASES  OF  THE   DIGESTIVE  SYSTEM. 


ulceration  uliicli  takes  ])la('e  at  tlu'  liasi'  of  tlu'  clininit!  fori;i ;  it  is  in 
tho  latter  condition  tiiat  tlio  bU'cdinif  l^  nio.it  co'iiiiion.  VIccim  (in  ti;,, 
jMKsterior  wall  may  crodo  tlio  s[)U'iiic  artery,  but  [)erlia[)s  more  rr('(|iii'iiilv 
the  bK't'dinu' proi-eeds  from  the  artery  oi'  the  lesser  curve.  In  tlic  cusi'i  f 
duodenal  ulrer  the  pancreatieo-duodeiial  artery  may  he  eroded  (,r  (;is  in 
one  of  my  eases)  fatal  iKi'iiiorriia^e  may  result  from  the  oii'iiiii;:  df  tlv 
hejiatic  artery,  or  more  rarely  Iht-  portal  vein.  Inti'ivstiiiij:  (  linnm's  dcinr 
in  the  vessels.  Kmbolism  of  the  artery  sii[)plyiiijf  tiie  ulcerated  reijidii  li;i> 
been  met  with  ii  several  eases;  in  others  dilViiso  endarteritis.  SniiiH 
aneurisms  have  been  found  in  the  Uoor  of  the  ulcers  by  Douglas  IViwiI!. 
Welch,  and  others. 

The  mode  of  the  orif^in  of  the  peptic  ulcer  has  heeii  much  disciisseij. 
Ulcers  have  been   [)roduced   in  animals  in  many  ways,  both  by  artiliciul 
emboli  and  l)y  direct  cheioical  and  mechanical  irritants  applied  to  the  mu- 
cosa,    '.riie  ulcers  thus  })roduced   heal  with  great  i-ajiidity  unless  tluaiii- 
mals  have  been  rendorod  anttmic  by  repeated  abstraction  of  blood.    Vir- 
chow's  view  that  the  process  may  result  from  plugging  the  nutrient  iirtirv 
of  the  jiart,  either  by  an  embolus  or  l)y  a  throiiibus,  and   the  iid'arrt  sm 
produced  is  destroyed  by  the  gastric  juice,  has  gained  general  accciitiiiin. 
It  is  in  eoiiforinity  with  Pavy's  well-known  experiments  and  with  tlirMii;!- 
tomical  facts  already  mentioned,  jiarticularly  with  the  funiiel-liko  sliain- 
of  the  uh'cr,  and  the  actual  demonstration,  in  some  cases,  of  the  jiliiu^'vii 
vessels;  but  this  view  scarcely  meets  all  the  cases,  in  many  of  wliicli  tlic 
etiology  is  still  obscure.     Mere   mechanical   injury  to  the  mucous  imin- 
brane  is,  howi'Vv'r,  in   most  cases,  iiisullicient  cause  for  an  ulcer,  I'or  hmi- 
mally  the  stonuudi    is    jicrfeclly  able  to  withstand  such  insults.    KwaM 
concludes  that  certain  predisposing  causes  ])lay  an  important  n'llr  in  it- 
developnu'iit.     lie  points  to  its   freipiency  in  c()iiditious  of  aJiii'iinirlKia. 
elilorosis,  aiia'iiiia  al'ti'r  conrniements,  etc.,  where  one  may  assiiiiic  tli;it  llic 
condition  of  the  blood  is  not  wholly  normal,  and  also  to  the  fait  that  in 
the  majority  of  cases  of  this  alTcction  there  is  a  hyjieracidity  of  the  ps- 
trie  juice.     One  or  both  of  these  ]»redisposiiig  factors  seem   to  be  pros- 
cut  in   most  cases,  and    il   has  \)vvn    recently  shown  that  in  the  varimi- 
anivniia>  there  is  an  ap})reciable  diininiition  in  the  normal  alkalinity nl 
the  blood,  a  tact  which  tends  to  explain  one  of  the  jircilisposiiiL'  niiw- 
in  these  alTi'ctions,  and  which  is  in  accord  with  the  "  alkalesi'ciice  theerv 
of  Cohnheim  rf  ah     The  duodenal  nicer  has  an  identical  origin,  hut  a  ft« 
cases  of  acute  ulcer,  as  already  nieutioiied,  have  a   curious  relation  wiili 
superticial  burns.     In  one  of  my  cases  there  was  an  nicer  in  the  iidstericr 
wall  of  the  duodenum,  l-ii  cm.  in  diameter,  with  overlajiping  eilues, ami 
not  far  from  it  was  a  cyst-like  cavity  in  the  submiicosa  associatnl  wit.i 
Brunner's  glands,  and  it  is  possible  that  the  open  ulcer,  with  uinleiiiiiiici 
edges,  resulted  from  the  rupture  of  one  of  these  cysts. 

Symptoms. — The  condition  may  be  met  with  accidentally,  post  mor- 
tem, in  cases  which  liavc  ])rcsented  no  indication  of  gastiit!  dislurbaua'. 


1    i'-iif 


THE  PEPTIC   ULCER-GASTRIC   AND   DUODENATi. 


ai)/ 


In  oHior  insiiuu'os  tlio  first  syniptoiiiH  may  In-  duo  to  ]H'rforiiii()ii.  In 
nthcrs  uiiuiu  the  syiuptonis,  for  iiioiitlis  ntul  years,  may  \)v  tlioso  of  ordi- 
!i;irv  ilvs|ii'|>sia,  and  tho  ulcer  may  not  have  been  sus]teeti'(l  until  the  oc- 
iiiriviico  perhaps  of  a  sudden  ha'iuorrlia;;i'. 

The  sviuptonis  sujjtrestive  of  peptic  ulcer  are:  (if)  l\vspopsia,  ■\vliieli 
iiiav  1)0  sliirht  and  trilliiiijc  <m-  of  a  most  a.Lrnravated  ciiaracter.  In  a  coti- 
"iili'vahle  i)rnpi)rtion  of  all  eases  nause:i  and  vomitinix  occur,  tiie  latter  not 
for  two  or  more  hours  after  eatin<^.  The  vomit  us  usually  contains  a  larjjjo 
amount  of  11  CI. 

(h)  Ila'iuorrliai^e  is  ])resent  in  at  least  one  half  of  all  eases.  Tt  may  ho 
MJL'lit,  hilt  more  commoidy  is  profuse,  and  may  he  in  such  <|uantities  and 
ln'iMiirhf  u])  so  (|ui<d<ly  that  it  is  fluid,  hrit^dit  rv<\  in  color,  and  (|uite  uiial- 
tri'i'd.  When  the  ))lood  remains  for  some  time  in  the  stonuieh  ami  is 
mixed  witli  food  it  may  bo  greatly  olian<;;ed,  hut  tho  vomitinLT  <'f  a  larf,'e 
Mimiititv  of  imaitered  blood  is  very  eliaracteristie  of  ulcer.  Syncope 
iiiav  follow  or  death  may  directly  result  from  the  ha'morrhaLiC.  A  most 
t'Xtromo  i,'rade  of  ana'inia  may  be  ])rodiice(l.  In  cither  the  j^astric  or 
iliioiji'iial  ulcer,  more  commoidy  in  th(>  latter,  the  l)lood  may  be  passi'd  in 
iho  stools  and  not  bo  vomiteil.  This  may  occur  when  the  ha'morrhajjfe  is 
>lii;lit,  Itut  also  when  it  is  profuse  enouijfh  to  produce  collapse  and  extreme 

;l!l.l'!lliM. 

('■)  I'iiiu  is  porhajis  the  most  constant  and  distinctive  feature  of 
lilirr.  It  varies  jfreatly  in  (duiraeter  ;  it  may  be  oidy  a  ^Miawinij  or  biii'ii- 
iiiL'soiisation,  which  is  particularly  felt  when  the  stonnudi  is  empty,  ami  is 
ivlii'vcil  by  takiuir  food,  but  the  im)ro  characteristic  form  comes  on  in 
iiarnxysius  of  llie  most  intense  <iastral,<,da,  in  which  the  jtain  is  not  only 
tVlt  ill  the  epiirastrium,  but  ratliatos  to  the  back  and  to  the  sides.  These 
attacks  arc  most  fnvpiently  induced  by  takini;  food,  and  they  may  recur 
;ita  vaviaitle  period  after  eatinjx,  sometimes  within  lifteen  or  twenty  min- 
utos,  at  others  as  late  as  two  or  three  hours.  It  is  usually  state(l  that 
winu  the  ulcer  is  near  tli(>  cardia  the  pain  is  apt  to  set  in  earlic'r,  but  there 
Ml"  icrtaiiity  on  this  point.  The  attacks  may  ociMir  at  intervals  with 
L'lvat  iiiiiMisity  for  weeks  or  months  at  a  time,  so  that  tho  patient  con- 
stantly rci|iiires  mor})hia,  then  airain  they  may'  disappear  entirely  foi-  a, 
I'i'iiloiiiriMl  period.  In  the  attack  the  jtatient  is  usually  bent  forward,  and 
iiiids  relief  from  pressure  in  the  epij^astric  reirion  ;  one  patient  dnriuiX  the 
Mtta.ck  Would  lean  over  tho  hack  of  ii  chair;  another  would  lie  flat  on  tho 
l!"|ii",  with  a  hard  i)illow  nnder  tlio  abdomen.  Pros-, ire  is.  as  a  rule, 
i.'''iitt'fiil.  It  liiis  been  tlioujj^ht  that  tho  posture  assumed  duriuL,'  the  attack 
«"iiM  imlii  ate  the  site  of  tho  ulcer,  but  this  is  very  doubtful. 

('/)  Tt  luleriiess  on  pressure  is  a  eotumon  symptom  in  ulcer,  and  pa- 
iiiuts  Weill-  (|i(>  waist-1)and  very  low.  There  may  bo  u  painful  point  of 
^''v  limited  extent,  most  fre(|Uently  an  inch  or  two  below  the  ousiforin 
'•"■t'liigo.  Ill  old  ulcers  Avith  thickened  bases  an  indurated  mass  can  usu- 
''"}' '"o  lelt  ill  the  neiijhborhood  of  tho  i)yloru8.     Pressure  should  be  nuide 


-ik: 


,  1 

1 


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ItSisP''' 


^'JS 


DISEASES  OF  THE  DIOESTIVE  SYSTEMS 


wiili    <fi'Oiit  cure,  us  ru})ture  of  tin  ulcer  lui.s  bcou  induced  l)y  careless 
rnanipuliitiou. 

((')  Of  jfcneral  syniptouiii,  loss  of  wci^^lit  rcsnlts  from  tlic  jiroloiir-n] 
dyspepsia,  but  it  rarely,  except  in  association  with  cicatricial  stciidsis  of 
the  pylorus,  reaches  the  high  grade  met  with  in  cancer.  The  anniiiia  ina,' 
be  extreme,  and  in  one  case  of  duodenal  ulcer  which  1  e.vainiiicil  thcljloml 
count  was  as  low  as  700,000  per  c.  mm.  There  aic  instances,  siuh  us  tlr 
OJU!  rei)orted  by  rc]>iier  and  (Jriflith,  in  which  the  extreme  auiciiiia  caiiiH  t 
be  explained  by  the  occurrence  oi  luemorrhage. 

According  to  AVelch,  perforation  occurs  in  about  six  and  a  half  jir 
cent  of  all  cases.  The  acute,  jjcrforating  form  is  nuich  more  cdnniinii  in 
women  than  in  men.  The  symptoms  are  those  of  i)erforative  ]icrit('iuti-. 
In  some  instances  the  ])ain  associated  with  perforation  is  not  referred  to 
the  al)d(imcn.  In  a  case  of  II.  ('.  Wood's  the  ciiii'f  symptoms  were  jiani  in 
the  left  shoulder  and  ex(!essive  pain  in  the  back  on  movement.  IVi- 
foration  is  not  necessarily  fatal.  Several  cases  of  rec(jvcry  have  Ix'iii  iv- 
ported. 

The  course  of  the  disease  is,  in  the  majority  (»f  cases,  chronic,  Oiil_, ,' 
few  instances  run  a  very  acute  course.  The  following  group  ef  e  v.ir. 
forms,  described  by  Welch,  imlicatc  the  diversity  of  this  all'eetinn  : 

"  1.  Latent  ulcers,  with  entire  absence  of  symptoms,  and  reveale  1  ii.> 
open  ulcers  or  as  cicatrices  at  the  autopsy. 

"2.  Acute  perforating  ulcers.  With  or  without  a  jieriod  of  brief  ^ir;.-- 
trie  disturbance,  perforation  occurs  and  causes  speedy  death. 

"■  ;>.  Acute  bicmorrhagic  form  of  gastric  ulcer.  After  a  latent  >  r  ;i 
brief  course  of  the  ulcer,  profuse  gastrorrhagia  occurs,  which  may  termi- 
nate fatally  or  may  be  followed  by  the  symptoms  of  chronica  ulcer. 

"4.  (iastralgi(!-dysi)eptic  form.  In  this,  which  is  the  moA  eeiiiiiinn 
form  of  gastric  ulcer,  gastralgia,  dyspepsia,  and  vomithig  are  the  syiii|itniii-. 
Sometimes  one  of  the  symi)t(»ms  predominates  greatly  over  the  ci hers, ?" 
that  lichcrt  distinguishes  separately  a  gastralgic.  a  dys[)ei)tie,  ami  a  voiiiii- 
ive  variety,     (iastralgia  is  the  most  fre([Ueiit  sym[)tom. 

"  0.  Chronic  liaimorrhagic  form,  Ci astro rrhagia  is  a  markeil  syiiiptoiii, 
and  occurs  usually  in  combination  with  the  symptoms  just  menlieiied. 

"  (!.  C'a(!hecti(^  form.  This  usually  corresponds  only  to  the  liiial  stai'' 
of  one  of  the  preceding  forms,  but  the  cachexia  may  d<iloj,  so  rapiilh 
and  become  so  nuirked  that  the  course  of  the  disease  closely  resembles  tbt 
of  gastri(,'  cancer. 

"  7.  Recurrent  form.  In  this  the  symptoms  of  gastric  ulcer  disappear. 
and  then  follow  intervals,  often  of  considerable  duration,  in  wliieli  then 
is  a])parent  cure,  but  the  symptoms  return,  esitecially  after  .-oiiie  iiidism- 
tion  in  the  mode  of  living.  This  intermittent  course  may  eontiniie  f- 
many  years.  In  these  cases  it  is  probable  either  that  fresh  ulcers  i'orir.  ■': 
that  the  cicatrix  of  an  old  ulcer  becomes  ulcerated. 

"  8.  Stenotic  form.      Bv  the  formation   of   cicatricial   tissue  in  mi'l 


ii   'I,      >i 


ilk  M'iti^:t4i 


THE  PEPTIC  ULCER— GASTIIIC  AND  DUODENAL. 


309 


iironnil  the  ulcer,  tlio  pyloric  orifice  becomes  obstruetcil  iiiul  tlic  syiiiptonm 
of  (liliitiition  of  the  stomach  develop." 

TluM'ourso  may  be  very  protracted,  and  there  are  cases  in  v.liich  the 
(li^tiisc  lias  persisted  for  over  twi'iity  years.  I  have  reported  two  iii- 
stiiiiirs  'if  jK'ptic  idccr,  probably  duodenal,  in  •which  well-mai'kod  symp- 
tiiiiis  were  ])resont,  in  one  case  for  eii^htrcn,  and  in  the  other  for  twelve 
vfiirs.    Both  -were  of  the  chronic  hannorrliaj,nc  form. 

Diagnosis. — The  recognition  of  gastric  ulcer  is  in  many  cases  easy, 
as  the  ciindiination  of  dyspepsia,  gastralgic  attacks,  and  Iiu'matemesis  is 
very  cliaracteristic.  Of  the  symptoms,  hivmorrhago  with  the  gastralgio 
littiiok  is  the  most  characte;istic.  The  distinctions  between  ulcer  and  can- 
irr  will  be  given  later.  I'lie  greatest  dilViculty  is  oifered  by  certain  cases 
(if  trust ralgia,  which  n:ay  resemble  ulcer  very  closely,  as,  with  the  exception 
of  the  huMiiorrhage,  there  is  no  single  symptom  wliich  may  not  ])e  i)resent. 
Kvcn  witii  luvmorrhage  the  case  may  not  be  clear,  and  uo  less  an  anthor- 
itvthiiii  the  late  Austin  Flint  made  a  diagnosis  of  recurring  gastralgia  in 
;i  putimt  who  had,  on  and  olT  for  nine  3-ears,  violent  pains  with  vonut- 
iii;'  ill  association  with  ulcer.  A  diniculty  also  results  frf)m  the  fa(>t  tliat 
in  inatiy  instances  gastralgia  is  oiu!  of  the  symtoms  of  nervous  dyspepsia, 
and  iTKiy  exist  witli  marked  emaciation. 

'riu'  following  points  are  of  value  in  discriminating  between  these  tw^) 
cimtlitiitns: 

{'()  In  ulcer  the  pain  is  more  definitely  connected  with  taking  food, 
thoiiirh  this  is  not  always  the  case,  as  in  the  duodenal  form  the  gastralgic 
att;ii'ks  iiuiy  occur  at  night  when  tlie  stomach  is  empty.  Kelief  of  jiain 
afUT  eating  is  certainly  less  common  in  ulcer  than  in  gastralgia,  though  it 
is  a  very  uncertain  feature,  and  in  certain  cases  the  pain  in  ulcer  is  (iliiua/x 
ivlievod  by  taking  food. 

{h)  In  ulcer  dyspeptic  symptoms  are  almost  invariably  present  in  the 
iiitti'vaU  between  the  attacks,  and  even  when  })ain  is  absent  there  is  slight 

lli.ltl\;SM, 

' !  Local  sensitiveness  in  a  particular  s])ot  in  the  epigastriiim  is  sug- 

'«'  rdcer.     External  [)rcssnre  usually  ags^ravates  ti>e  ])ain  in  ulcer, 

'  '  I'li  relieves  it  in  gastralgia.     'i'his  is,  however,  a  very  uncertain 

tVauh-  ;  -1  patients  writhing  with  the  jiains  of  idccr  may  |)ress  the  alido- 

nion  nvi,:  iho  back  of  a  chair  or  place  a  hard  jjillow  uiidi'r  it. 

('/)  Tlie  general  condition  and  histcu-y  of  the  patient  often  give  tho 
most  tnistworthv  information.  'I'he  nutrition  is  impaired  more  fre(|uent- 
ly  in  ulcer  than  in  gastralgia.  In  tlie  fornu-r  we  iiml  mure  commoidy 
(in  women)  dysnu^norrluea  and  chlorosis,  while  in  the  latter  there  are 
■Hsociatcd  nervous  pheiu>mena — liysterical  manifestations  or  neuralgias  in 
iitluT  rcirions. 

[')  (•n  examination  of  the  abdomen,  not  oidy  is  ])ain  on  pressure  much 
'"'t'coTTimon  in  ulcer,  but  there  nuiy  also  be  tluckeiung  about  the  pylo- 
•"••iind,  in  many  eases,  signs  of  dilatation  of  tho  stomach. 


I    f' 


iff 


Si' 


m 


,<•'(, 


I 


400 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


(/)  Ilyperficidity  of  the  fjastric  juice  exists  with  ulcer. 

Tlie  (jdslrir.  crises  wliidi  occur  iu  filTcctions  of  tlie  spinal  cord,  iiarJiin- 
larly  iu  l(K'()UU)t()r  ataxia,  may  siuiulate  very  closely  the  gastraliric  attacks 
of  ulcer,  aud  as  they  so  often  exist  iu  the  ])reataxic  staf:;e  ticir  true 
nature  may  l)e  overlooked  ;  but  the  occurrence  of  lig]itninf]f  j)aiiis,  the  (,vn. 
lar  symptoms,  and  the  absence  of  the  knee  reilex  arc  indications  usiialh 
suflicient  to  render  the  diagnosis  clear. 

Can  the  gastric  and  duodeiud  uh^er  be- distinguished  clinically':'  As 
already  stated,  they  originate  iu  the  same  Avay  and  present  the  same  ana- 
tomical characters.  In  the  great  nuijority  of  cases  they  cannot  '  ■  sepa- 
rated during  life,  as  the  symptoms  produced  are  identical.  BncijUdy  lias 
suggested  that  the  duodenal  ulcer  can  be  di;;tiugnished  by  the  fV.llnwiii" 
deiinite  characters :  {a)  Sudden  intestinal  Inunujrrhage  in  an  apparciitlv 
healthy  ])erson,  "which  tends  to  recur  aiul  produce  a  profound  aua'iiiiii. 
Ila'morrhage  from  the  stomach  may  precede  or  accompany  the  inclaiia. 
(h)  Pain  in  I'l"-  right  hyjiochondriac  region,  coming  on  two  or  three  Ikiiiis 
after  eating.  a.^tric   crises  of  extreme  violence,  during  which  the 

haemorrhage  is  i  .  apt  to  occur.  Certainly  the  occurrence  of  .^luhh'ii  in- 
testinal haemorrhage  with  gastralgic  attacks  is  extremely  suggestive  nf  (hio- 
denal  ulcer.  W.  W.  .Tohnston  has  reported  an  instance  in  which  he  iiiailc 
the  (liagiu)sis  on  these  symptoms,  and  in  one  of  the  Montreal  cases  Pahiicr 
Howard  suggested  correctly  the  ])resence  of  a  duodenal  idcer  on  similar 
grouiuls.  A  patient  under  my  care  who  had,  during  eighteen  years,  fre- 
quent attacks  of  hamuitemesis  with  gastralgia  had  meliiiua  repeatedly  «iili- 
out  vomiting  blood;*  but  as  a  rule  in  the  attacks  the  blood  was  voiiiileil 
first,  aiul  did  not  ai)])ear  in  the  stools  until  later.  Occasionally  this  syiii- 
ptom  will  be  found  an  ini})ortant  aid  in  diagnosis.  The  situation  of  llie 
pain  is  to(j  uiu  ertain  a  factor  on  which  to-lay  much  stress,  and  tin;  char- 
acter of  the  crises  is  usually  identical. 

(Jail-stone  colic  nuiy  occasioiudly  simulate  the  pains  of  gastric  ulcer. 
The  sudden  onset  and  as  sudden  termiiudiou,  the  swelling  and  tenderness 
of  the  liver,  the  enlargement  of  the  gall-bladder,  if  present,  and  the  oc- 
currence of  jaundice  arc  points  which  usually  make  the  diagnosis  clear. 

Treatment. — Post-nu)rtein  obscrvatiotis  show  that  a  very  hu'ge  laini- 
ber  of  ulcers  heal  completely,  but  the  jirocess  is  slow  and  tedious,  efh-n 
rerpiiring  montiis,  or,  in  severe  cases,  years.  The  following  are  the  im- 
portant points  in  treatment: 

(rt)  Absolute  rest  in  bed. 

{!))  A  caivfully  and  systematically  regulated  diet.  While  theoretically 
it  is  better  to  give  the  stomach  complete  rest  by  rectal  feeding,  vet  in 
Ijrai'tice  this  strict  limitation  is  not  found  satisfactory.  The  food  slumKl 
be  bhuul,  easily  digested,  and  given  at  stated  intervals.  The  folhtwing 
dietary  will  be  found  useful :  At  8  A.  m   give  200  c.  c.  of  Leube's  beef  sulu- 


■  On  tlio  Diuyiiosis  of  Duodenal  Uluer,  Mcdicul  Record,  November  24,  1888. 


::  t:,\   ... 


THE  PEPTIC   ULCER- GASTRIC  AND  DUODENAL. 


401 


tion;  at  12  M.,  300  o.  c.  of  inilk  gruel  or  peptonized  milk.  The  gruel 
f\v)nU\  lio  lUiulo  with  ordinary  Hour  or  arrowroot,  and  is  mixed  witli  an 
iniiul  iiuanlity  of  nulk.  If  necessary  it  maybe  pei)toiuzi'd.  Jiuttermilk 
is  vi'i'v  ivell  born«  by  these  patients.  At  •!  v.  M.  the  beef  solution  again, 
iuul  iit  8  r.  M.  the  milk  gruel  or  the  buttermilk. 

The  stomach  in  some  cases  is  so  irritable  that  the  smallest  amount 
of  food  1.5  not  well  borne.  In  such  eases  lavage  may  be  practised,  if  neces- 
f:irv,  tv(  ly  morning  and  evening,  with  mildly  alkaline  water,  after  wdiich 
thu  iK'i'f  solution  is  given  and  the  feeding  supplemented  by  the  rectal  in- 
ja'tioiis.  Ill  elfects  rarely  follow  the  careful  use  of  the  stonuich  tube  in 
i.'iistrit'  ulcer.  There  arc  some  cases  which  do  well  from  the  outset  on  a 
milk  diet,  given  at  regular  intervals,  three  or  four  ounces  every  two  hours. 
When  milk  is  not  well  borne  egg  albumen  may  be  substituted,  or  the  whites 
of  oi.ulit  eggs  may  be  alternated  with  Leube's  beef  scdution.  At  the  end 
(if  11  month,  if  the  condition  has  improved,  the  ])atient  may  be  allowed 
anijied  beef  or  young  chicken,  perfectly  fresh  sweet-l)read,  and  fai'ina- 
cemis  jjuddings  nuule  with  milk  and  eggs.  Local  ai)plications,  such  as 
wann  fomentations,  over  the  abdomen  are  very  useful.  The  patient  should 
lio  told  that  the  treatment  will  take  at  least  three  months,  and  for  the 
irirater  portion  of  the  time  he  should  be  in  bed. 

(r)  Mi'dicinal  measures  are  of  very  little  value  in  gastric  ulcer,  and 
the  ronK'dies  emjdoyed  do  not  })robably  benefit  the  ulcer,  but  the  gastric 
catarrh.  The  Carlsbad  salts  are  warmly  recommended  by  von  Ziems- 
M'l!.  The  artificial  preparation  (sulphate  of  sodium,  50 ;  bicarbonate  of 
Milium,  (1;  (diloride  of  sodium,  '.))  may  be  substituted,  of  which  a  tea- 
spoonful  is  taken  every  morning.  liismuth,  in  doses  of  thirty  to 
sixty  grains  three  times  a  day,  and  nitrate  of  silver  may  be  given,  but 
tliuy  inlluence  the  associated  conditions  rather  than  the  ulcer. 

Till'  pain  if  severe  re(|'ures  opium.  I^nless  the  gastralgia  is  intense 
morphia  should  not  be  given  hypodermically,  as  there  is  a  very  serious 
iliiiijri'r  in  these  eases  of  establishing  the  morphia  habit.  Doses  of  an 
eighth  of  a  grain,  with  the  bicarbonate  of  soda  and  bismuth,  Avill  allay  the 
mild  attacks,  but  the  very  severe  ones  require  the  hyjiodermic  injection  of 
a  iliiartcr  or  often  half  a  grain.  Antipyrin  and  antifebrin  maybe  tried, 
liiit,  as  a  rule,  are  (piite  ineftectual.  In  the  milder  attacks  Hoffman's 
anodyne,  or  twenty  or  thirty  drops  of  chloroform,  or  the  spirits  of  camphor 
^vill  (.nvi-  relief.  Counter-irritation  over  the  stomach  with  mustard  or 
uuitharidus  is  often  useful. 

For  the  vomiting  tiiero  is  no  measure  so  successful  as  lavage.  If  in- 
tvuctahk'  the  patient  must  be  fed  per  rectum.  The  patient  will  sometimes 
f'taiu  fddd  which  is  passed  into  the  stomach  through  the  tube,  and 
l-eubus  liirf  scdution  or  milk  maybe  given  in  this  way.  Cracked  ice, 
''liloroforin,  oxalate  of  cerium,  bismuth,  hydrocyanic  acid,  and  ingluvin 
may  he  tried.  When  ha;morrhage  occurs  the  patient  should  be  put  under 
l!ie  influence  of  ojiium  as  rapidly  as  possible.    No  attempt  should  be  made 


^\M\!^ 


fi-j 


I'.: 


tiM 


402 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


to  clu'ck  the  lui'Tiiorrliiig'o  by  administering  nu'dicinos  through  tlic  luoutli; 
as  tlic  j)r()riis('  bleeding  is  always  from  an  erodi'd  artery,  I'reqiienilv  I'l-dm 
one  of  eoMsi(leral)le  size,  it  is  (b)ubtful  if  ac(^tate  of  lead,  tannic  u\A 
gallic  aeids,  and  tlie  usual  ntnedies  have  the  slightest  inHuencc.  '[' . 
essential  [)oiiit  is  to  give  rest,  which  is  l)est  oljtained  by  ojiiiim.  K,- 
gotin  may  be  administered  hypoderniically  in  two-grain  doses.  Xdiliii;. 
should  bo  given  by  the  mouth  except  small  quantities  of  ice.  Jn  iinit'cM 
l>leeding  a  ligature  may  l)e  ai)i)lied  around  a  leg,  or  a  leg  and  ai'iii.  Xi.i 
infre(|uently  the  loss  of  blood  is  so  great  that  the  })atient  faints.  X  faial 
result  is  not,  however,  very  common  from  lueniorrhage.  Transfusion  iiun 
be  necessaiT,  or,  still  better,  the  subcutaneous  infusion  of  saline  solution, 

Tlie  ])atients  usually  recover  rapidly  from  the  luvmorrhage  and  rer|iiirf 
iron  in  full  doses,  which  nuiy,  if  necessary,  be  given  hypoderniically. 

When  symptoms  of  perforation  occur  laparatomy  should  be  perfoniioij 
at  once.  Barling  has  collected  31  cases  with  13  recoveries.  In  iHTsistciit 
ha'morrliage  the  stomach  has  been  opened  and  the  bleeding  surface  cauter- 
ized with  success. 

IV.    CANCER  OF  THE  STOMACH. 

Etiology. — The  stonuich  comes  next  to  the  uterus  as  the  most  fre- 
quent seat  of  primary  cancer,  amounting,  as  shown  by  the  statistics  of 
Welch,  to  21--1  per  cent  in  a  total  of  over  30,000  cases.  The  ratio  uf 
males  to  females  aifeeted  is  about  five  to  four.  Age  has  an  iniportiUit 
bearing.  Of  •^*,()3S  cases  tabulated  by  this  author  three  fourths  occurred 
between  the  fortieth  and  the  seventieth  year,  'H'o  per  cent  betwocti  the 
ages  of  forty  and  iifty,  and  30-4  between  the  ages  of  fifty  and  sixty,  in 
childhood  it  is  extrenudy  rare.  Cancer  of  the  stomach  is  a  very  coinuinn 
disease  in  this  couiUry,  though  statistics  would  indicate  that  it  is  rather 
less  frequent  than  in  Europe.  With  reference  to  heredity,  Welch  analyzed 
1,744  cases  and  found  that  a  family  history  was  present  in  243.  Loeii! 
coiulitions,  such  as  chronic  gastritis  and  traumatism,  have  been  thought 
by  some  to  be  important  factors.  Cancer  may  develoj)  in  a  siiiiple 
ulcer  of  the  stonuu'h,  but  this  sequence  is  extremely  rare.  It  is  unl 
probable  that  depressing  emotions,  mode  of  life,  or  previous  disease  have 
any  influence  Avhatever  in  the  causation  of  cancer. 

Morbid  Anatomy. — The  most  common  ^arietiesof  gastric  cancer 
are  the  cylindrical-celled  epithelionui  and  the  c-ncejdialoid  ;  next  in  fre- 
queiujy  is  scirrhou.s,  and  then  colloid  camber.  ^V'ith  reference  to  the  silua- 
tion  of  the  tumor,  Welch  analyzed  1,300  cases,  in  which  the  disti'ii)utini! 
was  as  follows:  Pyloric  region,  791;  lesser  curvature,  148;  canlia,  104; 
posterior  M-all,  (18  ;  the  whole  or  greater  part  of  the  stonuich,  01 ;  inultii)le 
tunuirs,  4.') ;  greater  curvature,  34  ;  anterior  wall,  30  ;  fundus,  19. 

The  nunlullary  cancer  occurs  in  soft  masses,  wdiich  involve  all  the  coat!- 
of  the  stomach  and.  usually  ulcerate  early.  The  tumor  nuiy  form  vilhm^ 
projections  or  cauliflower-like  outgrowths.     It  is  soft,  grayish  white  in  culer, 


CANCER  OF  TIIR  STOMACH. 


403 


iii\il  contains  iimch  blood.  Mierf)sco|»iciilIy  it,  shows  a  pr-aTity  piroina,  cii- 
iliisiiii,'  alveoli  which  (Joiitaiti  irregular  polyhedral  and  cyliiidi'ical  eells. 
The  (vliiulrieal-celled  epithelioma  may  also  form  larjife  iriVLrular  masses, 
liiit  till'  coiisistenec  is  usually  tinner,  })ai1ieularly  at  the  ed^ijes  of  the  ean- 
ccnius  ulcers.  Microscopically  the  section  shows  elon<fatcd  tubular  snaces 
lilk'il  with  columnar  epithelium,  and  the  intcrvi'iiini;  stroma  is  abundant. 
(vsts  are  not  nncoinmon  in  this  form.  The  scirrhous  variety  is  chanicter- 
izcd  bv  ,<ri"eat  hurdness,  due  to  the  abundance  of  the  stroma  and  the  limited 
amoiiiit  nt'  alveolar  structures.  It  is  seen  most  frerpiently  at  the  pylorus, 
where  it  is  a  common  cause  of  stenosis.  It  may  be  combined  with  the 
iinMiullarv  form.  It  may  be  diffuse,  involving  all  parts  of  the  organ,  and 
kuiliiiir  to  a  condition  which  cannot  be  recogiuzed  niacroscopically  from 
cirrliosis.  This  form  lias  also  been  seen  in  the  stomach  secondary  to  cancer 
of  the  (ivarics.  The  colloid  cancer  is  peculiar  in  its  wide-spread  invasion 
(if  all  the  coats.  It  also  s])reads  with  greater  fre(piency  to  the  lu'ighboring 
parts,  and  it  occasionally  causes  exten.sivo  secondary  growths  of  the  same 
nature  in  other  organs.  The  at)peariince  on  section  is  very  distinctive, 
and  even  with  the  naked  eye  large  alveoli  can  bo  seen  filled  with  the  trans- 
lueent  colloid  material.  The  term  alveolar  cancer  is  often  ap])lied  to  this 
form,  rieeration  is  not  constantly  j)resent,  and  there  are  instances  in 
which,  with  most  extensive  disease,  digestion  has  been  very  slightly  dis- 
turbed. There  is  a  specimen  in  the  Warren  Museum,  at  the  Harvard 
Medical  Scho(d,  of  the  most  wide-spread  colloid  cancer,  in  which  the 
sionuich  contained  after  death  large  portions  of  undigested  beef-steak. 

Secondary  cancer  may  also  occur  in  the  stomacdi.  Welch  lias  collected 
Ti  cases,  IT  of  which  were  secondary  to  cancer  of  the  breast.  The  cancier 
may  produce  important  changes  in  the  position  and  shape  of  the  organ, 
imi'ti(Milarly  when  the  orifices  are  involved;  thus,  a  cancer  at  the  cardia 
iiiav  be  associated  with  wasting  of  the  organ  and  reduction  in  its  size. 
The  (esophagus  above  the  obstruction  may  be  greatly  distended.  On  the 
iitlier  hand,  annular  cancer  at  the  pylorus  may  cause  stenosis  and  great 
'lihuation  of  the  organ  ;  not  necessarily,  however,  as  there  are  instances  on 
record  in  which  the  pylorus  has  been  extremely  narrowed  without  any  in- 
eroase  in  the  size  of  the  stomach.  In  scirrhous  cancer  the  organ  may  be 
very  greatly  thickened  and  contracted.  The  stoimudi  may  be  displaced  or 
altered  in  shape  by  the  weight  of  the  tumor,  jiarticularly  in  cancer  of  the 
pylorus,  which  has  been  found  in  every  region  of  the  abdomen,  and  even 
in  the  true  pelvis.  The  mobility  of  the  tumors  is  at  times  extraordinary 
and  very  deceptive,  and  they  may  be  pushed  into  the  right  hypochondriii  or 
into  the  splenic  region,  entirely  beneath  the  ribs.  Adhesions  very  fre(piently 
neeiu',  particularly  to  the  ccduu,  the  liver,  and  the  anterior  abdominal  wall. 

Secondary  cancerous  growths  are  very  frefpient,  as  shown  by  the  fol- 
lowing analysis  by  Welch  of  1,574  cases:  Metastasis  occurred  in  the  lym- 
phatic glands  in  551 ;  in  the  liver  in  475;  in  the  peritona.nim,  omentum, 
iiiul  intestine  in  357;  in  the  pancreas  in  13ii;  in  the  pleura  and  lung  in 


I  'I 


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18' 'W„ 


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1,11  ■'  r*^giii.i.:i  ■- :  ,-,■■^  . 


4(11 


DISEASES  OF  THE  DIGESTH'E  SYSTEM. 


OS  ;  in  tho  splooii  in  'Zi\  \  in  tlio  brain  and  meninges  in  0  ;  in  otlicr  iiiirts  in 
0"^.  Tlic  lyinpii  glands  aircctod  are  usually  those  of  tlie  abdonu'ti,  luit  the 
cervicid  and  inguinal  glands  are  not  infreciuently  attacked,  and  give  im 
im2)ortant  elew  in  diagnosis.  Occasionally,  a  secondary  metastatic  growth 
occurs  subeutaneously,  either  at  the  navel  or  beiu'uth  the  skin  in  the  vicin- 
ity.  In  an  instatice  recently  under  observation  in  a  i)atient  with  jaiiiKlicc, 
which  developed  somewhat  suddenly  and  was  believed  to  be  catarrhal,  there 
were  no  signs  of  eidargeiiu'nt  of  the  liver  or  tumor  of  the  stomach,  t)!it  u 
nodular  ])ody  developed  at  tlu;  navel,  which  on  removal  proved  to  hv  typi- 
cal scirrhus.  A  second  case  in  the  ward  at  the  same  time,  with  an  ohsciirr 
doubtful  tumor  in  the  left  hypochondria,  develoj)ed  a  juiinful  nodular  sub- 
cutaneous growth  nudway  between  the  navel  and  the  left  margin  of  tiic  ribs, 

In  the  extensive  ulceration  which  occurs  perforation  of  the  stomach  is 
not  uncommon.  It  occurred  into  the  ]ieritoiuiMim  in  17  of  the  oOT  cases  (if 
cancer  of  the  stomach  collected  by  I'.rinton.  AVhen  adhesions  fdim,  the 
most  extensive  destruction  of  the  walls  may  take  place  without  jieri'Di'ii- 
tion  into  the  jieritoiual  cavity.  In  one  instance  which  canu>  under  niv 
observation  a  huge  jiortion  of  the  left  lobe  of  the  liver  lay  within  the 
8tf)ma<'h.  Occasioiudly  a  gastio-cutaneons  fistula  is  established.  IV  rfniu- 
lion  niav  occur  into  the  colon,  the  small  bowel,  the  pleura,  the  linig  in- 
into  the  ]H'ricardiuiu. 

Symptoms. — Cancer  of  the  stonuich  may  not  ])roduce  syuiptdiiis 
other  tlian  gradual  failure  of  health,  and  death  may  take  jilace  from 
astlu'iiia  without  any  suspicion  of  the  existence  of  maligiuiut  diseiise. 
These  cases  are  not  uiu'omnion,  jjarticularly  in  elderly  persons  in  iu^tiui- 
tions.  In  a  great  majority  of  all  cases  there  are  very  delinite  syuiiitwins, 
but  the  disease  ])resents  a  very  diverse  clinical  i)ictu)'e.  Certain  g'lieiiil 
features  stand  out  with  special  jirominence.  '  The  onset  is  insidious,  some- 
times with  gastric  disturbance,  but  more  commonly  with  impainneiit  of 
health  aiul  strength.  A  dysi)i'])sia  which  may  have  been  troublesome  fer 
years  becojtu's  aggravated.  Ewald,  however,  states  that  dysi)ei)lic  symp- 
toms are  rare  prior  to  the  onset  of  gastric  cancer.  There  are  attacks  ef 
nausea  and  vonnting,  and  there  is  j^ain  in  the  region  of  the  sloiiiacli. 
which  is  aggravated  by  taking  food.  The  ])atient  emaciates,  the  aiia'tiiia 
becomes  pronounced,  and  the  i)rostration  may  l)e  extrenu\  A\  itli  slijrnt 
intermissions  the  course  is  progressively  downward,  and  froju  month  te 
month  the  loss  is  striking.  The  face  lias  a  sallow  cachectic  appearaiiee. 
the  amvnna  becomes  more  intense,  and  there  may  be  aMlema  nt  the 
ankles,  lilood  may  be  present  in  the  vomited  matter.  If  with  these 
general  features  a  tumor  can  be  felt  in  the  region  of  the  stoutach  the 
diagnosis  is  rendered  certain.  The  course,  in  rapid  cases,  may  he  from 
three  to  six  months,  but  as  a  rule  the  di.sease  extends  from  eighteen  iimiiths 
to  two  years.  There  are  cases  to  which  the  term  acute  cancer  may  be 
applied.  The  patients  may  die  in  from  three  to  eight  weeks  after  the  lirst 
onset  of  symi^toms. 


CANCER  OF  THE  STOMACH. 


405 


I)ysiiopsia  is  common  tit  the  outricl,  l)iit  in  so  niiiiiy  casos  tlio  jifitients 
liiivi'  hiul  iiuligi'stioii  for  years  tluit  the  trouble  is  supposed  at  (irst  to  be 
(iiilv  nil  iiffgravatioii  of  tho  ciiroiiic  complaint.  Loss  of  tlie  desire  for 
tnod  i.s  a  very  frequent  symptom.  There  arc  exee[itional  instances,  how- 
ever, in  which  the  appetite  is  retained  throufjjhout,  and  the  fiinctiojis  of 
tliu  .stoiiKU'ii  very  sli<,ditly  disturbed.  .Nausea  is  a  striking  feature  in  numy 
Ciiiios,  and  is  much  more  common  than  in  ulcer.  There  may  even  be  a 
sudden  repulsion  at  tho  sight  of  food. 

Viiiiii/iii;/,  which  is  one  of  the  most  constant  symptoms  of  cancer  of 
the  stomach,  may  come  on  early,  or  only  after  the  dyspe])sia  has  [lersisted 
for  SDiiic  lime.  At  llrst  it  is  at  long  intervals,  but  subse(|uently  it  is  more 
fiTi|nciit,  and  may  recur  several  times  in  the  day.  There  are  cases  in 
wliicli  it  comes  on  in  paroxysms  and  then  subsides;  in  other  eases,  it  sets 
iiu'tniy,  I'.crsists  with  great  violence,  and  nuiy  cause  a  fatal  termination 
wiiliiii  a  few  weeks.  Vomiting  is  more  frecjuent  when  the  cancer  involves 
the  orilices,  particularly  the  pylorus,  in  which  case  it  is  usiudly  dtdayed  for 
aiihour  or  more  after  taking  the  food.  AViien  tho  cardiac  orilicc  is  involved 
it  may  fcdlow  at  a  shorter  interval.  Kxteiisive  disease  of  the  fuiulus  or  of 
the  anterior  or  ])osterior  wall  may  l)e  present  Avithout  the  occurrence  of 
vomiting.  The  vomited  matters  consist  of  food  and  mucus  in  a  grayish 
or  dark  sour-smelling  fluid.  'J'he  food  is  sometimes  very  little  changed, 
even  after  it  has  x'ouuiined  in  the  stomach  for  twenty-four  hours. 

If(i'niiirr/i(i;/n\fi.  a  freqiu'ut  symptom,  but  the  bleeding  is  rarely  ])rofusc; 
niiM'o  ciiiiiiiKinly  there  is  slight  oozing,  and  the  bl^od  is  mixed  with,  or 
idteivd  by  the  secretions,  and  when  vomited  the  nniterial  is  dark  brown 
or  black,  the  f.o-called  "colfee-groiind  "  vomit.  This  is  present  in  ii  c(»n- 
sideralile  jn'oportion  of  all  cases  of  cancer,  and  is  an  important  indication. 
The  I'h.ud  can  be  recognized  by  the  nucroscope  as  sludls  of  the  red  blood- 
i"iqmsrk's  and  irregidar  masses  of  altered  blood  pigment.  In  cases  of 
diuilit  the  spectrosc()[)e  may  be  employed  or  ha'inin  crystals  obtained. 

Fragments  of  the  tumor  are  randy  found  in  the  vomit,  and  of  the 
iiuiiiiToiis  specimens  wlii(di  I  have  hail  occasion  to  examiite  I  have  never 
been  a!)le  to  satisfy  myself  of  the  existence  of  cancerous  tissue.  As 
lioseiihaoh  stales,  in  the  nniterial  washed  out  with  the  stomach-tid)e  un- 
doubted fragments  may  be  found.  The  yeast  fungus,  various  bacteria, 
and  the  sar(  ina  'entriculi  nuiy  be  present,  the  latter  not  so  often  in  cancer 
as  ill  dihitation.  « 

<ii'eat  stress  has  been  laid  of  late  years  ui)on  tho  absence  of  free 
liydi'dciibiric  iu'id  in  the  secretions.  As  an  outcome  of  the  enormous 
iiiimber  iif  observations  which  have  recentlv  been  made  it  mav  be  said 
tliat  live  hydrochloric  acid  is  absent  in  a  majority  of  cases  of  cancer  of 
the  sioiiiiiidi.  This  defect  is  associated  with  impairment  of  the  secreting 
luiietidii  of  the  organ.  Tho  examination  should  be  made  repeatedly,  by 
the  iiietliods  already  referred  to,  and  with  our  present  knowledge  tho  per- 
"isteut  absence  of  free  IICI  in  the  stomach  contents,  taken  in  conjunc- 


i   t 


11  ippvfr'nni  t 


40fi 


DISEASES  OF  TFIE   DIC.ESTIVR  SYSTEM. 


1^: 


'H^^ 


■r-ifii'ipM 


tii)ii  witli  (itlicM-  sviiiptonis,  may  Ix^  ivf,'iir(UMl  us  liij^lily  sufrjrostivo  of  I'luiccr. 
riit'ortiuiiitcly,  tlu!  I'ivl'  acid  may  ho  ub.st'iit  in  ccrtiiin  otiicr  ((iiiditioiis, 
such  as  atropiiy,  and  occasionally  in  chronic  gastritis,  so  thai  it  js  i,f 
"greater  value  from  the  negative  standpoint.  ,\s  Kinnicntt  cxin'csscs  it, 
"  the  ])ri'si'nc(' of  frci'  IK.'l  in  the  stomach  contents  in  rcpL-atcil  cxaiiiina. 
tions  in  donhtfnl  cases  is  of  the  <,n'eatest  diajj;nosti(!  valn<>,  and  jmints 
very  certainly  to  ahseiice  of  cuiicor."  Hosonhcim  has  recently  shown  tlmt 
in  cases  in  which  cancer  develops  in  the  liase  of  an  old  nicer  IICI  niuv  lu' 
present  throu<fhout  the  (bourse.  Mn(di  importance  has  ])een  laid  hy  |'>(ia> 
and  others  on  the  i)resence  of  lactic  acid  as  a  diaj^niostic  si<,qi  of  rimnn: 
After  the  rigid  IJous  test  breakfast  lactic  acid  is  very  rai'cly  found  in  tlii' 
chronic  catarrhs.     It  may  bo  found  curly  before  u  tumor  is  imli)al)le. 

Piii/i  is  an  early  and  important  symptom.  Tt  is  very  variable  in  situa- 
tion, and  while  most  common  in  the  e|>i;,''astrinm,  it  may  he  refciTci]  1 1 
the  shoulders,  the  back,  or  the  loins.  The  ])ain  is  described  as  diMLiiriiiL', 
bui'iiing,  or  gnawing  in  chai'actcr,  and  very  rarely  occurs  in  si'Vci'r 
})aro.\ysms  of  gastralgia,  as  in  gastrii;  nicer.  As  a  ride,  the  [laiii  is 
aggravated  by  taking  food.  '^I'licre  is  usually  marked  tenderness  m 
^iressurc  in  the  epigastric  region,  it  is,  however,  renuirkabic  how  iiiuin 
ca.ses  run  a  painless  course. 

'Yhv  ])I ysicdl  I'.i-iiiiiiii'iitui:  i)f  the  ali(h>nu'n  reveals  in  many  instaiicis 
the  jireseiice  of  u  tumor.  Inspection  nuiy  show  a  no(lnlar  uins<  in  \\\v 
ci)igastrium,  or  the  o;itliiu>s  of  a  dilated  stomacdi,  with  ])eristaltic  artimi. 
In  th(i  ])al|;:ition.  ,)f  the  st(nn.i(di  it  is  important  to  bear  in  miml  cir- 
t.iin  anatomical  points.  At  K'ast  two  thirds  of  the  organ  lie  in  tlu- lift 
vi)0(diondriiiin  beneath  tiie  ribs,  and  so  arc  prai'lically  out  of  rciirji, 
'1  lie  jnloric  oriiice  lies  to  tin;  right  of  the  median  line,  ])ai'ticul;iily 
when  the  stomach  is  full,  in  wbi<di  ca.^e  it' may  be  readied,  ll  is  al^Mit 
on  a  level  wilii  the  iiuu'r  extremity  of  the  eighth  right  costal  eartihifrc. 
The  ])yloriis  is  movable  and  (dianges  considcfdiiy  in  posi'iou  with  tln' 
distention  of  the  stomach.  I'ractically,  m  liealtb  there  is  availahk'  fm 
palpation  only  a  part  of  the  anterior  surface  of  the  stomach  and  the 
pylorus,  which  is  sometimes,  but  not  always,  overlapjicd  hy  the  liver. 
Tumors  limiti'd  to  the  cardia,  even  wlien  extensive*,  cannot  lie  felt  at  all. 
Tumors  involving  the  fundiis,  the  jiostcrior  wall,  and  the  greater  piirt  of 
the  lesser  curvature  cani.ot  be  detected  unless  very  large.  Tiimoi's  ef  tlio 
pylorus,  of  tlu'Wnti'rior  wall,  and  of  a  large  part  of  the  greater  ciirvatiiro 
are  in  accessible  situations.  In  the  examination  the  knees  sIkhiM  bo 
drawn  up,  and  the  patient  asked  to  relax  the  nbdoniinal  walls  as  nimli  a- 
possible.  Sometimes,  when  nothing  can  be  felt  on  (piiet  hrcalliiiiL'.  ;i 
deep  ins])iration  will  force  down  the  stomach  and  bring  a  tunier  iiia>' 
within  reaidi.  E.xa.mination  should  also  be  made  in  the  knec-eliiow  pi'si- 
tiim.  Cancerous  tumors  of  the  stomach  are  usually  felt  in  the  {pi.uastric 
region,  but  a  mass  at  the  pylorus  may  be  felt  in  the  umbilical  rcgi"". 
or,  in  cases  of  extreme  inobility,  in  a  hypochondriac  region,  or.  very  cx- 


,o*iis,iiilli:i.,.i,.. 


C'ANL'EK  OF  Tin<:  STOMACH. 


407 


i.entioii;ill\,  low  down  in  tlio  iliiic  ivfjion.  'IMio  tuninr  i.s  usiiiilly  tlrni, 
liiinl,  iHMliihir,  iitnl  itiiiiiful  on  invs.siii'c.  At  the  pylorus  tlii'  mass  may 
be  roiiiiilcfl,  ball-like,  and  readily  j^nisped.  (Jas  miiy  sometimes  he  felt 
liiihliliiiLr  tliroiij^di  it.  Commiiiiieiited  jjulsatioii  from  the  aorta  is  not  at 
111!  iniciiiiitnon.  Inllation  of  the  stomach  with  j.fas  is  often  a  valiiahle  aid 
ill  (liiiu'iiosis.  A  teuspoonfid  of  l)iearl)onate  of  soda  is  lirst  iriven  in  water, 
fiilliiwed  by  the  same  amount  of  tartaric  acid.  'I'he  distention  of  tho 
stoiimeli  which  follows  may  sulVice  to  brini?  tunuir  masses  into  reach. 

Careful  examination  should  be  imide  to  determine  the  presence  of  scp- 
iiiiilary  eanct'r  of  the  liver  or  involvement  of  the  lym))h  ^dands  in  tlie  groins 
lii' ill  llie  su[)riiclavi(HUar  spaces.  As  already  mentioned,  the  development 
,il'  nodules  about  tho  navtd  may  irive  an  important  hint,  or  there  nuiy  be 
si:,nis  of  secondary  involvomont  of  tho  j)oritoiueiiiii. 

Ititestinal  symptoms  are  not  very  common.  Constipation  is  more  fro- 
i|'iinllv  |)resent  than  diarrlio'a,  which  may,  however,  set  in  and  prove  ob- 
,s  iiiiite  toward  the  end.  When  there  is  much  bleeding  the  stools  may  bo 
ihirk  in  color. 

A  pi'oj,M'essive  anmnin  is  one  of  the  most  striking  features  of  jrastric 
iMiictT.  As  a  ride  the  blood-count  does  not  fall  Ijelow  fifty  per  cent.  A 
K'licdcylosis  is  almost  constantly  present,  and  Wekdi  has  noted  an  instance 
in  wliicli  the  ratio  of  white  to  red  oorpnscK\-,  uas  one  to  twenty.  'I'here 
;iiv  instances  in  which  the  clinical  ])icturc  is  rather  that  of  a  pernicious 
iiiiiviiiiu,  with  reiliiction  of  the  re(]  blood-corpuscles  to  twenty-five  per  cent 
ami  marked  poikilocytosis.  'I'he  careful  examination  of  the  l)lood  shows, 
hnu'ever,  rather  the  (diaraeters  of  a  secoiulary  arnvmia.  The  condition  is, 
iiiKi'eover,  an  ana'inia  with  wasting,  and  .the  layer  of  panniculus  is  not  re- 
laiiu'i]  as  in  the  ordinary  forms  of  ])ernicious  ansvmia.  Ultimately  the 
luiiiMit  ilev'lops  an  aspect  to  whi(di  the  term  cachectic  is  applied,  aiul 
uliicli  is  perhaps  more  marked  in  gastric  cancer  thai",  in  any  other  disease. 
There  may  be  a  sliglit  yellowish  tint  to  the  skin,  and  it  is  not  uueommou 
to  see  l)ri)\vnish  stains,  the  cachectic  chloasma. 

Associated  with  the  anannia  and  directly  dependent  upon  it  are  tlio 
'h'opsical  symptoms  so  common  in  this  alTection.  (Edema  of  tiie  ankles  a;ul 
of  the  legs  is  present  anil  may  i)rogress  to  a  general  anasarca ;  the  cases 
may  be  mistaken  for  heart-disease  or  dropsy,  'i'here  are  no  special  cardiac 
syiiiptonis;  tho  pulse  becomes  rapid  and  feeble  toward  the  eiul.  The 
ann'inia  may,  however,  produce  such  palpitation  and  dyspmea  that  ^'locase 
may  hr  regarded  as  cardiac.     T'hrombosis  of  a  femoral  vein  may  0(H;ur. 

The  urine  may  contain  a  trace  of  albumin  and,  toward  the  (dose,  tube- 
'"ists.  Indican  is  often  present  in  increased  quantity,  and  occasionally 
ii"t'toiio  and  diacetic  acid. 

The  ti'in[)erature  is  usually  normal,  and  toward  tlie  end,  when  cachexia 
i<  Well  marked,  subnormal.  There  are,  however,  interesting  j)aroxysnuil 
"li'vatiniH  of  temperature,  definite  chills  with  fever,  in  which  the  ther- 
mi)!iietcr  registers  1013"  or  lU-t",  followed  by  profuse  sweating.    The  rigors 


t    J'n' 


\i   4  f  ^^ 


408 


niSPlASES  OP  TIIR   niOKSTIVE  SYSTEM. 


may  rocur  at  Intorvals  for  weeks,  and,  if  no  tumor  is  felt,  may  ''oinjilipnto 
the  diajfiiosis.  In  a  case  at  the  Philadelphia  Hospital  the  jtarowsins  ro. 
ciirred  for  more  than  six  weeks.  The  autopsy  showed  a  caiicir  of  the 
stomach  with  adhesions  to  the  colon  and  extensive  suppuration  at  the  '  ;isc 
of  the  cancer  and  in  a  ])ocket  hetwiKMi  the  stomach  and  onuMituni. 

The  mind  usually  remains  clear  to  tho  close.  Naturally  the  patient 
lias  attaciks  of  desi)ondency.  Toward  the  end  delirium  is  coihiikui.  .\ 
form  of  coiua  resendjliri<(  that  which  occurs  in  diahetes  is  occasiniiallv 
mot  with  in  <^^istri(M'aucer.  'i'he  jjatient  heconies  restless  or  excited,  and 
gradually  uiu-onsciousiu'ss  suju'rvenos,  with  or  without  dyspiKi'a.  It  is 
(lu(*  to  the  presence  of  sonic  toxic  agent  in  the  hlood,  ])ossil)ly  the  diace- 
tic  acid. 

Among  symptoms  referahle  to  the  development  of  seeoudarv  gmwlli- 
those  pertaiuiug  to  the  liver  are  nu»st  importaut.  .Jaundice  is  not  niiedni- 
mon,  and  there  nuiy  he  signs  of  great  eidargemeut  of  the  liver.  Manv 
instances  whiidi  arc  clinically  recorded  as  primary  cancer  of  this  (iii:;iii  are 
in  reality  secondary  to  latent  cancer  of  the  stoiiuudi.  The  iiiipditainc 
of  etdargemeul  of  the  supra-clavicular  and  inguinal  glands  in  gastric  can- 
cer has  already  heen  emi)hasized.  'I'he  new  growths  may  extend  to  the 
perihuiiiMim  and,  if  there  is  much  effusion,  pmduce  ascites.  liclVronee 
has  l»ecn  made  to  tho  ]ierforations  lialile  to  occur  in  gastric  cancer.  Tli" 
course  of  the  disease  is  progressively  downward.  In  the  majoritv  of  all 
cases  death  occurs  within  two  years,  and  the  average  duration  is  not 
than  eighteen  months.     In  cases  of  scirrhiis  the  j)rogress  is  slower. 

Diagnosis. — WhoJi  a  tumor  is  present  there  is  not  mu(di  dillieiiity 
in  determining  the  nature  of  the  (rouhle;  even  in  its  ahsence  the  pro- 
gressive cwnaciation,  the  loss  of  energy  and  strength,  the  anu'iiiia  and 
cachexia,  when  associated  with  mai'ked  gastric  symptoms,  are  almost  path- 
ognomonic.  There  are  many  instances,  however,  in  whicdi  a  ])ositive  diai'- 
iU)sis  is  impossihle.  Tho  diseases  with  whi(di  cancer  is  most  liahle  to  lie 
confounded  are  ulcer  and  chronic  gastric  catarrh,  and  the  tlillVreiitial 
features  are  so  well  drawn  in  tho  elahorate  article  hy  my  colleague  Welch 
that  1  here  append  them  :  * 


GASTRIC   CANCKU. 

1.  Tumor  is  jjresent 
in  throe  fourths  of  the 
cases. 

2.  Ihiro  under  forty 
years  of  age. 


GASTRIC    ULCER. 

1.  Tumor  rare. 


CHRONIC    CATAItKirAI. 
(iAsriMllS. 

1.  No  tumor. 


2.  Jfay  occur  at  any 
age     after     childhood,     age, 
Over  one   half  of   the 
cases  under  forty  vears 


3.  May  occur  at  any 


of  age. 


Op.  cit.,  vol.  ii,  p.  570. 


CANCKU   OF   TIIH  SToM.Uir. 


409 


OASTUIO   CANCEU. 

.').  .\vi'ra;,'<'»liinifii>n 
;,l,oiit  oiif  yi'iir,  ruri'ly 
uvt'i'  t\Mi  yciirs. 

1.  (iiistric  lia'iiior- 
ihiinc  rriMiiunt,  liiit 
rai'i'Iv,  iinifiisc ;  most 
11)1111111)11  ill  tlio  cut'liuc;- 
tio  stage. 


■  ').  V()iiiiiiii<jf  often 
has  till'  |)fciiliiii'iti('.s  of 
that  of  (lihitiitioii  of  tliu 

HlullUU.'ll. 

tl.  Free liyd rod iloric 
iiiiiliisiiiilly  absent  from 
tiio  ifastric  contents  in 
caiU'crDiis  dilatation  of 

tllO   SlDllUU'll. 

T.  Caiiceriiiis  fra<;- 
iiiiiits  iiiuv  !)('  found  in 
the  Uiisiiiiio-s  from  tlio 
-t:);iKii'li  or  in  the  vomit 

(IMIV). 

8.  SccDiidiiry  can- 
dors may  lie  reeogni/ed 
111  tho  liver,  the  perito- 
lui'iiiii,  the  lympliatio 
.'liUitls,  and  rarely  in 
flla-r  parts  of  the  body, 

i).  Loss  of  iK'sh  and 
■tiviigtli  and  develop- 
iiii'iit  of  eaeliexia  usii- 
;illy  more  marked  and 
iiii've  nipiil  than  in  ul- 
'W  01-  in  ,!j;astritis,  and 
It'ss  L'X|)licul)le  by  the 
j;iistne  symptoms. 

1".  ]^l)i,^'astric  pain 

1^  often  more  continu- 

'•I'S  loss  ilepen(h'nt  np- 

'Jii  taking  food,  loss  re 

27 


(jastuk;  ri.cKii. 


(  IIIIOMC    (A  lAlillllA  I, 
(IA>Tliiri:>. 


.'{.    Diiralioii    indeli-  '.\.    Duration  indeli- 

nite;    may  be  for  "tiev-     nite. 
vni\  years. 

•1.    (lasti'ic    ha'inor-  1.    (laslrit;    luvinor- 

rhaye  less  fri'(pienl  than  I'liagi'  I'are. 
in  cancer,  l)ut  oftener 
profuse ;  not  uncom- 
mon wlicii  the  jj,ciici'al 
health  is  but  little  im- 
paired. 

5.    N'omiling  I'arely  5.  Vomitinginay  or 

referable    to   dilatation     may  nut  bo  present, 
of    the    stomach,    and 
then     only    in    a    late 
stage  of  llu!  disease. 

0.  I"'ree  liydrochlori('  <!.  ]''rce  hydroehloric 

acid  usually  present  in     acid  luay  be  present  or 
the  mistric  con  touts.  altsent. 


7.  Absent. 


7.  Absent. 


8.  Absent. 


8.  Absent. 


0.  Cachectic  appear-  0.  "When  uncompli- 

anceusiudly  less  marked     cated,    usually   no    ap- 
and  of  later  occurrence     pearanco  of  cachexia. 
thanincancer,aiid  more 
manifestly     dependent 
npon  the  gastric  disor- 
ders. 

10.    Pain    is    often  10.  The  pain  or  dis- 

more  paroxysmal,  more  tress  induced  by  taking 

influenced     by    taking  food  is  usually  less  se- 

food,    oftener    relieved  vero  than  iu  cancer  or 


iv 


f# 


)   \- 


!!■ 


'l 

(  I, 
I  -ill 

^1 1  1 

!,    1    ( 


! 


m 


m 


r 


i 


>   i' 


f  1 

^^^^^^K 

w^- 

■f'  ' 

'1 

IB^i 

m 

HhH 

if 


410 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


m 

OA>:.i:C    CAXCKH. 

licvcd  by  voniitiu<f,  uiul 
less  loftilizeil  than  in 
ulcer. 

11.    Causatiou    not 
kuowu. 


GASTUIC    ULOEU. 

by  vomiting,  iiiul  mow 
,sluir])ly  localized  than 
ill  cancer. 

11.    Causation    not 
known. 


12.  No  imj^rove- 
ment,  or  only  tempo- 
rary improvement,  in 
the  course  of  the  dis- 
ease. 


CTIUOXIO    CATAIiUIIAI, 
UASTKITIS. 

ulcer.  Fixed  point  of 
tenderness  usually  ab- 
sent. 

11.  Often  referable 
to  some  known  cause, 
such  as  abuse  of  alcd- 
hol,  gormandizing,  and 
certain  diseases,  as 
phthisis,  Brin^htV  dis- 
ease, cirrhosis  of  the 
liver,  etc. 

1^.  May  he  a  l.i'tdrv 
of  previous  similar  at- 
tacks. More  anii'iialili' 
to    regulation   of   ditt 


12.  Sometimes  a  his- 
tory of  one  or  m.>ix'  pre- 
vious similar  attacks. 
The  course  may  be  ir- 
regular and  intermit-  than  is  cancer, 
tent.  Usually  nuirked 
improvement  by  regula- 
tion of  diet. 

Treatment. — The  disease  is  incurable  ami  palliative  moasuros  are 
alone  indicated.  The  diet  shonhl  consist  of  readily  digested  substances  nf 
all  sorts.  Many  patients  do  best  on  milk  alone.  Washing  out  of  the 
stomach,  which  may  be  done  with  a  soft  tube  without  any  risk,  is  partii  ii- 
larly  advantageous  when  there  is  obstruction  i)t  the  pylorus,  ant!  is  by  far 
the  most  satisfactorv  means  of  combatting  the  vomitin<r.  Tlie  exeessive 
fermentatioji  is  also  best  treated  by  huage.  AVhen  the  pain  becoim's se- 
vere, particularly  if  it  disturbs  the  rest  at  night,  morphia  must  he  <rivon. 
One  eighth  of  a  grain,  combiTU'd  with  carbonate  of  soda  (gr.  v),  l)isiiiiith 
(gr.  v-x),  usua"y  gives  ])ronipt  relief,  and  the  dose  does  not  always  re- 
quire  to  be  increased.  Creosote  (ill  j-ij)  and  carbolic  acid  are  very  useful 
The  bleeding  in  'ifastrie  cancer  is  rarely  ameiud)le  to  treatment.  Opera- 
tive measures  have  been  advised  ajul  practised,  and  in  exceptional  in- 
stances there  are  cases  in  which  the  limited  cancer  cotdd  be  resei  ted  with 
reasonable  hojie  of  recovery. 

Xon-anirerous  fniixirs  of  the  stonuudi  rarely  cause  inconvoiiieiicc- 
Poh/pi  (polyadenomata)  ;'-.c  common  and  they  may  be  nunicnms;  us 
many  as  one  hundred  ami  fifty  have  bf>en  reported  in  one  case.  Tliert'  r> 
a  form  in  which  the  adenoma  exists  as  an  extensive  area  slightly  niistd 
above  the  level  of  the  nuwosa—poIi/tK/oiome  en  nappe  of  the  iMviicn, 
Sarcomata  are  very  rar-^      Fibroma/a  and  lipomatn  have  been  deseribi'd. 

Foreign  Inidivs  occasiomilly  })roduce  renuirkable  tunu)rs  of  tlio  stom- 
ach.    The  most  extraordinary  is  the  hair  tumor,  of  which  a  nuiiibor  el 


ki-%d. 


tm^x^ 


niEMORIUlAGE   PROM  THE  STOMACH. 


411 


instances  liave  been  reported  in  liysterical  women  wlio  have  b*  en  in  tlio 
hiibit  of  eating  their  own  hair.  A  speciiiion  in  the  medical  museum  of 
Mtdill  I'liiversity  is  in  two  sections,  wliicli  form  au  exact  mould  of  tho 
stdiiiiuli-  'i'lie  tumors  winch  they  form  ii"e  large  and  very  ])uzzliTig  a:  I 
hiivc  Ik'cii  mistaken  for  cancer.  In  one  instance  the  ball  oi'  hair  was  re- 
iiidvtd  hy  a  surgical  operation.  The  tumor  Avas  thought  to  be  a  r-  Si;'''e 
kidnev. 


VIII.    H>EMORRHAGE  FROM  THE  STOMACH  {Ihrmatrmes,-,). 

Etiology. — Gastrorrhagia,  as  this  symptom  is  called,  may  result  from 
niaiiv  (diulitions,  simie  of  which  are  local,  others  gcjieral. 

1.  la  local  disease  in  the  stomach  itself:  {a)  Cancer;  (/;)  ulcer;  (r) 
liisrusc  of  the  blood-vessels,  such  as  miliary  aneurisms  of  the  smaller  arte- 
ries and  occasionally  varicose  veins ;  (i/)  acute  congestion,  as  in  gastritis, 
;iih1  possibly  in  vicarious  Inemorrhagc,  but  both  of  these  are  extremely 
niiT  causes. 

;'.  Passive  congestion  due  to  obstruction  in  the  portal  system.  This 
iiiuy  1h'  citlicr  (a)  hepatic,  as  in  cirrhosis  of  the  liver,  thrond)osis  of  the 
imi'tal  vein,  or  pressure  upon  the  portal  vein  by  tumor,  and  secondarily  in 
i;isos  of  clironic  disease  of  the  heart  and  lungs  ;  (/>)  splenic.  Gastrorrhagia 
i.-  liy  no  ni  ans  an  uncommon  symptom  in  enlarged  spleen,  and  is  ex- 
jilaiiu'd  1)\  the  iatinuite  relations  which  exist  between  the  vasa  breviu  and 
ilu'  splciii'  cinadation. 

3.  Toxic :  {(i)  "i'lie  poisons  of  the  specific  fevers,  small-pox,  measles, 
yt'lldw  fever ;  (//)  poisons  of  unknown  origin,  as  in  acute  yellow  atrojihy 
;in(l  in  purpura;  (c)  ])hosphorus. 

•4.  TrauiMidism  :  (a)  Mechanical  injuries,  such  as  blows  and  wounds, 
uml  occasionally  by  the  stomach-tube;  {d)  the  result  of  severe  corrosive 

li'iisnllS. 

'i.  Cerlaiu  constitutioiud  diseases:  {a)  IlaMnojihilia ;  {//)  ijrofound 
aiKMiiias,  whether  idiopathic  or  due  to  splenic  enlargements  or  to  malaria ; 
I/)  clioheiiiia. 

''.  In  I  ertain  nervous  affections,  particularly  hysteria,  and  occasionally 
111  pr(ii:res<ive  paralysis  of  the  insane  and  ci)ilcpsy. 

i.  The  hlooil  may  not  come  from  the  stomach,  but  flow  into  it.  Thus 
If  may  pa<s  from  the  nose  or  the  i)harynx.  In  ha'i>;oj)iysis  some  of  the 
i'"il  may  find  its  way  into  the  stomach.  'I'hc  Idccding  may  take  i)lace 
ii"iii  the  ie>(iphiigus  and  trickle  into  the  stomach,  from  which  it  is  eject- 
^'1-  Ihis  (leeurs  in  the  case  of  rui)ture  of  ani'urism  and  of  the  (csopha- 
r'al  varices.  A  child  may  draw  blood  with  the  milk  from  the  mother's 
I'l'wist  evtii  ill  considerable  quantities  and  then  vomit  it. 

B.  Miscellaneous  causes:  Aneurism  of  the  aorta  or  of  its  branches 
""ly  rupfmv  into  the  stonuicli.     There  are  instances  in  which  a  patient 


m 


n!i: 


tP   > 


m 


A'\ 


mK 


ill 


,1?       !., 


i4> 


412 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


lias  ii  siiifrlo  attack  of  liivmorrliafrc  witliout  oven  having  a  rociin'oiicc  or 
without  synii»toiii,s  pointing  to  disuLsc  of  the  stoniacli. 

In  new-born  infants  lui'mateniosis  may  occur  alone  or  in  ediiiurtiiiii 
with  bleeding  from  other  mucous  membranes  (see  Ila-morrluige  in  tk. 
New-born,  p.  :547). 

in  nicdical  jiraetice,  ha-niorrhage  from  the  stomach  occurs  most  fre- 
quently in  connection  with  ciri'hosis  of  the  livi'r  and  ulcer  of  the  sldnjirli. 
it  is  more  frequent  in  women  than  in  men,  owing  to  the  gicalcr  iiiva. 
knee  (if  I'ouml  ulct'r  in  the  foi'mer. 

Morbid  Anatomy. — AVhen  death  has  occurred  from  the  hii'iiiatr- 
nu'sis  there  are  signs  df  intense  ana'Uiia.  'J'he  conditiim  of  the  stoiiuiili 
varies  extremely.  The  lesion  is  evident  in  cancer  and  in  ulcer  of  iIk- 
stDUiach.  It  is  to  be  l)oriie  in  mind  that  fatal  iKciUDri'liage  muv  ci'm 
from  a  snudl  miliary  aneurism  eoiuTuunicating  Avith  the  surface  liv  a  j  i :. 
hole  ])erforation,  or  the  bleeding  may  be  due  to  the  I'upture  i<\'  u  >■!- 
miH'ous  vein  aiul  the  erosion  in  the  mucosa  may  be  small  and  naiii>, 
overlooked.  It  may  recpiire  a  cai'i'fid  aiul  prolonged  search  to  imuil  nvir- 
looking  siK'h  lesions.  In  the  large  group  associated  with  poi'tal  i.li^inn- 
tion,  whellu'r  due  to  hej)atic  or  sjilenie  disease,  the  nnu-osa  is  usualh'  jwk, 
smooth,  and  shows  no  trace  of  any  lesion.  In  cirrhosis,  fatal  by  hainnr- 
rhage,  one  may  sometimes  seari-h  ,n  vain  for  any  focal  lesioa  to  iiceoinu 
for  the  gastnu'rhagia,  and  we  must  conclude  that  it  is  jiossildc  fur  i'\.i: 
the  most  [irofuse  bleeding  to  otcur  by  diapedesis.  'I'he  stomach  iiiay ! 
distended  with  blo(-d  and  the  source  of  the  luvmorrhage  not  a]ij)ii;'(r,t 
either  in  the  stomach  cr  in  the  the  portal  system.  In  such  ca.-i'.s  \hv 
a'so[)hagus  sliould  be  examini'd,  as  the  bleeding  may  eonu.'  from  tJ!;:; 
source.  In  toxic  cases  tlu're  are  invariablv  hnMnorrhat;es  in  the  iniKi.i:- 
niendii'ane  itself. 

Symptoms.  —  In  rare  instances  fatal  .-^ymjope  nuiy  occur  wiihoiil  ;.;.; 
vomiling.  Jn  a  case  of  the  kind,  in  which  the  wonum  had  fallen  cvcra!.! 
died  in  a  few  miinites,  tlu'  stonuudi  contained  between  thi'ee  ami  I'l'ir 
pounds  of  blood.  The  suddoi  profuse  bleedings  ra[>idly  lead  to  prnt'oii!:! 
ana'inia.  When  due  to  ulcer  or  cirrhosis  the  bleeding  usually  recurs  f  r 
-everal  days.  Fatal  lui'iuori'liage  from  the  stomach  is  met  with  in  ula:'. 
cirrhosis,  enlargemi'iit  of  the  si)leen,  and  in  instances  in  whieli  iui  aiiii;;- 
ism  ruptures  into  the  stomach  or  (esophagus,  (iastrorrhagia  may  (i^;;i 
in  si)lenic  ana'iiiia  or  in  leukaemia  before  the  condition  has  arou; 'il  tlii' 
attention  of  friends  or  physician. 

The  vomited  blood  may  be  iliiid  or  clotted  ;  it  is  usually  dark  in  i"!"'' 
but  in  the  basin  the  outer  part  rapidly  becomes  red  from  the  iictimpf 
the  uir.  The  longer  blood  remains  in  the  stomach  the  more  aheri'd  i>  i! 
wdieii  ejected. 

The  amount  of  blood  lost  is  very  variable,  and  in  the  cour-c  of  a  l;!} 
the  patient  nniy  bring  up  three  or  four  ])ounds,  or  even  iimiv.  I"  ■' 
case  under  the  cure  of  George  l{oss,  in  the  Montreal  General  llospilaljtiii 


HAEMORRHAGE  FROM  THE  STOMACH. 


413 


niitit'iit  Inst  (hinng  seven  days  ten  pnuiids,  1)y  measurement,  ol"  blond, 
'i'ho  usual  synii)toins  of  ana>mia  develop  rapidly,  and  there  itiav  he  i-liLrht 
tVvei',  iiiid  suhsequently  O'denia  may  occur.  An  interestiuf,'  eireumstanee 
idiniccled  with  <fastro-intestinal  ha-morrhage  is  the  develo])ment  of  umuu- 
ni,-i>,  the  mode  of  production  of  whieli  is  still  under  discussion. 

Diagnosis. — In  a  majority  of  instances  there  is  no  question  as  to 
the  niiniu  of  the  hlood.  Occasionally  it  is  difficult,  particularly  if  the 
t;i>i'  lias  not  heen  seen  during  the  attack.  Examination  of  the  vomit 
ivadilv  ilctennines  whether  blood  is  pi'csent  or  not.  The  nuiterials  vom- 
iti'il  iiiav  lie  stained  l)y  wiiu',  the  juice  of  strawberries,  raspberries,  or  cran- 
lirrries,  which  give  a  color  very  closely  resembling  fresh  Idood,  while  iron 
aiul  liisiiuith  and  bile  may  produce  a  blackish  color  like  alti'red  blood. 
In  sifli  cases  the  microscope  will  show  clearly  the  presence  of  the  shadowy 
iiutliiu's  (if  the  red  blood-corpuscles,  and,  if  necessary,  sijcctroscopi;.'  aiul 
ihcmieal  tests  may  be  applied. 

Deception  is  sometimes  ])ractised  bv  hysterical  patients,  who  swallow 
iiml  tlu'U  vomit  lihjod  or  colored  licjuids.  With  a  little  care  such  cases  can 
usually  l)e  detected.  The  eases  must  be  excluded  in  which  the  blood 
parses  from  the  nose  or  ])harynx,  dv  in  which  infants  swallow  it  with  the 
milk. 

There  is  not  often  diffictdty  in  distinguishinsj:  between  ha^moi)tysis  and 
liiviuateiiicsis,  though  the  coughing  and  the  vomiting  are  not  infnvjucntly 
combined.     The  following  are  points  to  be  borne  in  mind  in  the  diagnosis  : 


ILKMOPTY.SIS. 

1.  Cough  or  signs  of  some  ])ul- 
moiiary  (U'  cardial'  di>ease  ]trecciU's, 
in  maiiv  ease     the  hannorrhatr<'. 


ll.KMATKMKSIS. 

1.  I'l'evious  history  points  to  gas- 
trie,  hepatic,  or  .splenic  disease. 

v'.  The  blood  is  brought  up  by  -i.  The  d     is    coughed    up, 

vomiting,  prior  to  which  the  patient  and  is  usuall\  ,>«'ceded  by  a  .^cnsa- 
nia)  experien<'e  a  feeling  of  giddi-  tion  of  tickling  in  \\\r  iiroat.  If 
luw  (ir  faiiitness.  vonnting     occurs,    it     folh  ws     the 

coughing. 

.1  The  blood  is  usually  clotted,  .'i.  The  blood    is   frothy,  bright 

mixed  with   particles  of    food,   and     red    in    color,  alkaline  in   reaction. 
lia<  an  aeid    reaction.      It    nuiy   be     If  clotted,  rarely  in  such  large  ( • 
'lark,  jrniinous,  and  lluid.  agtda,  ami  nuu'o  !)us  luay  be  nuxed 

with  it. 

4.  Sul)so(juent  to  the  attack  tlie  4.  The  t'ough   ]iersists,  physical 

piUioiU  pu.sses  tarry  stools,  and  siijns  signs  of  local  disease  in  the  chest 
"I  (lisease  of  the  abdominal  viscera  nuiy  usually  be  detected,  and  the 
niiiy  be  detected.  sputa  may  be  blood-stained  for  many 

days. 

Prognosis. — Excejit  in  tlie  ease  of  ru])ture  of  aneurism  or  of  large 
^fiU3,  ha  niatemcsis  rarely  proves  fatal.     In  my  experience  death  has  fol- 


■Mm 


fgt 


i' 


!K 


414 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


lowed  more  frequently  in  cases  of  cirrliosis  and  splenic  enlargenuiu  tliaii 
in  ulctT  or  cancer.  In  iilcer  it  is  to  l)e  reniemhcred  that  in  tlic  chrdiiii' 
lia?niorrhagic  form  tlio  Weeding  may  recur  for  years.  The  treatment  of 
liaMuatemesis  is  considered  under  gastric  ulcer. 


r     •■ 


VII.   DISEASES  OF  THE  INTESTINES. 

I.  DISEASES    OF    THE    INTESTINES    ASSOCIATED   WITH 

DIARRHCEA. 

CATARRHAL   ENTERITIS;   DIARRHCEA. 

In  the  classification  of  catarrlial  enteritis  the  anatomical  divisions  of 
the  l)o\vel  iuive  lieeii  too  closely  followed,  and  a  duodenitis,  jejiinitis,  ik'i- 
tis,  typhlitis,  colitis,  and  ])roctitis  have  been  recognized;  whereas  in  a 
nuijority  of  cases  the  entire  intestinal  tract,  to  a  greater  or  lesser  extent.  i< 
involved,  sometimes  the  small  most  intensely,  sometimes  the  large  bowti, 
but  during  life  it  may  be  quite  impossible  to  say  which  portion  is  sjK'cially 
uU'ected. 

Etiology. — The  causes  may  be  altimr  jn'itnary  or  seconduri/.  Anmv: 
the  causes  of  j)riiiiitnj  catarrhal  enteritis  are  :  («)  Improper  food,  (nie  nf 
the  most  frecpieut,  especially  in  children,  in  whom  it  follows  ovcrcutint:. 
or  the  ingestion  of  unri])e  fruit.  In  some  imlividuals  special  articles  nf 
diet  will  always  produce  a  slight  diarrluea,  which  nuiy  not  be  due  ton 
catarrh  of  the  mucosa,  but  to  increased  peristalsis  induced  by  the  oirond- 
ing  nuiterial.  {h)  Various  toxic  sul)stances.  Many  of  the  orgaiuc  \m- 
sons,  such  as  those  i)roduced  in  the  decomposition  of  milk  and  articksif 
food,  excite  the  most  intense  intestinal  catarrh.  Certain  inorganic  sul'- 
stances,  as  arsenic  and  mercury,  act  in  the  same  way.  (r)  ("hanges  in  the 
weather.  A  fall  in  the  temperature  of  from  twenty  to  thirty  degrees,  pin- 
ticularly  in  the  spring  or  autumn,  nuiy  iiulucc— how,  it  is  ditliciilt  to  say 
—an  acute  diarrlujea.  We  sjieak  of  this  as  a  catarrhal  process,  the  result 
of  cold  or  of  chill.  On  the  other  hand,  the  diarrheal  diseases  of  childivi; 
are  associated  in  a  very  si)ecial  way  with  the  excessive  lioat  of  suniiiur 
months,  {d)  Changes'  in  the  constitution  of  the  intestinal  secretion?. 
We  know  too  little  about  the  aiicrus  niterina^  to  be  able  to  speak  of  intlii- 
ences  iiuluced  by  change  in  its  (puintity  or  quality.  It  has  long  been  lidtl 
that  an  increase  in  the  amount  of  bile  ])0ured  into  the  l)owcl  might  oxciton 
diarrhoea ;  hence  the  term  bilious  diarrhaia,  so  frequently  used  by  tlie  oMcr 
writers.  Possibly  there  are  conditions  in  which  an  excessive  amount  of  Itilf 
is  poured  into  the  intestine,  increasing  the  peristalsis,  and  hurryiufr  on  the 
contents;  but  the  opposite  state,  a  scanty  secret  ion,  by  favoring  llie  natural 
fermentative  processes,  much  more  commonly  causes  an  intestinal  caturrli. 
Absence  of  the  pancreatic  secretion  from  the  intestine  has  been  associate 


PISF.ASKS   OP  THE   INTESTINES  ASSOCIATED   WITH   DIARRIICEA.  415 


in  certain  enses  with  a  fatty  diarrlicpa.  (e)  Nervous  influences.  It  is  by 
no  iiH'Uii.s  clear  liow  mental  states  aet  upon  the  bowels,  and  yet  it  is  an  old 
1111(1  triistu-(jrt!iy  observation  wbieli  every-day  experience  confirms  that  the 
mental  state  may  profoundly  affect  the  intestinal  canal.  These  influences 
slidiilil  not  properly  be  considered  under  catarrhal  processes,  as  they  result 
simply  from  iiuireased  peristalsis  or  increased  secretion,  and  arc  usually  de- 
scribed under  the  heading  iwrrovs  diarrh(e(i.  In  chiklren  it  frequently 
fdllows  fright.  It  is  common,  too,  in  adults  as  a  result  of  emotional  dis- 
tiirhancos.  Canstatt  mentions  a  surgeon  who  always  before  an  important 
operation  had  watery  diarrluea.  In  hysterical  women  it  is  seen  as  an  occa- 
sional occurrence,  due  to  transient  excitement,  or  as  a  chronic,  protracted 
diarrluea,  which  nniy  last  for  months  or  even  years. 

Among  the  .srco»y/«?'_y  causes  of  intestinal  catarrh  may  be  mentioned : 
[(i)  Infectious  diseases.  Dysentery,  cholera,  typhoid  fever,  pyaemia, 
septicannia,  tuberculosis,  and  pneumonia  are  occasionally  associated  with 
intestinal  catarrh.  In  dysentery  and  ty])hoid  fever  the  ulceration  is  in 
part  responsible  for  the  catarrhal  condition,  but  in  cholera  it  is  probably  a 
direct  inlluence  of  the  bacilli  or  of  the  toxic  materials  produced  by  them. 
[li)  The  extension  of  inflammatory  i)rocesscs  from  adjacent  parts.  Thus, 
in  peritonitis,  catarrhal  swelling  and  increased  secretion  are  always  present 
in  the  mucosa.  Ii'  cases  of  invagination,  hernia,  tuberculous  or  cancerous 
ulceration,  catarrhal  processes  are  common,  (c)  Circulatory  disturbances 
eause  a  catarrhal  enteritis,  usually  of  a  very  chronic  character.  This  is 
oonimon  in  diseases  of  the  liver,  such  as  cirrhosis,  and  in  chronic  affections 
of  the  heart  and  lungs — all  conditions,  in  fact,  Avhich  produce  engorge- 
ment of  the  terminal  l)ranches  of  the  ])ortal  vessels.  {<])  In  the  cachectic 
ponditions  met  with  in  cancer,  profound  anannia,  Addison's  disease,  and 
lhi<.'lit's  disease  intestinal  catarrh  may  develop,  and  may  terminate  life. 

Morbid  Anatomy. — Changes  in  the  mucous  membrane  are  not 
always  visible,  ami  in  cases  in  which,  during  life,  the  symp.toms  of  intes- 
tinal catarrh  have  I)een  nuirked,  neither  redness,  swelling,  nor  increased 
secretion — the  three  sigJis  usually  laid  down  as  characteristic  of  catarrhal 
intlanniiation — may  be  present  post  mortem.  It  is  rare  to  see  the  mucous 
membrane  injected ;  more  commonly  it  is  pale  and  covered  with  mucus. 
In  the  upper  part  of  the  small  intestine  the  tij^s  of  tlie  valvula?  conniventes 
maybe  deeply  injected.  Even  in  extreme  grades  of  portal  obstruction 
intense  hyperiemia  is  not  often  seen.  The  entire  mucosa  may  be  softened 
and  intiltrated,  the  lining  epithelium  swollen,  or  even  shed,  and  appearing 
ii>  liirjre  Hakes  among  the  intestinal  contents.  This  is,  no  doubt,  a  post- 
mortem (diange.  The  lymph  follicles  are  almost  always  swollen,  particu- 
liulyin  (hildren.  The  Peyer's  patches  maybe  prominent  and  the  solitary 
follielos  in  the  large  and  snudl  bowel  may  stand  out  with  distinctness  and 
present  in  the  centres  little  erosions,  the  so-called  follicular  ulcers.  This 
maybe  a  striking  feature  in  the  intestine  in  all  forms  of  catarrhal  enteri- 
tis in  children,  quite  irrespective  of  the  intensity  of  the  diarrhoea. 


'iM\ 


41(5 


DISEASES   OF  THE   DIGESTIVE  SYSTEM. 


K'# 


I* 


When  the  process  is  more  elironic  tlie  iiuicosii  is  llniicr,  in  some  in- 
stances  thickened,  in  others  distinctly  tliinned,  and  the  villi  and  follicles 
present  ii  slaty  pigmentation. 

Symptoms. — Acute  and  chronic  forms  may  be  recognized.  The  im- 
portant symptom  of  both  is  diarrluea,  which,  in  the  majority  of  iiistaiiees, 
is  the  sole  indication  of  this  condilioii.  It  is  not  to  be  sup})osed  tlirt  (li;ir. 
rliu'a  is  invariably  caused  by,  or  associated  with,  catarrhal  eiitci'itis  as  i; 
may  be  2)roduced  by  nervous  and  other  iniluences.  It  is  probidili!  t!ia! 
catarrh  of  the  jejunum  nuiy  exist  without  any  diarrluea  ;  indeed.,  It  i.;  ;; 
very  common  circumstance  to  lind  ])ost  mortem  a  catarrhal  state  of  {Vx 
snudl  bowel  in  persons  wlio  have  not  had  diarrha-a  during  life.  TIii' 
stools  vary  extremely  in  character.  7'be  color  depends  upon  tlic  aindiiiit 
of  bile  with  which  they  are  mixed,  and  they  may  be  of  a  dark  or  l)IuokisIi 
brown,  or  of  a  light-yellow,  or  even  of  a  grayish-white  tint.  The  coi!;i.-t- 
enco  is  nsnally  very  thin  and  watery,  but  in  some  instances  the  stools  mv 
2)ultaceons  like  thin  grueh  Portions  of  undigested  food  can  often  he  seen 
(lientoric  diarrliani),  and  flakes  of  yellowish-brown  mucus.  3Iit  rosco]  ic- 
ally  there  are  innumerable  micro-organisms,  epithelium  and  mucous  cells 
crystals  of  phosjjhate  of  lime,  oxalate  of  lime,  and  occasionally  cholesteriii 
ami  Charcot's  crystals. 

Pain  in  the  abdomen  is  usually  present  in  the  acute  catarrhal  enteritis. 
particularly  when  due  to  food.  It  is  of  a  colicky  character,  and  when  tlir 
colon  is  involved  tiu're  may  be  tenesmus,  ^[ore  or  less  tyni})anites  exists. 
and  there  are  gurgling  noises  or  borborvgnn,  due  to  the  ra}iid  p;iss!ijie  I'f 
fluid  and  gas  from  one  i)art  to  another.  In  the  very  acute  attacks  \hm- 
may  l)e  vomiting.  I'ever  is  not,  as  a  rule,  present,  but  there  may  lie  ;i 
slight  elevation  of  one  or  two  degrees.  The  api)etito  is  lost,  there  is  in- 
tense thirst,  and  the  tongue  is  dry  and  coated.  In  very  iicute  case-;,  when 
the  quantity  of  lluid  lost  is  great  and  the  pain  excessive,  there  may  !"■ 
collapse  symptoms.  The  number  of  evacuations  varies  from  foui'  or  fiw 
to  twenty  or  more  in  the  course  of  the  day.  The  attack  lasts  for  two  nr 
three  days,  or  nuiy  l)e  prolonged  for  a  Aveek  or  ten  days. 

Chronic  catarrh  of  the  bowels  may  follow  the  acute  form,  oi'  ma\  ik- 
velop  gradually  as  an  independent  alTection  or  as  a  sc([uence  of  oil^tnl(■- 
tion  in  the  portal  circulation.  It  is  characterized  by  diarrho'a,  with  or 
without  colic.  The  dejections  vary ;  when  the  small  bowel  is  eliiclly  in- 
volved the  diarrha'a  is  of  a  lienteric  character,  and  Avhen  tlie  coldii  r 
afTected  the  stools  are  thin  and  mixed  Avith  much  mucus.  A  speciii! 
form  of  mucous  diarrluea  Avill  bo  subsequently  described.  'i"he  f^eiu'inl 
nutrition  of  the  patient  in  these  chronic  cases  is  greatly  disturlu'd  ;  tlii^'iv 
may  be  much  loss  of  flesh  and  great  ])allor.  The  ])atients  are  ineHiied  tn 
suffer  from  low  sjiirits,  or  hy])ochondriasis  may  develop. 

Diagnosis. — It  is  imjiortant,  in  the  first  jdace,  to  determine,  if  pn^- 
sible,  Avhether  the  large  or  small  bowel  is  chiefly  afTected.  In  eatanii  ot 
the  small  bowel  the  diarrha-a  is  less  marked,  the  pains  are  of  u  (ulieky 


DIsr.ASKS  OF   THE   INTESTINKS   ASSOCIATED   WITH   DIAHUIKKA.  417 

rlianirlcr,  l)()r1)orv<?nii  are  not  so  frcqtuMit,  tlio  firooa  usually  oontaiii  jior- 
timis  111'  fund,  and  aro  more  ycllnwi.h-trrccn  or  ^'rayisli-vcllow  and  flof- 
(uk'iit  and  do  not,  contain  mnch  iinicus.  ^^'llon  the  larLTc  intestine  is  at 
fault  till  re  may  1)e  no  ])ain  whatever,  as  in  tlie  eatarrli  of  the  larire  iiitos- 
tiiio  !is<oiiated  with  tnhereulosis  and  Hi'i.rlit's  disease.  When  |ii'eseiit.  thi' 
pains  are  most  iideiise  and,  if  the  lower  portion  of  the  howel  is  involved, 
tluw  liKiv  he  marked  tenestnns.  The  stools  have  a  nniforni  soupy  eon- 
^isttiiee,  grayish  in  color  and  ,ii:raindar  throii^rliout,  with  here  and  there 
llaki's  of  mucus,  or  they  may  contain  very  larj,'e  ([uantities  of  nuu-iis. 

There  are  no  positive  sym[)tonis  by  whicli  the  diai,niosis  of  iluodenitis 
can  he  made.  It  is  usually  associated  -with  acute  ji^astritis  and.  if  ,:ie  pro- 
irss  extends  into  the  bile-duet,  with  jauiulice.  Neither  jejunitis  nor 
ileitis  can  ho  separated  from  general  intestinal  catarrh. 

ENTERITIS   JN  CIIILDKEX. 

We  may  recojjjnizo  three  forms  ;  (1 )  The  acute  dyspeptic  diarrhcea  ;  (v) 
rhiili'vu  iid'antum;  iuul  {'■>)  acute  entero-colitis. 

General  Etiology  of  the  Diarrhoeas  of  Children.— The  dis- 
lasi-'  is  most  fi'eipu'Ut  in  artilicially  fed  children,  and  the  jjfreatest  number 
iif  cases  occur  between  the  a^yi-:  of  six  and  eiji'hteen  nu)nths.  A  po[)ular 
and  well-founded  belief  ascrii)es  special  danger  to  the  second  summer  of 
tlif  infant.  Infantile  diarrlura  is  very  prevalent  among  the  poorer  classes 
ill  the  lar^'e  cities.  It  attacks,  however,  (ddldren  with  the  most  favorable 
suiTuimdiiigs.  Two  factors  iidluence  the  disease,  diet  aiul  temperature. 
An  iiimu'nso  majority  of  all  fatal  cases  are  artificially  fed.  Of  1,94:5  fatal 
oases  in  Holt's  statistics,  oidy  three  })er  cent  were  exclusively  breastfed. 
Among  the  poor  the  bowel  e(miplnint  in  children  begins  Avith  the  artificial 
tVoding.  The  relation  of  temperature  to  the  prevalence  of  diarrlueal  dis- 
eases in  children  has  long  been  recognized.  The  mortalitv  curve  bt'gins 
t>  rJM'  ill  May,  increases  in  June,  reaches  the  maximum  in  July,  and  grad- 
ually siid\s  through  August  and  September.  Tlie  maximum  corresponds 
cldsely  with  the  highest  mean  tem])erature  ;  yet  we  cannot  regard  the  heat 
itself  us  the  direct  agent,  but  oidy  one  of  several  factors.  Thus  the  mean 
temperature  of  June  is  only  four  or  five  degrees  lower  than  that  of  .Fuly, 
aiiil  yet  the  mortidity  is  not  more  than  one  third.  Seibert,  who  has  care- 
fully analyzed  the  mortality  and  the  temperature,  moiith  by  mouth,  in 
New  York,  for  ten  years,  fails  to  find  a  coushint  relation  between  the 
ileiri'ee  of  heat  and  the  lunnber  of  cases  of  diarrluea.  Neither  barometric 
pies-^uic  11,11-  huiiiidity  appears  to  have  any  influence. 

Relation  of  Bacteria. — The  healthy  faeces  of  sucklings  contain  a 
iiumlier  (.f  1)acteria  and  micrococci,  the  most  important  of  whicli  are  the 
•-"iiirruhii-  huiis  (icnit/oies  and  the  hactcrivm  roll  rniininiiie.  The  former 
isonly  ]iresent  in  the  intestine  after  a  milk  diet,  the  milk  sugar  a{)[)ear- 
"ig  to  furnish  the  materials  necessary  for  its  growth.      It  occurs  more 


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418 


DISEASKS  OF  THE   DIGESTIVE  SYSTEM. 


in  tho  iipjicr  jioriiDii  of  tlic  bowel,  ami  in  this  rcjfinn  excites  iho  fpr- 
mtmtiitive  ])r()('ossos  in  the  niilk.  The  hitrfrn'inii  mli  ninninnii'  is  fdunil 
more  aljiindaritly  in  the  lower  portion  of  the  small  inli'stiiu!  and  in  the 
<'olon,an(l  excites  f(>rnientative  chanj^'es  Avl.ich  are  i)rol)ahly  associjitci]  with 
certain  |)ha:-es  of  (lijfestion.  'Die  observations  of  Kscherieh  show  the  rc- 
niarkahlo  siniplieity  of  this  l)acterial  vei^etaiion  in  the,  healthy  facw  df 
milk-fed  children,  as  theso  two  alono  develop  and  are  constant.  In  iiifiui- 
tilt!  diarrlnea  the  nnmherof  haeteria  which  may  Ix*  isolated  from  llicstoii]. 
is  remarkahl(>.  Hooker  has  discriminated  forty  varieties,  the  ^M'catest  mini- 
bcr  of  which  were  found  in  the  cases  of  cholera  infantum.  The  two  con- 
stant forms  noted  above  do  not  disappear  in  the  diarrlueal  stools.  \(, 
forms  hav(!  been  fonnd  to  beiir  a  constant  or  specilie  relation  to  tlii'  diar- 
rlui'al  i'a'ces,  siudi  as  tho  two  above  mentioned  do  to  tlut  healthy  milk 
fivccs.  Tho  baeteriii  of  tho^)>v)/^'/^N•  i^roup  are  most  i're(pient,  and  ]iossc>> 
pathojienic  ])ropertios.  All  tlio  varieties  develop  and  produce  important 
chantje.s  in  the  milk,  which  have  been  dealt  Avith  very  fully  by  Booker  in 
liis  studies.  This  anthor  concludes  that  in  the  diarrlnea  of  inl'ants  'Mut 
one  specific,  kind,  but  many  dilh^reiit  kinds  of  bacteria  are  cmiccrmd. 
nnd  that  tluMr  action  is  manifested  more  in  tlio  alteration  of  tiio  food  and 
intestinal  contents  and  in  the  production  of  injurious  ])roducts  tlum  in  a 
direct  irritation  u])on  the  intestinal  wall."  AVith  these  a^n-ee  the  coiiflii- 
sions  of  Jtdfrics  and  l?a,i,dnsky  reixardinj;  clndera  infantum. 

Morbid  Anatomy. — We  find  most  frc(pu>ntly  a  catarrhal  swellin'r 
of  tho  mucosa  of  both  small  and  large  bowel  with  enlarijfemeiit  of  tlic 
lymph  follicles.  In  more  chronic  cases  tho  latter  show  snudl  erosions  or 
follicular  nlciMv;  more  rarely  there  is  croupous  enteritis  atTcctiiiir  the 
lower  j)art  of  the  ileum  and  tho  colon.  The  changes  in  the  other  or^'an< 
arc  neither  numerous  nor  cliaracteristic.  'Broncho-pneumonia  occiir-s  in 
many  cases.  Tho  sjjleen  may  be  swcdlen.  Brain  lesions  are  ntiv;  tin 
membranes  and  substance  are  often  ana-^mic,  but  meningitis  or  tliromboMs 
is  very  uncommon. 

Clinical  Forms. — Acute  Dyspeptic  DIarrhoBa. — The  chiM  muya;- 
pear  in  its  usual  health,  but  lias  an  increase  in  the  munber  of  stools,  vitli- 
out  fever  or  special  disturbance  except  slight  restlessness  at  night.  After 
persisting  for  a  day  or  two  tho  stools  become  more  frerpient  aiul  coiitain 
undigested  food  and  curds,  and  are  very  olTensive.  In  other  cases  tlio  div 
case  .sets  in  abru])tly  with  vomiting,  griping  jjains,  and  fever,  wdiicli  iiiay riff 
rapidly  and  reach  104"  or  105°.  There  may  bo  convulsions  at  the  outset. 
The  abdomen  is  .sensitive,  and  the  child  lies  with  the  legs  drawn  up.  Tin 
stools  consist  of  grayish  or  greenish-yellow  fivces  mixed  Avith  gas,  ourds, 
and  portions  of  food.  In  children  over  two  years  of  age  such  attacks  not 
infrequently  follow  eating  freely  of  unrii)e  fruit  or  the  drinking  of  niilK 
wliich  lias  been  tainted.  AVith  judicious  treatment  the  children  imin'ov*' 
in  a  few  days;  but  relapses  arc  not  uncommon,  and  in  the  hot  weatliei 
the  attack  may  be  the  starting  point  of  a  severe  entero-colitis.    In  a  t'*'" 


immi 


DISKASKS  OP  THE  INTKSTINES   ASSOCIATED  WITH   DIAUUIKEA.  419 

liilitattMl  cliild  a  mild  iiitack  may  provo  fatal.  This  (lysiK'ptic;  diarrluea  is 
(li.stiii;,niislu'(l  .siiarply  from  cliolorji  infantum  hy  the  charaottT  of  tho 
st(M»ls,  \\lii(/li  never  haw.  a  watery,  serous  charaeter.  In  nuiny  instaucoa 
iliis  Idiiii  |)recedes  the  onset  of  the  sijeeific  fevers,  particularly  during  tho 
hut  wi'iillicr. 

Cholsra  Infantum. — This  is  tlie  (!0unter])art  in  the  infant  of  the  so- 
lallcd  I  liok'raic  diarrluwi  in  the  adult,  and  in  their  elinical  aspecits  these 
t«()  I'di'iiis  arc  identical.  It  is  l)y  no  means  so  common  as  the  ordinary 
(Ivsiu'iitic  diarrhoui  of  children,  and,  according  to  Holt,  occurs  only  in 
two  or  tiiree  per  cent  of  the  cases  of  summer  diarrho-a.  It  j)revails  in 
tliL'  hut  weather  and  in  children  artilicially  fed  or  who  have  had  jjre- 
vioiisly  some  slight  dyspeptic  derangement.  It  is  characterized  by  vomit- 
iii;r.  iiiirontrollahle  diarrho-a,  and  collapse.  The  disease  sets  in  with 
voiiiitiiius  which  is  incessant  and  is  excited  hy  any  attempt  to  take  food  or 
ilriuk.  The  stools  are  profuse  and  frequent;  at  first  faical  in  (character, 
brown  or  yellow  in  (!olor,  and  Imally  thin,  serous,  and  watery.  The  stools 
first  passed  are  very  offensive;  subsequently  they  are  odorless.  'J'he  thin, 
serous  stools  arc  alkaline.  There  is  fever,  but  the  axillary  tem])eraturo 
may  rcjzistor  three  or  more  degrees  below  that  of  the  rectum.  From  the 
oiit'iut  there  is  marked  prostration ;  the  eyes  are  sunken,  the  features 
piuclicMl,  tlie  fontaiUiUe  depressed,  and  the  skin  has  a  peculiar  ashy  pallor. 
At  iirst  restless  and  excited,  the  child  subsequently  becomes  heavy,  dull, 
and  listless.  The  tongue  is  coated  at  the  onset,  but  subsequently  becomes 
ri'il  and  dry.  As  in  all  choleraic  conditions,  the  thirst  is  insatiable;  the 
jiulsL'  is  rapid  and  feeble,  and  toward  the  end  becomes  irregular  and  im- 
liereeptibie.  Death  may  occur  within  twenty-four  hours,  with  symptoms 
of  t'ollupse  and  great  elevation  of  the  internal  temi)eraturc.  Before  the 
end  tho  (liarrlui'a  and  vomiting  may  cease.  In  other  instances  the  intense 
-ymptoins  subside,  but  the  child  remains  torpid  and  semi-comatose  with 
lingtM's  rhit(!hed,  and  there  may  be  convulsions.  The  head  may  be  retract- 
ed and  the  respirations  interrupted,  irregular,  and  of  the  Cheyne-Stokcs 
typo.  The  child  nuiy  remain  in  this  condition  for  rsome  days  without  any 
•igus  of  iin[)rovement.  It  was  to  this  group  of  symjitoms  iji  infantile 
diiirrluca  that  MarsIiall-IIall  gave  the  term  "  hydrenceiihaloid  "  or  spuri- 
ous hydrocephalus.  As  a  rule,  no  changes  in  the  brain  or  othe'-  organs 
:iio  found,  and  the  condition  is  no  dou])t  caused  by  the  toxic  agents 
ahsorhed  from  the  intestine.  A  remarkalde  condition  of  sclerema  is  de- 
fPi'ibed  as  a  sequel  of  cholera  infantum.  The  skin  aiul  subcutaneous  tis- 
sues l)C('(jine  hard  and  firm  and  the  appearance  has  been  compared  to  that 
of  a  half-frozen  cadaver. 

^0  constant  organism  has  been  found  in  these  cases.  Baginsky  con- 
'id'rs  the  disease  the  result  of  the  action  on  the  system  of  the  poisonous 
products  of  decomposition  encouraged  by  the  various  bacteria  present — a 
tnuhuss  disease.  The  clinical  picture  is  that  produced  by  an  acute  bac- 
t^^rial  infection,  as  in  Asiatic  cholera. 


M 


' '  V  ■•'li 


u 


mil 


420 


DISEASES  OF  THE   DKJESTTVE   SYSTEM. 


I*  I 

u 


f'l 


'riic  <ll(i(j)iosiK  \^  roiidily  iiiiidi'.  'PliciH!  is  no  otlicr  iiitcstiniil  ,itH'ctii,ii 
ill  children  I'oi-  whicli  it  can  he  iiiislMkcii.  'I'lic  c(iiisl!iiit  voiniiinij,  tl  >■ 
friMjiu'iit  Wiiti'iT  di.>chiiri^{'S,  tiic  colljipsc  syiiiptonis,  and  tlic  ('lc\;ii  mI  tc : . 
penitiirc  lUMkc  an  iimiiistal'kahjf  clinical  pictnrc.  'I'lic  oiitlodk  in  t!ii'ii:i- 
jority  of  cases  is  had,  particidarly  in  children  artilicialiy  U'A.  Ih|cr['V- 
rexia,  extreme!  collapse,  and  incessant  vomiting  arc  tlie  most  scrinii,  svi;/. 
tuiiis. 

Acute  Entero-colitis. — In  this  form  llie  ileum  and  colon  mv  iii,,.i 
ailVcted,  chielly  in  the  lym[)li  follicles,  lionco  tluv  term  foliicidnr  ciitfiii:. 
or  follicniar  dysentery.  It  occurs  most  fre(|uently  in  warm  wcatlii  r.  iu 
artilicialiy  fed  children;  but  it  may  set  in  at  any  .season  of  the  year,  a:  (1 
is  the  form  of  enteritis  most  common  a.->  a  secondary  com])lication  in  thi' 
spocilic  fevers  of  childhood. 

The  attack  inay  follow  the  ordinary  dyspeptic  diarrlio'a.  The  (rin- 
peraturo  incireases,  the  stools  change  in  character  and  contain  ti'acisdf 
blood  and  mucus,  the  former  nsually  only  in  .streaks.  Tlie  fa'ces  nro 
passed  without  any  pain.  The  abdomen  is  distended  and  tender  alni':; 
the  line  of  the  colon.  Vomiting  may  bo  i)rosent  at  the  outset,  Imt  i>  n  t  a 
characteristic  feature,  as  in  cholera  infantum.  The  diarrlioa  luav  K 
gradually  checked  and  convalescence  is  established  in  two  or  three  wi'cks; 
in  other  instances  the  disease  becomes  subacute,  the  fever  subsides,  hut  the 
diarrluwi  persists  and  the  general  health  of  the  child  rajjidly  detcridra;:  -. 
The  case  may  drag  on  for  five  or  six  weeks,  when  improvenunt  gradualh 
occurs  or  the  child  is  carried  olf  by  a  severe  intercurrent  attack.  In  a 
third  form  of  acute  entero-colitis,  in  which  anatomically  the  lesions  an 
those  already  mentioned — namely,  an  intense  follicular  inilanuiiatii'M— tla 
symptoms  are  of  a  more  severe  character,  and  the  alTection  is  s(  iiutiiiK- 
spoken  of  as  acute  dysentery.  It  attacks  children  u])  to  the  tliinl  nr 
fourth  year  or  even  older.  The  onset  is  sudden,  Mith  high  fmer,  vomit- 
ing, fre((uent  stools,  whicdi  at  lirst  contain  remnants  of  fond  ami  lari- 
and  subsequently  much  nnieus  and  some  blood.  There  is  incessant  fiaiii. 
which  may  be  more  severe  than  in  any  intestinal  alTection  of  cliiMlKniil. 
The  prostration  is  very  great  and  the  fatal  termination  may  occin'  uitli';! 
forty-eight  hours.  !More  commonly  the  case  lasts  for  a  week  oi'  l"n;'rr. 
In  two  cases  of  this  sort,  in  one  of  Avhich  death  occin-rcd  in  rorly-(i;'lit 
and  in  the  other  in  sixty-four  honrs,  the  anatomical  characters  were  tliH-i 
of  the  most  acute  follicular  enteritis,  characterized  by  great  swelling  cf 
the  lymph  follicles,  some  of  which  already  ])rescnted  necrotic  fi  ci. 

The  CoBliac  Affection. — rnder  this  heading  (ice  has  descrihed  an  inte-- 
tinal  disorder,  most  commonly  nu^t  with  in  children  between  tin  airc^  "t 
one  and  five,  characterized  by  the  occurrence  of  pale,  loose  stools,  imt 
nnlike  gruel  or  oatmeal  porridge.  They  iife  bnlky,  not  water,  yeasty. 
frothy,  and  extremely  otfensive.  The  affection  has  received  various  iianii'N 
such  as  (linrrluva  alba  or  diarrha'a  chylasa.  It  is  not  associatiMl  with 
tuberculosis  or  other  hereditary  disease.     It  begins  insidiously  ami  tlicri' 


DISKASKS   OF  TIIH  INTKS'lMNIvS  ASSOCIATKI)  WITH   DIAKKIKKA.    4'2l 


;iiv  |iii':.M'cssivo  wiistiiif;,  wciikiicss,  ami  piiUor.  'I'lui  Ir-IIv  licconicrt  doufrliy 
;i!iil  iiirlastic.  Tlicni  is  ortcn  IIiitiilciHn-.  I-'cvcr  is  usually  ahsciit.  'I'Ik' 
ili-iMsr  's  liii;;i'riiij,'  ami  a  fatal  tcrmiiiatiuii  is  coiumon.  So  far  lujtliiu^'  is 
kiMjuiiof  tlif  i»atli()lo^'y  of  the  tlisrasc.  rictTation  of  tiic  inti'stincs  luis 
Urii  nut  with,  hilt  it  is  not,  consiaut.  'I'liis  alTcction  rcscinijii'S  Homowhat 
till-  (hM'ax'  ill  ailiiUs  known  as  tiio  Iii/l  i/iiirr//(i'ii,  or  tiu'  wliitc  flux  of 
iiidia,  with  uhicli  the  pxilusis  or  .^prue^  aiiollicr  tro|ti('al  (lisoidi  r,  is  con- 
.iilind  iiiciitical  by  soino  writers.  Certain  of  tiiesct  tropical  (liarriui'as  arc, 
;i-  will  111'  nientioneil,  ussouiateil  witii  tiie  presi'iiee  of  the  (n/c/ii//ns/(iiii((. 

DirilTlIKIJITIC   OR  CIlOLTPOrs   KNTKUITIS, 

A  croiipons  or  dipiitlieritic  inllanimation  of  the  mucosa  of  the  small 
;iiii]  laiL;-c  intestines  occurs  [a)  most  frtHiuently  as  a  secondary  process  in 
till'  iiil'fi'tioiis  diseases — pneumonia,  jiyiemiu  in  its  various  forms,  ami 
iv|iliiii(l  fever;  (//)  us  a  terminal  jiroeess  in  many  chronic  aireetioiis,  such 
as  liri^ilil's  disease,  cirrhosis  of  the  liver,  or  cancer;  and  (c)  as  an  elTect  of 
uTiain  poisons — mei'cury,  leail,  and  arsenic. 

Till  re  arc  three  dilTcrent  anatomical  ])ieturos.  In  one  group  of  cases 
the  iiiiii'osa  presents  on  the  top  of  the  folds  a  thin  <fra}isli-ycllow  diph- 
tlii'i'itii-  exudate  situated  upon  a  deeply  congested  liasc.  In  some  cases 
;ill  unaili's  may  be  seen  between  the  thinnest  film  of  superlicial  necrosis 
ami  iiivolvement  of  th(^  entire  thickness  of  the  mucosa.  In  the  colon 
Miiiilar  transversely  arranged  areas  of  necrosis  are  seen  situated  upon  hy- 
ln'ia'iiiic  patches,  and  it  may  be  here  much  more  extensive  and  involve 
a  lari:i'  portion  of  the  membrane.  There  may  be  most  extensive  inllam- 
luatinii  without  any  involvement  of  the  solitary  follicles  of  the  huge  or 
-iiiall  liiiwel. 

Ill  a  second  group  of  oases  the  moTiibrane  has  rathev  a  croupous  char- 
ai'tcr.  It,  is  grayish  white  in  color,  more  tlake-like  and  extensive,  limited, 
jM  rliaps,  to  the  civicum  or  to  u  portion  of  the  colon ;  thus,  in  several  ca.scs 
"i' I'liriiiiioiiia  1  found  this  flaky  adherent  false  mombraiu',  in  one  instance 
toiininjr  patches  1  to  2  cm.  in  diameter,  which  were  not  unlike  in  form  to 
niliia  crusts. 

In  a  tliird  group  the  affection  is  really  a  follicular  enteritis,  involving 
ihf  Solitary  glands,  which  are  swollen  and  cap})cd  with  an  i.rca  of  di])h- 
ilu'i'ilie  necrosis  or  are  in  a  state  of  su})puration.  Folliculai'  ulcers  are 
I'liiiunon  in  this  form.  The  disease  may  run  its  course  without  any 
>.viiiiit(j!Ms,  and  the  condition  is  unexpectedly  met  with  post  mortem.  In 
iitliiT  instances  there  are  diarrluea,  ])ain,  but  not  often  tenesmus  or  the 
passairi'  of  blood-stained  mucus.  In  the  toxic  cases  the  intestinal  symp- 
tuius  may  be  very  marked,  but  in  the  terminal  colitis  of  the  fevers  and  of 
'■'iiistiiutional  atfcctions  the  symptoms  are  often  trilling. 

Thr  ulcerative  colitis  of  chronic  disease  may  be  only  a  terniiiial  event 
ill  tlu'se  diphtheritic  processes. 


•1 


^M 


*     'ff 'I  1 


I  s' 


422 


DISEASES  OP  TIIK   DKJKSTIVE  SYSTEM. 


PIir.KGMONOUS  ENTHIUTIS. 

As  an  independent  iilTeetion  this  is  excessively  rare,  even  less  ficfjuont 
than  its  coiintei'itart  in  tlu^  stuniaeh.  Jt  is  seen  «H'casi(tnally  in  fuiiiuctj,,,, 
with  iMtnssusce|ttioii,  straiij:nlate(l  licrMJa,  and  <'hi'(ini(' ohstruction.  Aimrr 
frotii  Miese  eoiidilions  it  oceiirs  most  t'recineiilly  in  the  duodeiiiiin,  and 
leads  to  suppuration  in  the  siihniueosa  and  al)scess  formation.  Kxci.tit 
when  associated  with  hernia  or  intnssiisception  the  alFeetion  cannot  be 
diagnosed.     Tho  syni])t()nis  usually  resend)le  those  (tf  peritonitis. 


MUCOUS  COLITIS. 

Tliis  afTeotion  is  known  by  various  names,  sueli  as  mrinhfnhnux  n,. 
terilis,  tiiliKlid'  (Harrlut'ti,  awX  vmniHs  ntlir.  It  is  u  rcniarkalilc  disca.-c. 
to  which  much  attention  has  been  paid  Tor  several  centuries.  An  cvliimst- 
ive  descriiition  of  it  is  given  by  Woodward,  in  Vol.  II  of  the  Mnliial 
and  Surgi<!al  Reports  of  the  Civil  War.  It  is  an  alTcdion  of  the  Jaii^c 
bowel,  characterized  by  the  ])roduction  of  a  very  tenacious  adherent  iiiikus, 
which  may  be  passed  in  long  strings  or  as  a  continnoiis,  tubidar  iiniii- 
brane.  I  have  twice  had  o]i])ortunities  of  sei'ing  this  membrane  ///  silu, 
closely  adherent  to  the  mucosa  of  the  colon,  hut  capable  of  separation 
without  any  lesion  of  the  surface.  Judging  frotu  tho  statement  nf  Km.'. 
lish  authors  as  to  its  rarity,  it  would  aj)pear  to  be  a  more  freipu'nt  (Hseasi' 
in  this  country.  According  to  W.  A.  Edwards,  SO  per  cent  of  the  re- 
corded adult  cases  have  been  in  women.  It  occurs  occasionally  in  cliiMicii. 
Of  111  cases  six  were  under  the  age  of  ten.  The  cases  are  almosl  invari- 
ably seen  in  nervous  or  hysterical  women  or  in  men  with  neurastlicnia. 
All  grades  of  the  affection  occur,  from  the  passage  of  a  slimy  mucus,  like 
frog-spawn,  to  large  tubular  casts  a  foot  or  more  in  length.  Micioscdjii- 
cally  the  easts  are,  as  shown  by  Sir  Andrew  Clark,  TU)t  fibrinous,  but 
mucoid,  and  even  the  firmest  consist  of  dense,  opaque,  transformed  nuiciis. 
It  is  due  to  a  derangement  of  the  mucous  glands  of  tho  colon,  tiie  iiatiiri' 
of  which  is  quite  unknown. 

Symptoms. — The  disease  persists  for  years,  varying  extremely  from 
time  to  time,  and  is  characterized  by  j)aroxysms  of  pain  in  thf  ali  lomen, 
tenderness,  occasionally  tenesmus,  and  tlu;  passage  of  flakes  or  long  strings 
of  mucus,  sometimes  of  definite  casts  of  the  bowel.  The  attacks  ]a>t  for 
a  day  or,  in  some  instances,  for  ten  days  or  two  Aveeks.  Mental  eniolioiis 
and  worry  of  any  sort  seem  i)articularly  apt  to  bring  on  an  attac  k.  Occu- 
sionally  errors  in  diet  or  dyspei)sia  j)rec!ede  an  outbreak.  ^Memhriincs  are 
not  passed  with  every  paroxysm,  even  when  the  pains  and  cramps  aic  severe, 
There  are  instances  in  which  the  morphia  habit  has  been  contracted  on 
account  of  the  severity  of  the  pain.  There  may  be  marked  nervous 
symptoms,  and  authors  mention  hysterical  outbreaks,  hypochondriasis,  and 
melancholia.     Mucous  colitis  is  an  important  cause  of  enteralgia. 


mil' 


DISKASKS  UF  TllM  INTKSTINES  ASS(JCIATED  WITH  DIAKUIKKA.   423 


4 


Tlu!  (lidi/nosis  h  niroly  (l()iil)tful,  hut  it  is  iin[H>rt,aiit  not  to  mistake' 
tlio  iiiciiiliniiii's  for  otiiiT  8iil)staii('('s;  thus,  tiic  fXttTiial  cutich^  of  aspara- 
■'iisiiml  iuiili.i,'t'Sli'(l  itorti(jiis  of  meat  or  sausagt'-skins  sotnctiuics  ussumu> 
fiiriiis  not  iiiiliki!  muuouH  casts,  hut  tlu;  inicroscttpical  t'xainiuatioii  will 
,iiii(kly  (iilTeri'iitiatf  them.  'I'wii-t'  1  iiav(!  known  niuoous  colitis  witii  so- 
vi'.'o  puiu  to  ho  mistaken  for  a])i»en(liciti8. 

UI/'KRATIVK    KNTEUITIS. 

11  inMition  to  tho  specific  uh-crs  (»f  tuhcrculosis,  sypliilis,  and  typhoid 
kwT,  tiic  followiuf;  forms  of  ulceration  occur  in  tlic  l»o\vcls: 

(d)  FiiUicidtir  I'/rrnifion. — As  previously  uienlioncd,  this  is  met  with 
virv  coniiMoiily  in  the  diarrlKcal  diseases  of  children,  and  also  in  the  sec- 
,iiii|;irv  or  tcrMiinal  intlanunations  in  many  fevers  and  cniistitutiomd  disor- 
iliTs.  'i"he  ulcers  are  small,  ])unched  out,  with  shar|tly  cut  edp's,  and 
tiu'v  arc  usually  limited  to  the  follicles.  AVith  this  form  may  he  placed 
liii' ("itiU'rhal  idcers  of  some  writers. 

(//)  Sfirriind  /Vrr/w,  which  occur  in  long-standiiifi  rases  of  constipa- 
tion. Very  remarkahle  indeed  aro  tho  cases  in  which  the  sacculi  (»f  thu 
loliiii  iicciiiue  lilh'd  with  roundi-o  stnall  scyhala,  souu'  of  which  jtroducc 
ilistiiu't  ulcers  in  tho  mucous  memhrane.  'i'he  fa'cal  nuis.<es  nuiy  have 
liiiH' salts  deposited  in  them,  and  tlius  form  little  enteroliths. 

[(•)  Simple  lleeratirc  Colitis. — This  alfection,  which  clinically  is  cluir- 
aitfri/c(I  hy  diarrho'a,  is  often  rej^arded  wronjrly  as  a  form  of  dysentery. 
It  i- not  a  very  uiu'ommon  alfection,  and  is  most  fre(piently  met  with  in 
!i  11  ahove  the  middle  period  of  life.  The  idccration  may  he  very  exten- 
sive, su  that  a  large  })roportion  of  the  mucosa  is  removed.  The  lumen  of 
tho  colon  is  sometimes  greatly  increased,  and  the  muscidar  walls  hypcr- 
tro|iliii'(l.  There  are  instances  in  which  the  howel  is  conti'a<'tt'd.  Fre- 
liK'iitly  tho  remnants  of  tho  mu(!osa  are  A'ory  dark,  even  hlack,  ami  there 
may  ho  polypoid  outgrowths  hotwoen  tho  uU-ers. 

TIk'so  cases  raroly  come  niulor  observation  at  tlio  outset,  aiul  it  is  diffi- 
cult to  spi-ak  of  the  mode  of  origin.  They  are  characterized  hy  diarrhoea 
"f  a  hentorio  rather  than  of  a  dysonterii;  character.  There  is  raroly  blood 
ir  pus  in  the  stools.  Consti[)ation  may  alternate  with  the  diarrlui-a. 
riicre  is  usually  great  impairment  of  nutrition,  and  tho  ^tationts  get  weak 
;iiid  sallow.     Perforation  occasionally  occurs. 

The  (liseuso  may  prove  fatal,  or  it  may  pass  on  and  l)ecome  chronic. 
Iho  utTiction  was  not  very  infrequent  at  the  IMiiladelphia  IIosi)ital,  and 
ili'uigh  the  disease  boars  some  resemblance  to  dysentery,  it  is  to  bo  sepa- 
rated from  it.  Some  of  the  cases  which  we  have  learned  to  recognize  as 
iini(i'l)ic  dysentery  rosemldo  this  form  very  closely.  An  excellent  descrip- 
tion of  it  is  given  hy  Hale  White.  Dickinson  has  described  what  ho  calls 
iilljuniiiuivic  ulceration  of  the  bowels  in  cases  of  contracted  kidney. 

("')  I'hcration  from  External  Perforation. — This  may  result  from  the 


Jl^w. 


■M 


<  'Ml' 
-.  **.    ■■ 

"  ,i  t 


!\t\'  ,1 
Ma : 


:nr  i 


\  % 


h^^^' 


IH 


DISEASES  OF   THE   DIGESTIVE  SYSTEM. 

erosion  of  lunv  ^.^'owtlis  or,  more  commonly,  from  localized  pcritmiiiis  witl. 
ubsooss  fonmition  ami  perforation  of  the  bowel.  Tins  is  met  witli  innstfiv. 
(|iiciitlv  in  tulierciiloiis  ]ieritonitis,  l)nt  it  may  ocenr  in  tlie  al)S('css  wliiili 
follows  perforation  of  the  ii[)pen(lix  or  sni)piirative  or  fi:an,L,n'eniiii.'  i.ini. 
creatitis.     Fatal  ha-morrhajje  may  resnlt  from  the  perforation. 

(r)  ('itiifi'Viiiis  f'/nrs. —  In  M'ry  rare  instances  of  niulti])lc  cancfr  dr 
sarcoma  the  siihniucons  nodule-  break  down  and  nlcerate.  In  niu.  ^,\^^. 
the  ileum  containeil  citrht  or  ten  sarcomatous  nlcers  secondary  tuaii  cv- 
tensive  sarcoma  in  the  neiirhlxirhood  of  the  shoulder-joint. 

( /')  ( >ccasionally  a  sulihiiji  ii/rrr  is  met  with  in  the  ca-cnm  np  cdlo)!. 
which  may  lead  to  ]terforation.  Two  instances  of  nicer  of  the  (Mriini. 
both  with  ])erforation,  have  come  nnder  my  observation,  ami  in  nii,. 
insta.ice  a  simple  nicer  of  the  colon  perforated  and  led   to  fatal  iKiitn. 

Diagnosis  of  Intestinal  Ulcers. — .\s  a  rule,  diarrhoa  i<  invMur 
in  all  case;!,  but  exceptionally  there  may  be  extensive  ulcei'atinn,  jnu'licii- 


tlie  small  bowel,  without  diarrluea.     Very  linuted 


uleeriitliiii  ill 
tli.. 


on  may  b^.!  associated  wiih  friMpient  stools.  'IMie  character  ol 
ms  is  of  ;,freat  im2K)rtunce.  Pus,  shi'cds  of  tissue,  ami  MikkI  ur, 
st  valuable  in<lications.  Pus  occurs  most  fretpiently  in  cninui  i  ni 
ccrs  in  the  larije  intestine,  but  wlu-n  the  bowel  alone  is  iiivolvcil 
onnt  is  rarely  ^nvat,  and  the  jtassaire  of  any  (piantity  of  lunv  ]Mi>i- 
ication  that  it  has  come  from   without,  most  commoidv  frein  ih,' 


if 


I  iierica'cal 


bscess,  or  m  women  an  ahscess  o 


f  tl 


le  iM'eiHl 


'  line 


Pus  may  also  be  ])resent  in  cancer  of  the  bowel,  or  it  may 
1  disi'ase  in  the  rectum.  A  ]nirulent  mucus  may  be  jtresciit  in  the 
n  cases  of  ulcer,  but  it  has  not  the  sauu'  diaumistic  value.  TIn' 
1,  sa,i,'ii-like  massi's  of  mucus  which  are  believed  by  some  to  iiiilitatc 
follicular  ulcerati<in  are  met  with  also  in  mucous  I'olitis.  Jla'mmrliiiL'i' i? 
an  ini))oi'tant  and  valv.aliie  symptom  of  ulcer  of  the  Vowel,  parliciihrly  if 
}»r()fuse.  It  occurs  under  so  many  cimditiiuis  that  .aken  almie  it  iii.iv 
not  be  si)Ocially  sij^iulicant,  but  with  other  coexisti/ig  circun'-t.uicis  it 
may  be  the  most  important  indication  of  all. 

l'"rairnients  of  tissue  an*  occasionally  found  in  the  stools  in  ulcer,  par- 
ticularly in  the  extensive  and  ra|iid  slouirbini:  in  dysentci'ie  iirnirsMN, 
Detinite  jiortions  of  mucosa,  shreds  of  connective  tissiu-,  ami  cncii  liitsof 


tl 


le  muscida"  coat  mav  Ik 


foul  I 


aiii  occurs  m  manv  cases,  eitlicnil  a 


dilfuse,  colicky  charactei',  or  sonu'times,  iii  the  ulcer  of  the  culun,  virv 
linuti 


and  well  deiim 


Perbiralion  is  an  accident  liable  to  happen  when   the  ulcer  cxtciiil 
deeply.     In  the  small  bowel  it  leads  to  a  localized  or  general  jiiiileii 


\n> 


In  till'  larire  iutesline,  lo(.,  a  fatal  peritonitis  may  result,  or  if  |iirferiiniiii 
tjikes  place  in  the  jiosterior  wall  of  the  ascendiiifj  or  desecudiiiL'  cd.n!'. 
the  ])rodtictioii  of  a  lartre  abscess  cavity  in  the  rctro-irrit-.ua'iiiii.  Ina 
case  at  the  University  Hospital,  l'hiladel])hia,  there  was  a  perforatiuu  at 


>?•"    I: 


DISEASES  OF  THE  INTESTINES  ASSOCIATED  WITH   DIAUIllKEA.     425 

the  spli'iiio  floxure  of  tlie  colon  •with  tin  iil)scess  containing  air  and  pus 
—luomlition  of  subphrenic  i)yo-pneiiin()thi)rax. 
Treatment  of  the  Previous  Conditions. 

[it)  Acute  Dyspeptic  Diarrhoea.— All  solid  food  should  be  withhold. 
It  vomiting  is  present  ice  may  be  given,  aiul  snuill  fpiantilies  of  milk  and 
SI iilii  water  may  be  taken.  If  the  attack  luis  followed  the  eating  of  large 
iimmtities  of  uiuligestible  material,  castor  oil  or  calomel  is  advisable,  but 
is  iKit  necessary  if  the  patient  has  bet'n  freely  jjurged.  If  the  pain  is  se- 
vtir,  twenty  drops  of  laudanum  and  a  drachm  of  spirits  of  chloroform 
imiv  1)1'  given,  or,  if  the  colic  is  very  intense,  a  hyitodermic  of  a  (puirter  of 
ai'niiii  of  morphia.  It  is  not  well  to  check  the  diarrluea  nidess  it  is  iiro- 
fust',  us  it  usually  stops  si)ontaneously  within  forty-i-ight  hours.  If  per- 
sistent, the  aroimitio  chalk  powder  or  large  doses  of  liismuth  (tliirty  to 
fiiitv  grains)  may  be  given.  A  small  eni'ina  of  starch  (two  ounces)  with 
t.vciitv  (li'nps  of  laudanum,  every  six  hours,  is  a  most  valuable  renu'.dy. 

[ii)  Ohronic  Diarrhoea,  including  chronic  catarrii  and  ulcerative  enter- 
itis, ll  is  inii)ortant,  in  the  lirst  place,  to  a.scertain,  if  possible,  the  cause 
mill  whether  ulceration  is  present  or  not.  So  much  in  treatment  depends 
upon  the  careful  exanunation  of  the  stools — as  to  the  amount  of  mucus, 
tlie  presence  of  jms,  the  occurrence  of  parasites,  and,  above  all,  the  state  of 
dij.'i'sti(in  of  tlui  food — that  the  })ractiti()ncr  should  jiay  special  attention 
to  thcia.  Many  cases  simply  re(piire  rest  in  bed  and  a  restricted  diet. 
(iiriiiiir  diarrluwi  of  many  months'  or  even  of  several  years'  tluration  may 
k' SDiiictiMies  cured  by  strict  conlinement  to  bed  and  a  diet  of  boiled  milk 
ami  albumen  water. 

hi  that  form  in  which  immediately  after  eating  there  is  a  tendeTU'y  to 
lnusi' evacuations  it  is  usually  found  tlial  some  oiu'  article  of  diet  is  at 
fault.  The  patier.t  should  rest  for  an  hour  or  more  after  meals.  Somo- 
tiiin's  this  alone  is  sullici.  nt  to  jirevcnt  the  occurrence  of  tlu^  diarrho>a. 
Ill  thiisi,' forms  which  (h'pend  upon  abnormal  conditions  in  the  small  in- 
i'-tiiu',  citlu'r  too  rapitl  i)eristalsis  or  faulty  fermentative  ))rocesse-i,  bis- 
iiuitli  i.s  indicated.  It  must  be  given  in  large  doses— from  half  a  drachm 
'"  :i  ilrarhm  three  tinu's  a  day.  The  sniallcr  do.ses  are  of  little  use. 
Naiihtliiilin  preparations  here  do  much  good,  given  in  do.xes  of  from  ten 
til  lit'tft'ii  grains  (in  caitsule)  four  or  live  limes  a  day.  Larger  <loses  may 
U'limlcd.    Sa'.ol  and  the  salicylate  of  bismuth  may  be  trie.i. 

All  e\tre>,ie1y  obstinate  and  i  tractable  form  is  the  diarrluea  of  hyster- 
''■''  "iiiiuMi.  A  .systematic  rest  cure  will  be  foiiiid  i.'ost  advantageous,  and 
if  a  mill,  liiet  is  not  wi-H  Jxune  the  patient  may  be  fi'd  exclusivelv  on  e:rg 
'"'""I't'ii.  The  condition  .seems  to  be  a.ssoeiatcd  in  some  ca.<es  with  in- 
■''"i^imI  peristalsis,  and  in  siieh  the  Sromides  may  do  go  .d,  or  preparations 
"'"I'l'iiu  may  be  neces.sary.  There  are  instances  whicli  jtrove  most  obsti- 
''"'t'  aiiil  Yi'Mst  all  forms  of  treatment,  and  the  palient  may  bo  greatly 
rt't.uml.    A  change  of  air  and  sur.  .aimlings  may  tlo  more  than  nuMlieinos. 

Ill  a  large  group  of  the  chronic  diarrhieus  the  mischief  is  seated  in  tho 
28 


>  I'M  " 


If'    tHm  sil*" ;« 


426 


DISEASES  OF  THE  DIOESTIVE  SYSTEM, 


i4 


colon  and  is  due  to  iilcoration.  'Medicines  by  the  mouth  arc  here  of  litdo 
value.  The  stools  should  be  carefully  watched  and  a  diet  arnuiLrid  wliidi 
shall  leave  the  smallest  possible  residue.  Boiled  or  2)e]»ti>Mized  milk  niav 
be  j^^iveu,  but  the  stools  should  be  examined  to  see  whether  tliciv  is  nii 
excess  of  food  or  of  curds.  Meat  is,  as  a  rule,  badly  bonu;  in  Uich'  ckscs. 
The  diarrluea  is  best  treated  by  enemata.  The  starch  and  laiulaiuim 
should  be  tried,  but  when  ulceration  is  present  it  is  better  to  use  astriiifrcnt 
injections.  From  two  to  four  pints  of  warm  water  containiiij;  fnnii  Imlf  ^ 
drachm  to  a  drachm  of  nitrate  of  silver  may  be  used.  In  tlie  cliniiiic 
diarrho'a  which  follows  ily.^entery  this  is  particularly  advautap'ous.  hi 
giving  large  injections  the  j>atient  should  bo  in  the  dorsal  position,  with 
the  hips  elevated,  and  it  is  best  to  allow  the  injection  to  How  in  ;,Ma(hiallv 
from  a  siphon  bag.  In  this  way  the  entire  colon  can  be  irripttcd  ami  the 
])atient  can  retain  the  injection  for  some  time.  The  silver  injections  mav 
be  very  i)ainful,  but  they  are  invalualde  in  all  forms  of  ulcerative  coliti-. 
Acetate  of  lead,  boracic  acid,  sulphate  of  copper,  sul])hate  of  zinc,  ami 
salicylic  acid  nuiy  be  used  in  one  per  cent  solutions. 

In  mucous  colitis  no  benetit  can  lie  cxjicctml  fnun  remedies  adtninis- 
tered  by  the  mouth.  The  topical  applications  should  hv  inailc  to  the 
mucous  membrane  of  the  colon  by  the  cnenuita  just  nu'ntinucd,  and  flu.' 
general  nervous  condition  should  receive  ajipropriate  treatmeut. 

In  the  intense  furms  of  (duderaic  diarrho'a  in  atluUs  associatrd  with 
constant  vomiting  and  frequent  watery  discduirges  tiie  patient  slioidd  U' 
given  at  oiu'c  a  hypodermic  of  a  (puirtcr  of  a  grain  of  inoriiliia,  wliiih 
should  be  repeated  in  an  hour  if  the  pains  return  or  the  i)urgiiig  iMisisls. 
This  gives  jiromjjt  relief,  and  is  often  the  only  nu'dicine  needed  in  tlif 
attack.  'I'he  patient  should  be  given  stimulants,  aiul,  when  the  vomiting 
is  allayed  by  suitable  renu'ilies,  sjnall  (|uaiitities  ..f  juilk  and  lime  water. 

(rj  The  DiarrhoBa  of  Children.— //////(>■/' /r  waiiai/emoi/  is  (d'  tin  tir-^? 
importance.  'I'he  effect  of  a  change  from  the  hot,  stifling  atiiiosphcroi.f 
a  town  to  the  mountains  or  the  sea  is  ofteii  seen  at  oiU'C  in  a  ivduWion 
in  the  mnnber  of  sto(ds  and  a  rapi<l  improvenu-nt  in  the  physical  cmidi- 
tion.  Even  in  cities  nun  h  may  be  dom^  by  sending  the  child  into  tlie 
parks  or  for  daily  excursions  on  the  water.  However  extreme  tlic  ('(111111- 
tion,  fresh  air  is  indicated.  The  child  should  not  be  to(«  thickly  clad. 
Many  mothers,  even  in  the  warm  weiithcr,  chdhc  their  (diildreti  too  licavily. 
loathing  is  of  value  in  infantile  diarrhu-a,  ami  when  the  fever  ri<cs  alicvc 
l(r.'-r)°  the  child  should  be  placed  in  a  warm  bath,  the  teiuperatiire  nf 
which  nuiy  be  gra<lually  reduced,  or  the  (diild  is  ke])t  in  the  I'idh  f"r 
twenty  minutes,  by  whi(di  time  the  water  is  siifhciently  cooled.  Much 
relief  is  (d)tained  by  the  application  of  ice-cold  (doths  or  of  the  ice-cap  to 
tlie  head.  Irrigation  of  tlie  c(don  with  ice-cold  water  is  sometimes  favor- 
able, but  it  has  m»t  the  advantage  of  the  general  bath,  the  beuedcial  •■fft't't 
of  which  is  seen,  not  oidy  in  the  reductioti  of  the  temperature,  Imt  nu 
general  8timulati(m  of  the  lu'rvous  system  of  the  child. 


DISEASES  OP  THE  INTESTINES  ASSOCIATED  WITH   DIARRHEA.    427 

[)it'ti/ir  Treatment. — In  the  case  of  ,i  luuHl-fcd  child  it  is  important, 
if  |io.sji!»it',  to  got  a  wot-mirse.  ^Vllilo  fever  is  present,  digestion  is  sure 
t(i  k' imuh  disturbed,  and  the  amount  of  food  sliould  be  restricted.  If 
water  ur  hurley  water  l)e  given  the  child  will  not  feel  the  deprivation  of 
fdiid  so  iiHich.  When  the  vomiting  is  incessant  it  is  much  better  not  to 
aiti'iiipt  to  give  milk  or  other  articles  of  food,  but  let  the  child  take  the 
wulcr  win'iiever  it  will. 

In  tlu'  dvspe]>tic  diarrhams  of  infants,  j)ractically  the  whole  treatment 
isaniaiter  of  artificial  feeding,  and   there  is  no  subject  in  medicine  on 
which  it  is  more  ditlicult  to  lay  down  satisfactory  rides.     N(»  iloubt  within 
;ifow  vcars  the  study  of  the  bacterial  jjrocesses  going  on  in  the  intestines 
(if  till"  cliild  will  give  us  most  important  suggestions.     From  his  observa- 
tions Esclierich   lays   down   the   following   rules,  recognizing  two  well- 
ilctined  forms  of  intestinal  fermentation — the  acid  and  the  alkaline:  If 
tliL'ir  is  much  decomposition,  with  foul,  otfensive  stools,  the  albuminous 
;i!ticlcs  should  be  withheld  from  the  diet  and  the  carbohydrates  given, 
-mil  us  dextrin  foods,  sugar,  and  milk,  which,  on  account  of  its  sugar, 
Viiiiks  with  the  carbohydrates.      If  there  is  acid  fermentation,  with  sour 
but  not  fetid  stools,  an  albuminous  diet  is  given,  such  as  broths  and  egg 
iilliunicn.    It  is,  however,  by  no  means  certain  whether  the  reaction  of  the 
5:.iols,  upon  which  this  author  relies,  is  a  sullicient  test  of  the  nature  of 
the  intestinal  fermentation.     In  the  dyspeptic  diarrha'iis  of  artificially  fed 
infants  it  is  best,  as  a  rule,  to  withhold  nulk  and  to  feed  the  child,  for  the 
tinii'  111  least,  on  egg  albumen,  broths,  and  beef  juices.     To  prepare  tlu; 
.'Lii;  alhniiu'u,  the  whites  of  two  or  three  eggs  may  be  stirred  in  a  pint  of 
waicr  and  a  teaspoonful  of  brandy  and  a  little  salt  mixed  with  it.     The 
ihikl  will  usually  take  tliis  freely,  and  it  is  buth  stimulating  and  nourish- 
ing.   It  is  soMU'tiiues  rcmarkid)le  with  what  ra[)idity  a  (diild  whicli  has 
iHvn  fed  on  arliiieial  food  and  milk  will  jdck  up  and  improve  on  this  diet 
iiliiu".     Beef-juiee  is  obtained   by  i)ressing  with  a  leuioJi-s(|ueezer  fresh 
s'lak,  previously  minced  ami  either  uncooked  or  slightly  broiled.     This 
may  1)0  jiiveii  altenuitely  with  the  egg  albumen  or  it  nuiy  be  given  alone. 
Mutton  or  chiidvcn  broth  will  be  fouiul  e(|iuilly  serviceable,  but  it  is  pre- 
jaivd  with  greater  ditliculty  and  contains  more  fat.     In  the  prejiaration,  a 
pimnd  of  mutton,  chicken,  or  beef,  carefully  freed  from  fat,  is  mim-ed  and 
i'laird  in  a  pint  of  cold  water  and  allowed  to  stand  in  a  glass  jar  on  ice 
dr  three  or  four  hours.     It  should  then  be  cooked  over  a  slow  lire  for  at 
Itast  three  hours,  then  strained,  allowed  to  cool,  the  fat  skimmed  olT,  suf- 
lii'itnl  salt  adiled,  and  it  may  then  be  given  either  warm  or  c(dd.      These 
luiturally  invpared  albumen  foods  are  very  much  to  be  preferred  to  the 
variiius  arliiieial  substances.     Tlu're  is  no  form  of  m)uris!unent  .so  readily 
Mniilated  and  apt  to  cause  so  little  disturbance  as  egg  albumen  or  the 
■imjileheef  juices.     The  chill  should  be  fed  every  two  hour.s,  and  in  the 
"itirvids  water  may  be  freely  given.     It  cannot  be  expecti'd  that,  with 
'lit' digestion  seriously  impaired,  us  nnieh  food  can  be  tiiken  as  in  health, 


"Mil 


U  i  ■ 


(•?'( 


428 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


I. 


■;  vi,,! 


and  in  many  instancos  wo  see  the  (liarrlKPji  a^ifgravatorl  by  pcrsistont  nvor- 
f('0(lin<r.  Wlion  the  child's  stomach  is  quieted  and  tlic  diarrlid'n  clurkhl 
there  may  be  a  p^radnal  return  to  the  milk  diet.  'Die  milk  slionld  he  ster- 
ilized, and  in  institutions  and  in  cities  this  sini[)le  i)ro[)hylacti(^  iiicasinv  i- 
of  the  very  first  importance  and  is  readily  carried  out  by  means  ni  the  Ar- 
nold steam  sterilizer,  'i'he  milk  should  be  at  first  freely  diluted— fimr 
parts  of  water  to  one  of  milk,  which  is  ])(>rhaps  the  preferable  w;iv_,iri' 
nuiy  be  jieptonized.  The  .stools  should  be  exanuned  daily,  as  iui|irirtaii; 
indications  nuiy  be  obtaiiu'd  from  them.  Milk-whey  aiul  forms  (if  fer- 
mented milk  are  sometimes  useful  and  may  be  employed  when  tlie  stdiii- 
ach  is  very  irritable.  These  general  directions  as  to  food  also  huld  (.'oml 
in  cholera  infantum. 

Mnlirinal  Trvdlmevt. — 'I'he  first  indication  in  the  dyspeptic  dinrrliiM 
of  children  is  to  <j;et  rid  of  the  decomposini;  matter  in  the  stnmarli  mii 
ijitestines.  The  diarrhoea  and  vomitinj;  partially  effect  tiiis.  hut  it  m;i\ 
be  more  thoroughly  accomplished,  so  far  as  the  stoma<di  is  coiicornod,  In 
irrigation.  It  nuiy  seem  a  harsh  procedure  in  the  case  of  young  infiint-. 
but  in  reality,  with  a  large-sized  soft-rubber  catheter,  it  is  ])racti>eil  ^vitli- 
out  any  ditticidty.  Hy  means  of  a  funiud,  lukewarm  water  is  alloffiv 
to  pass  in  and  out  until  it  c(nnes  away  ([uite  clear.  I  can  s))eak  in  tlii' 
very  warmest  nuniner  of  the  good  results  obtained  by  this  siiii]il(>  pv"- 
cedure  in  cases  of  the  nH)st  obstinate  gastro-intestinal  catarrh  in  fliiMnn. 
In  most  cases  the  warm  water  is  sufficient.  In  some  bauds  this  iiictlMH! 
has  probably  been  carried  to  excess,  but  that  does  not  detract  from  lis 
great  value  in  suitable  cases.  To  remove  the  fermenting  substance?  fnmi 
the  intestines,  doses  of  calonu'l  or  gray  ]iow;1er  maybe  adniinisterod.  Tln' 
castor  oil  is  equally  efficacious,  but  is  more  apt  to  be  vomited.  Irri- 
gation of  the  larg(f  bowel  is  useful,  ami  not  oidy  thoroughly  ri'iiiovt< 
fermenting  substances,  but  cleanses  the  mucosa.  The  (diild  should  bf 
placed  on  the  liack  with  the  hips  elevated.  A  fiexible  catheh'r  is  passcil 
for  from  six  to  eight  inches  ami  from  a  pint  to  two  pints  of  water  allo«vil 
to  flow  in  from  a  f(mntain  syringe.  A  jdnt  will  thoroughly  irrigate  tlf 
colon  of  a  child  of  six  months  and  a  quart  that  of  a  child  of  two  year?. 
The  water  nuiy  be  lukewarm,  but  wlien  there  is  high  fi'vcr  iie-'uld  wat-r 
may  be  used.  In  cases  of  entero-colitis  there  nuiy  be  injectiitiis  with 
borax,  a  dracdim  to  the  ])int,  or  dilute  nitrate  of  silver,  whifli  iiiiiy  I'c 
either  given  in  large  injections,  as  in  the  adult,  or  in  injections  "f  tlir(r»r 
four  ounces  with  three  grains  of  nitrate  of  silver  to  the  ounee.  'Iln-i' 
often  cause  very  great  pain,  and  it  is  well  in  such  cases  to  fcdlow  tlie-ilvir 
injection  with  irrigations  of  salt  solution,  a  drachm  to  a  jiint. 

AVe  are  still  without  a  reliable  intestinal  antiseptic.  Neither  naplitli;!- 
lin,  salol,  resorcin,  the  salicylates,  nor  mercury  meets  the  ijulicatioii?.  As 
in  the  diarrham  of  adults,  bismuth  in  large  doses  is  often  veiy  ofTectivc 
but  practitioners  are  in  the  habit  of  giving  it  in  doses  which  are  ijinto  in- 
sufiHcient.     To  be  of  any  service  it  must  be  used  in  large  dost's,  so  that  an 


APPENDICITIS. 


429 


iufant  a  yrur  old  will  take  as  iiiuch  as  two  drachins  in  the  day.  The  gray 
iMJwder  lias  long  been  a  favorite  in  this  condition  a»ui  may  be  given  in 
lialf-"iaiii  doses  every  hour.  It  is  perha])s  j)referable  to  calomel,  which 
iiiav  lie  ii.^ed  in  small  doses  of  from  one  tenth  to  one  fourth  of  a  grain 
tvi'ry  Imur  at  the  onset  of  the  troubl'A  The  sodium  salicylate  (in  ilosea 
,,1'  t\v(Mir  three  grains  every  two  hours  to  u  child  a  year  old)  has  been 
ivcciuinuiidcd. 

Ill  ciiolcra  infantum  serious  symjitoms  may  develop  with  great 
niiiitlitv,  and  here  the  incessant  voiniliug  and  the  frequent  purging 
iviiiK'r  the  administration  of  remedies  extremely  diHicult.  Irrigation 
of  tlu'  stomach  and  large  bowel  is  of  great  service,  and  when  the  fevor 
is  liijrli  ill-water  injections  may  be  used  or  a  graduated  bath.  As  in 
till!  iuiite  clioleraic  diarrluea  of  adults,  mor])hia  hy[H)dermically  is  tho 
iviiii'ilv  which  gives  greatest  relief,  and  in  the  conditions  of  extreme 
voinitiiij;  and  purging,  with  restlessness  and  colla{)se  symptoms,  this 
(iniir  aliiiie  commands  the  situation.  A  cliild  of  one  year  may  be  given 
liiiiii  jl^  to  ^jf  of  a  grain,  to  be  re})eated  in  an  hour,  and  again  if  not 
lii'tti'i'.  When  tile  vomiting  is  allayed,  attempts  nuiy  be  made  to  give 
gray  |iou(ler  in  half-grain  doses  with  -j^  of  Dover's  powder.  Starch  (  3  ij) 
ami  hiiKlaiium  (niij-iij)  injections,  if  retainetl,  are  soothing  and  beneti- 
rial.  Tlie  cond)ination  of  bismuth  with  Dover's  imwder  will  also  be  found 
kiiutii'ial.  No  attempt  slunild  be  nuide  to  give  food.  Water  nuiy  bo 
allowiHJ  freely,  even  when  ejected  at  once  by  vomiting.  Snudl  doses  of 
iiruiuly  or  champagne,  freipiently  repeated  and  given  cold,  are  sometimes 
rttaiiiid.  When  the  collapse  is  extreme,  hypodermic  injections  of  one  per 
iviit  siiliiii'  solution  may  be  used  as  recommended  in  Asiatic  cholera,  and 
livpoiliTiiiic  injections  of  ether  and  brandy  may  be  tried.  The  convales- 
d'lK'i'  riMjiiires  very  careful  management,  as  many  cases  pass  on  into  tho 
iiimlitien  of  entero-colitis.     Wiicu  tiie  intense  sympt^nns  have  subsiiled, 

;lit'  I' I  sliould  ])e  gradually  given,  beginning  with  teaspoonful  doses  of 

(.1:^:  alliuiiien  or  beef-juice.  It  is  best  to  withhold  milk  for  several  days, 
mill  whin  used  it  siiould  be  at  first  complett>ly  piptonized  or  ililutcd  with 
j-'iuii.  A  teaspoonful  of  raw,  scraped  meat  three  or  four  times  a  day  is 
ufteu  Well  borne. 

II.  APPENDICITIS. 

lutlamniation  of  tho  vermiform  appendix  is  the  most  important  of 
acute  intestinal  disorders.  Formerly  the;  "  iliac  phlegmon  "  was  thought 
to  be  iliu'  to  disease  of  the  ciecum — ////>// ////.v — and  of  the  peritonanim  cov- 
eriiij;  it  inritjiphUtis  ;  but  we  now  know  that  with  rare  excei)tiojis  tho 
Citeiiiu  itself  is  !iot  affected,  and  even  the  condition  formerly  described  as 
stiiVDial  typhlitis  is  in  reality  ap[)eiulicitis.  The  recognition  of  the  im- 
liiirtaiiir  of  appendicitis  is  due  largely  to  the  work  of  American  i)hysician8 
iiuil  surguuus— to  Pepper,  who  described  in  1883  the  relai)sing  form;  to 


m 

% 

' 

Im,  Mill 


4'i*'- 


':  f    '!»ifii 


--4-- 


5M",|^1:J 


430 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


Fitz,  whoso  oxlianstivn  article?  in  1880  served  to  put  the  wliolc  (iiicstion  nn 
a  rational  l)asi.s  ;  to  Willanl  I'arker,  who  was  tlio  first  to  advocate  eurlv 
operation;  and  to  Sands,  Hull,  McjBurney,  Weir,  Morton,  Keen,  Scim.,!. 
'William  White,  Deavor,  and  others,  who  have  done  so  much  \n  iiii|irii\v 
the  operative  nieastn'es  for  its  relief.  Treeves,  of  London,  lias  Ipcch  fdi,.. 
most  in  advocating  the  pro))cr  surgical  treatment  of  the  disease.  The  in. 
terest  attached  to  the  subject  is  manifest  by  the  appearance  witliinafmv 
}ears  of  a  number  of  special  nionograj)hs  by  Kelynack,  'I'elamon,  Fowler, 
Sonnonberg,  and  Tawkins. 

Anatomy. —  Tlu^  appendix  vermiformis  is  a  functionless  relic  of  h 
large  ancestral  ca'cum.  It  measures  usually  about  three  inches  \n  leii^nli, 
but  it  may  be  scarcely  an  inch.  The  dianu'ter  is  about  one  fourth  df  nii 
inch.  In  a  majority  of  instances  it  has  a  triangular-shaped  iiicso-iiji. 
peiulix,  usually  shorter  than  the  tube,  whifdi  thus  becomes  a  little  ciiiir.] 
or  bent  upon  itsidf.  There  is  often  a  small  lymph-gland  just  at  tlio  nmt 
of  its  mesentery.  The  jiosition  of  the  appeiulix  is  very  variai)lo.  Tin' 
most  common  direction  it  assumes  is  upward  and  inward,  the  tip  piintiii' 
toward  the  spleen.  The  position  next  in  frequency  is  behind  the  cii'cmr. 
and  next  passing  over  the  p(ilvic  brim.  It  tnay  be  met  with,  liowevor,  in 
almo.st  every  region  of  the  abdomen,  and  adherent  to  almost  every  or;.';in 
in  it.     I  have  seen  it  in  close  contact  with  the  bladder,  adherent  to  n\w 

ovary  and  the  broad  ligament ;  in  tlie  central  portion  of  the  ahdnnioii  el 

to  the  navel ;  in  contact  with  the  gall-bladder,  passing  out  at  right  iinirK- 
and  adherent  to  the  signu)id  tlexure  to  the  left  of  the  middle  lino  of  tlir 
abdomen;  and  in  one  case  it  entered  with  the  Civcum  the  inguinal  cuiimI. 
curved  upon  itself,  re-entered  tlie  abdomen,  and  was  adherent  to  tho  wiill 
of  an  abscess  cavity  just  to  the  right  of  the  promontory  of  the  siiciiiin 
The  structure  of  the  aj)pendix  is  almost  identical  with  that  of  the  oa'riini; 
it  is  ])articularly  rich  in  lymphoid  tissue.  The  blood  supply  is  doriwil 
from  a  smtdl  artery  which  jiasses  along  the  free  edge  of  its  nioseiit<M'y. 

Morbid  Anatomy  and  Etiolog^y.— The  following  are  the  m  ■' 
common  morbid  coiuliticns  : 

(^0  FsBCal  Concretions.— The  lumen  of  the  appemlix  jnay  eontaiii  ;i 
moidd  of  fa'ces,  which  can  readily  be  scpieezed  out.  Even  while  soft  tln' 
contents  of  the  tube  may  be  moidded  in  two  or  three  se-jtions  with  roiindt'i 
ends.  Concretions — enteroliths,  coproliths — arc  also  co'iimon.  The  nn"!' 
of  formation  is  not  very  clear.  Possibly,  as  with  gall-stones,  the  niiri"- 
organisms  mav  have  a  favoring  influence  in  their  formation.  Thov  were 
jiresent  in  ;58  cases  in  400  autopsies  (Kibbert),  atul  in  179  of  4")!i  :uitop.«i<-; 
in  perityphlitis  collected  by  Uenvers.  The  enteroliths  often  resemble  i" 
shai)e  date-stones.  The  importance  of  tliesc  concretions  is  shown  bv  \\w 
great  frequetu*y  with  which  they  are  found  in  all  acute  inflammations "' 
the  appendix. 

(h)  Foreign  bodies  are  by  no  means  so  frequently  met  with— only 
twelve  per  cent  in  152  cases  of  appendicitis  collected  by  Fitz.    Only  t»o 


APPENDICITIS. 


431 


instances  came  nncier  my  obsorvixtion  in  ten  years'  pathological  work  in 
Montmil ;  in  one  there  were  eight  snipo-sliot  ami  in  another  five  apple- 
iiiiij.  'I'lie  stones  and  seeds  of  various  fruits,  bits  of  bone,  and  pins  liave 
k'on  foiniil.  It  is  well  to  bear  in  mind  that  some  of  the  concretions  bear 
;i  vci'V  >triking  resernblaiu'e  to  cherry  and  date  stones. 

((•)  Obliterative  Appendicitis.— The  entire  tul)e  is  thiekened,  the  i)eri- 
toin'iil  surface  smooth  or  injected,  and  eillier  with  adhesions  from  slight 
circuiiiscrilH'd  peritonitis,  or  perfectly  free.  The  mucosa  may  show  noth- 
iiii' more  than  a  shedding  of  epithelium  with  infiltration  of  leucocytes  in 
ilio  subnuR'osa,  while  in  more  chronic  cases  there  is  almost  eoinph'te  de- 
iiiii!;ition  of  the  mucosa,  which  is  replaced  by  graindalion  tissne.  The 
mii.-culiir  coats  are  thickened  throughout,  and  the  entire  tube  is  firm  and 
stiiT,  as  if  in  a  state  of  erection.  When  laid  open  longitudinally  it  at  once 
;i;siiines  a  rolled  form  in  the  reverse  direction. 

Tlie  term  ni/arr/ial,  which  has  been  applied  to  this  condition,  is 
fcarct'lv  appropriate,  since  the  changes  are  dilTu.se  throughout  the  whole 
tube.  Ju  tlie  majority  of  instances  the  term  appendicitis  oblifcrans,  used 
Ijv  Sonn,  is  in  reality  more  appropriate.  As  Hawkins  remarks,  this  con- 
dition is  probably  a  fertile  source  of  local  peritonitis,  and  one  may  see  in 
this  stage  fresh  adhesions  on  the  peritoneal  surface  or  more  extensive 
lii'cuinscribod  peritonitis.  It  may,  however,  be,  as  he  says,  the  })recursor 
'if  complete  immunity  from  such  attacks.  "  For  if  by  the  pressure  of 
the  surrounding  i)arts  the  opposed  granulating  surfaces  are  brought  into 
contact,  and  if  the  whole  organ  remains  at  rest,  union  may  take  place, 
iiiul  tlie  appendix  as  a  source  of  disease  then  ceases  to  exist."  In  other 
cases  obliteration  of  the  lumen  cannot  take  jilace  on  account  of  the  rigid 
iiieollapsil)le  character  of  the  Wiills,  and  it  is  this  condition  of  chronic 
appendicitis  which  may  lead  to  recurrences  of  attacks  of  colic  and  local 
symptoms  in  the  right  iliac  fossa. 

Mclbiriiey  lays  great  stress  upon  the  narrowing  of  the  lumen  as  pre- 
venting nornud  drainage  of  the  tibe  and  establishing  conditions  favorable 
fur  tlio  development  of  septic  processes. 

Obliterative  appendicitis  is  met  with  in  about  two  per  cent  of  all  sub- 
jects. AViien  the  stricture  occurs  at  the  civcal  end  of  the  tube  the  lumen 
may  become  greatly  dilated,  forming  a  cystic  appendix  which  may  reach 
the  size  of  the  thumb,  or  even  the  size  of  an  ordinary  sau.sage.  The  con- 
tents of  the  cyst  are  either  a  clear  fluid  or  pus.  Ulceration  and  perfora- 
tidii  are  very  apt  to  occur.  Obliterative  api)endicitis  may  goon  as  an, 
wdinai'v  involution  process  without  causing  any  symptoms,  but  in  many 
instances  there  are  attacks  of  pain — appendicular  colic;  in  others,  exacer- 
liations  of  fever  with  pain  and  swelling ;  while  in  others  again  ulceration 
aiitl  perforation  may  take  place. 

('0  Ulcerative  Appendicitis. — Local  ulceration  in  the  appendix  is  met 
^ith  as  a  result  of  the  presence  of  concretions  or  of  foreign  bodies,  or  as 
the  result  of  the  action  of  certain  micro-organisms,  either  those  normally 


"  "fir 
r 

'>, 


432 


DISRASKS  OF  THK   DIGESTIVK  SYSTKM. 


1   ■  ■■ 

■    i         ' 

'■■    ,■ 

1 : 

w 

i 


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'i' 


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-7  =  -sil*l    *• 


I 


inliiibiting  tlio  cncoiim  or,  under  certain  ciroumstjinces,  tlio  typlidid  aiii] 
tubiTcIt"  hiicilli.  FiiT-al  concretions  and  foreijjjn  bodies  are  met  with  in 
the  appendix  without  aj'pareiitly  causing  tlie  sli<,ditest  aI)rasioii  of  its  mii. 
cosa.  In  oilier  cases  tiie  eiiterolitli  lias  caused  atrophy  of  the  iiuirdiw 
monihranc  with  which  it  is  in  contact.  In  other  cases  ajjain  the  coiiciv- 
tion  or  foreign  hody  may  be  jiocketed  in  an  ulcer  at  the  tip  of  the  ;i|i. 
])eiulix,  from  which  it  may  be  shelled  out.  These  conditions  ihmv  lie 
j)resent  witliont  adhesions  and  without  reddcniuff  of  the  .'^eroiis  siirfaiv, 
but  one  iH)t  infrequently  sees  thickening  of  the  peritona.>um  witii  udlii'. 
sions  to  the  adjacent  parts  in  ulcerative  appendicitis. 

'J'uberculosis  of  the  appendix  is  by  no  meaJis  uncommon,  riccnition 
in  tyi)hoid  fever  is  also  frequently  nu't  with;  in  a  series  of  eighty  aiitiiji. 
aies  there  were  three  instances  of  perforation  of  the  appendix  by  a  typlmjil 
ulcer.     An  actinomycotic  ulcer  has  also  been  described. 

{(•)  Necrosis  and  Sloughing  of  the  Appendix— Acute  Infective  Appendi- 
citis.—  Kollowing  upon  the  conditions  descrilx'd  under  (r)  and  ('/),  iiccidM-: 
and  slou;.,duii,i,'  nuiy  take  i)lace  either  in  a  limited  portion  of  the  a|)|itii(li\ 
with  perforation,  or  en  wnssc  without  perforation,  in  both  cases  IriuliiiL' 
to  the  most  intense  peritonitis,  localized  or  gcTUM'al.  .Most  coninpinl\  ih,. 
gaiifjrene  is  localized  to  one  spot,  either  at  the  tip  or  in  some  pditicn  df 
the  tube.  Usually  the  organ  is  swollen;  the  color  nuiy  be  reddish  l>rn\vii, 
black,  or  greenish  yellow.  Necrosis  may  occur  p)i  wm.<tw,  and  the  ciiiin' 
appeiulix  may  indeed  slough  o(T  from  the  caMMim  and  lie  Uro  in  an 
abscess  cavity.  In  one  remarkable  case  operated  upon  by  my  crdloafrih'. 
Halsted,  the  appendix,  between  four  and  five  inches  in  Icnirtli,  w;i< 
shrunken,  blackish  brown  in  color,  sphacelated  throughout,  and  lonkni 
like  a  desiccated  earthworm. 

These  active  processes  leading  to  ulceration  and  necrosis  anMlup  t'^ 
the  action  of  micro-organisms,  and  much  work  has  been  done  to  dot"!- 
mine  their  character.  Ilodenpyl  showed  that  the  bacillus  <'oli  cniiumiiii'; 
was  jtrcsent  in  a  very  large  nuniber  of  cases  of  appendicitis.  In  si\ty- 
one  cases  of  ])eritoneal  inllatnmation  consequent  upon  disease  of  tW  up- 
pendix  the  bacillus  c(di  communis  was  found  in  fifty-seven,  ami  in  liftynf 
these  it  was  the  onJy  organism  present.  The  streptococcus  pyogeiu'.*  ami 
the  staphylococcus  pyogeiU'S  aureus,  the  proteiis  and  liacillus  pyi.cvanon?, 
have  also  been  found.  The  streptococcus  infection  is  the  most  virnloiit. 
Probably  too  much  stress  has  been  laid  upon  the  bacillus  (!oli  c(iiiuiiii!ii< 
as  a  cause  of  infective  jirocesses  in  and  about  the  appendix,  lii  many 
cases,  with  slight  fresh  adhesion  and  a  little  sero-fibrin,  the  cidtiins  air 
negative.  As  Wtdch  remarks,  "There  is  reason  to  believe  that  the  liijrlily 
resistant  colon  bacillus  may  survive  in  an  inflamed  part  after  the  |iriniary 
organism  whi<'h  started  the  trouble  has  died  out,  or  has  been  crowdcil  ntit 
by  the  invader."  The  pronene.ssof  the  appendix  to  infective  itifl;unniati"ii 
of  this  sort  lies  "  in  that  subtle  structure  which  determines  the  dcgno  nf 
resistance  of  u  tissue  to  disease.     One  man  differs  from  anotlur  in  Ins 


Jii*r.' 


APPKNDKITIS. 


433 


iKiwor  of  rcsistiincc ;  tlic  more  dogenonito  the  man  tlie  less  resistiinco  can 
hf  cxiTt.  In  like  manner,  one  organ  in  a  man  dilTers  from  anotlier.  And 
ill  ilic  appendix  we  are  dealing  with  an  organ  which  is  degenerate  and 
fiiiictioidess  from  first  to  last,  and  its  seanty  power  of  resistanee  to  bac- 
ti'iiiil  invasion  is  but  anotlier  way  of  expressing  this  fact"  (llawkitis). 

It  lia-  been  urged  that  the  anatomical  relations  of  the  nu'so-apju'ndix 
iiml  the  iidj.icent  peritoneal  folds  are  such  that  distention  of  the  ciecum, 
(irof  the  lower  portion  of  the  ileum,  may  cause  dragging  with  torsion  and 
interfere  seriously  with  the  l)lood  su])ply  of  the  tube.  Tiie  swelling  of  the 
iiiiicosa  so  induced  nuiy  be  an  important  factor  in  the  infection  of  its 
tissues. 

FduKr  suggests,  and  b.  ingsaease  in  support,  that  in  some  of  these 
casi's  the  necrosis  is  due  In  the  thrombosis' of  a  large  arterial  branch. 

Immediate  Effects  of  the  Perforation.  {(/)  Acute  General  Peritonitis.— 
If  the  ap[ieiidix  ".-.  free,  witluMit  adiu'sions,  the  perforation  may  lead  at 
once  to  ii  wiilo-spread  peritonitis.  The  inllammation  varies  much  in  \  iru- 
leiiee,  (U'liending  ai)parently  upon  the  infecting  organism.  The  worst 
eases  are  those  in  which  the  streptococcus  pyogeiu's  is  present.  A  general 
]ierit()Mitis  is  more  common  in  the  acute  infective  a])peiulieitis  than  in 
the  ether  forms.  It  })robably  n-sidts  less  frequently  from  direct  perfora- 
tion, iir  sl()Ughii\g  of  the  appendix,  than  from  extension  of  inilanunation 
from  a  local  pcri-appeiulicular  abscess. 

(//)  Localized  Peritonitis,  with  Abscess. —Perforation  leads  usually  to 
the  I'lirniatioii  of  a  circumscribed  intra-peritoiu'al  abscess  cavity,  which 
varies  in  situation  with  the  position  of  the  ajjpendix,  and  in  size  from  a 
wahiut  to  a  cocoanut.  Perhaps  the  most  common  situation  is  on  the 
]i.-oas  muscle,  just  at  the  angle  between  the  ileum  and  the  Civcuin.  The 
perforateil  appendix,  however,  may  be  within  the  pelvis,  (u*  u{ion  the 
promontory  of  the  sacrum,  or  lie  between  the  coils  of  small  bowel  in 
the  neighborhood  of  the  umbilicus.  A  common  situation  for  the  large 
eireumscribed  intra-peritoneal  abscess  is  in  the  iliac  region  midway  be- 
tween the  navel  and  the  anterior  superior  spine.  Perforation,  adhesive 
peritonitis,  and  the  production  of  a  localized  abscess  may  ))ro(H'ed  without 
eaiisjiig  any  serious  symptoms,  and  the  condition  nuiy  be  found  when 
ileath  has  resulted  from  accident  or  from  some  intercurrent  alleetion. 
Tlie  eoiitcnts  of  the  abscess  may  be  a  grayish  yellow,  thick  iv;.-,,  i...  lally 
with  a  strong  fiecal  odor;  but  in  the  old,  limited,  small  abscesses  it  is 
usually  dark  gray  in  color,  and  horribly  olfensive.  'J'he  aj»pendix  may  be 
louml  fri'c  ill  the  localized  abscess;  in  other  instances  it  is  so  covered, 
v.ith  pus  autl  inflammatory  exudate  that  it  is  impossible  to  find  it.  While 
in  a  majority  of  all  instances  the  abscess  cavity,  even  when  large,  is  intra- 
peritoneal, there  may  be — 

(' )  Extensive  Extra-Peritoneal  Suppuration.— When  an  appeiulix  per- 
forates, it  lies,  of  course,  in  immediate  contact  with  the  peritoiueum ;  if 
on  the  iliac  fascia,  or  the  wall  of  the  pelvis,  or  behind  the  cajcuni,  the  ad- 


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DISHASMS  OK  Till':   DUJHSTIVH  SVSTKM. 


lio.-^ioii  may  tiiko  ulace  in  siR'h  a  way  tliat  the  jHTforatioti  occurs  into  tlip 
n'tro-jicritoiioal  tissue.  In  these  days  of  operation  we  do  not  so  tpfti'iiM, 
the  extensive  retro-peritoneal  abscesses  due  li»  appendix  disease.  The  |i;;< 
may  [lass  In^iu'ath  the  iliac  fascia  and  appear  at  I'oupart's  ligaiiiciil,  m 
wiiich  situation  external  perforation  may  occur  and  recovery  take  |ila>r, 
Tlie  pus  may  he  chiefly  in  the  rctro-pei'itoncal  tissue  in  the  flarilv,  furmin;. 
a  lar;^e  perinephritin  ab.scess.  In  a  casi'  under  the  care  of  (lanhii'i',  uf 
Montreal,  an  eiU)rmous  ah,<<cess  cavity  developed  in  this  Kituation.  whirli 
contained  air,  pushed  up  the  diaphrai^m  nearly  to  tlic  second  rii),  and  imi. 
duced  the  .symptoms  of  pneunu)lhorax.  I'ci'foration  of  the  j)lcuni  iiiav 
occur  in  these  cases,  formiuf;  a  fecal  i)leural  fistula.  'I'lie  pus  may  cxtiinl 
along  the  p.soas  muscle  and  may  i)erforate  the  hip  joiiit,  or  pass  ti»  the 
neighl)orhood  of  thi'  rectum,  or  produce  multiple  absces.ses  of  the  scrotum; 
or,  passing  through  the  obturator  fora?ncn,  form  a  large  gluteal  aljsc'i'.<.<, 
Both  the  intra-  and  extra-peritoneal  appendix  abscess  nuiy  perfoiatu  iiito 
the  bladder  or  into  the  bowel,  and  recovery  may  follow,  thougii  llicivis 
greater  danger  in  perforation  into  the  latter.  The  aiipendix  has  Irtii 
discharged  jicr  (inioii. 

Remote  Effects. — The  remote  effects  of  perforative  ai)})endi(itis  nw 
interesting.  Ila-morrhage  may  occur.  In  one  of  my  cases  the  appiinlix 
•was  adherent  to  the  promontory  of  the  sacrum,  and  the  abscess  cavity  hail 
jjcrforateil   in  two  places  into  the  ilei.  Death  resulted  from  ]irofii-.c 

ha.'morrhage.  (.'ases  are  on  record  in  which  the  internal  iliac  artery  ur 
the  deep  circumflex  iliac  aru-ry  has  been  opened.  Suppurative  pylr|ilil('- 
bitis  may  result  from  inflammation  of  the  mesenteric  veins  lU'ar  the  pir- 
forated  appendix.  Two  instances  of  it  have  come  under  my  notico;  ii 
one  there  was  a  small  localized  abscess  which  had  resulted  from  the  ]"  i- 
foration  of  a  tyi)hoid  ulcer  of  the  ajipendix.  In  the  other  case,  which  I 
saw  with  Machell,  of  Toronto,  the  symptoms  were  those  of  septica'niiii  ami 
of  suppuration  in  the  liver.  'I'he  abscess  of  the  appendix  was  small  iiiid 
had  not  prodiu-ed  symptoms.  In  the  healing  of  extensive  innauiniiilinii 
about  the  margin  of  the  pelvis  the  iliac  veins  may  be  greatly  coiniircsst'ij. 
and  one  of  my  patients  had  for  months  a'dema  of  the  right  leg,  wimh  is 
now  permanently  enlarged. 

The  appendix  may  perforate  in  a  hernial  sac.  Several  instances  of 
this  have  been  recorded  rcccMitly.  In  a  case  which  came  under  my  care  at 
the  University  Hospital,  Philadelphia,  there  was  a  hernia  of  the  r.vnm  iii 
the  inguimd  canal.  The  proximal  orifice  of  the  appendix  was  at  tlio  ex- 
treme end  of  the  hernia  in  the  inguinal  canal.  The  tube  then  ciincil 
upon  itself,  passed  into  the  abdomen,  and  the  terminal  three  fourths  of  an 
inch  had  sloughed  in  a  small  circumscribed  sac  situated  close  to  tlicimiiii- 
ontory  of  the  sacrum. 

The  following  additional  facts  may  be  mentioned,  bearing  on  the 
Etiology : 

Age. — Appendicitis  is  a  disease  of  young  persona.    According  tn  Fitzs 


APPKNDIcrriS. 


435 


stiitii^tii'S,  moro  tliiin  fifty  por  coiit  of  tlic  casos  nornr  licforc  tlio  hvnifictli 
vi>;ir;  iirconliiix  t')  Mitilionrn,  sixty  per  cent  hctwcoii  tlu-  sixtcciitli  and 
thiitii'th  years.  It  lias  hci'ii  mot  witli  as  farly  U8  thf  seventh  week,  l>iit  it 
ismrclv  seen  prittr  to  tlic  third  year. 

Sex. — It  U  imich  more  coiiiinoii  in  males  than  i)i  females,  ei;,dity  per 
rent  of  the  former  in  the  tahle  of  Fit/,.  In  Hawkins's  sfiies,  one  hundred 
and  si\tv-one  were  nniles  and  sixty-tliree  females.  Contrary  to  the  p-n- 
(lal  cxiiericnoo,  the  Munich  figures  given  by  Einhorn  indicate  a  relatively 
I'lviitiT  iiiimher  "f  women  attacked. 

Occupation.-  Persons  whose  work  necessitates  the  lifting  of  heavy 
\viii:iit«  scciii  more  prone  to  the  disca.se.  Trauma  plays  a  very  definite 
/•(//'',  and  in  a  iiumher  of  cases  the  8ym])toms  havo  followed  very  clo.sely  a 
fall  or  a  lilow. 

Indiscretions  in  diet  are  very  prone  to  bring  on  an  attack,  parti<-iilarly 
ill  till'  recurring  form  of  the  disease,  in  whiidi  pain  in  the  appendix  region 
!i  it  iiifre<|uently  follows  the  eating  of  indigestihle  art  ides  of  food.  I  have 
lurii  impressed,  too,  with  the  numher  of  ca.sos  in  boys  in  which  there  has 
Ihm'U  a  history  of  gorging  with  ju-annts. 

Symptoms. — In  a  large  proportion  of  all  cases  of  acute  ajipendicitis 
the  fullowiiig  symptoms  are  i)re.sent;  (1)  Sudden  pain  in  the  abdomen, 
usually  referreil  to  the  right  iliac  fo.ssa ;  {'1}  fever,  often  of  moderate 
giiulo;  {'■])  gastro-intestinal  disturbance — nausea,  vomiting,  and  frequently 
(■oiistipatioii ;  (4)  tenderness  or  pain  on  pressure  in  the  aiipendix  region. 

Such  a  group  of  symptoms  in  a  young  person,  particularly  following 
an  iiulisciTtioii  in  diet  or  an  injury  oi'  strain,  in  the  absciici  of  signs  of 
hernia,  indicate  the  exi.stetice  of  appendicitis;  they  do  not  suggest  in  any 
wav  lilt'  nature  of  the  lesion,  whether  obliterative,  ulcerative,  or  an  acute 
niiiotic  ap]ieiidicitis.  We  may  first  consider  more  fully  these  general 
symptoms  of  the  disea.se. 

Pain. — .V  sudden,  violent  pain  in  the  Hl)dome!i  is,  according  to  Fitz, 
tlic  most  constant,  first,  deciiled  symptom  of  perforating  innammatioji  of 
the  appendix,  and  occurred  in  eighty-four  ])er  cent  of  the  cases  analyzed 
hy  him.  In  fiillv  half  of  the  cases  it  is  localized  in  the  right  iliac  fossa, 
Imt  it  may  be  central,  dilTnse,  or  indeed  in  almost  any  region  of  the  abdo- 
men. Kven  in  the  eases  in  which  the  pain  is  at  first  not  in  the  appendix 
region,  it  is  usually  felt  here  within  thirty-six  or  forty-eight  hours.  It 
may  extend  toward  the  perinaMim  or  testicle.  It  is  sometimes  very  sharp 
and  colic-like,  and  cases  have  been  mistaken  for  neiihritic  or  for  biliary 
Odlic.  Some  patients  speak  of  it  as  a  sharp,  intense  pain — .serons-mem- 
biane  pain;  others  as  a  dull  ache — connective-tissue  ])ain.  While  a  very 
valuahle  symptom,  i)ain  is  at  the  same  time  one  of  the  most  misleading. 
Some  of  the  forms  of  recurring  pain  in  the  appendix  region  Talamon  has 
called  appendicular  colic.  The  condition  is  believed  to  be  due  to  partial 
occlusion  of  the  lumen,  leading  to  violent  and  irregular  peristaltic  action 
ijf  the  circular  and  longitudinal  muscles  in  the  expulsion  of  the  mucus. 


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niSKASKS  OK  TIIK    [)|{»KSTIVK  SYSTKM. 


Fever. — A  rise  in  the  tomponituro  follows  rii|ti(lly  upon  the  [lain,  and 
is  one  of  the  most  valiiiilde  of  llie  Hyinjitonis  f»f  tlio  early  stnjie  of  a|i|Hinli. 
(litis.  All  initial  cliiil  is  very  rare,  'i'lu?  fever  may  be  niotlciatc,  from 
iOU"  to  lo-i°;  sometimes  in  cliildren  at  tiie  very  outset  tlie  liu'niioiia'tor 
nuiy  re^'istrr  above  lo;}")".  Tlie  tiiermometer  is  one  of  the  most  triisit- 
worthy  jjuitles  in  the  diagnosis  of  aeute  appendicitis.  I'ain  in  tlie  ii<;lit 
iliae  fossa  without  fever,  in  an  acute  attack,  rarely  nu-ans  ap|iiiiilititi^. 
When  a  localized  al)scess  has  formed,  and  in  sonu- very  virulent  rase?  of 
geiuTal  jU'rilonilis,  tluf  temperature  nuiy  be  almost  normal,  but  iit  this 
stage  there  are  other  symptoms  which  indicate  the  gravity  of  the  situation, 
TIk!  pids(!  is  quickened  in  proportion  to  the  fever. 

Gastro-intestinal  Disturbance.— The  tongue  is  usmilly  furred  ami  moist, 
seldom  dry.  Nausea  ami  vomiting  are  symptoms  which  may  be  aliseiit, 
but  which  are  commonly  i)resent  in  the  acute  i>erforative  cases.  The 
vomiting  rarely  persists  beyond  the  second  day  in  favorable  cases.  {'„||. 
stipation  is  the  rule,  but  the  attack  may  set  in  with  diarrluea,  purtieulailv 
in  children. 

Local  Signs. — Inspection  of  the  abdomen  is  at  first  negative;  there  is 
lu)  distention,  and  the  iliac  fossa'  look  alike.  On  palpatioti  there  arc  usu- 
ally from  the  outset  two  imj)ortant  signs — nanudy,  great  tension  of  the 
right  rectus  muscle,  and  tenderness  or  actual  paii\  on  deei)  ju'essiire.  Tlic 
muscular  rigidity  nuiy  be  so  great  that  a  satisfactory  examiiuit ion  caiiiii.t 
be  made  without  an  ana'sthetic.  McHurney  has  called  attention  to  the 
value  of  a  localizeil  point  of  tenderness  on  deep  pressure,  which  is  sitiiatiil 
at  the  intersection  of  a  line  drawn  from  the  navel  to  the  anterior  siiiKrinr 
spine  of  the  ilium,  with  a  second,  vertically  jdaecd,  corresponding  to  tliu 
cuter  edge  of  the  right  rectus  muscle.  Firm,  deep,  conliinu)us  pressure 
with  one  finger  at  this  spot  causes  pain,  oftt>n  of  the  most  e.\(|uisite  (  hnr- 
acter.  In  addition  to  the  tenderness,  rigidity,  and  actual  pain  on  iKep 
pressure,  there  is  usually  to  be  felt  in  a  majority  of  the  cases  an  induration 
or  swelling.  In  some  cases  this  is  a  l)<>ggy,  ill-defined  mass  in  the  sitna- 
tion  of  the  ca'cum;  more  commoidy  the  swelling  is  circiimscribed  and 
definite,  situated  in  the  iliac  fossa,  two  or  three  fingers'  breadth  aliove 
Poupart's  ligament.  Some  have  been  able  to  feel  and  roll  beneath  the 
fingers  the  thickened  api)endix.  The  later  the  case  comes  under  observa- 
tion the  greater  the  probability  of  the  existence  of  a  well-marked  tumor 
mass.  It  is  not  to  be  forgotten  that  there  may  be  neither  tumor  mass  nor 
induration  to  be  felt  in  some  of  the  most  intensely  virulent  cases  of  per- 
forative appendicitis. 

In  adtlition  may  be  mentioned  great  irritability  of  the  bladder,  which 
I  have  known  to  lead  to  the  diagnosis  of  cystitis.  It  may  be  a  very  early 
symptom.  The  urine  is  scanty  and  often  contains  albumin  and  imlican. 
Peptonuria  is  of  no  moment.  The  attitude  is  somewhat  suggestive,  the 
decubitus  is  dorsal,  and  the  right  leg  is  semi-flexed.  PLxamiiiatioii  }»'T 
rectum  in  the  early  stages  rarely  gives  any  information  of  value,  unless  the 


Ari'KNDICITIS. 


4.37 


,npoiiilix  lit'S  woll  ovor  tlic  brim  of  the  jiclvi.s,  or  unless  tlioro  is  a  lari,'o 
iihsrc-.-i  ciivit y. 

TluTf  iiri'  three  jjossibilities  in  any  ease  of  ajipeiidieitis  presentiiifj  tlio 
iibove  syiiiptonis :  (1)  (Jradiial  reeovcry,  {'i)  tlie  formation  of  a  local  al»- 
sr(N>.  ami  (I))  the  (levelopment  of  a  general  peritonitis. 

Recovery  is  tluf  rnle.  Out  of  "^'t;!  eases  at  St.  Thomas's  Hospital 
with  ilie  aI)ove-mentione(l  elinieal  eharaeters,  lUO  recovered.  In  one  in- 
stuiiee  the  appemlix  wa.s  removed,  and  in  two,  attempt.s  wen-  made  to  re- 
move it  (Hawkins).  There  are  sur^feons  who  claim  that  the  ^^ettiuLf 
wi'll  in  these  eases  does  not  mean  much;  that  the  patients  have  reeiir- 
rciicis  and  are  constantly  liable  to  the  j^raver  ac^eidents  of  the  disease. 
This,  I  feel  sure,  is  an  undidy  dark  picture.  I  have  known  personally 
nuiiihers  of  cases  in  which,  after  one  or  two  attacks,  the  indiviiluals  liavo 
rcinaiiieil  in  jterfect  health. 

Ill  a  case  whi(di  is  proceeding  to  recovery  the  pain  lessens  at  the  end 
of  the  third  or  fourth  day,  the  temperature  falls,  the  ton<^uc  becomes 
cleaner,  the  vomiting  ceases,  the  local  tendcrni'ss  is  less  nuirked,  and 
t!i"  Ixiwels  are  moved.  Hy  the  end  of  a  week  the  acute  symptoms  have 
subsided.  The  entire  attack  nniy  not  last  more  than  te.i  days.  In  other 
instances  slight  fever  jtersists,  and  it  may  be  two  or  three  weeks  before 
coiivaleseenco  is  established.  .\n  induration  or  an  actual  small  tumor 
ina-s  fioni  the  size  of  a  walnut  to  that  of  an  I'gjr  muy  jiersist — a  condition 
ill  uhii'li  patients  are  very  liabh-  to  a  recnrriMiee. 

In  tiiese  eases  there  is  either  a  (dironic  appendicitis  without  perforation 
or  involvement  of  the  serous  surface,  or  there  is  involvement  of  the  peri- 
toneal surface,  usually  from  jHM'foration,  with  u  sero-fibrinous  exudate  and 
an  a;.'ghitination  of  the  contigin)US  parts.  In  the  cases  with  a  wcdl-delin-d 
tunmr,  whether  large  or  small,  there  is  almost  always  pus  fornnitioii. 

Local  Abscess  Formation. — As  a  result  of  nlceratioi\  and  perforation, 
soniciJMKs  following  the  tiecrosis,  randy  as  a  sequence  of  the  dilTusc  ap- 
]HMi(iicitis,  the  patient  lias  the  train  of  symptoms  above  described  ;  but  at 
tilt' end  of  the  (irst  week  the  bx^al  features  persist  or  become  agirravate(l. 
The  course  of  tiie  disease  nniy  be  indeed  so  acute  that  by  the  end  of  the 
fourth  or  iifth  day  there  is  an  extensive  area  of  induration  in  the  right 
iliae  fossa,  with  great  tenderness,  and  ojierations  have  slK)wn  that  even  at 
this  very  early  date  an  abscess  cavity  nuiy  have  formed.  Though  as  a 
mill  the  fever  becomes  aggravated  with  the  onset  of  suppuratinii,  this  is 
I'.iit  always  the  case.  The  two  most  inii)ortant  elements  in  the  diagnosis 
of  abscess  formation  are  the  gradiuil  increase  of  the  local  tumor  and  the 
Mir.'ravation  of  the  general  symptoms.  Nowadays,  when  operation  is  so 
fivi|ii(>nt,  we  have  opportunities  of  seeing  the  abscess  in  various  sttigcs  of 
ilfvcloimiont.  Quite  early  the  pus  may  lie  between  the  ciecum  and  the 
('|'il>  of  the  ileum,  with  the  general  peritonaeum  shut  off  by  fibrin,  or  there 
IS  a  sero-fibrinous  exudate  with  a  slight  amount  of  j)us  between  the  lower 
coils  of  the  ileum.     The  abscess  cavity  may  be  small  and  lie  on  the  psoas 


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438 


DISEASES  OF  THE   DIGESTIVE  SYSTP^M. 


muscle,  or  at  the  edge  of  tlie  promontory  of  the  sacriiin,  iincl  novcr  iciuli 
a  j)ali)al)k'  size.  'IMie  sac,  wlion  larg(U',  may  l»e  roofuil  iti  by  the  small  bowi'l 
and  pri'scnt  irregular  [jrocesses  aiul  pockets  leading  in  tlilTereiit  dircctidns. 
In  larger  colleetions  in  the  iliac  fossa  tiic  roof  is  generally  formed  liv  the 
ahdiimiiial  wall.  Some  of  the  most  important  of  the  localized  uIimcs-cs 
are  lliitse  which  are  situated  entirely  within  tlio  pelvis.  The  vaiimis;  ilj. 
rections  an<l  positions  into  which  the  abscess  nuvy  pass  or  perforate  li;iv(.' 
already  been  referred  to  iiiuier  morbid  anatomy,  but  it  may  be  here  nicii- 
tioiied  again  that,  li'ft  alone,  they  iiay  discharge  externally,  or  burmw  in 
various  directions,  or  discharge  through  the  rectum,  vagina,  or  lihuliltr. 
Death  may  be  caused  by  septica'inia,  jy  jjcrforation  into  an  artery  or  vein, 
or  by  pyleplili'ljilis. 

General  Peritonitis. — This  may  be  cau.sed  by  direct  perforation  of  the 
aj»peii(ii\:  and  genei'al  infection  of  the  jteritoiueum  before  any  delitnilin;,' 
inllammation  is  excited.  In  a  second  group  of  ca.ses  there  has  been  .m  at- 
tempt at  localizing  the  infective  pnxiess,  but  it  fails,  and  the  general  ]i('ii- 
tomeum  lu'comes  involved.  In  a  ihirtl  group  of  eases  a  localize,]  focu.^  of 
suppuration  exists  about  an  inllamed  appendix,  ami  from  this  perforatiuii 
takes  place. 

Death  in  appendicitis  is  duo  usually  to  general  peritonitis. 

We  see  at  operations  all  grades  of  the  alTection,  from  the  mildest,  in 
which  the  serous  surface  is  injected,  turliid,and  sticky,  but  without  lyiii|i]i 
or  elTusion,  except  in  'he  immediate  neighborhood  of  the  perfoiatcd  a|i- 
pendix.  In  other  cases  there  is  a  librinous  exudate  gluing  the  cuiis 
together  and  a  variable  amount  of  turbid  serous  iliiid.  In  other  instaiioi-. 
as  the  abdomen  is  opened,  pus  wells  out,  and  there  is  a  dilTii.se  i)iiriili"ii 
inllammation  of  the  peritona-um.  It  is  interesting,  however,  to  note  tW:' 
com[iiirative  rarity  of  f.atal  peritonitis  froih  apixMidix  disease  in  gciu'ial 
medical  work.  In  ■l')()  I'onsecutive  autojisios  on  patients  dead  in  my  uaids 
there  was  not  a  single  instance  of  general  peritoiutis  from  a{)pendix  dis- 
ease. (Ml  the  surgical  side  there  have  been  admitted  during  the  same 
period  ten  cases  id'  dilTu.se  peritoi.!i,is  from  this  cause.  Kigh*^  \vei'i(i|i- 
eraled  upon  ;  all  died.  In  tiine  cases  there  was  founci  <i  perfoijitr.j  a;!il 
more  or  less  gangrenous  a'ppendix,  with  little  or  no  attempt  at  liiiali,':a- 
tion :  in  one  ca.><e  rupture  of  an  ab.scess  caused  the  general  peritonitis. 

Till'  11  nil' it jl  nf  fippi'iii/i.r  i/isi'iisf  Ill's  in  llicfiirl  lliiil  friiiii  tlir  I'rnj  ""/- 
si'l  lliv  pvriti'iiii'iiiii  iiinji  hi'  iiifrrli'il  :  tin'  iiiitiiil  si/ni/ifoiiis  nf  paiiu  inth 
ju'iisi'ii  mill  rniiii/iiiit,  J'i'i'ri\  iniil  hn'iil  tnnlnnrss,  prrsnit  in  nil  nisi''", 
mill/  i ml i rati'  a  /riilr-sprciul  iiifcrtiiDi  nf  this  niciiihraiii'.  The  onset  is 
usually  sudden,  the  pain  dilTuse,  not  always  localized  in  the  right  iliiic 
fossa,  but  it  is  not  so  nuudi  the  character  as  the  greater  intensity  of  tin' 
8ymp,-,oms  from  the  out.set  that  nuikos  one  suspicious  of  a  gent  ral  pi  ri- 
tojiitis.  Alidominal  distention,  diiTu!<(^  tenderness,  ami  ab.seiicc  cf  iili- 
(himinal  movements  are  the  most  tri.stworthy  local  signs,  Itut  they  arc  ii"t 
really  so  trustworthy  as  the  general  symptoms.     The  initial  iiaii-i'n  iir.l 


^  mm^^ 


ArPENDICITIS. 


439 


voniitiii.2  persist,  the  pulse  bocoiucs  iiioro  rapid,  the  tong  lo  is  dry,  the 
iiriiK'  Hiiiiitv.  Ill  vrry  acute  cases,  l)y  the  end  of  tweiity-fciir  hours  the 
ali(!(i!ii('n  may  be  distended,  \^y  the  third  and  fourth  (hiys  the  chissieal 
hii'tiiii'  of  a  general  peritonitis  is  well  established — a  distended  and 
iiiotii)iiless  abdomen,  a  rapid  ]iiilse,  a  dry  ton^rue,  dorsal  decubitus  wilh 
till'  knees  drawn  up,  and  an  anxious,  piiu'he(l,  ilippoeratic  facies. 

Fever  is  an  uncertain  element.  It  is  usually  present  at  first,  but  \f  the 
iihysirian  does  not  see  the  case  until  the  third  or  fourth  day  he  shoulvi 
nut  lie  dect'ived  by  a  temperature  below  l(i()-."»°.  'I'lie  i)ulse  is  really  a 
lictler  iiidication  than  the  tempt-rature.  One  raroly  has  any  doubt  on  the 
third  or  fourth  day  whether  or  not  peritonitis  exists,  but  it  must  bo 
iK'kiiowledf^ed  that  there  are  e.xceptions  which  trouble  the  judgment  not  a 
liulo.  While  on  the  one  hand,  without  suggestive  symptoms,  u  lai)ar()tomy 
has  iliselused  an  unexpected  general  peritonitis,  on  the  other,  with  severe 
ciiiisiitutional  symptoms  and  apparently  i  !i;:racteristic  local  signs,  the 
[iiTit')ii;eum  has  been  found  smooth. 

Relapsing  Appendicitis.-  IVp per,  in  188.'},  called  attention  to  the 
niiuivkalile  liability  to  relapse  in  perityphlitis.  'I'he  i)atient  gets  well 
ami  all  trace  of  induration  and  tenderiie.<s  disappears;  then  in  tliree  or 
fma'  months,  or  earlier,  he  again  has  fever,  pain,  and  local  signs  of  trouble. 
The  attacks  may  recur  for  years.  The  cases  whi(di  recover  with  the  per- 
sistence tf  an  induration  or  tumor  mass  are  most  proiu'  to  relapse.  There 
arc  more  severe  cases  in  which  the  intervals  between  the  altiicks  are  very 
shurt,  'iiid  the  patient  becomes  a  chronic  invalid.  After  repeated  attacks, 
hiiwever,  recovery  may  be  perfect.  The  fretiueiiey  of  recurrence  is  dilli- 
iiilt  to  estimate,  Fitz  places  it  at  44  per  cent,  Hawkins  at  )i'.V('t  per  cent. 
The  recent  statistics  of  operations  given  by  Deaver,  Murphy,  and  otiiei's 
imlicate  how  eomi.ion  must  be  this  ty])e  of  the  disea.se.  Hiill  has  cullccti'd 
■II".'  (i[ierations  in  ehronic  relapsing  ap]iendicitis  by  eighty  sui'geoiis,  with 
a  iiMirtality  of  1'8  per  cent,  but  he  thinks  that  5  or  (i  per  cent  would  be  a 
fairer  estimate. 

The  iiKirbid  condition  in  this  form  is  either  a  simple  oblilerative  ap- 
pciidiciiis  with  or  without  adhesions,  or  an  adherent,  perhaps  peiforated, 
:i|i[>eiulix  with  a  small  localized  ab.scess  circumscribed  by  dense  tibroid 
tissue. 

Diagnosis. — Ajipendicitis  is  by  far  the  most  common  inllammatory 
iiiiulitidii,  not  only  in  the  ea'cal  region,  but  in  the  alidnmcn  generally  in 
pirsotis  iMider  thirty.  'JMie  surgeons  have  taught  us  that,  alnmst  without 
i'Sri'[iMi.n,  sudden  pain  in  the  right  iliac  fossa,  with  fever  ami  Incali/ed 
liiiiliTiiess,  with  or  without  tumor,  means  appeinlix  disease.  There  an.« 
irrtuiii  ilhseases  of  the  abdominal  organs  cdiaracrterized  by  pain  which  arc 
ajit  to  tie  i'onrounde(l  with  appendicitis.  Hillary  colic,  kidney  colic,  and 
tlii'oolicky  pains  at  the  menstrual  period  in  woiin  n  have  in  .some  cases  to  be 
"i"st  carefully  considered.  I  have  n<tt  met  wilh  an  instance  of  eitlu'r  renal 
"!' hepatic  euleuluh  causing  any  dilliculty  in  diagnosis,  but  u  patient  was 


4. 


I) 
) 

I    ' 
|l    . 


m  j 


;h,,  r 


''infill 


m 


f^' 


440 


DISKASKS  OF   THR   DlfiKSTIVE  SYSTEM, 


i 


m 


^0 


adiiiittod  to  my  wards  a  {v\\  inoiitlis  afro  with  a  liistory  of  vpi'v  siulden 
oiisi't  of  si'vcro  pain  til rco  (lays  jHVviou.sly  in  tlio  right  side  of  the  alidn- 
men,  and  with  an  ill-doliiu'd  tiinioi"  mass  low  in  the  right  Hank'.  I'diiu. 
iiatfly,  she  was  transforrcd  at  on<'c  to  thi'  snrgical  sidt'  for  olifratidn,  an.l 
tli(>  coiidilion  provcil  to  he  an  a<'utcly  distoiuled  and  inflaincd  galllilacKKr 
almost  on  tho  ])r)int  of  [x'rforating. 

l)is(>as(>  of  tho  tiilx's  and  pelvic  peritonitis  may  sinmlatc  ap[i(  iidicitis 
very  closely,  hnt  the  history  and  the  local  examination  under  etlier  .-ludiKl 
in  most  cases  enal>le  the  practitioner  to  rea(di  a  diagnosis.  I  haM'  sen 
several  cases  siii)posed  to  he  recurring  a})i)endicitis  which  proved  tu  bo 
tnho-ovarian  disease. 

'i'he  nieiTs  crises  in  floating  kidney  and  the  odd,  anomalous,  (diuli- 
tion  of  (>nteroi)tosis  in  neurotic  patients  may  cause  some  little  dillienitv. 

\\o\h  intnssusc(>ption  and  internal  strangula'ion  may  present  vcrv 
similar  symi)toms,  and  il  the  patient  is  only  seen  at  the  latter  stages,  whi'U 
there  is  dilTuso  jteritonitis  and  great  tymjiany,  the  features  may  be  almost 
identical.  Ka'cal  votniting,  which  is  comirion  in  ohstrnction,  is  in\,r 
seen  in  appendicitis,  and  in  (diildren  the  marked  tenesmus  and  hlddih 
stools  are  important  signs  of  intussusc^-ption.  It  is  not  offen  ditlieult 
when  the  cases  are  seen  early  and  when  the  history  is  clear,  but  inistaki's 
have  been  made  l»y  surgeons  of  the  tirst  rank. 

Acute,  ha^morrhagic  pancreatitis  nuiy  also  [iroduce  symjitniis  verv  Jiku 
tKo.se  of  apiiendici'iis  with  general  ])eritonitis.  Typludd  fe\<r  has  lurii 
niistakeii  -.'or  ajijiendicitis.  I  was  told  of  a  ca.sc  recently  in  one  of  tlv 
large  hospitals  <if  this  country  in  which  the  fever,  the  pn-.sence  of  a  tender 
induration  in  the  right  iliac  fossa,  seemed  to  indicate  so  (dearly  apjMtnlii 
di.sease  that  an  operation  was  performed,  hut  the  induration  was  hmtid  to 
be  the  swollen  ileum  and  adjacent  glands.  Itt  a  persoi\  who  had  had  [ire- 
vious  appendicitis  the  diagnosis  might  he  e.\trcm(dy  ditlicult,  as  iii  a  'iis'' 
mentioned  by  Da  Costa.  Late  in  the  convalescence  of  tyj.hoid  fever 
symploins  of  appendicitis  may  develop,  due  to  the  perforation  of  an  uii- 
heale(l  ulcer. 

There  is  a  well-marked  appendicular  hypocliotidriasis.  Throiigli  the 
pernicious  inllnence  of  the  daily  press,  appciidii'itis  has  became  a  .-ert  of 
fad,  and  the  jihysi(dan  has  often  to  deal  wiih  patients  who  ha\e  a  .surt 
of  lixeil  id('a  that  they  have  the  disease.  'I'lie  worst  cases  of  thi^  cluis 
whi(di  1  have  seen  have  heen  in  metuliers  of  our  profession,  and  I  kmnvnf 
at  least,  one  instance  in  wlii(di  a  ])erfectly  normal  apiiendi.x  was  n  nidvcd. 
The  (juestion  really  has  its  ludicrous  side.  A  w(dl-known  jdiysiidaii  in  a 
We-^lern  (dty  having  one  night  a  Ik  llyache,  and  fc(ding  convinced  tlial  liisi 
aj)}>endix  had  perforated,  summoned  a  surgeon,  who  (piickly  removed  tin' 
suppose(|  olTcndcr ! 

Ilystei'ia  may  of  course  simulate  appendi'-itis  very  clostdy,  ami  it  iiu'}' 
re(piire  a  very  keen  judgment  to  nuike  a  diagnosis. 

Mucous  colitis  with  eiiteralgia  in   nervous   women   is  sometiiiic'*  ;'i!^- 


APPENDICITIS. 


4U 


tiikcn  fur  appondicitis.  In  two  iiijjtaiiccf!  of  the  kind  I  havo  proventod 
|iroiiiisril  (ipiTiitioii,  and  I  have  hoard  of  cases  in  wliicii  the  appendix  lias 
hirli  ivMidVi'd. 

P.TJni'pliritic  and  jK'i'ica^oal  ah.sooss  from  pcrfonitioti  of  idctT,  citluT 
-imnli'  or  caiifiToiis,  and  cin'umscrilx'd  peritonitis  in  this  re;^non  from 
(iiluT  laiises,  can  rarely  ho  dilTerontiutod  until  an  exploratory  incision  is 

iiiu'le. 

Chronic  obliterative  cannot  always  he  dilTerentiated  from  perforative 
anjteiiilii'itis,  and  in  intensity  of  pain,  severity  of  sym})toins,  and,  in  rare  in- 
-uiiii'cs.  even  i'l  the  productiim  of  peritonitis,  tlie  two  may  he  identical. 

Ihiellv  stated,  loeali/eil  pain  in  the  riijlit  iliac  fossa,  with  or  without 
luihiraiiou  or  tumor,  the  I'xistence  of  Mcl'»urncy's  tender  point,  fever, 
fiirrcil  ton,s.nn',  vomiting,  with  constipation  or  diarrlnea,  indicate  appendi- 
,  ;;i-.  The  uccurrcMce  of  general  peritonitis  is  stiggested  by  increase  and 
(iilTiisii)U  of  the  aliilominal  pain,  tympanites  (as  a  rule),  marked  a,LrL,'rava- 
lioii  of  the  constituti<iiuil  symptoms,  paiticularly  eU'vation  nf  fever  and 
iiicrciiseil  rapidity  of  the  pulse.  Oiiliteration  of  hepatic  dullness  is  randy 
[Hvst'iit.  as  the  periton!i?um  in  these  cases  does  not  ofU'ti  contain  j^as. 

Prognosis.— While  we  cannot  overestimate  the  gravity  (»f  certain 
fiiiiii-  (if  ai)pt'ntlicitis,  it  is  well  to  recognize  tiiat  a  large  j^roportion  of  all 
■ast's  recover.  It  is  the  element  of  uiiii'iifiiii/i/  in  individual  cases  which 
liiis  iriven  such  an  impetus  to  tlio  surgical  treatment  of  the  di.seiwe.  That 
all  intlaiiu'd  appendix  may  heal  [)crfectly,  even  after  [uu-foration,  is  shown 
iiv  instances  (post  mttrtem)  of  obliterated  tul>cs  lirmly  iud>cdi|ed  in  old 
-'■ar  tissue.  We  have  not  had  a  full  knowh'dge  of  the  natural  historv  of 
tlu'(li-:ease.  As  J.  Uilliain  White  rcuiarkctl  last  year  in  his  aildress  at 
tlif  Ci.lii'L'c  of  l'iiysi''iaus,  I'hihidi'lphia,  ''  W C  are  in  special  neeil  ,>['  rt«- 
iiiMr  iiieilieal  statistics  as  to  this  point."  These  have  now  l)ccn  supplied 
111  \\\v  admirable  monograph  of  Hawkins  (London,  IS'.).')),  in  wliich  he  has 
iiiii1\/im1  the  cases  at  St.  Thomas's  Hospital, '^lil  in  numl)er.  The  work  is 
t'l  he  loimnended  i)articularly  to  surgeons,  since,  while  written  from  the 
-taiiiliMiMit  of  the  physician  and  pathologist,  the  iiuthor  \h  fully  alive  to 
tlic  surgical  aspects  of  the  disea.se,  and  does  ample  justice  r.o  the  work  of 
.Vnu'ricau  operattu's.  His  ligtiros  ;  e  as  follows:  {n)  I'eritoniti.s,  limited 
til  tlio  riirlit  iliac  fo.ssa.  and  not  proceeding  to  the  formation  of  pus.  I'.iO 
"i-i's.  no  deaths;  (/t)  peritonitis,  similarly  localizeil,  hut  emling  in  the 
formation  of  pus  (perityphlitic;  ab.sce.ss),  US  (jhsus,  with  1(»  dcatli- ;  {r)  gen- 
'•ral  jicritniuti-i,  :h;  cases,  with  '.'7  deaths.  This  gives  a  total  mortality  of 
14  |HM' lent.  Fifty-nine  of  the  '-IM  patients  had  had  one  .jr  more  previous 
litaik-;  [')  of  thes(>  had  simple  "  perityphlitis."  and  all  recovered;  of  7 
^vitli  alls  'CSS  forniiition, :}  died  ;  of  T  with  general  peritonitis, ;{  di»>d.  Tln^iw 
ii;;iin's  eiiinpare  very  favorablv  with  those  collected  by  I'orter  :  Hemovul 
'^f  itppindix  during  the  attack,  i".>'T  per  i-ent  mortality;  incision  ami 
'Iraiiiatre  of  abscess,  IS-IS  per  cent.  'I'he  statistics  of  indiviilmd  operaiors 
trivi'  a  niiiih  more  favorable  showing,  and  we  may  sav  that  in  acuie  cases 


M;',  i 


m 


'  r 
i  I 
I.  t 


wmtmn 


V' 


:,.. 


■^"■^1- 


If 


m 


;r?i 


if" 


442 


DisEAsr:s  OP  the  dkjestivk  systkm. 


without  jjonomlizod  peritonitis,  and  in  tiie  localized  appendinilur  ubscoss. 
the  peroontaj^e  of  deaths  in  the  hands  of  good  surgeons  is  now  very  niiicli 
lower. 

Dr.  Hldodgood  lias  kindly  furnished  nu'  the  details  of  the  eases  oppr- 
ated  u[)()n  in  the  wards  of  my  colleague,  llalsted,  in  the  surgical  ilciiart. 
nient  of  the  Johns  Hopkins  l[osj)ital  to  June  1,  IS!*').  Verv  niaiiy  df 
these  eases  were  admitted  to  my  wards  and  transferred  at  once. 

Of  olj  oases,  10  were  admitted  with  general  ]K'ritonitis,  eonlirmod  itv 
operation  or  autopsy,  'i'wo  oidy  of  these,  moriltiind  when  adiiiitlcd,  «viv 
not  operated  upon.  In  all  there  was  a  perforateil  iiud  gangrennus  miiiicii- 
dix.  'riicrc  were  operations  upon  17  cases  of  pcri-appendieular  iiIkmt,-: 
1  death  followed  from  bron(djo-i>neunionia  in  a  ))atieiit  witii  cliidnir 
ne[)hritis  and  amyloid  disease.  Of  14  cases  of  acute  appendicitis  oiitratcii 
upon  there  was  1  death  from  wide-spread  acute  pneumonia  on  the  sciMtiii 
day.  Of  T-i  eases  <»f  the  chronic  relajtsing  form  operated  on  helweeii  tiir 
attacks  there  were  Jio  deaths. 

Treatment. — So  impres.sed  am  I  by  the  fact  that  we  physicians  lose 
lives  Ity  temporizing  with  certain  cases  of  appendicitis,  that  I  prefer,  in 
hospital  work,  to  have  the  susp^cti'd  cases  admitted  direi-tly  to  the  siiri.M  mI 
side.  The  ircneral  practitioner  does  well  to  renu-mher  whether  lii^;  lean- 
ings be  towai-d  the  consci'vativr  or  the  radical  methods  of  treatnu'iit--tiii;i 
the  surgeon  is  often  called  too  late,  never  too  early. 

There  is  no  medicinal  treatment  of  appendicitis.  There  iirc  reiiiedir- 
which  will  allay  the  pain,  but  there  are  none  capatile  in  any  way  (if  row- 
trolling  the  course  of  the  disease.  Kest  in  bi'il,  a  light  diet.  iiiea>iiiv- 
direeted  to  allay  the  vomiting — upon  these  all  are  agreed.  There  aiv  tw" 
points  on  which  the  profession  is  very  miudi  divided,  namely,  tlu'  ii.>e  il 
opium  and  of  saline  purges.  The  practice  of  giving  opium  in  .-nine  fdiin 
in  appendicitis  and  peritonitis  is  almost  univer.sal  with  physicians.  Sip 
geons.  on  the  other  hand,  almost  imaninioiisly  condemn  the  praetire.  a- 
obscuring  the  clinical  pi"ture  ami  tending  to  give  a  fal.-^e  sense  of  seciniti: 
and  since  they  control  the  situation,  I  think  we  should — deferring  in  tlii- 
matter  to  their  jmlgment  — give  less  opium,  and  trust  to  the  ])ersisLeiil  iim 
of  ice  locally  to  relieve  the  pain. 

The  use  of  .saline  purges  early  in  the  disease,  which  is  advocated  !>} 
Bome  surgeons,  is,  I  believe,  a  most  injurious  ])ractiee.  In  any  given  ca.'i 
tlw  pain  anil  te'uderne.ss  at  the  oiit.set  may  nu'an  perforiitioii  of  die  !i|i|iiii- 
dix,  and  the  life  of  the  patient  may  depend  upo.i  whether  a  liiiiiliiig  iidiic- 
sive  itillammation  is  set  up.  ruder  these  circumstances,  aiiylliiiig  that 
will  stimulate  active  peristalsis  of  the  lH)wel  wall  throughout  its  extent  i.' 
certainly  contra-indicated.  Surgery,  too,  has  ta'ight  us  that  tlii'  e;veniii  is 
rarely,  if  ever,  lilled  with  hardened  fa»ces,  so  that  it  is  really  on  tlicoiTtii'iil 
grounds  that  a  saline  is  urged  to  clear  this  \rdrt  of  the  bowid.  I  ;iin  I'linl 
to  see,  too,  that  some  surgeons  of  the  largest  (^xp<'rience,  as  Midiiuiu'v. 
state  that  tlu'y  never  employ  purgatives.    They  are  also  contra-indiciiti'ii.l 


INTRSTINAL  OBSTlUTfTloy. 


443 


m 


think,  wlion  thoro  aro  siijiis  of  tlio  forniiition  of  a  lof.-il  al)S('t'ss.  Tf  nsofiil 
at  all,  ii  is  when  jfctKM'al  ju'ritotiitis  lias  been  c'stal)lislu'(l,  hut  then,  as  u 
mil',  till'  iiiiscliiof  is  (lone,  aii<i  piiruativcs  caiinot  ititliu'iu'e  the  result. 

Opiiation  is  itulicuited  in  all  (!a.ses  of  acute  iiillaiiiTnatorv  trouhie  in  the 
I'liral  nirioM,  whether  tumor  is  present  or  not,  when  the  jreneral  syniptonis 
!iiv  si'Vi'i'i",  ami  irhc/i  />//  f/ir  fhirti  ddji  tin'  ffdtiircx  of  lltv  ruse  poinf  fo  a 
jiriKjirssirv  h'sinn.  'I'he  niortality  from  early  operation  under  these  eir- 
oiunstiinces  is  very  sli^'ht. 

Ill  ricurriiiir  apiu-ndieiti.s,  when  the  attacks  are  of  such  severity  and 
fni|iii'iiry  as  seriously  to  interrupt  the  patient's  occupation,  the  iifxures 
ulrcaily  'iiveii  show  how  sli<rht  the  mortality  is  m  the  hands  of  eapahio 
ii|i(ratnis.  I'lifortunately,  in  hospital  practice  too  many  oasvs  are  brought 
111  with  general  peritonitis — a  condition  in  which  operation  is  rarely  suc- 
cessful. 

111.     INTESTINAL  OBSTRUCTION. 

Iiitistinal  obstruction  may  be  caused  by  stran;.fulation,  intussusception, 
lui-N  and  knots,  strictures  and  tumors,  and  by  abiiorn.'d  contents. 

Etiology  and  Pathology.— (")  Strangulation.— This  is  the  most 
fivi|ii(iit  ciiiise  of  acute  ((bstriictioii,  and  occurred  in  tbirty-i'oiir  per  cent 
'if  llic  ".",1.")  cases  analyzed  by  l''itz,*  and  in  thirty-live  per  cent  of  'he  l,ll{-4 
ascs  (if  Leichtcnstern.f  Of  the  1(»1  casi-s  of  straiiirulation  in  Kitz's  t.able, 
vliirli  lias  the  soecial  value  of  having  been  cari'ful'y  selected  from  the 
litrratiire  since  IH.SO^  tlu;  following  were  the  causes:  Adhesions,  (il} ;  vitel- 
liiu'  I'l'inaiiis,  "Jl  ;  ailherent  appendix,*!;  ni<'scincric  and  omental  slits,  ti; 
iM'ritoiieal  pouches  and  openings,  ;$ ;  adherent  tube,  1;  peduncular  tu- 
iMur,  1.  The  bands  and  iidbcsions  result,  in  a  majority  of  cases,  from  for- 
iiii'i'  |icril(iiiitis.  A  number  of  instances  Lave  been  reported  following 
'ijicratioiis  ii|)on  the  pelvic  organs  in  woincu.  The  strangulati(Ui  may  bo 
nviiit  iinil  ^\w  to  adhesion  of  the  bowt  I  to  the  abdominal  wound  or  a 
luil  may  he  caught  between  the  pedi(de  i.f  a  tumor  and  the  p(dvic  wall. 
>iii'li  cases  are  only  too  common.  Late  occlusiini  after  recovery  from  tho 
''pfratieii  is  due  to  bands  and  adhesions. 

Till'  vitelline  remains  are  represeiitcil  liy  Meckel's  diveiticulutn,  which 
fi'i'iiis  a  liiigerdike  projection  from  the  ileum,  usually  within  eighteen 
iii'hcs  (if  the  ileo-ca'i-al  valve.  It  is  a  reiiinaiit  of  the  oniphalo-niesentcric 
lii'i,  .rough  which,  in  the  early  embryo,  the  intestine  communicated 
"itii  tlic  \()lk-siU'.  'riu>  end,  though  commonly  free,  may  be  attached  to 
'I'  i;l»l  ""iiial  Willi  near  the  navel,  or  to  the  mesentery,  ami  a  ring  is  thus 

iiii.    ,, rough  which  the  gut  may  pass. 

Si'vcaty  ]ier  cent  of  the  cases  of  obstruction  from  stranuulation  occur 


T-iiiis,!  linns  of  ttic  ('iin);n"-s  (if  AincnVnn  I'liysjciaiis  and  8urgcoiis,  vol.  i,  lb8H. 
•hf  ,    M'iiiiiii.|.:j  ,if  (ij^;  tables  arc  used  ttirtui^'lMHit  this  scclioii. 
*  ^"11  /.■(•in^si'ii's  KiicycioptiMlitt  of  rraelieal  MviliLiiie. 


'  ii     .'»i  I 

!'!,;,:';f!. 


1^^  Ifflif   i^  ^f 


444 


DISKASKS  OP  THE   DIGKSTIVE  SYriTRM. 


ill  mules;  forty  jkt  i-ciit  of  all  the  ciist's  octnir  between  the  ii^((s  of  WUvm 
unci  thirty  yeiirs.  ]ii  ninety  per  eent  of  the  easert  of  obstruction  fnun 
these  causes  the  site  of  tiie  trouble  is  in  the  small  bowel ;  the  [lositidn 
of  the  stranirulatetl  portion  was  in  the  rifjht  iliac  fossa  in  sixlv-scvia 
]»er  cent  of  tiu'  cases,  and  in  the  lower  abdomen  in  eighty-three  ikt 
cent. 

{b)  Intussusception. — In  this  condition  one  portion  of  the  intestiiu' 
slijts  into  an  adjacent  portion,  forming  nn  invagination  or  intu.ssnsce|iti()ii, 
The  two  portions  make  a  cylindrical  tumor,  which  varies  in  length  iidm  a 
lialf-in<di  to  a  foot  or  more.  The  condition  is  always  a  descemiing  intus- 
susception, and  as  the  jirocess  ])roceeds,  tlie  middle  and  inner  liiveis  in- 
crease  at  the  exj»eiisi'  of  the  outer  layer.  An  intussusception  consists  of 
three  layers  of  bowel :  the  outermost,  known  as  the  intussiisci[)iens.  (ir  n'- 
ceiving  layer;  a  middle  or  returning  layer;  and  the  iniu'rmost  or  cnlcrinir 
layer.  The  student  can  obtain  a  clear  i  lea  of  the  arrangement  liy  iniikiiii.' 
the  end  of  a  glove-iinger  jjass  into  the  lower  })ortion.  The  actual  ciiiuli. 
tion  can  lu-  very  clearly  studied  in  the  ])ost-mortem  invaginations  vhji  h 
are  so  common  in  the  small  bowel  of  children.  In  the  statistics  of  I'ii/, 
\)'i  of  '2U^}  cases  of  acute  intestinal  obstruction  were  due  to  this  ciiMsc.  of 
these,  o^i  were  in  males  and  27  in  females.  The  casi'S  are  most  connimn  in 
curly  life,  thirty-four  ju'r  cent  nnder  one  y<'t»r  siml  fifty-six  jier  cent  uiidir 
the  tenth  year.  >so  definite  causes  could  be  assigned  in  4'i  of  the  cases; 
in  the  others  diarrlnea  or  liabitual  constipation  had  existed. 

The  site  of  the  invagination  vai'ies.  ^Ve  may  recognize  (1)  an  ilriHWi'l. 
■wlien  the  ileo-civcal  valve  descends  into  the  ccdon.  There  are  cases  in 
■whid)  this  is  so  extensive  that  the  valve  lias  been  felt  jier  rectum.  Tliis 
form  occurred  in  sevi'iity-five  per  cent  of  the  cases.  In  the  ileo-rolir  the 
lower  part  of  the  il-'um  passes  through  the  ileo-ca'cal  valve.  ('')  The  ilail. 
in  which  the  ileum  is  alone  involved.  (;J)  The  colir,  in  which  it  is  ('(in- 
fined  to  the  large  intestine.  And  (4)  colico-recfal,  in  which  the  colon  ami 
rectum  are  involved. 

Irregular  ])eristalsis  is  the  essential  ''^usc  of  intussusception.  X(iili- 
nugel  found  in  the  localized  jieristalsis  caused  by  the  faradic  current  tliai 
it  was  not  the  descent  of  one  portion  into  the  other,  but  the  (irawiii;,M,p 
of  the  receiving  layer  )»y  contraction  of  the  longitudinal  (;oat.  Invagina- 
tion may  follow  any  limited,  sudden,  and  severe  peristalsis. 

In  the  ]K)st-mortem  examination,  in  a  case  of  di'ath  from  iiitussii.wp- 
tion,  the  condition  is  very  charucteristic.  Peritonitis  may  be  )iivsiiit  ev 
an  acute  injection  of  the  serous  membrane.  When  death  occurs  early.  ;i^ 
it  may  do  from  shock,  there  is  little  to  bo  seen.  The  portion  of  howvl 
afTected  is  large  and  tlii'-k,  and  forms  an  elongated  tumor  with  a  ciirvoil 
outline.  The  parts  are  swollen  and  congested,  ('wing  to  the  constrictMH 
of  the  mesentery  iHtween  the  layers.  Tln^  entire  mass  may  lie  "f  ii  '''''T 
livid-red  color.  If  very  recent  there  is  only  congestion,  and  iHiliais  a 
•light  layer  of  lymph,  anri  the  intussusception  can  bo  reduced,  hnl  wlir!i  it 


INTESTINAL  OBSTRUCTION. 


445 


trraHHS 


has  lasted  for  a  few  (lays,  ]yiiii))»  is  thrown  out,  the  layers  arc  glued  to- 
irctluT.  and  the  euterin,'^  portion  of  the  gut  cannot  bo  withdrawn. 

The  anatomical  condition  aiicounts  for  the  presence  of  the  tumor,  wliicli 
( :;i  ts  ill  two  thirds  of  all  cases;  and  the  engorgement,  which  results  from 
tho  conipression  of  the  mesenteric!  vessels,  explains  the  fre((uent  occurrence 
,,f  1)1(I(m1  in  the  discharge's,  which  has  so  imjiortaiit  a  diagnostic  value.  If 
the  iiaii;'iii  survives,  necrosis  and  sloughing  of  the  invaginatcd  jiortion 
iiiuv  fiiiiir,  and  if  unicm  lias  taken  place  hetween  the  middle  and  outer 
!,:vir,  the  cali)/re  of  the  gut  may  he  restored  and  a  cure  in  this  way  ef- 
fiiti'd.  Many  cases  of  the  kind  are  on  record.  In  the  Museum  of  the 
Medical  Faculty  of  McOill  University  are  \7  incdics  of  small  intestine, 
whieh  were  passed  by  a  lad  who  had  had  symptoms  of  internal  strangiila- 
tiiiii,  and  who  made  a  complete  re(!overy. 

(')  Twists  and  Knots. — Volvulus  or  twist  ooonrred  in  43  of  the  295 
eiises.  Sixtv-cight  per  cent  were  in  males.  It  is  most  frequent  lietwcen 
the  aires  of  tliirty  and  forty.  In  the  great  majority  of  all  cases  tiie  twist 
is  axial  and  associated  with  an  unusually  long  mesentery.  In  fifty  per 
(viil  (if  the  cases  it  was  in  the  sigmoid  ilexure.  'I'he  next  most  common 
>ititati(Hi  is  about  the  ca'cum,  whi(di  may  be  twisted  upon  its  axis  or  bent 
niKm  itself.  As  a  rule,  in  volvulus  tlm  loop  of  liowcd  is  simply  twisted 
ii|ioii  its  long  axis,  and  the  jiortions  at  tlu^  end  of  the  loop  cross  cjicli  other 
;i!i(l  so  cause  the  strangulation.  It  occasionally  hap[)ens  that  one  portion 
i.f  tlu!  bowel  is  twisicd  about  another. 

('/)  Strictures  and  Tumors. — These  are  very  much  less  important 
liiiises  of  acute  obstruction,  as  may  b(>  judged  liy  the  fact  that  there  arc 
.iiily  1.")  instaiu'cs  out  of  tlu'  21)5  cases,  in  14  of  which  the  obstruction  oo- 
I'urred  ill  the  large  intestine.  On  the  other  haml,  they  are  common  causes 
<if  elironie  <ihstruction. 

The  obstruction  may  result  from:  (1)  CoiDiciiihtl  siricturc.  'Phese 
arc  exceed inglv  rare.  Much  more  commonly  the  conilition  is  that  of  com- 
]i|i  le  (icchision,  either  forming  the  imperforate  iiniis  or  (he  congenital 
ilcfcct  i>y  which  the  duodenuni  is  not  united  to  the  pylorus.  (•*)  Simple 
I'initrifinl  s/nidsis,  which  results  from  ulceration,  tnI)erciilous  or  syphi- 
litic, more  raindy  from  dysentery,  and  most  rarely  of  all  from  typhoid 
ulceration.  (.'{)  Xcir  f/ron'ffin.  'I'he  malignant  strictures  are  due  chiefly 
tn  cylindrical  epithelionui,  whitdi  forms  an  annular  tumor,  most  eom- 
iiiciily  met  with  in  the  large  l)(»W(d,  about  the  sigmoid  flexure,  or  tho 
licsccnding  colon.  Of  benign  growths,  papillomata,  adenomata,  lipomata, 
ami  tiltrnmata  occasionally  induce  obstruction.  (4)  ( 'iDii/irfssian  and  tiutr- 
'"'«.  'I'limors  <d'  jieigh])oring  organs,  particularly  of  the  pelvic  viscera, 
may  cause  obstruction  by  adhesion  and  traction;  more  randy,  a  coil,  siu'h 
■I''  the  sigmoid  flexure,  lllled  with  fa-ccs,  compresses  an<l  obstructs  a 
iici(;lil)oriiig  coil.  In  the  healing  <»f  tuberculous  peritonitis  the  contrac- 
tion of  the  thick  oiidate  nuiy  cause  compression  and  narrowing  of  tho 

cnilg. 


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446 


IHSKASES  OP  TflFJ  DIOKSTIVE  SYSTEM. 


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(c)  Abnormal  Contents.— Foivi^j^ii  hotlU^s,  kucIi  uh  fruit  Hton.  s,  ooins. 
pins,  lu'cdlcs,  or  falso  teolli,  uiv  occasioimlly  swiillowt'd  ucciUontallv,  or  by 
luimtics  DM  |(iir|iiis('.  IJoiiml  worms  limy  Imh^oiiio  rolled  into  a  tiin;.'lt,i 
mass  ami  cause  ultstructioii.  In  reality,  lu)\vever,  tlio  nuijority  of  furcii-n 
bodies,  such  as  coins,  buttons,  and  pins,  swulbnved  Ity  children,  cause  n,, 
inconvenience  whatever,  hut  in  u  day  or  two  arc  found  in  the  stools.  (»,.,a- 
sionall}  siiili  a  foreij^n  hody  as  a  pin  will  pass  throu;,di  the  (esoplia^'iis  imd 
will  he  louud  lod^fed  in  some  adjacent  or^'an,  as  in  the  heart  (I'cuIhkUj, 
or  u  harley  car  may  reach  the  liver  (Dock). 

Medicines,  such  as  ma.irncsia  or  l)ismuth,  have  heen  known  to  acciunu- 
liite  in  the  howeis  and  produce  ohstructioii,  but  in  the  great  niajuritv  of 
the  cases  the  condition  is  caused  by  fa'ees,  gall-stones,  or  enti'roiillis.  (if 
44  cases,  in  :;♦.'{  the  obstruction  was  by  gall-stones,  in  lit  by  fa'ces,  ami  in  •,' 
by  enteroliths.  Obstruction  by  Heces  nuiy  happen  at  any  period  oF  jil',, 
As  nu'utioned  when  speaking  of  dilatation  of  the  colon,  it  nwiy  imciu'  in 
young  children  and  jiersist  Tor  weeks.  In  fiucul  accumulation  the  l;ir;j. 
bowel  may  reach  an  enormous  size  and  the  contents  become  very  lianl. 
'i"he  retained  nuisscs  may  be  channeled,  and  snudi  (puintitics  of  fa'cal  iiKit- 
ter  are  passed  until  a  mass  too  larg(^  enters  the  lumen  and  causes  oli;;t ruc- 
tion. There  may  be  very  few  symptoms,  as  the  condition  may  Ik^  Ihuii 
for  weeks  or  even  for  nu)nths. 

Obstruction  by  gall-stom-s  is  not  very  infrei|uent,  as  nuiy  be  frallu'inl 
from  the  fact  that  twenty-three  cases  were  reported  in  the  literatuiv  in 
eight  years.  Kighteeii  of  these  were  in  wonu'ii  and  live  in  nu'U.  la  .-ix 
sevenths  of  the  cases  it  occurred  after  the  liftieth  year.  The  obslriK  tinn 
is  usually  in  the  ileo-ca-cal  region,  but  it  may  be  in  the  duoilemiin.  Tlit«t 
large  solitary  gall-stones  ulcerate  through  the  gall-bladiler,  usually  iiil" 
the  small  intestine,  occasionally  into  ihc-colon.  In  Ihc  latter  case  tlicv 
rarely  cause  obstruction.  C'ourvoisicr  bus  collected  one  hundred  ami  thirt}- 
oiR'  cases  in  the  literature. 

Enteroliths  nuiy  be  fornu'd  of  nuissi>s  of  hair,  nu)re  commonly  i>f  ilic 
phosphates  of  linu'  and  magnesia,  with  a  nu<'leus  formed  of  a  loreiirn  ixily 
or  of  hardened  fa'ces.  ^s'early  every  museum  po-^sesses  siu'cimeus  of  tl.is 
kiiul.  They  arc  not  so  common  in  nu'ti  as  in  ruminants,  and,  as  iiidicali'! 
in  l"'itz's  statistit  s,  are  very  rare  causes  of  obstruction. 

Symptoms.— ('0  Acute  Obstruction.— Constipation,  pain  in  iIii'iiImIu- 
nu'ii,  and  vomiting  aiv  the  three  important  symptoms.  Pain  sets  in  liiHv 
and  nuiy  conu'  on  abru])tly  while  the  patient  is  walking  or,  wnv  cniii- 
monly,  during  the  performance  of  .so:n(!  action.  It  is  at  lirst  colicky  m 
character,  but  sul)set|uently  it  becomes  continuous  and  very  inteii.-f.  \oiii- 
iting  follows  ((uickly  and  is  a  constant  and  most  distressii'.g  syni|iliiMi.  Ai 
first  the  contents  of  the  stomach  are  voided,  and  tlu'u  greciii-li,  liilr- 
stained  material,  and  soon,  in  cases  of  acute  ami  permanent  olK-truclinii- 
the  material  vomited  is  a  brownish-black  lifp'.id,  with  a  distinctly  lii'cal 
odor.     This  seipience  of  gastric,  bilious,  and.,  liiuilly,  stercoraceniis  voiiiit- 


m,- 


INTKSTINAL  OHSTRUCTION. 


447 


ini»  is  pcrliaps  tho  most  itnportutit  (liiif^nostic  fciiturc  of  iwuic  oltst ruction. 
TliiM'oiistipiitioii  may  !»•'  alisoliitc,  without  the  (lisciiar<ri'  a!  t  itlicr  I'a'ces 
,,!•  (rji.s.  N'cry  often  tlio  contents  of  the  l)o\vcl  hi'h)\v  the  stricture  are  dia- 
oliiip;cti.  Distention  of  the  ahdomen  usually  occurs,  and  when  the  hirj^e 
i)o\vt'l  is  involved  it  is  extretne.  On  the  otiier  liand,  if  the  oi)structioii  is 
lii^rh  M|i  in  the  small  iulc-^iine,  there  may  he  very  sli^lit  tympany.  At 
iiist  the  abdomen  ia  not  ])ainful,  but  subseiiuently  it  nmy  become  acutely 
tfinli'r. 

The  constitutional  symptoms  from  flie  outset  are  severe.  The  fai-e  i.s 
piillid  ;ind  anxious,  and  linally  collapse  .><ymptoins  superveiu'.     'I'he  eyes 

In jiir  .  iinken,  the  features  pinched,  and  the  skin  is  covered  with  a  cold, 

chiiiiniv  sweat.  The  pul.se  becomes  rapid  and  feelile.  'I'here  nmy  l)e  no 
fivrr;  I  lie  axillary  temperature  is  often  subnornnd.  The  toui,nie  is  dry 
ainl  |i;in'lK'd  and  the  thirst  is  incessant.  'I'he  urine  is  hij^h-colored,  scanty, 
anil  tin  re  may  be  suppression,  particularly  whi-n  the  obstruction  is  hif^ii 
ii|)  in  the  bowel.  T'his  is  probal)ly  due  to  the  constant  vomitin;.^  and  the 
viiKill  iimountof  lifpiid  which  is  ab.sorbed.  'I'Jic  ca.-.'  terminates  as  a  rule 
111  timn  tliree  to  six  days.  In  8omo  instances  the  [tatient  dies  fnnn  shock 
or  sinks  into  coma. 

(/')  Symptoms  of  Chronic  Obstruction.— When  due  to  l;ecal  im))acti<m, 
tliri'c  is  a  history  of  lonaj-standinj^  constipatinu.  There  nuiy  have  bi'cn 
ilisrliiULre  of  mucus,  or  in  some  instances  the  fa'cal  nui,s.ses  liave  been  chan- 
iidi'il,  and  i.o  have  allowed  the  contents  of  the  upp(M'  portion  of  the 
liowel  to  pa.ss  throu^di.  In  elderly  persons  this  is  not  infre(|uent  ;  but 
examination,  either  prr  rvrfid/i  or  extcrmilly,  in  the  course  of  the  colon, 
will  reveal  the  presence  (tf  hard  scybalous  nnisses.  There  may  be  retention 
(if  fa'ces  for  wci^ks  without  excitintjf  serious  symptoms.  In  other  instances 
there  are  vomit inj;,  pain  in  the  alulomeii,  <rradinil  distention,  and  linally 
the  ejccta  become  fa'cal.  The  hardened  nnisses  nmy  ex<'ite  an  intense 
<'Mliti>  (ir  even  perit(tniti.s. 

In  stricture,  whether  cicatricial  or  cancerous,  the  symptoms  of  obstruc- 
tiuii  are  very  diverse.  Constipation  fjradually  comes  on,  is  extremely  varia- 
nt', and  it  may  be  nninths  or  even  years  before  there*  is  complete  obstruc- 
tion. There  are  transient  attacks,  in  which  from  some  cau.se  the  fa'ces 
arcuinulati*  above  the  stricture,  the  intestiiu'  beconu'S  jrreatly  distended, 
ami  in  the  swollen  abdomen  tlu>  coils  can  be  seen  in  active  peristalsis.  In 
Miili  attacks  there  nmy  be  votnitiui:,  but  it  is  very  rarely  of  a  fivcal  clmr- 
iicter.  Ill  the  majority  of  these  cases  the  ireiieral  health  is  seriously  im- 
piiiivil;  tint  patii'iit  jfradually  beconu>s  ana-mic  and  emaciated,  and  finally, 
111  Mil  attack  in  which  the  obstruction  is  complete,  (U-ath  occurs  with  all 
tlif  tealiires  of  acute  occlu.sion  or  the  case  may  be  prolonjred  for  ten  or 
twciv  days. 

Diagnosis.— (f/)  The  Situation  of  the  Obstruction.— Hernia  nnist 
lie  oxrliidcd,  wijich  is  by  no  means  always  easy,  as  fatal  obstruction  may 
'"'■ur  from  the  involvement  of  a  very  limited  portion  of  the  gut  in  the 


Lv0''l 


rl    J 


J-'A 


k 


448 


DISKASKS  <H<'  TIIK   lUdKSTIVK  SVSTKM. 


cxtcnml  riiii,'  or  in  tlic  nlttiinitor  fonimfu.  Mistakes  from  liotli  df  tiios,. 
ciiiiscs  liiivu  como  iiiidcr  my  obscrvalioii ;  llicy  Wiwv.  ciiscs  in  wliii  h  it  wib 
im|)ossil)lc>  to  make  ii  diu^nosis  utlicr  tiniii  ticiitu  ohstniotioii.  Tiniciv 
opiTiilioM  would  liiivo  siivcd  both  livcH.  A  tlioroii^'ii  rectal  and  Vii^'iiu,! 
cxan'iitialinn  siioiild  l)c  made,  wliicli  will  <;iv(^  imporlant  inrormatidn  as  to 
tlu*  condition  of  tlu-  pt'lvic  and  rectal  conteiilfi,  partieidai'iy  in  cn^.s  cf 
iMt,nksns(!{'|ilion,  in  wliicii  tlic  desccntjinj;  i)owel  can  Hometirnes  lie  f(li.  In 
(Uirit's  of  ol)strut;tion  lii;,di  up  tlie  empty  coils  v\\\k  into  tlie  pelvis  ninl  ciui 
there  hi!  detected.  Uectul  exploration  with  the  entire  hand  is  of  (lniiliiful 
value.  In  the  inspection  of  the  alxloinen  there  are  important  indie;. tinn,, 
as  the  special  prominence  in  certain  re^jions,  the  occni'reiu'e  of  deliniie. 
well-dellned  masses,  and  the  presence  of  hypertrophied  coils  in  acti\u 
peristalsis.  John  Wyllle  has  recently  called  utteiition  to  the  ^wcai  vhIih' 
in  diaj^nosis  of  the  "patterns  of  alxlomiiial  tnmidiiy."  *  In  ohslnicijdii 
of  the  lower  end  of  the  lai'<;e  intestine  not  only  may  the  horseshdc  of  ihc 
colon  stand  ont  plainly,  when  the  bowel  is  in  ri<iid  s|iasm,  iiiit  even  tin- 
pouches  of  the  <jtit  may  be  seen.  When  the  cu'cnm  or  lower  end  nf  tin- 
ileum  is  ohstrueted  the  tumidity  is  in  the  lower  central  rejjion,  and  diiriiiL' 
spasm  the  coils  of  the  small  l)owel  may  stand  out  pronnnentiv,  one  hImivc 
the  other,  either  ol)li(pU'ly  or  transver.sely  placed — the  .so-called  "  laililcr 
pattern."'  In  ol)strnction  in  the  diuxlenum  or  jejunum  there  iiiiiv  (nih 
be  slight  distention  of  the  upper  j)arl  of  the  abdomen,  associated  iisiiiillv 
with  rapid  collapse  and  anuria. 

In  the  ileum  and  ca'cum  the  distention  is  moi'e  in  the  central  jiorlinii 
of  the  abdomen;  the  vomitiuf^  is  distinctly  faecal  and  occurs  earlv.  In 
obstruction  of  the  colon,  tympanites  is  mucii  more  extensive  and  irciK  liil. 
Tenesmus  is  more  common,  with  the  pa.s.saij;e  of  mucus  and  liNiud.  The 
course  is  not  .so  tpiick,  the  collapse  <loes  lutt  supervem-  .so  rapidly,  mid  tin' 
urinary  .secretion  is  not  .so  much  reduced. 

In  obstruction  from  stricture  or  tumor  the  situation  can  in  sonic  i"A>v> 
be  accurately  localized,  but  in  others  it  is  very  diiVicult.  Piyital  e.\;iiiiiii;i- 
tion  of  the  rectum  should  lirst  be  made.  The  reidal  tube  may  tlicii  Ik' 
passed,  but  it  is  impo.ssible  to  <j;et  beyond  the  si<^moid  tlexurc.  In  the  ii^c 
of  the  rii^id  tube  there  is  dant,'er  of  perforation  of  the  i)owel  in  the  iici^'ii- 
borhood  of  a  stricture.  The  quantity  of  tliiiil  which  can  be  ]>asMMl  intn 
the  large  intestine  should  be  estimated.  The  capacity  of  the  largi  \n>\\A 
is  about  six  (piarts.  The  safe  limits  of  pressure  have  been  deteriiiiiinl  in 
be  under  ten  feet  in  an  infant-  aiid  tvvi'nty  feet  in  an  adult.  To  thiumij:]!- 
ly  irrigate  the  bowel  the  patient  should  be  chlorofornu'd  and  should  lit' mi 
the  back  or  on  the  side — best  on  the  back,  with  the  hips  elevated.  Ticws 
suggests  that  the  ca'cal  region  should  beau.«cultated  during  tlie  jias-iiirc  "f 
the  lluid.  l''or  diagiu)stic  purposes  Mie  ri-ctum  may  be  inllated,  eillni'lty 
the  bellows  or  by  the  u.se  of  bicarbonate  of  .soda  and  tartaric  acid.    In  w\- 


*  Kdinburgh  Hospital  lioports,  vol.  ii. 


INTKSTINAIi   OliSTIU*  TI(>>J. 


441) 


tain  cases  tlicsc  rnoiiHurcs  ^'ivc  irnportant  iiidicutioiis  as  to  tho  Hitimtiori  of 
iho  {ili<trii<'ti()M  ill  ttic  liirirt'  Ixiwd. 

(//)  Nature  of  the  Obstruction. — 'I'liis  is  (iftcn  (liHicnlt,  imt  iiifrcnui'iit- 
I\  i!ii|"i>-i'il'',  ti)  lifttriiiiM',  ^>i-,nniiiliiliiin  is  not  I'dniiiioii  in  vcrv  early 
life.  111  iiiiiiiy  instances  tlicri'  have  liccn  prrvimis  all;ii'k.>'  nf  iiliilnuiinal 
iniiii,  III'  there  are  ('ti(>l<i<ji('al  factors  which  ;.nvc  a  clew,  such  as  (dd  pcri- 
toiiiti-  or  operation  on  the  pelvic  viscera.  Neither  tlie  onset  nor  the  char- 
acter "f  tlie  pain  ;iives  us  any  information.  In  rare  instances  nausea  and 
vdiiiitiiiu:  may  he  absent.  The  vomiting'  usually  becomes  fiecal  froni  tbo 
lliinl  to  the  fifth  day.  .V  tumor  is  not  common  in  stranj^nlalion,  and 
was  i)resent  in  only  one   liftli  of  the  cases.     Fever  is  not  of  dia^Mio^tic 

value. 

Inl\i!tsii!<ci'p(ii))i  is  an  alTectioii  of  childhood,  aiul  is  of  all  forms  of  in- 
tiTiiiil  ohstruction  the  one  most  readily  dia;,niose(l.  'I'he  presence  of  tumor, 
Mdody  stools,  an<l  tenesmus  are  the  imitortant  fa<"tors.  'I'he  tuiiutr  is 
ii>ii;illv  saiisa;fe-shapi'd  and  felt  in  the  re;;ion  of  the  transver.s(!  cohm.  It 
rxi-tril  ill  liii  of  d;]  eases.  It  was  pri'.si'iil  on  the  tirst  day  in  more  than  one 
tjiinl  of  the  ea.ses,  on  the  wcond  day  in  more  than  one  fourth,  and  on  the 
third  (l;iv  in  more  than  one  lifth.  Hlood  in  the  stools  occurs  in  at  least 
tlnvi' lllths  of  the  eases,  either  sp(tntaneously  or  fidlowiii;,'  the  use  of  an 
iiiciiia.  The  blood  may  be  nu.xed  with  mucus,  'i'encsmus  is  pi'csent  in 
Miic  third  of  the  ea.ses.  I-'a'cal  voinitiu",'  is  not  very  common  and  was  pres- 
ent ill  (inly  VI  of  ihe  !».'5  instances.  Abdondnul  tympany  is  a  symptom  of 
dii:lit  iiiiportaiiee,  oceiirrinj^  in  only  one  third  of  the  eases. 

Viilnilux  can  randy  be  diaj,Miosed.  The  fre(pH'ncy  with  wlii(di  it  in- 
viilvcs  liie  si^rnioid  tlexure  is  to  be  borne  in  mind.  The  passajrc  of  a  lU'.x- 
ililc  tiitie  or  iiijectinj(  iluids  mi;,dit  in  these  cases  <;ive  valuable  indications. 
.\ii  iiliMdiite  diagnosis  eiin  j>robal)ly  lie  made  only  by  an  alidominal  section. 

In  ftvcttl  (j/js/ruf/ion  the  condition  is  usually  (dear,  as  the  fares  can  bo 
iVIt  per  rectum  and  al.so  in  the  distended  colon.  Fa'cal  vomitinj.;,  tym- 
|>aiiy,  iilidoiniiial  pain,  nausea,  and  vomitinjif  are  lati'  ami  are  not  so  eon- 
■^taiit.  ill  (distriKdion  I)y  {^all-stone  a  few  cd"  the  cases  jjave  a  previous  his- 
tnry  (if  L^dl-stone  colic.  .laundic*!  was  present  in  only  two  of  the  twenty- 
tliivc  cases.  Pain  and  vomit injf,  as  a  rule,  occur  early  and  are  severe,  and 
t'iical  voiiiitin;,'  is  present  in  two  thirds  of  the  cases.  .\  tumor  is  rarcdy 
"vidciit. 

('■)  Diagnosis  from  other  Conditions.— .\cut(>  enteritis  with  {rreat  re- 
liixatidii  (if  the  intestinal  (toils,  vomitinfr,  and  pain  may  lie  mistakeJi  for 
'itistnictiiiii.  In  an  autop.sy  on  a  case  of  this  kind  the  small  and  larjre 
lidwcls  were  intensely  inllamed,  relaxed,  sodden,  and  enormously  distended. 
'lie  syiiiptonis  wore  Lhos',-  of  acute  obstruction,  l)ut  the  intestine  wa.*^  free 
tidin  dinidcimm  tc  rectuia.  Of  late  years  many  instances  luive  been  re- 
lilted  in  whi(di  peiiioniLis  followintj  disease  of  the  aj)pendix  lias  been 
inistakt  II  for  acute  oh.druetion.  The  intense  vomitint,',  the  ^fcneral  tym- 
pany and  abdominal  tenderness,  and  in  some  instances  tlie  suddenness  of 


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450 


DISEASES  OF  THE   DIGESTIVE  SYSTEM. 


the  oJist't  aro  very  deceptive,  and  in  two  cases  which  have  come  \v.v]<-t  nw 
notice  tlie  symptoms  pointed  very  strongly  to  internal  strangula  idii.  {^ 
appendix  disease  the  temperature  is  more  frequently  elevated,  \]w  vomit- 
ing  is  never  fivcal,  and  in  many  cases  there  is  a  history  of  previous  iittucks 
in  the  ctecal  region.  Acute  ha'morrhagic  pancreatitis  may  proihicc  svinii. 
toms  which  simulate  closely  intestinal  obstrucition.  A  boy  was  adiiiitttd 
to  the  Johns  Hopkins  Hospital  with  a  history  of  obstinate  vomitinfr,  in- 
tense abdominal  pain,  gradually  increasing  tympany,  an<l  no  piissai:(  f,,r 
several  days.  His  condition  seemed  serions  and  he  was  transferred  at  (i.ice 
to  the  surgical  wards.  At  the  operatioti  the  coils  were  found  unifornilv 
distended  and  covered  in  places  ■with  the  thinnest  film  of  lymph.  'So 
obstruction  existed,  but  there  Avas  a  tumor-like  mass  surrounding  the  pan- 
creas, firm,  hard,  and  deeply  infiltrated  Avith  blood.  The  patient  improvwl 
after  the  ojjoration  and  recovered  comjiletcly. 

Treatment. — Purgatives  should  iu)t  be  given.  For  the  ])aiii  liy|io- 
dermics  of  morphia  are  indicated.  To  allay  the  distressing  voiuitiiig.  tin' 
stomach  should  be  washed  out.  Not  only  is  this  directly  Ijeiieiicial,  but 
Kiissnuiul  claims  that  the  abdominal  distention  is  relieved,  the  ])re.-su!'c  in 
the  bowel  above  the  seat  of  obstruction  is  lessened,  and  the  violent  leii- 
stalsis  is  diminished.  It  may  be  practised  three  or  four  times  a  day,  iiiid 
in  some  instances  has  proved  beneficial ;  in  others  curative.  'I'liordiifrh 
irrigation  of  the  large  bowel  Avith  injections  should  l)e  i)ractised,  the  tliiid 
being  alloAved  to  fioAV  in  from  a  siphon  syringe,  and  the  amount  caret'iilly 
estimated.  Jonathan  Hutchinson  recommeiuls  that  the  patient  he  iilaetd 
under  an  anit'sthetic,  the  abdomen  thoroughly  kneaded,  and  a  eo[miii!> 
enema  given  Avhile  in  the  inverted  position.  Then,  Avith  the  aid  el'  tlireu 
or  four  strong  men,  the  [)atient  is  to  be  thoroughly  shaken,  lii>t  with  tliu 
abdomen  held  downward,  and  subse({uently  in  the  inverted  position. 

Infiation  nuiy  also  be  tried,  by  forcing  the  air  into  the  rectum  with  tlio 
bellows  or  Avith  a  Davidson's  syringe.  It  is  a  measure  not  witlnnit  risk. 
as  instances  of  rujituj-e  of  the  bowel  have  been  reported.  FitzV  ligures 
show  that  in  the  first  eight  years  of  the  last  decade  there  Avere  tliii'ty-thne 
cases  of  recovery  after  injection  or  inflation  in  cases  of  cei'tain  or  probablf 
intussusception,  and  eleven  deaths.  In  cases  of  acute  obstruction,  if  tlitw 
means  do  not  prove  successful  by  the  third  day,  surgical  nu'asiires  slionlil 
be  resorted  to,  and  Avhen  the  obstruc^tion  seems  persistent  and  tlie  condi- 
tion serious,  laparotomy  should  be  p:M-formed  at  once. 

For  the  tympanites  turpentine  stu])es  and  hot  applications  may  lie 
applied ;  if  extreme,  the  bowel  may  be  jiunctured  with  a  snudl  aspirator 
needle.  In  cases  of  elironic  obstruction  the  diet  must  })e  ctirefully  r('<.'ii- 
lated,  and  o])iuin  and  belladonna  are  useful  for  the  paroxysmal  piiins. 
Enemata  should  l)e  employed,  and  if  the  obstruction  becomes  eumplett', 
resort  must  be  had  to  surgical  measures. 


'A, 


CONSTIPATION. 


451 


IV.    CONSTIPATION    (Costiveness). 

Definition. — Kotentioii  of  fajcos  from  any  cause. 

Constipation  in  Adults. — Tlio  causes  arc  varied  and  may  be  classed  as 
gciKTal  and  local. 

(Icni'ral  Cau.^cs. — (a)  Co)'stitutional  peculiarities:  Tor])idity  of  the 
liiiwcls  is  often  a  family  com2)laint  and  is  found  more  often  in  dark  than 
ill  fair  prrsons.  {b)  Sedentary  habit.s,  particularly  in  persons  who  eat  too 
iiiiicli  and  neglect  the  calls  of  nature,  (c)  Certain  diseases,  such  as  anae- 
mia, iieiinisthenia  and  hysteria,  chronic  alfections  of  the  liver,  stomach, 
ami  intestines,  and  the  acute  fevers.  Tnder  this  heading  may  appropri- 
ately be  placed  that  most  injurious  of  all  habits,  druy-fakiiu/.  {(/)  Kitber 
a  coarse  diet,  which  loaves  too  much  residue,  or  a  diet  which  leaves  too 
little,  may  be  a  cause  of  costivoness. 

J,(iail  Catises. — Weakness  of  the  abdominal  muscles  in  obesity  or  from 
ovordi'^tention  in  repeated  pregmincies.  Atony  of  the  large  bowel  from 
chronic  disease  of  the  mucosa;  the  presence  of  tumors,  physiological  or 
pathological,  pressing  upon  the  bowel ;  enteritis ;  foreign  bodies,  large 
masses  of  scybala,  aiul  strictures  of  all  kinds.  An  important  local  cause 
is  atony  of  t!ic  colon,  particularly  of  the  muscles  of  the  sigmoid  ilexure  by 
wliieli  the  faeces  are  propelled  into  the  rectum.  By  far  the  most  obstimito 
form  is  that  associated  with  a  contracted  state  of  the  bowel,  which  is 
soiiietinies  spoken  of  as  spasmodic  constijnition.  This  may  be  met  with 
in  three  conditions  :  First,  as  a  sequence  of  chronic  dysentery  or  ulcerative 
colitis;  second,  in  protracted  cases  of  hysteria  and  neurasthenia  in  women, 
jiarticidarly  in  association  with  uterine  disease ;  and,  thirdly,  in  very  old 
piTsoiis  often  without  any  definite  cause.  It  may  be  that  tiio  signu)id 
tifxure  and  lower  colon  are  in  a  com^ition  of  contraction  and  spasm,  while 
the  transverse  and  ascending  parts  are  in  a  state  of  atony  and  dilidatiou. 
The  most  characteristic  sig)>  of  this  variety  is  the  presence  of  hard,  globu- 
lar masses,  or  more  rarely  small  and  sausage-like  ficces. 

Symptoms. — The  most  persistent  constipation  for  weeks  or  even 
months  may  exist  with  fair  health.  All  kinds  of  evils  have  been  attrib- 
uwd  to  poisoning  by  the  resorption  of  noxious  matters  from  the  retained 
fa'ces— (!oprwinia — but  it  is  not  likely  that  this  takes  place  to  any  extent. 
Chlorosis,  which  Sir  Andrew  Clark  attributes  to  fitcal  poisoning,  is  not 
always  associated  with  constipation,  and  if  due  to  this  cause  should  be  in 
iiiL'U,  women,  and  children  the  most  common  of  all  disorders.  Debility, 
lassitude,  and  mental  depressi?n  are  frequent  symptoms  in  constipation, 
liarlieularly  in  persons  of  a  nervous  temperament.  Headache,  loss  of  ap- 
[H'titf,  and  a  furred  tongue  may  also  occur.  Individuals  differ  extraor- 
dinarily iu  this  matter  :  one  feels  wretched  all  day  without  the  accustomed 
evacuation;  another  is  comfortable  all  the  week  except  on  the  day  on 
which  l)y  purge  or  enema  the  bowels  are  relieved. 

^^  hell  persistent,  the  accumulation  of  fa-ces  leads  to  unpleasant,  somo- 


ifl 


m^^^^ 


i.,,  Li  1     i! 


452 


DISEASES  OP  THE   DIGESTIVE  SYSTEM. 


times  serious  symptoms,  such  as  piles,  ulceration  of  the  colon,  (listcntjon 
of  the  sacculi,  perforation,  enteritis,  and  occlusioii.  In  women,  pressure 
may  cause  pain  at  tlie  time  of  menstruation  and  a  sensation  of  fiiliHss 
and  distention  in  the  pelvic  oroans.  Neuralgia  of  the  sacral  nerves  niiiv 
be  caus'.'d  by  an  overloaded  sigmoid  flexure.  The  fu'ces  collect  cliioHv  in 
the  colon.  Even  in  extreme  grades  of  constipation  it  is  rare  to  liiid  drv 
ftcces  in  the  caecu  ii.  The  fsBces  nuiy  form  large  tumors  at  the  hepatic  or 
splenic  flexures,  or  a  sausage-like,  doughy  nuiss  above  the  navel,  or  an 
irregular  lumpy  tumor  in  the  left  inguinal  region.  In  old  persons  the 
sacculi  of  the  colon  become  distended  and  the  scybala  may  reriiaiii  iu 
them  and  undergo  calcification,  forming  enteroliths. 

In  cases  with  prolonged  retention  the  fttcal  masses  become  cli.inncllecl 
and  diarrhovi  may  occur  for  days  before  the  true  condition  is  discovered 
by  rectal  or  external  examination.  In  women  who  have  been  iiabituallv 
constipated,  attacks  of  diarrhiea  with  nausea  and  vomiting  should  excite 
suspicion  and  lead  to  a  thorough  examination  of  the  large  bowel.  I'Vvcr 
may  occur  in  these  cases,  and  Meigs  has  reported  an  instance  iu  whiili 
the  condition  simulated  typhoid  fever. 

Constipation  in  infants  is  a  common  and  troublesome  disorder.  'I'lio 
causes  are  congenital,  dietetic,  and  local.  There  are  instances  in  wliieli 
the  child  is  constipated  from  birth  and  may  not  have  a  natural  movement 
for  years  and  yet  thrive  and  develop.  An  instance  of  the  kind  was  in  my 
ward  recently  in  which  a  baby  of  seven  months  had  never  had  a  movement 
witiiout  preliminary  injections.  The  abdomen  became  swollen  every  day, 
but  subsided  after  an  injection  and  tlie  passage  of  a  long  catheter.  \o 
stricture  could  he  felt.  There  are  cases  of  enormous  dilatation  of  the  large 
bowel  with  })ersi<tenc  constipation.  The  condition  appears  sometimes  tn 
be  a  cojigenital  ilefect.  In  some  of  these  p'atients  there  may  be  constrict- 
ing bands,  or,  as  in  a  case  of  Cheever's,  a  congenital  stricture. 

Dietetic  causes  are  more  common.  In  sucklings  it  often  arises  from 
an  unnatural  dryiu>ss  of  the  small  residue  which  passes  into  the  colon,  ami 
it  may  be  very  dithcult  to  decide  whetlier  the  fault  is  in  the  motlier's  m'lk 
or  in  the  digestion  of  the  child.  Most  probably  it  is  the  latter,  as  lonie 
babies  nniy  be  persistently  costive  on  natural  or  artificial  foods.  Dcti- 
ciency  of  fat  in  the  milk  is  believed  by  some  writers  to  be  the  cause.  In 
older  cliildren  it  is  of  the  greatest  importance  that  regular  habits  shouM 
be  enjoined.  Carelc-'sness  on  the  part  of  the  mother  in  this  matter  often 
lays  tlie  foundation  of  troublesome  constipation  in  after  life.  Iui[iairnieiit 
of  the  contractibility  of  the  intestinal  wall  in  con.sequence  of  inflammation, 
disturbance  iu  the  normal  intestinal  secretions,  and  mechanical  ohstn.o- 
tion  by  tumors,  twists,  and  intussusception  are  the  chief  local  causes. 

Treatment. — Much  may  be  done  by  systematic  habits,  particularly 
in  the  young.  'IMie  desire  to  go  to  stool  should  always  be  granted.  ExtT- 
cise  in  moderation  is  helj.ful.  In  stout  persons  and  in  women  with  peiul- 
ulous  abdomens   the   muscles   should    have   the  support  of   a  han(liij;e. 


CONSTIPATION. 


453 


Fi'ictiiiii  or  regularly  appliotl  niiissatro  is  iiivalimble  in  the  more  clironio 
eu.sert.  A  good  substitute  is  a  metal  ball  weighing  from  four  to  six  pounds, 
which  may  be  rolled  over  the  abdomen  every  morning  for  five  or  ten  min- 
i;tfs,  Tlie  diet  should  bo  light,  with  })lenty  of  fruit  and  vegetables,  par- 
ticiihu'lv  salads  and  tomatoes.  Oatmeal  is  usually  laxative,  though  not  to 
nil:  hniwn  bread  is  better  than  that  made  from  line  wiiite  Hour.  Of 
lii|iiiil.s  water  and  the  aerated  mineral  waters  nuiy  be  taken  freely.  A 
tumblerful  of  cold  water  on  rising,  taken  slowly,  is  cHicaeious  in  many 
easi'S.  A  glass  of  hot  water  at  night  may  also  bt;  tried  alone.  A  pipe  or 
ii  eiijar  at  er  bi'eakfast  is  with  many  men  an  infallible  remedy. 

When  the  condition  is  not  very  obstinate  it  is  well  to  try  to  relieve  it 
bv  hygienic  and  dietetic  measures.  If  drugs  must  be  used  they  should  be 
the  milder  saline  lay."*^ives  or  the  com])()und  liquorice  powder,  Knoinata 
arc  often  necessary,  and  it  is  much  preferable  to  emjdoy  them  early  than 
to  constantly  use  })urgative  pills.  Olycerine  either  in  the  form  of  sup- 
pository or  as  a  snudl  injection  is  very  valuable.  Half  a  drachm  of  boric 
acid  placed  within  the  rectum  is  sometimes  efficacious.  The  injections  of 
tepid  water,  with  or  without  soap,  may  be  used  for  a  prolonged  period 
with  good  elTect  and  without  damage.  The  patient  should  be  in  the 
dorsal  position  with  the  hips  elevated,  and  it  is  best  to  let  the  iluid  flow  in 
slowly  from  a  fountain  syringe. 

The  usual  remedies  employed  are  often  useless  in  the  constipation 
associated  with  contracted  bowel.  A  very  satisfactory  measure  is  the 
olive-oil  injection  as  recommended  by  Kussmaul.  ^riie  patient  lies  on  the 
liiuk  with  the  hips  elevated,  and  with  a  cannula  and  tube  from  fifteen  to 
twenty  ounces  of  pure  oil  are  allowed  to  flow  slowly  (or  are  injected)  into 
the  bowel.  The  operation  should  take  at  least  fifteen  minutes.  'I'iiis  may 
be  repented  every  day  until  the  intestine  is  cleared,  and  subsequently  a 
smaller  injection  every  few  days  will  suffice. 

There  are  various  drugs  which  are  of  special  service,  particularly  the 
conihination  of  ipecacuanha,  nux  vomica,  or  belladoniui,  with  aloes,  rhu- 
barb, colooynth,  or  podophyllin.  Meigs  recommends  particidarly  the 
comliination  of  extract  of  belladonna  (gr.  ^ij),  extract  of  nux  vomica  (gr. 
I),  and  extract  of  colooynth  (gr.  ij),  one  pill  to  be  taketi  three  times  a 
ilay.  In  ana'mia  and  chlorosis,  a  sulphur  confection  taken  in  the  morn- 
iii;:.  and  a  pill  of  iron,  rhubarb,  ami  aloes  throughout  the  day,  are  very 
serviceable. 

In  children  the  indications  should  be  met,  as  far  as  possible,  by  hygienic 
ami  dietetic  measures.  In  the  constipation  of  sucklings  a  change  in  the 
diet  of  tlie  mother  may  be  tried,  or  from  one  to  three  teasj)oonfuls  of 
fi'cam  may  be  given  before  each  nursing.  In  artificially  fed  children  the 
tiip  milk  with  the  cream  should  be  used.  Drinking  of  water,  barley 
Water,  or  oatmeal  water  will  sometimes  obviate  the  difficulty.  If  laxatives 
aie  required,  simple  syrup,  manna,  or  olive  oil  may  be  sufficient.  The 
conical  piece  of  soap,  so  often  seen  in  nurseries,  is  sometimes  efllicacious. 


■m 


I  f,)  " 


■  f 


!   .M^ 


454 


DISEASES  OF  THE   DIGESTIVE  SYSTEM. 


Massage  along  tlm  colon  may  bo  tried.  Small  injections  of  culii  water 
may  be  used.  Large  injections  should  be  avoided,  if  possible.  If  it  js 
necessary  to  give  a  laxative  by  the  mouth,  castor  oil  or  the  fluid  niajfnesia 
is  the  best.  Jf  there  aiv  signs  of  gastro-intestinal  irritation,  rhn barb  and 
soda  or  gray  powder  may  be  given.  In  older  children  the  diet  slidiild  be 
carefully  regulated. 


V.   MISCELLANEOUS  AFFECTIONS. 

Dilatation  of  the  Colon. — This  inay  be  general,  or  localizeil  to  the  sig- 
moid flexure. 

It  occurs  not  infrequently  as  a  transient  condition,  and  in  maiiv  case? 
it  has  an  important  influence,  iiuisinuch  as  the  distention  may  bo  ex- 
treme, pushing  up  the  diaphragm  and  seriously  impairing  the  acfimi  of 
the  heart  and  lungs.  II.  FenwicU  has  called  attention  to  tiiis  as  occasion- 
ally a  cause  of  sudden  heart-failure. 

Dilatation  of  the  sigmoid  flexure  occurs  ])articularly  when  this  portion 
of  the  bowel  is  congeiiitally  very  long.  In  such  cases  tlie  bowel  may  lie 
so  distended  that  it  occupies  the  greater  part  of  the  abdomen,  pushiiii'"  up 
the  liver  atid  the  dia{)hragm.  An  acute  condition  is  sometimes  caiiseil  hy 
a  twist  in  the  juesocolon. 

There  is  a  chronic  form  in  which  the  gut  reaches  an  enormous  .qze. 
The  coats  may  be  hypertropiiicHl  without  evidence  of  any  special  or^aiiio 
change  in  the  mucosa.  The  most  remarkable  instance  has  been  reporteil 
by  Formad.  The  patient,  known  as  the  "balloon-man,"  aged  twenty- 
three  at  the  time  of  his  deatli,  had  had  a  distended  abdomen  from  iiifanev. 
Post  mortem  the  colon  was  fou)id  as  large  as  that  of  an  ox,  the  circiun- 
ference  ranging  from  fifteen  to  thirty  inches.  The  weight  with  the  con- 
tents was  f  )rty-seven  pounds.  Cases  are  not  uncommon  in  children. 
I  have  had  three  well-marked  instances  under  my  care  (Archives  of 
Pediatrics,  ISIKJ). 

Affections  of  the  Mesentery. — There  are  various  diseases  of  the  stiiic- 
tures  embraced  in  the  mesentery  of  more  or  less  importance. 

(1)  HsBinorrhage  [htemafonui).— Instances  in  which  the  bleeding  is  con- 
fined to  the  mesenteric  tissues  are  rare;  more  commonly  the  condition  is 
associated  with  hannorrhagic  infiltration  of  the  pancreas  and  with  retro- 
peritoneal liitMuorrhage.  It  occurs  in  rupture  of  aneurisms,  either  of  the 
abdominal  aorta  or  of  the  superior  mesenteric  artery,  in  malignant  fornts 
of  the  infectious  fevers,  as  small-pox,  and,  lastly,  in  individuals  in  whom 
no  predisposing  conditions  exist.  In  1887,  at  the  Philadelphia  Ilos[iital. 
there  was  a  patient  in  the  ward  of  my  colleague,  Bruen,  who  had  ob- 
scure abdominal  symptoms  for  several  days  with  great  pain  and  ])rostra- 
tion.  I  found  at  the  post  mortem  the  greater  portion  of  the  mesentery 
and  the  retro-peritoneal  tissues  infiltrated  with  large  blood-clots.    There 


liM  i-i-i 


CONSTIPATION. 


455 


was  iii>  ilii^oase  of  tho  aorta  or  of  Uik  branclu's  of  tlio  cu'liac  axis  or  of  tlie 
tiicsi'iitcric  vossols.  Isatiibard  Owoii  has  reportod  a  case  of  siuldon  death 
in  ;i  woman  aged  sixty-seven  from  luvmorrhago  in  the  transverse  nieso- 

rulnll. 

(•.')  Affections  of  the  Mesenteric  Arteries.— (rr)  ANcxris))!  (see  im^c 

:is). 

(//)  KiithoJixm  (1)1(1  ThromhoxiK — hifdvrlion  of  fhc  Itoihcl. — Wlioti  the 
iii('stiih'ri(;  vessels  are  bh)eked  by  eiiil)oIi  or  tliroinbi  tlie  condition  of  in- 
farction follows  in  the  territory  snpjilicd.  I'robai)ly  the  occlnsion  of  small 
vessels  does  not  prodnee  any  symptoms,  and  the  cirenlation  nuiy  be  re- 
t'stiiblislied.  If  the  snperior  ineseiiteric  artery  is  blocked,  a  serions  and 
f:it;il  condition  follows.  'I'hree  instances  liavo  come  under  my  observation. 
Ill  one,  a  woman  aged  fifty-ilve  was  seized  with  nansea  and  vomiting, 
w!ii(li  persisted  for  more  than  a  week.  There  was  pain  in  the  abdomen, 
tviii|iiinites,  and  toward  the  close  the  vomiting  was  incessant  and  fa'cal. 
TIr'  autopsy  showed  great  congestion,  with  swelling  and  infiltration  of  the 
jcjiiiuiin  and  ileum.  The  snperior  mesenteric  artery  was  blocked  at  its 
orilice  i)y  a  firm  thrombus.  In  the  second  case,  a  woman  aged  seventy-five 
was  seized  with  severe  abdominal  pain  and  fre(pient  vomiting.  At  first 
"i-e  was  diarrlura ;  subsequently  the  symptoms  pointed  to  obstruction, 
w.  great  distention  of  the  abdomen.  The  post  mortem  sliowed  the 
sniaii  Itowel,  with  the  exception  of  the  first  foot  of  the  jejunum  and  the 
last  six  inch's  of  the  ileum,  greatly  distended  and  deeply  infiltrated  with 
blddd.  The  mesentery  was  also  congested  and  infiltrated.  The  snperior 
iiusentevic  artery  contained  a  firm  brownish-yellow  clot.  There  were 
iiiiiuy  recent  warty  vegetations  on  tlie  mitral  valve.  In  the  third  case, 
a  iiiun  aged  forty  was  suddenly  seized  with  intense  jiain  in  the  ab- 
(liiiiicn.  i)eeame  faint,  fell  to  the  ground,  and  vomited.  For  a  week  he 
liail  persistent  vomiting  severe  diarrluea,  tympanites,  and  great  pain  in 
the  abdoni'-'n.  The  stools  were  thin  and  at  times  blood-tinged,  'i'lie 
aiitDpsy  showed  an  aneurism  involving  the  aorta  at  the  diaphragm.  Tho 
superior  mesenteric  artery,  half  an  inch  from  its  origin  on  the  sac,  was 
bliicked  by  a  portion  of  the  fibrinous  clot  of  the  aneurism.  Watson  has 
analyzed  the  symptoms  in  27  cases  ;  in  18  there  was  pain,  usually  colicky 
mill  violent;  diarrluea  occurred  in  14-;  vomiting  in  1-1;  and  abdominal 
ilistoiition  in  1'^.  In  a  nuijority  of  the  cases  the  heart  or  the  abdominal 
aorta  was  diseased.  In  one  sixth  of  the  cases  the  lesion  was  limited 
eiioiigli  to  have  permitted  tlie  successful  resection  of  the  bowel.  J.  W. 
Kllint  has  operated  upon  two  cases  of  infarction  of  the  bowel,  in  one  of 
whieli  (thrombosis  of  the  mesenteric  veins)  ho  successfully  resected  forty- 
eight  inches.  In  the  liorse,  infarction  of  the  intestine  is  extremely  com- 
mon in  connection  with  the  verminous  aneuri  nis  of  the  mesenteric 
iU'teric-;.  uiid  is  the  usual  cause  of  colic  in  this  animal. 

(•))  Diseases  of  the  Mesenteric  Veins. — Dilatation  ami  sclerosis  occur 
111  eirrliosis  of  the  liver.     In  instances  of  prolonged  obstruction  there  may 


mi 


I  ! 


j     1  f  1  "I 


*'  *  si 


I)    '?  ij  til 


i>  All 


1-5 


111  r 


456 


DISEASES  OF  THE   DIGESTIVE  SYSTEM. 


1k'  liir<;o  sociiliir  diliitutions  witli  ciilfiliwition  of  tlie  intimii,  as  in  n  case  „f 
o))liti'niti()ri  of  the  vena  ])()rta'  (h'scril)c(l  l)y  nw.  Suppuration  of  il,,. 
im'scntcru!  vein.;  is  not  rair,  and  occurs  usually  in  connection  with  u\\.. 
I)lilel)itis.  Tlio  mesentery  may  be  nincli  swollen  and  is  like  u  ba<:  of  iHis 
utid  it  is  only  on  careful  dissection  that  oiui  sees  that  the  pus:  is  rt-allv 
within  channels  represent iii<,f  extremely  dilated  mesenteric  veins.  Twii 
of  the  threr>  cases  I  have  seen  were  in  connection  with  local  iiiiiicinjix 
iibs(M'ss. 

(4)  Disorders  of  the  Chyle  Vessels.— \'aricose,  cavernous,  and  cvstic 
diylangionuita  are  met  with  in  the  muco.sa  and  snbmncosa  of  the  small 
intestine,  occasioiudly  of  the  stomach.  K.xtravasation  of  chyle  into  iIk- 
mesenteric  tissues  is  sometimes  seen,  ("hylons  cysts  are  found.  I  saw 
one  the  size  of  an  ogg  at  tiie  root  of  the  mesentery.  Hramann  rcconlsa 
case  in  a  nuiii  aged  sixty-three  in  which  a  cyst  of  this  kind  the  six.cofa 
child's  head  was  healed  by  o])eration.  There  is  an  instance  on  rccdnl  (,f 
a  congenital  malformation  of  the  thoracic  duct  in  which  the  receptaciilnm 
formed  a  llattencd  cyst  whiidi  discharged  into  the  peritoiueuui,  luid  a 
cliylons  a.scitic  fluid  was  withdrawn  on  several  occasions. 

(5)  Cysts  of  the  Mesentery.— Much  attention  has  been  directed  of  late 
years  to  tlie  occurrence  of  mesenteric  cysts,  and  the  literature  wliidi  is 
fully  given  by  Delmez  (Paris,  Thesis,  1S91)  is  already  extensive.  Tluy 
may  be  either  dermoid,  hydatid,  serous,  sanguinou.s,  or  chylous.  Tlicv 
occur  at  any  portion  of  the  mesentery,  and  i-ange  from  a  few  iiicbcs  in 
diameter  to  lai'ge  masses  oceui)ying  the  entire  abdomen.  They  are  fre- 
quently adlierent  to  the  neighboring  organs,  to  the  liver,  spleen,  uterii;:, 
and  sigmoid  flexure. 

Tiie  symptoms  usually  are  those  of  a  progressively  enlargiiig  tuiimr 
in  the  abdomen.  Sometimes  a  mass  develops  rapidly,  particularly  in  the 
haemorrhagic  forms.  Colic  and  constipation  are  present  in  sonic  cases. 
Tiie  general  health,  as  a  rule,  is  well  maintained  in  spite  of  the  ])rogi'os- 
sive  enlargement  of  the  abdomen,  which  is  most  prominent  in  the  um- 
bilical region.  Mesenteric  cysts  may  persist  for  many  years,  even  ten  or 
twenty. 

The  diagnosis  is  extremely  uncertain,  and  no  siiigle  feature  is  in  am 
way  distinctive.  Augagneur  gives  three  important  signs  :  the  great  mo- 
bility, the  situation  in  the  middle  line,  and  the  zone  of  tympany  in  front 
of  the  tumor.  Of  these,  the  second  is  the  only  one  v.hich  is  at  all  con- 
stant, as  when  the  tumors  are  large  the  mobility  disappears,  and  at  this 
stage  the  intestines,  too,  are  pushed  to  one  side.  It  is  most  frequently  mis- 
taken for  ovarian  tumor.  Movable  kidney,  hydronephrosis,  and  cysts  rf 
the  omentum  have  also  been  mistaken.  In  certain  instances  puncture  may 
be  made  for  diagnostic  purposes,  but  it  is  better  to  advise  laparotomy  for 
the  purpose  of  drainage,  or,  if  possible,  enucleation  may  be  practiced. 


.-;.■;  4 


ii,^' 


JAUNDICK.  4:,7 


VIII.    DISEASES   OF   THE   LIVER. 
I.    JAUNDICE  (/r/<;»,v). 

1.  Jaundice  as  a  Symptom. — Cases  witli  ictorus  muy  l)o  divided  into 
two  L'lcat  groups  :  'I'Iioho  in  which  '•'lere  id  obstruction,  fitlicr  in  the  sniull- 
cr  (ir  in  the  hirger  ducts — the  Iir/Ki/nf/ciioiifi  form  ;  cases  in  whicli  tlie  jaun- 
dice is  line  to  suppression  of  the  function  of  tiie  liver-cells,  as  in  the  wide- 
spivad  necrosis  of  acute  yellow  atrophy,  and  those  in  Avhich  an  excess  of 
tlie  ehniiuatogenous  nuiterial,  as  in  nudaria,  pernicious  auiuniia,  and  cer- 
tiiiii  fevers,  in  which  the  liver  function  cannot  keep  pace  with  the  blood 
(k'strnction  (iuiMiujlysis) — //(fiiKi/df/riKiKs  or  non-obstructive  jaundice. 

The  following  classilication  of  the  causes  of  hepatogenous  jaundice  is 
urranired  by  Murchison,  to  whose  writings  on  the  liver  we  owe  so  much  : 
Obstruction  (1)  by  foreign  bodies  within  the  ducts,  as  gall-stones  and 
parasites;  (2)  by  inflammatory  tumefaction  of  the  duodenum  or  of  tlie 
lininj:  membrane  of  the  duct;  {'^)  by  stricture  or  obliteration  of  the  duct; 

(4)  bv  tumors  closing  the  orifice  of  the  duct  or  growing  in  its  interior; 

(5)  by  pressure  on  the  duct  from  without,  as  by  tumors  of  the  liver  itself, 
of  the  stouuicli,  pancreas,  kidney,  or  omentum ;  by  2)ressure  of  enlarged 
glands  in  the  fissure  of  the  liver,  and,  more  rarely,  of  abdominal  aneurism, 
fa'cal  accumulation,  or  the  pregnant  uterus;  (0)  to  these  may  be  added 
lowering  of  the  blood  pressure  in  the  liver,  so  that  the  tension  in  the 
smaller  bile-ducts  is  greater  than  in  the  blood-vessels.  In  this  class  very 
probably  may  be  placed  the  cases  resulting  from  mental  shock  or  depress- 
iiijT  emotions. 

(Iciivral  Siimptomx  of  Ohsfruiiicc  Jaundice. — (1)  Icterus,  or  tinting 
of  the  skin  and  conjunctiva'.  The  color  ranges  from  a  lemon-}'ellow  in 
catarrhal  jaundice  to  a  deep  olive-green  or  bronzed  hue  in  permanent 
ob.strnction.  In  some  instances  the  color  of  the  skin  is  greenish  black, 
the  so-ealled  "  black  jaundice." 

(v)  Of  other  cutaneous  symptoms,  pruritus  in  the  more  chronic  forms 
may  be  intense  and  cause  the  greatest  distress.  It  may  precede  the  onset 
of  the  jaundice,  but  as  a  rule  it  is  not  very  nuirked  except  in  cases  of  pro- 
loiiired  obstruction.  Sweating  is  common,  and  nuiy  be  curiously  localized 
to  the  abdomen  or  to  the  palms  of  the  hands.  Lichen,  urticaria,  and 
boils  nniy  develop,  and  the  skin  disease  known  as  xanthelasma  or  vitili- 
sroidea.  The  jaundice  may  be  due  to  the  extension  of  the  xanthomata  to 
the  l)ile  passages.  The  visceral  localization  of  this  disorder  has  been 
I'hiolly  ol)served  when  there  are  numerous  punctuate  tubercles  on  the 
limbs  (Ilallopeau). 

(•))  The  secretions  are  colored  with  bile-pigment.  The  sweat  tinges 
the  linen  ;  the  tears  and  saliva  and  milk  are  rarely  stained.  The  expecto- 
lation  is  not  often  tinted  unless  there  is  inflamination,  as  when  pneumonia 
30 


m 


;   :^ 


.^i^ 


\- 


'     W 


H  '-rf  I J 


m%'m\  Mu! 


458 


DISKASKS  OF  TIIK   DKJKSTIVK  SVSTK.M. 


-m 


1 

f 

I"      ■  .1 

1 

mill 

1 

^NWB 

coexists  with  jiiiiiKlico.  'I'lic  urine  tiiay  eoutain  tlie  piirmciit  Ik  f  uv  it  is 
iippiireiit  ill  the  skin  or  eoiijiiiii'livii.  Tlie  ('((lor  viii'ies  frorii  li;:hl  mi'cnixli 
yellow  to  11  (h-ep  bhu'iv-^frecii.  (iiiieliii's  test  is  iiiiide  by  aiiowiii'i  Hm.  ,.i' 
six  (lro])s  of  urine  and  a  siniihir  amount  of  eoinmoii  nitric;  acid  lo  ilow 
toilet iuT  slowly  on  the  Hat  surface  of  a  white  plate.  A  play  of  colurs  js 
))ro(luce(l — various  shades  of  green,  yellow,  violet,  and  red.  In  ci^cs  of 
jauiulice  of  lon<,'  standing  or  great  intensity  tliu  urine  usiudlv  ( miiiiiii. 
albumin  and  always  bile-stained  tube-easts. 

(4)  'So  bile  ])asses  into  the  intestine.  'I'he  sto(»ls  thercfnn'  an'  of  a 
pale  drab  or  slate-gray  color,  and  usually  very  fetid  and  pasiv.  Tlnic 
may  be  constipation;  in  many  instances,  owing  to  decompositiun.  tluivi; 
diarrho'a. 

(.J)  Slow  pidse.  The  lieart's  uf^tion  may  fall  to  4(t,  .'{(),  or  even  to  •.'ii 
per  minute.  It  is  particularly  noticeable  in  the  cases  of  catarrhal  jaun- 
dice, and  is  not  as  a  rule  an  unfavorable  .symptom. 

{())  Ila'inorrhage.  Purpura,  large  subcutaneous  extravasatidiis,  iiKin' 
rarely  ha'tnorrhages  from  the  mucous  membranes,  occur  in  piniractcil 
jaundice,  and  in  the  more  nudignant  forms. 

(T)  ('erebral  symj)toms.  Irritability,  great  depression  of  spirits,  or 
even  mehnndiolia  nuiy  be  present.  In  any  ease  of  persistent  jauiidiir 
special  nervous  iihenomena  may  develop  ami  rapidly  prove  fatal— siuli  as 
sudden  coma,  acute  delirium,  or  convulsions.  Usually  the  jiatient  liasa 
rapid  pulse,  slight  fever,  and  a  dry  tongue,  and  he  passes  into  the  sn-callid 
"  typhoid  state."  These  features  are  not  nearly  so  common  in  (ilistnuiiw 
as  in  febrile  jaundice,  but  they  not  infrequently  terminate  a  clironic  ictciiis 
in  whatever  way  produced.  The  group  of  symjitoms  has  Ijccii  tcnm 
r/iola')ni(t  or,  on  the  supposition  that  cholesterin  is  the  ])ois()U,  i-lii}ksli 
(vmiii  ;  but  the  true  nature  of  the  poison-has  not  yet  been  determined.  In 
some  of  the  cases  the  symptoms  may  be  due  to  urivmia. 

Kon-ohstrnclirc  jtnonlice  may  be  thus  classified  : 

(1)  The  form  in  which  there  is  wide-spread  necrosis  of  the  livcr-fclls 
and  direct  interference  with  their  bile-forming  function,  as  in  aciitf  vclldw 
atrophy,  and  possibly  in  certain  cases  of  hypertrophic  cirrhosis.  Strictly 
speaking,  this  is  a  hepatogenous  jaundice. 

(3)  The  toxic  form.  The  poisons  of  yellow  fever,  malarin,  typjioiil, 
epidemic  jauiulice,  and  pyaemia;  snake  virus,  as  well  as  chlornforiiuetliff. 
phosphorus,  and  mercury,  act  by  causing  increased  destruction  of  the  nil 
blood-corpuscles.  More  blood-])igment  is  set  free  than  can  l)e  dispitscd  of 
by  liver,  spleen,  or  kidiieys,  ami  the  bilirubin  (transformed  hu'iudirlobin) 
is  deposited  in  the  tissues.  The  sj/mpfojni't  of  liaMuatogenous  jiiuiuiici' aiv 
not  nearly  so  striking  as  in  the  obstructive  variety.  The  skin  lias  in  iiiiiiiy 
cases  only  a  light  lemon  tint.  In  the  severer  forms,  as  in  aiiitc  ycllmv 
atrophy,  the  color  may  be  more  intense,  but  in  malaria  and  |irriii(iiiii> 
anannia  the  tint  is  usually  light.  In  these  mild  cases  the  urine  may  con- 
tain little  or  no  bile  pigment,  but  the  urinary  pigments  are  ciiiisiik'nil'l." 


tlnl 


JAUNDICK. 


4.V.> 


iiiorca-i'l.  Tlio  stools  iiw  not  cluy-folonMl  iuul  niiiy  iti  some  itistjuici's  !)(• 
vcrvilaik.  In  tlic  toxic  forms  of  this  variety  tlu'  ('fi'i'l)riil  syiiiploins  aro 
iiiiirkcil  imd  there  may  be  acUve  (h'iiriiim,  roma,  or  convulsioiis. 

;',  Icterus  Neonatorum. — New-itorn  infants  are  liable  to  jaiindiee,  which 
iiisoiii"  instances  ra[>itlly  proves  fatal.  A  mild  and  a  severe  form  may  l)c 
rccou'iiizi'd. 

Tlie  iiiih/  irfenis  of  the  now-born  is  a  common  disease  in  fonndlinj; 
liospitals  and  is  not  very  infre<|uent  in  private  practice.  'I'he  discoloration 
aiiiiuurs  early,  usually  on  the  first  or  second  day,  and  is  of  moderate  inten- 
-itv.  Thi'  urine  may  1)0  bile-staiiu-d  and  the  fa-ces  colorless.  'I'he  nutri- 
lidii  ut  the  child  is  not  seriously  disturl)ed,  and  in  the  majority  of  cases 
the  jaundice  disappears  within  two  weeks.  Jt  is  supposed  that  the  dimin- 
\A\vi\  iirt'-siire  in  the  portal  vessels,  following  the  severance  of  the  placental 
I  ir('iilati()n,alloVvS  al)sorption  from  the  bile  capillaries,  in  which  the  tension 
IS  urcater.  I'ossibly  too,  as  (^uiiu^ke  suggests,  the  ductus  venosus  may 
ivMiaiii  open,  allowing  some  of  the  portal  blood  containing  bile  to  flow 
iiiiu  the  systemic  circulation.  On  the  other  hand,  it  is  held  that  the  jaun- 
iliir  is  lia'inatogenous  and  due  to  the  destruction  of  largo  numbers  of  red 
lildoil-cdrpiiscles  during  the  first  few  days  after  birth. 

The  .yrrcrc  farm  of  icterus  in  the  new-born  may  depend  upon  {a)  con- 
L'rnital  absence  of  the  common  or  hepatic  duct,  of  which  there  are  sev- 
(lal  iiistaiicos  on  record;  {!>)  congenital  syphilitic  hepatitis;  and  {r)  sep- 
tic peisoning,  associated  with  phlebitis  of  the  umbilical  vein.  This  is  a 
«ivoro  and  fatal  form,  in  which  also  ha'inorrhago  from  the  cord  may  occur. 
Occaj^ionally  jaundice  sets  in  and  persists  for  many  weeks,  or  even 
iiiiiiitlis,  without  interfering  seriously  with  the  nutrition  of  the  child. 

;].  Acute  Yellow  Atrophy  of  the  Liver ;  Malignant  Jaundice  ?  Icterus 
Gravis. 

Definition. — Jaundice  assocsiated  with  marked  cerebral  symiitoms 
;i!m1  cliaiacterized  anatomically  by  extensive  necrosis  of  the  liver-cells  witli 
I'rdir.'tion  in  volume  of  the  organ. 

Etiology. — This  is  a  rare  disease.  In  a  somewliat  varied  post-mor- 
'"111  ami  clinical  experience  no  instance  has  fallen  under  my  ob.servation. 
On  tlio  other  haiul,  a  physician  nuiy  see  several  cases  within  a  few  years, 
ui'  even  within  a  few  months,  as  happened  to  Iliess,  who  saw  live  cases 
within  lliree  months  at  the  Charite,  in  Berlin.  The  disease  seems  to  be 
rare  in  this  country.  'Ko  case  is  reported  in  the  Transactions  of  the  l*atho- 
In-icul  Societies  of  New  York  (Vols.  I  to  III)  or  of  i'biladeli)hia  (Vols.  1 
to  .Xlll).  The  disease  is  more  common  in  women  than  in  men.  Of  the 
li'O  c';is(s  (Hil'cctod  by  Legg,  G9  were  in  females;  and  of  Thierfelder's  1-1:5 
ea^^cs,  ss  were  in  women.  There  is  a  remarkable  a.ssociation  between  the 
disea.<e  and  pregnancy,  which  was  present  in  'i')  of  the  OO.wonuui  in  Legg's 
stiUistic.-i,  and  in  ?i\]  of  the  88  wo-nen  in  Thierfelder's  collection.  It  is 
most  eoiunion  between  the  ages  of  twenty  and  thirty,  but  is  occasionally 
sien  in  young  children.     It  has  followed  fright  or  profound  mental  emo- 


( 


i'|:  ''i 


4*  )        5 


u 


W  *'<'P 


l1 


4*;<) 


DISKASMS  OF  TIIK    DKJKSTIVH  SVSTKM. 


lion.  'I"lii»ii;,'li  tlio  syniptr»ins  pmdiiccil  by  ))liospli()rus  )ntisoiiiiiLr  cldsrlv 
Kiiiuiliit(!  those  of  iiriitf  yellow  iilrojiliy,  tlic  two  conditicjiis  art  imt  i(|ii|. 
ticiil. 

Morbid  Anatomy.  -'I'lic  liver  is  greatly  reduced  in  size.  Iui,k.s  thin 
iiiid  llatteiicd,  and  soiiieliines  does  not  rea(di  more  tliaii  one  liall'  or  cvfn 
ono  tlurd  (d"  its  .lorinal  wei;,f|it.  It  is  llal)l)y  and  \ho  capsule  is  wiinkltil. 
On  section  the  color  is  of  a  yellowish  brown,  yellowish  red,  oi'  iiM.tilid, 
uiul  the  outlines  of  the  lol)ules  are  imlistinct.  'riio  yellow  and  diuk-inl 
portions  represent  di'l'ereiit  statues  of  tlu;  sain:^  process — the  yellnw  jm  (nr- 
licr,  the  rod  a  more  advanced  stai^e.  The  or^an  may  (Mit  with  cnnHdcialj!!' 
firmness.  Microscopically  the  liver-cells  are  seen  in  all  staj^'es  of  lunnsiv 
imd  in  spots  appear  to  have  underjjfoiu;  complete  destruction,  liavini;  a 
fatty,  <jranular  dvliri'^  with  j)if,Miu'nt  grains  and  crystals  of  leuciii  ;iiii|  tvni- 
sin.     Tho  hilc-ducts  and  gall-bladder  arc  empty. 

Macallum  and  Mcl'hedran,  in  a  case  studied  with  especial  care,  fdiiinl 
obstruction  of  tho  ilno  bilo  capillaries  between  the  liver-cells  nt  th' 
periphery  of  the  lobules,  with  blocking  of  tlu^  remaining  bile  capillaries  df 
the  lobules  by  protoidasmic  nmsses.  They  also  describe  somi^  I'eiiiMikalilc 
endocytos  similar  to  those  met  with  in  the  epithelial  cells  in  I'amt'sili-- 
ease.  The  changes  suggest  the  action  of  some  poisonous  clieniical  (mn- 
pound,  tho  producu  probably  of  deranged  digestion,  wdiicli  causes  \-,\\\v\ 
necrosis  of  the  cel's  of  the  liver  and  of  the  bile  capillaries. 

The  other  organs  show  extensive  bile-staining, and  there  are  niiiiienni' 
luBniorrhages.  The  kidneys  may  show  marked  granular  dcgenonitioii  of 
the  epithelium,  and  usually  there  is  fatty  degeneration  of  the  heart.  In  ;i 
majority  of  the  cases  the  sjdeen  is  enlarged. 

Symptoms.—  Tn  the  initial  stage  there  is  a  gastro-duodenal  eatanli, 
and  at  first  the  jaun.lice  is  thought  to  be  of  a  simj)le  nature.  In  some  in- 
stances this  lasts  only  a  few  days,  in  others  two  or  three  weeks.  Then 
severe  symptoms  set  in — headache,  delirium,  trembling  of  the  iimseks 
and,  in  sotne  instanccc!,  convulsions.  Vomiting  is  a  constant  syiniitom. 
and  blood  may  be  brought  up.  Ilii'morrhages  occur  into  the  skin  or  fmni 
the  mucous  surfaces  ;  in  pregnant  women  abortion  may  occur.  With  tlif 
development  of  the  liead  symptoms  the  jaundice  usually  increases.  l'oni;i 
sets  in  and  gradually  deeiiens  until  death.  The  body  temi)eratiiro  is  vari- 
able; in  a  majority  of  the  cases  the  disease  runs  an  afebrile  course,  thoii!:li 
.sometimes  just  before  death  there  is  an  elevation.  In  some  iiisfaiiees. 
however,  there  has  been  marked  pyrexia.  The  pulse  is  usually  rapid,  tin' 
tongue  coated  and  dry,  and  the  patient  is  in  a  "  typhoid  state." 

The  urine  is  bile-stained  and  often  contains  tube-casts.  I.cncin  aiiu 
tyrosin  are  constantly  present;  the  former  as  rounded  disks,  the  latter  in 
needle-shaped  crystals,  arranged  either  in  bundles  or  in  groups,  'iln' 
tyrosin  may  sometimes  be  seen  in  the  urine  sediment,  but  it  is  best  first  t' 
evaporate  a  few  drops  of  urine  on  a  cover-glass.  In  the  majority  of  castj 
no  bile  enters  the  intestines,  and  the  stools  are  clay-colored.     I'lic  tliscast' 


.1 

i«  aliiKtst 

■■\W  ill    lil 

Diag 

ilcliriiiiii. 

aeleristic 

iiiit,  liowe 

iliee  will) 

It     ! .;     I 

with  iiitei 

hypertrop 

liver,  the 

mill  tyros 

simulate  a 

ami  the  il 

usually  iik 

the  urine. 

.\o  kiK 

i-- 


AFFKCTIONS  (»F  TIIK    IJLoolt  VKSSKI.S  OF  TIIK   IA\K\1.        4(;| 

i^iilinn.-l  iiiviiriiibly  filial.  Tn  ii  few  iiHtnncos  rccovory  1ms  boon  noted.  1 
.;i\v  ill  l.iMilic's  I'iiiiic,  at,  \Vi"ir/,Iiiir<r,  a  case  wliidi  was  coiivaU'SccMt. 

Diagnosis. — .lamidifc  with  dcliriimi,  <liiiiiiiuti(iii  id"  tlic  liver  voliinu'. 
ililiriiiiii,  and  tliu  prost'iico  of  Iciiciii  and  t_vri)siii  in  tlic  iiriiu'.  form  n  cliar- 
acturistii'  and  miiiiistakahli'  <rr()ii[)  •»!'  Hyiii[)toiii.«i.  Ijoiiciii  and  tyrosiii  iirc 
iiiit,  liKWfvcr,  distinctive,  'i'licy  may  be  jtrcsciit  in  cases  of  afebrile  jaun- 
dice with  sliijlit  enlai'^reineiit  of  liic  liver. 

It  is  not  to  bo  for<,'otten  that  any  .severe  jaundice  may  be  associated 
uitli  iiiiiiise  cerebral  symptoms.  The  (dinical  features  in  certain  cases  of 
hviicrtrophii!  cirrhosis  are  almost  identical,  but  tbe  enlar<,'<'nu'nt  of  the 
liver,  tilt'  more  constant  occurreiu/e  of  fever,  and  the  absence  of  leucin 
mill  tvi'iisin  are  distin<,niisliiiig  si;,'ns.  IMiospiiorus  poi.sotung  may  clo.sely 
<imiiliil('  acute  yellow  utrfiphy,  purticularly  in  the  ha'morrha<,fes,  jiiuiuiice, 
aiiil  the  diminution  in  the  liver  v(dume,  liiit  the  j,'astric  symi)toms  are 
iisiiMJly  more  marked,  and  leucin  and  tyrosin  are  stated  iu)t  to  occur  in 
tlie  urine. 

No  known  remedies  have  any  inlluonco  on  the  cciirse  of  the  diseuso. 

II.  AFFECTIONS  OF  THE   BLOOD-VESSELS  OF  THE 

LIVER. 

(i)  An-emia. — On  the  post-mortem  tabic,  when  the  liver  looks  aniLMiiic, 
a«  ill  the  fiitty  or  amyloid  organ,  the  blood-vessels,  which  during  life  were 
ltroliiil)ly  well  tilled,  can  bo  readily  injected.  There  tiro  no  symptoms  in- 
liji'iitive  of  tliis  condition. 

('.'I  Hyi)era3mia. — This  occurs  in  two  forms,  {a)  Arfirc  Ji^u'rcpiniii. 
Afiirt-arh  meal  the  rapid  absorption  by  the  jiortal  vessels  induces  transient 
iiiii<;estion  of  the  organ,  which,  however,  is  entirely  physiological ;  but  it 
i- f|uite  possible  that  in  persons  who  persistently  cat  and  drink  too  much 
rhis  iiitive  liyiiera'Piia  may  load  to  functional  disturbance  or,  in  the  case 
nf  drinking  too  freely  -)f  alcohol,  to  organic  cliauge. 

Tile  sipiip/omii  of  active  hypera'mia  are  indetinite.  Possibly  the  sense 
"f  distress  or  fulness  in  the  right  hypochoiulrium,  so  often  mentioned  by 
ily>peptiis  and  by  tho.se  who  cat  and  drink  freely,  may  bo  duo  to  this 
muse.  There  are  probably  diurnal  variations  in  the  volume  of  the  liver. 
liieiniiosis  with  enlargement  the  rapid  reduction  in  volume  after  a  coj)!- 
"iis  lui'iiiorrliago  indicates  the  important  jiart  which  hyperamiia  plays  even 
ill  Di'puiic  troubles.  It  is  stated  that  suppression  of  the  fnenscs  or  suppres- 
-i'lii  of  a  JKeniorrhoidal  flow  is  followed  by  hyi)era'mia  of  the  liver.  Aiulrew 
H-  Smith  lias  described  a  case  of  periodical  enlargement  of  the  liver. 

(//)  I'dssive  Confjestioii. — This  is  much  more  common  and  results  from 
:in  increase  of  pressure  in  the  eiferent  vessels  or  sub-lobular  branches  of 
till'  lii'parii;  veins.  Every  condition  leading  to  venous  stasis  in  the  right 
lit'art  at  once  affects  these  veins. 

Tirchi'Diiie  valvular  disease,  in  emjihyserr.a,  cirrhosis  of  tiie  lung,  and 


;>» 


VM 


<  11 


'It  1 


in 


j.:^ 


-'!-— .4'-  '^s 


402 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


in  uitratlioraoic  tumors  meoliaulcal  rontjostion  occurs  and  finally  loads  to 
\<-ry<iffinite  changes.  The  liver  is  enlarged, firm, and  of  :  deep-nil  idld). . 
th(!  hepatic  vessels  are  greatly  engorged,  particularly  tlie  centnil  vein  in 
ea-'ii  lobule  and  its  adjacent  capillaries.  On  section  the  organ  ]iivs(iits  u 
fM'ciiliar  mottled  appearance,  owing  to  the  deeply  congested  li(|iaiic  mni 
the  an.T'mif!  portal  territories;  lience  the  term  nnh)ii^  which  has  lui.), 
j(iveii  to  this  condition.  (Jradually  the  distention  of  the  central  ia|iillarii'.. 
rtrAchvn  such  a  grade  that  atrophy  of  the  intervening  liver-cells  is  indiur,!. 
IJrown  pigment  is  dejiosited  about  the  centre  of  the  lobules  aiul  the  con- 
rn'ctive  tissue  is  greatly  increased.  In  this  cyanotic  induratifni  or  cardiac 
liver  the  organ  is  large  in  the  earlv  stage,  but  later  it  may  beccjtiii.  c,,,]. 
tracted.  Occasionally  in  this  form  the  connective  tissue  is  increased  about 
tlie  lobules  as  well,  but  the  process  usually  extends  from  the  sublohidar  ami 
(jontral  veins. 

The  symptoms  of  this  form  are  not  always  to  be  sepiirated  from  tliosr 
of  the  associated  conditions.  (Jastro-intestinal  catarrh  is  usually  |ircsciit 
and  ha'matemesis  nuiy  occur.  The  portal  obstruction  in  advaiiccd  casts 
Iwids  to  ascites,  Avhi(di  may  jireccde  the  development  of  general  dropsy. 
There  is  ofteti  slight  jaundice,  the  stools  nuiy  be  day-colored,  and  tln' 
urine  contains  bile-i)ignu'nt. 

()u  examination  the  organ  is  found  to  be  increased  in  size.  It  may  he 
a  full  hand's-breadth  below  the  costal  margin  and  tender  on  ])ressiiro.  It 
i>*  in  this  condition  particularly  that  we  meet  with  i)ulsation  of  the  liver. 
We  must  distinguish  the  communicated  throbbing  of  the  heart,  wliicli  i- 
very  common,  from  the  heaving,  diffuse  impulse  due  to  regurgitati(»ii  into 
the  hepatic  veins,  in  whiidi,  when  one  hand  is  ui)on  the  ensiforni  cartilairf 
anri  the  other  upon  the  right  side  at  the  margin  of  the  ribs,  the  v.iioli' 
liver  can  be  felt  to  dilate  with  each  impulse. 

Tlie  indicatioi\s  for  treatment  in  passive  hypera-mia  are  to  restore  the 
balance  of  the  circulation  and  to  uidoad  the  engorged  j)()rtal  vessels.  In 
<;a«i'j*  of  intense  hypenemia  eigliteen  or  twenty  ounces  of  blood  may  ln' 
directly  aspirated  from  the  liver,  as  advised  by  George  Ilarley  and  pnn- 
tijW'd  by  many  Anglo-Indian  physicians,  (iood  results  sonietiincs  follow 
this  hej>ato-phIebotomy,  The  prom})t  relief  and  marked  nMliii'lioii  in  tin' 
volume  of  the  organ  which  follow  an  attack  of  ha'matemesis  oi'  bleeding' 
from  piles  suggests  this  practice.  Salts  administered  by  ^latthew  Hays 
method  deplete  the  portal  system  freely  aiul  thoroughly.  As  a  rule,  \\w 
treatnu-nt  must  be  that  of  the  condition  with  which  it  is  associated. 

(;{)  Diseases  of  the  Portal  Vein.— (f')  Tlirombosis ;  Ailh'sirv  Piji'- 
plilf'Jntix. — Coagulation  of  blood  in  the  portal  vein  is  rarely  seen  except  in 
trirrliosis.  Exceptional  causes  are  invasion  of  the  branches  by  caiirer,  pr^- 
lif«-rative  peritonitis  involving  the  gastro-hepatic  omeiituni,  and  perfom- 
lion  of  the  ve.n  by  gall-stones.  In  rare  instances  a  conii)leto  collateni. 
circulation  is  established,  the  tlirombus  undergoes  the  usual  (dnmires,  anu 
ultimately  the  vein  is  represented  by  a  librous  cord,  a  condition  uliieli  lia-^ 


DISEASES  OF  THE   BILE-1'ASSAOES. 


403 


hcoii  called  pi/Icp/ih'/ji/ix  (tdhcsii'a.  \\\  ii  case  of  this  kind  wliicdi  I  dissoct- 
,.il  the  piii'tal  vein  was  ropresonti'd  by  a  narrow  fibrous  cord  ;  the  colhitcral 
I inulation,  which  must  have  boon  coniplotely  i'stal)lislH'(l  for  years,  ulti- 
iiuitilv  failed,  ascites  and  hainiatemesis  su|)ervciicd  and  rapidly  ])roved 
t:it;il.*  'I'lio  dia<<nn>is  of  obstruction  of  the  portal  vein  can  rarely  1)0 
iiiinU'.  \  sugiijestive  symptom,  however,  is  a  sudden  onset  of  tlie  niost 
iiitfiise  engorgement  of  the  branches  of  the  portal  system. 

pjnboli  in  the  branches  of  the  portal  vein  do  not,  as  a  rule,  produce 
iiifarctiini,  for  blood  reaches  the  lobular  cajjillary  ])lexus,  as  shown  by 
(oliiiln'im  and  Litten,  through  the  free  anastomosis  with  the  lie[)atio 
iirU'i'v.  In  rare  instances,  however,  a  condition  resembling  itifarction  does 
(Mcur,  sdMietiines  in  small  areas,  at  others  in  quite  extensive  territories. 
Si'ptic  end)oli,  on  the  other  hand,  may  induce  su])puration. 

(//)  Suppurative  pylephlebitis  will  be  considered  in  tiic  section  on 
al)H('i'jif!. 

(I)  Affections  of  the  hepatic  vein  are  extremely  rare.  Dilatation 
occurs  in  cases  of  chronic  eidargement  of  tiie  right  heart,  from  whatever 
(uusr  produced.  Emboli  occasionally  pass  from  the  right  auricle  into  the 
hepatic  veins.  A  rare  and  uinisual  event  is  stenosis  of  the  orifices  of  the 
JK'iiatic  veins,  which  I  met  in  a  case  of  fibroid  obliteration  of  the  inferior 
vena  cava  and  was  associated  with  a  greatly  enlarged  and  indurated  liver.f 

(•"»)  II  'patic  Artery. — Eidargement  of  this  vessel  is  scon  in  cases  of 
rinliosis  of  the  liver.  It  may  be  the  seat  of  extensive  sclerosis.  Aneurism 
(if  the  hepatic  artery  is  rare,  but  instances  are  on  record,  and  will  be  re- 
ferred to  in  tlie  section  on  arteries. 

III.    DISEASES  OF  THE  BILE-PASSAGES. 

Catauuhal  .Jaixuick. 

Definition. — Jaundice  due  to  swelling  ami  obstruction  of  the  tcrmi- 
iiiil  portion  of  the  common  duct. 

Etiology.— Oeneral  catarrhal  inflammation  of  the  bilo-ducts  is  usu- 
iilly  associated  with  gall-stones.  The  catarrhal  process  now  under  consid- 
eration is  probably  always  an  extension  of  a  gastro-duodcnal  catarrh,  and 
ilie  process  is  most  intense  in  the  pars  '  '  stiiialis  of  the  duct,  which 
projects  into  the  duodenum.  The  mucous  membrane  is  swollen,  and  a 
pluj:  0*'  insjiissatcd  mucus  fills  the  diverticulum  of  Vater,  and  the  narrower 
portioi,  just  at  the  orifice,  completely  obstructing  the  outfiow  of  bile.  It 
i''  not  known  how  wide-spread  this  catarrh  is  in  the  bile-passages,  ami 
whether  it  really  passes  up  the  ducts.  It  would,  of  course,  be  possible  to 
li;ive  u  I  atavrh  of  the  finer  ducts  within  the  liver,  whii'h  some  French  writ- 
"'■' think  may  initiate  the  attack,  but  the  evidence  of  this  is  not  strong. 


I 


f 


15,:.! 


is 


■■•■  Journal  of  Anatomy  and  Physiology,  vol.  xvii. 


t  Ibid.,  vol.  xvi. 


-M 


\ 


I  I 


-T  'IV 


if 


<  "fii 


f 

,lii 


4(U 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


and  it  seems  more  likely  that  the  terminal  ])()rti()n  of  tlic  duct  is  ahvavs 
first  involved.  In  the  only  instance  which  J  have  had  an  opportuiiitv  to 
examine  post  mortem  the  oriiice  was  ])lu<jjjf(Ml  with  inspissated  iiiihiis,  the 
(!oinni()n  and  hepatic  ducts  were  slightly  distended  and  (jontaiiicil  n  lii|(.. 
tinged,  not  a  clear,  mucus,  and  there  were  no  ohservable  chaugi's  in  the 
mucosa  of  the  ducts. 

This  catarrhal  or  simple  jaundice  results  from  the  following  lau-ics: 
(1)  Duodenal  catarrh,  in  whatever  way  produced,  inj)st  eomnionly  fdl- 
lowing  an  attack  of  indigestion.  It  is  most  frequently  met  with  in  yuuii;' 
persons,  but  may  occur  at  any  age,  and  may  follow  not  oidy  errors  in  diet. 
but  also  cold,  exposure,  and  mahu'ia,  as  well  as  the  conditions  iissociatcil 
with  portal  obstruction,  chronic  heart-disease,  and  liright's  disease.  (;') 
Enu)tioiud  disturbances  may  l)e  followed  by  jaundice,  which  is  believed  tn 
be  due  to  ciitarrhal  swelling.  Cases  of  this  kind  are  rare  aiul  tlie  anatdiii- 
ical  condition  is  unknown.  {',])  Simple  or  catarrhal  jaundice  may  (kmui 
in  epidemic  form.  (4)  Catarrhal  jauiulice  is  occasionally  seen  in  the  in- 
fectious fevers,  such  as  ])neumonia,  and  ty]>hoid  fever. 

Symptoms. — There  may  be  neither  pain  nor  distress,  and  tlu' 
patient's  friends  may  first  notice  the  yellow  tint,  or  the  patient  hinisclt' 
may  observe  it  in  the  looking-glass.  In  other  instances  there  are  dysju'ii- 
t]c  symptoms  and  uneasy  sensations  in  the  hepatic  region  or  pains  in  tin' 
back  and  limbs.  In  the  ei)ideinic  form,  the  onset  may  be  more  severe, 
with  headache,  chill,  and  vomiting.  Fever  is  rarely  jn-esent,  though  the 
temperature  may  reach  101°,  sometimes  102°.  All  the  signs  of  ()l)strii('- 
ive  jaundice  already  mentioned  are  present,  the  stools  are  clay-eoldivd, 
and  the  urine  contains  bile-pigment.  The  jauiulice  has  a  bright-yellow 
tint ;  the  greenish,  bronzed  color  is  never  seen  in  the  simple  form.  Tin' 
pulse  may  be  normal,  but  occasionally  it  is'  remarkably  slow,  and  may  fall 
to  forty  or  thirty  beats  in  the  minute.  The  liver  may  be  normal  in  sizo. 
but  is  usually  slightly  enlarged,  and  the  edge  can  be  felt  below  the  ee.-lal 
margin.  Occasionally  the  enhirgcnu'nt  is  more  marked.  The  diiratimi 
of  the  disease  is  from  four  to  eight  weeks.  There  are  mild  cases  in  wliii'ii 
the  jaundice  (lisai)pears  within  two  weeks;  on  the  other  hand,  it  may  iht- 
sist  for  three  months.  The  stools  should  be  carefully  watched,  fur  tlirv 
give  the  first  intimation  of  removal  of  the  obstruction. 

The  f/i(ii/iiiisis  is  rarely  dithcult.  The  onset  in  young,  eoniparaiively 
healthy  persons,  the  moderate  grade  of  icterus,  the  absence  of  einaeiatinii 
or  of  evidences  of  cirrhosis  or  cancer,  usually  make  the  dingnosis  easy 
Cases  which  persist  for  two  and  three  njonths  cause  uneasiness,  as  the  sus- 
picion is  aroused  that  it  nuiy  be  more  than  simjde  catarrh.  The  ahseiur 
of  pain,  the  negative  character  of  the  physical  examination,  and  the  main- 
tenance of  the  general  nutrition  are  the  points  in  favor  of  sim[)le  janiidiec. 
There  are  instances  in  which  time  alone  can  determine  the  true  nature  el 
the  case.  The  possibility  of  AVeil's  disease  must  be  borne  in  miu'l  ^ 
anomalous  ciises. 


DISEASES  OF  THE   BILE-PASSAGES. 


405 


Treatment. — As  a  rule  the  patient  can  keeji  on  his  feet  from  the 
outset.  Measures  sIiouM  l)e  used  to  aUay  tlie  <fastri(!  eatarrh,  if  it  is  pres- 
t'lit.  A  (lose  of  eah)jnel  may  be  given,  and  tiie  l)o\vels  kept  open  subse- 
niHMitly  by  salines.  The  i)atieiit  sliould  not  be  violently  purijjed.  J?jsnuith 
jiiiii  l»i(arl)onate  of  soda  may  be  given,  imd  the  patient  should  driidc  freely 
of  the  alkaline  mineral  waters,  of  whieh  Vieliy  is  the  best.  Irrigation  of 
tlu'  large  Ijowel  with  cold  water  may  be  prac-tised.  The  eold  is  supposed 
to  excite  peristalsis  of  the  gall-bladder  and  duets,  and  thus  aid  in  the  ex- 
pulsioiMif  the  mucus.  'J'his  practice  has  l)een  followed  in  my  wards  for 
several  years,  but  1  cannot  speak  warndy  of  the  results. 

Cholelitij ixsis  {Gall-Stunex). 

Calculi  are  formed  in  the  gall-bladder.  Evidence  is  wanting  to  show 
timt  they  are  fornu'd  within  the  liver  ducts,  except  in  very  rare  instances. 
They  may  be  single,  in  whicdi  case  the  stone  is  usually  ovoid  aiul  may  at- 
tain a  very  large  size.  Instances  are  on  record  of  gall-stones  measuring 
more  than  live  inches  in  length.  They  may  bo  extremely  numerous,  rang- 
ing Iroiii  a  score  to  several  hundreds  or  even  several  thousands,  in  whieh 
case  the  stones  are  very  small.  AVhen  moderately  nunuM-ous,  they  shov/ 
signs  of  mutual  pressure  and  liave  a  ]iolygonal  form,  with  smooth  facets; 
occasionally,  however,  five  or  six  gall-stones  of  nu'dium  size  are  mec  with 
ill  the  hhidder  whieh  are  roujid  or  ovoid  and  without  facets.  They  are 
soiiict lilies  mull)errv-shaped  and  very  dark,  consisting  largely  of  ])ile-])ig- 
iiiciit.  Again  there  are  small,  black  calculi,  rough  and  irregular  in  shape, 
anil  varying  in  size  from  saiul  to  small  shot.  These  are  sometimes  kiu)wn 
as  uMll-saihl.  On  section,  a  calculus  contains  a  nucleus,  which  consists 
of  !»ile-|)igment,  rarely  a  foreign  body.  The  gi'eater  portion  of  the  stone 
is  iiKulti  up  of  c^holesterin,  which  may  form  the  entire  calculus  and  is  ar- 
raiigpil  in  concentric  lamiiiie  showing  also  radiating  lines.  Salts  of  lime 
and  magnesia,  bile  aculs,  fatty  acids,  and  traces  of  iron  ami  copper  are  also 
fouiol  in  them.  A  nuijority  of  gall-stc/ues  consist  of  from  seventy  to 
ciirhty  per  cent  of  cholesterin,  in  either  the  amorphous  or  the  crystalline 
fnnii.  As  above  stated,  it  is  sometimes  pure,  but  more  commoidy  it  is 
mixed  with  the  bile-pigment.  The  outer  layer  of  the  stone  is  usually 
lianlcr  and  brownish  in  color,  and  contains  a  larger  proportion  of  lime 
>ahs. 

'I'lie  mode  of  formation  is  by  no  means  clear.  A  defect  in  the  sodium 
s:ihs  seems  to  favor  the  })recipitation  of  the  cholesterin  and  of  the  bile- 
piirmeiit.  The  lime  exists  in  such  slight  quantities  in  the  bile  that  it  is 
prolialily  a  pathological  product  of  the  mucous  glands  of  the  gall-bladder. 
When  the  bile  is  retaimnl  long  in  the  gall-bladder  its  concentration  favors 
the  deposition,  (.'ontrary  to  old  ideas  of  the  aseptic  qualities  of  the  bile, 
It  is  imw  known  that  the  bile-passages  often  contain  micro-organisms, 
itiiii  it  lias  been  suggested  that  their  presence  in  the  gall-bladder  induces 


;;  ;».:;  '* 


r  1 


'  1 


4        i       '  4         ' 

'mi:  ■ 


t'  -life 


466 


DISEASES  OP  THE   DIGESTIVE  SYSTEM. 


1-       >  '    L. 


'M 

W 

1 

1 

J 

1 

1 

ft! 

^ '' 


changes  which  favor  the  formation  of  concretions.  ::S'auriyu  holi]y  that, 
the  cholesterin  is  chiefly  the  secretion  of  the  mucous  membrane  of  iia-  bilf.. 
passages,  and  Qiay  be  formed  iujargcr  amount  in  an  angio-choHtis,  cau  d 
by  tlie  irritation  of  bactena. 

Etiology. — Three  fourths  of  the  cases  of  gall-stones  occur  in  Wdinon, 
most  frequently  between  the  ages  of  thirty  and  sixty.  Sedentary  (mciij,;!. 
tions,  i)articularly  when  cond)iiied  witli  overindulgence  in  eating,  seem 
important  factors.  The  subjects  ai'o  often  stout,  and  usually  very  fond  of 
starchy  and  saccharine  food.  The  conditions  which  induce  lithie  .tcid  also 
favor  the  development  of  gall-stones.  Tight-lacing  is  regarded  by  ilarcluiiKl 
as  an  im])ortant  factor  in  retarding  the  flow  of  the  bile.  Pregnancy  Imsa 
similar  influence,  Kaunyn  states  that  ninety  per  cent  of  wonieii  with 
gall-stones  have  borne  children.  Constipation  and  depressing  ineiital  in- 
fluences have  been  regarded  as  favoring  circumstances. 

Symptoms. — In  a  majority  of  the  cases,  gall-stones  canse  no  symp- 
toms. The  gall-])ladder  wdl  tolerate  the  presence  of  large  numl)ers  for  an 
iniTefinite  period  of  time,  and  post-mortem  examinations  show  that  tluy 
are  present  in  twenty-five  j)er  cent  of  all  women  over  sixty  years  of  age 
(Xaunyn). 

The  effects  of  gall-stones  may  be  considered  under  the  following  head- 
ings:  '^riie  symptoms  produced  by  the  passage  of  a  stone  through  the 
ducts — bjliary  colic  ;  tlie  effects  of  permanent  plugging  of  the  duct;  and 
the  more  remote  effects,  due  to  ulcex'ation  and  perforation,  and  the  estab- 
lishment of  fistuliv. 

1.  Biliary  Colic. — Tt  would  appear  that  gall-etones  may  become  en- 
gaged in  the  cystic  or  the  common  duct  without  jn'oducing  ])ain  or 
severe  symi)toms.  ^lorc  commonly  the  jiassage  of  a  stone  excites  thi' 
violent  symiitoms  known  as  biliary  colic,  'J'lie  attack  sets  in  abruptly 
■with  agonizing  pain  in  the  right  hypochondriac  region,  which  radiates  to 
the  shoulder,  or  is  very  intense  in  the  epigastric  and  in  the  lower  thoraeie 
regions.  It  is  often  associated  Mdth  a  rigor  and  a  rise  in  temi)eratui'e  from 
10'^°  to  10;]°,  The  pain  is  usually  so  intense  that  the  patient  rcdls  aliout  in 
agony.  There  arc  vomiting,  profuse  sweating,  and  great  depression  of  the 
circulation.  Theie  may  be  nuirked  ten(lern(\ss  in  the  region  of  th'!  liver 
which  may  be  enlarged,  and  the  gidhbladd^r  may  become  pidpable  and 
very  tender.  In  other  cases  the  fever  is  more  marked.  The  si)leen  is 
enlarged  (Xaunyn)  and  the  urine  contains  albumin  with  red  blood-coi'pns- 
cles.  Ortner,  who  has  recently  described  in  connection  with  gall-stones. 
the  condition  as  f/ioleciislilis  acuta,  believes  that  it  is  caused  l)y  a  septic 
(bacterial)  infection  of  the  bile-passages.  In  a  large  number  of  the  case-! 
jaundice  develops,  but  it  is  not  a  necessary  symptom.  Of  course  it  doi» 
not  occur  during  the  passage  of  the  stone  through  the  cystii'  duct,  bnt 
oidy  when  it  becomes  lodged  in  the  common  duct.  I'rob.tbly  the  intense 
pain  is  due  to  the  slow  progress  in  tlie  cystic  duct,  in  Avhich  the  stone 
takes  a  rotary  course  owing  to  the  arrangement  of  the  lleisterian  valve. 


Mm 


DISEASES  OF  THE   BILE-PASS  AUKS. 


HVi 


The  attack  varies  in  duration.  It  may  last  for  a  few  hours,  several 
(liiv.s  or  e\'"n  a  ■vveek  or  more.  If  the  stone  becomes  impacted  in  tlie 
oritici'  of  tiie  common  duct,  tlie  jaundice  becomes  intense;  much  more 
(Dminniily  it  is  a  slight  transient  icterus.  The  attack  of  colic  may  be  re- 
peated at  intervals  for  some  time,  but  finally  the  stone  i)asses  and  the 
sviii]itoiiis  rapidly  disappear. 

Occasionally  accidents  occur,  such  as  rupture  of  the  duct  with  fatal 
peritonitis.  Fatal  syncope  during  an  attack,  and  the  occurrence  of  re- 
])oatt(l  convulsive  seizures  have  come  under  my  observation.  These  are, 
liowevcr,  rare  events.  Palpitation  and  distress  about  the  heart  nuiy  be 
present,  and  occasionally  a  mitral  murmur  develops  during  the  paroxysm; 
l)ut  tlie  cardiac  conditions  described  by  some  writers  as  coming  on  acutely 
in  biliary  colic  are  probably  pre-existent  in  these  patients. 

Tlie  (h'df/nnsis  of  acute  hepatic  colic  is  generally  easy.  The  pain  is  in 
the  upper  abdominal  and  thoracic  regions,  whereas  the  pain  in  nephritic 
colic  is  in  the  lower  abdomen.  A  chill,  with  fever,  is  much  more  frequent 
ill  biliary  colic  than  in  gastralgia,  with  which  it  is  liable,  at  times,  to  be 
confounded.  A  history  of  previous  attacks  is  an  important  guide,  and  the 
(tccurrence  of  jaundice,  however  slight,  determines  the  diagnosis.  To  look 
for  the  gall-stones,  the  stools  should  be  thoroughly  mixed  with  water  and 
carefully  liltered  througli  a  narrow-meshed  sieve.  Pseudo-biliary  colic  is 
not  infrequently  met  with  in  nervous  women,  and  the  diagnosis  of  gall- 
stones made.  This  nervous  hepatic  colic  may  be  periodical,  the  pain  in 
riiiiit  side  and  radiating;  sometimes  associated  with  other  nervous  phe- 
noineiia,  often  excited  by  emotion,  tire,  or  excesses.  The  liver  may  be 
tender,  but  there  are  neither  icterus  nor  inflammatory  conditions.  The 
eoiiibiuation  of  colic  and  jaundice,  so  distinctive  of  gall-stones,  is  not 
always  present.  The  pains  may  not  be  colicky,  bu  'lore  constant  and 
(irairiiing  in  character.  Of  fifty  cases  operated  upon  by  Iiiedel,  ten  had 
not  had  colic,  only  fourteen  presented  a  gall-bladder  tumor,  while  a  ma- 
jority had  not  had  jaundice.  A  remarkable  xanthoma  of  the  bile  passages 
has  been  found  in  association  with  hejiatic  colic. 

••'.  Chronic  Obstruction  of  the  Ducts  by  Gall-stones.— 0/  il/e  ('ij-siir, 
/'"'■/.-   'I'lie  effects  may  be  thus  enumerated  : 

Iblatation  of  the  gall-bladder — hydrops  vesicie  felleiv?.  This  occurs 
niucii  nioro  fi.^quently  than  in  obstruction  of  the  common  duct.  The 
lliiid  is  almost  invariably  of  a  thin  mucoid  nature,  though  it  may  bo 
mixed  with  bile.  In  all  case,  when  the  obstruction  persists,  the  bile  is 
ii'lilaceil  l)y  a  clear  fluid.  This  is  an  important  point  in  diagnosis,  j)ar- 
lieulaily  as  a  dropsical  gall-bladder  may  form  a  very  large  tumor.  The 
ivactioii  is  not  alwa^'s  constant.  It  is  either  alkaline  or  neutral ;  the  con- 
^^istencc  is  thin  and  mucoid.  Albumin  is  usually  present.  The  organ 
may  reach  an  enormous  size,  and  in  one  instance  Tait  found  it  occupying 
the  ui'cater  part  of  the  abdomen.  In  such  cases,  as  is  not  unnatural,  it 
lias  been  mistaken  for  an  ovarian  tumor.     The  dilated  gall-bladder  can 


^ih 


m-  f . 


;i'^ 


iff  !  ' 


*1   '  5 


,1 
,1  ' 


4(58 


DISEASES  OF   THE  DIGESTIVE  SYSTEM. 


usually  bo  folt  b(!lo\v  the  edge  of  the  liver,  ami  in  many  instances  ii  has  a 
cliaracti'i'istio  outline  like  a  (fourd.  It  usually  projects  directly  dowiiuanl, 
Tiirely  to  one  side  or  the  other,  though  occasioiudly  toward  the  miildli. 
line.  It  may  reach  below  the  luivel,  and  in  j)ersons  with  thin  walls  tlu' 
outline  can  bo  accurately  defined.  Kiedel  has  civllcd  attention  to  a  tunLriK.. 
like  projection  of  the  anterior  margin  of  the  right  lobe  in  connection  with 
eidarged  gall-bladder.  It  is  to  be  remembered  that  distention  df  the 
gall-bladder  may  occur  witlu  ut  jaundice;  indeed,  the  greatest  enlarge- 
ment has  been  met  with  in  such  cases. 

(Jail-stone  crepitus  is  felt  when  the  bladder  is  very  full  of  stones  and 
its  walls  not  very  tense.  It  is  rarely  well  felt  unless  the  abdominal  walls 
are  much  relaxed.  It  may  be  found  in  i)atients  who  have  never  had  aiiv 
symptoms  of  cholelithiasis.  In  obstruction  of  the  common  duct  the  gall- 
bladder is  not  necessarily  greatly  enlarged.  Occasiomilly  it  may  be  iiuidi 
disteiuled  without  the  occurrence  of  any  tumor  which  can  be  felt  during  lifi-. 

Acute  phlegmonous  cystitis.  This  is  a  rare  event.  Only  seven  in- 
stances of  it  have  been  collected  in  the  enormous  statistics  of  {.'(lurvoi- 
sier.     Perforation  may  occur  with  fatal  jieritonitis. 

Suppurative  cholecystitis,  empyema  of  the  gall-bladder,  is  nuudi  nidie 
common,  and  in  the  great  nuijority  of  cases  is  associated  with  gall-stunos 
— 41  in  55  cases  (Oourvoisier).  There  may  be  enormous  dilatation,  and 
over  a  litre  of  pus  has  been  found.  Perforation  and  the  formatidii  of 
abscesses  in  the  neighborhood  are  not  uncommon. 

Calcification  of  the  gall  bladder  is  commonly  a  termination  of  tiio  pre- 
vious condition.  There  are  two  sei)arate  forms  :  incrustation  of  the  mucosa 
with  lime  salts  and  the  true  infiltration  of  the  wall  with  lime,  the  so-called 
ossification.  A  remarkable  example  of  the  latter,  sent  to  me  by  (i roves, 
of  Carp,  is  now  in  the  McGill  Medical  INIuse'um. 

Atrophy  of  the  gall-bladder.  This  is  by  no  means  uncommon.  The 
organ  shrinks  into  a  small  fibroid  mass,  not  larger,  perhaps,  than  a  good- 
sized  pea  or  walnut,  or  even  has  the  form  of  a  narrow  fibrous  stiing; 
more  commonly  the  gall-bladder  tightly  embraces  a  stone.  This  condition 
is  usually  preceded  by  hydro})s  of  the  bladder. 

Occasionally  the  gall-bladder  presents  diverticula,  ■which  nuiy  be  cut 
off  from  the  main  portion,  and  usually  contain  ealcu.li. 

Obstrnction  of  the  Common  Ducf, 

The  stone  usually  lies  at  the  termination  of  the  duct,  just  at  tlicoriliee 
of  the  papilla,  Avithin  a  sort  of  pouch  formed  by  the  diverticulum  of  \'at(r. 
Examined  from  the  duodenum,  it  seems  to  be  directly  beneath  the  nm- 
cosa.  It  is  as  a  rule  single ;  but  two,  and  in  some  instances  a  pciics  of 
stones,  may  occupy  the  entire  duct.  The  effect  of  the  obstruction  is  dila- 
tation, Avith  catarrhal  or  suppurative  cholangitis. 

(1)  Obstruction,  with  catarrhal  cholangitis. 

'^riie  common  duct  may  be  as  large  as  the  thumb;  the  hepatic  duct  and 
its  branches  through  the  liver  are  greatly  dilated,  and  the  distention  may 


'H't  '!  'ffi^ 


DISP]ASES  OP  THE  BILE-PASSAGES. 


409 


even  1)('  apparent  benoatli  the  liver  capsule.  Cireat  enlarf^emeiit  of  the 
iriill-liladder  is  rare.  The  mucous  uieTiihraue  of  the  ducts  nuiy  he  smooth 
1111(1  clear,  uud  the  contents  a  thin,  colorless  mucus. 

(Mtarrhal  cholangitis  with  gall-stones  is  characterized  hy  a  special 
syiiiptoiu  group;  <(t)  Ague-like  paroxysms,  chills,  fever,  and  sweating; 
^//)  jiiuiidice  of  varying  intensity,  which  ])ersists  for  months  or  even  years, 
iiiid  dccpeus  after  each  paroxysm  ;  (r)  at  the  time  of  the  paroxysms,  paitis 
in  the  region  of  the  liver  with  gastric  disturbance.  The.se  sym])toms  may 
(■iiiitimie  on  and  o(T  for  tiiree  or  four  years,  without  the  development  of 
siiiipuriitive  cholangitis.  In  one  of  my  cases  the  jaundice  and  recurring 
lu>|iiitic  intermittent  fever  existed  from  July,  18|!),  until  August,  18H^; 
the  |)atient  recovered  and  still  lives.  The  condition  has  lasted  from  eight 
iiioiitlis  to  three  years.  The  rigors  are  of  intense  severity,  and  the  tem- 
pciutiiic  rises  to  103°  or  105°.  The  chills  may  recur  daily  for  weeks,  and 
prcMiit  a  tertian  or  (puirtan  type,  so  that  they  often  are  mistaken  for 
niulaiia,  with  which,  however,  they  have  no  connection.  The  jaundice 
is  vju'iable,  and  deepens  after  each  paroxysm.  1Mie  itching  may  be  most 
iiiiciise.  Pain,  which  is  sometimes  severe  and  colicky,  does  not  always 
occur.  There  may  be  marked  vomiting  and  nausea.  As  a  rule  there  is 
11(1  progressive  deterioration  of  health.  In  tlie  intervals  between  the  at- 
tacks the  tom2)erature  is  normal. 

The  clinical  history  and  the  post-mortem  examinations  in  my  cases* 
liavo  shown  conclusively  that  this  condition  may  persist  for  years  without 
a  tracts  of  suppuration  within  the  ducts. 

The  nature  of  the  hepatic  intermittent  fever  is  not  settled.  Charcot 
holds  that  it  is  due  to  the  production  of  a  ferment  in  the  bile-passages. 
15actcriological  studies  have  shown  that  in  all  these  cases  the  bile-passages 
arc  infected,  and  the  colon  bacillus,  the  streptococcus  pyogenes,  and  the 
micrococcus  lanceolatus  have  been  found.  This  local  infection  accounts 
for  the  recurring  attacks  of  fever,  and  also  for  the  proneness  to  secondary 
.-c|)ti('  processes,  endocarditis,  and  pericarditis. 

The  effect  upon  the  liver  of  chronic  obstruction  of  the  bile-duct  is 
very  variable.  The  organ  is  rarely  enlarged,  but  it  has  been  described  as 
(inn,  with  the  connective  tissue  moderately  increased.  Jn  none  of  my 
caries  of  jiersistent  obstruction  by  gall-stones  was  the  liver  greatly  enlarged, 
nor  (li(l  it  present  macroscopically  the  features  of  cirrhosis.  On  this  point 
iiiy  experience  is  in  accord  with  that  of  Sharkey,  Avho  has  recently  called 
in  (|iic>tion  the  statements  of  Charcot  and  Wickhain  Legg  as  to  the  occur- 
I'ciicc  of  cirrhosis  under  these  circumstances. 

(■.*)  Obstruction,  with  suppurative  cholangitis. 

When  suppurative  cholangitis  exists  the  mucosa  is  thickened,  often 
eroded  or  ulcerated  ;  there  may  be  extensive  suppuration  in  the  ducts 
tiiroiighout  the  liver,  and  even  empyema  of  the  gall-bladder.    Occasionally 


'Johns  Hopkins  Hospital  Reports,  vol.  il,  No.  1,  1890. 


+ 


'II 


li'^ 


!  >■' 


■<  s 


470 


DISEASES  OP  THE  DIGFISTIVE  SYSTEM, 


'■I  xi$ 


'  1-1  ( 


feff 


5  5  it 


hi 


till'  suppuration  exte.uls  beyond  tlie  diu^ta,  and  there  is  lot'alizcil  liver 
abscess,  or  there  is  perforation  of  the  gall-bladder  with  tlie  formal  idii  nf 
a.l)sr('ss  betwt'en  the  liver  and  stomach. 

('liniciilly  it  is  characterized  by  a  fever  which  may  be  inteniiilicnt,  Imt 
more  commonly  is  remittent  and  without  prohuiged  intervals  of  npvivxi;!. 
The  jaundice  is  rarely  so  intense,  nor  do  avc  see  the  deepenin<f  o!  tlir  coldr 
after  the  paroxysms.  There  is  usually  greater  enlargement  of  the  liver 
and  temlerness  and  more  definite  signs  of  septicanuia.  The  cases  nm  a 
shorter  course,  and  recovery  never  takes  place. 

;}.  The  More  Remote  Effects  of  Gall-stones.  —  (a)  Biliary  I'istnliv. 
These  are  ]U)t  uneoniinon.  There  nuiy,  for  instance,  be  abnoriii:il  ((iin. 
numication  between  the  gall-bladder  and  the  hepatic  duct  or  the  ;,'iiil- 
bladder  and  a  cavity  in  tiie  liver  itself.  More  rarely  perforation  occurs 
between  the  conunon  duct  and  the  jiortal  vein.  Of  this  there  arc  at  ku-t 
four  instances  on  r(;cord,  among  them  the  celebrated  case  of  Ignatius 
Loyola.  Perforation  into  the  abdominal  cavity  is  not  unconnnoii ;  lilt 
cases  exist  in  the  literature  (Courvoisier),  in  10  of  which  the  niptuiv 
occurred  directly  into  the  peritoneal  cavity;  in  40  there  was  encapsulated 
abscess.  Perforation  may  take  place  from  an  intrahepatic  l)rancli  cr 
from  the  hepatic,  common,  or  cystic  ducts.  Perforation  from  the  gall- 
bladder is  the  most  common. 

Fistulous  communications  between  the  bile-passages  and  the  gastro-in- 
testinal  canal  are  frequent.  Oj)enings  into  the  stomach  are  rare,  rx'twciii 
the  duodenum  and  bile-passages  they  are  much  more  common.  Cmir- 
voisier  has  collected  10  instances  of  coninmincation  between  the  ductus 
communis  and  the  duodenum,  and  T3  cases  between  the  gall-bladder  and 
the  duodenum.  Communication  with  the  ileum  and  jejunum  is  cxtrciiicly 
rare.  Of  fistulous  opening  into  the  colon- ;j!J  cases  are  on  record.  Tlicse 
communications  can  rarely  be  diagnosed ;  they  may  be  present  uitliout 
any  sym})toms  whatever.  It  is  probably  by  ulceration  into  the  dnodciiuui 
or  colon  that  the  large  gall-stones  escape. 

Occasionally  fistulous  communication  exists  between  the  gall-liladdcr 
and  the  urinary  ])assages,  and  the  stones  may  be  found  in  the  Idaddci'. 
The  opening  has  been  either  into  the  pelvis  of  the  kidney  or,  as  has 
been  supposed,  the  gall-bladder  has  become  adherent  in  the  ludglibor- 
luiod  of  the  navel,  and  the  stone  has  escaped  through  an  open  urai  liiis. 
It  is  possible  that  adhesions  may  form  between  the  distended  gidl-ldaddcr 
and  urinary  bladder,  since  the  former  has  been  found  adherent  as  low  as 
the  broad  ligament. 

j\Iany  instances  are  on  record  of  fistuliu  between  the  bile-]iassajros  and 
the  lungs.  C^ourvoisier  has  collected  twenty-four  cases.  Bile  may  Ik' 
coughed  up  with  the  expectoraticm,  sometimes  in  considerable  qnauiities. 
In  only  seven  cases  did  recovery  take  place.  In  some  of  these  the  alisicss 
formation  was  due  to  hydatids,  in  some  to  ascarides.  The  2)erfoi'ation  u-^ii- 
ally  takes  i)lace  through  the  lung,  by  a  liver  abscess  communicatiiii,'  with 


p 


DISEASKS  OF  TIIK   lULK-PASSACJES. 


471 


the  ]ili'iira,  or  oooasioiially  the  uljscoss  enters  tlio  niedinstimim  and  por- 
f(irahs  a  l)roiielius. 

or  all  listulous  communications  the  external  or  cutaneous  is  the  most 
(niniiiMU.  Courvoisier's  statistics  number  lS-4  cases,  in  fifty  per  cent  ol' 
wliicli  the  perforation  took  place  in  the  rijrht  liypochoudrium  ;  in  tweiity- 
I'liiio  |mt  cent  in  the  rej^non  of  the  navel,  'riu^  numher  of  stones  dis- 
ihiiiunil  varied  from  one  to  two  to  nuiny  huudivds.  K'eeovery  took  jdaco 
ill  Ts  ciises;  some  with,  some  without  operation. 

(//)  ()l)struction  of  the  bowel  by  gall-stone.s.  llefcrcnco  has  already 
hecii  made  to  this,  the  frcfpiency  whi(di  appears  from  the  fact  that 
of  -VX)  cases  of  obstruction,  occurring  during  eight  years,  analyzed  l)y 
Fit/.,  >';i  were  by  gall-stone.  Courvoisier's  statistics  give  a  total  number 
of  i:!l  cases,  in  six  of  which  the  calculi  had  a  ])eculiar  situation,  as  in  a 
(iiverticulum  or  in  the  appendix.  Of  the  remaining  T-i.")  cases,  in  70  the 
stone  was  spontaneously  passed,  usually  with  severe  symittonis.  The  post- 
ninrtciu  reports  show  tiiat  in  some  of  these  cases  even  very  large  stones 
have  passt'd  per  rinm  nafuralem,  as  the  gall-duct  has  beeu  enormously  dis- 
ti'iided,  its  orifice  adnutting  the  finger  freely.  This,  however,  is  extremely 
rare.    The  stones  have  been  found  most  commonly  in  the  ileum. 


Othku  Affkction's  of  the  Bili:-i)Ucts. 

Ciiiirrr  will  be  considered  later. 

Stt'iiosis  or  complete  occlusion  may  follow  ulceration,  most  commonly 
al'tcr  the  passage  of  a  gall-stone.  In  these  instaiui'S  the  obstru(!tion  is 
ii-ually  situated  low  down  in  the  common  duct.  Instances  of  this  are 
cxtrcinely  rare.  Foreign  bodies,  such  as  the  seeds  of  various  fi'uits,  may 
I'lilcr  the  duct,  and  occasionally  round  worms  crawl  into  it.  In  the  Wistar- 
liunier  .Museum  of  the  irniversity  of  rennsylvania  there  is  a  remarkable 
speciineii  showing  the  common  and  hepatic  ducts  enormously  distended 
and  densely  packed  with  a  dozen  or  more  lumbricoid  worms.  Similar 
sjieeiinciis  exist  in  one  of  the  Paris  museums,  and  at  the  Koyal  Victoria 
!l(is|tital,  Netley.  Liver-flukes  and  echiuococci  are  rare  causes  of  obstruc- 
tion in  man. 

Obstruction  by  ])rcssi(re  from  without  is  more  frequent.  Naturally 
oanicr  of  the  head  of  the  pancreas  is  apt  to  involve  the  terminal  portion 
of  till' duct ;  less  often  cancer  of  the  pylorus.  Secondary  involvement  of 
the  lyinph-glands  of  the  liver  is  a  common  cause  of  occlusion  of  the  duct, 
and  is  inct  with  in  many  cases  of  cancer  of  the  stonuich  and  other  abdomi- 
nal origans.  Kare  causes  of  obstruction  are  aneurism  of  a  branch  of  the 
cii'liiu;  axis  or  of  the  aorta,  or  pressure  of  very  large  abdominal  tumors. 

The  symptoms  jiroduced  are  those  of  chronic  obstructive  jaundice.  At 
Inst,  the  liver  is  usually  enlarged,  but  in  chronic  cases  it  may  be  reduced 
ill  size,  ;ni(l  pf  a  deeply  bronzed  color.  The  hepatic  intermittent  fever  may 
Iju  associated  with  occlusion  of  the  duct  from  any  cause,  but  it  is  most  fre- 


DISK  ASKS  OV  TIIK   DKIKSTIVK  SYSTKM. 


',  j'j 


I  i  ^- ' 


(|iu'iitly  met  with  in  clirniiic  olistructioii  by  giill-stoiicH.  IVrinniuiit  ocij,. 
sioii  of  the  (liict  tcriiiiiiatcs  in  di'iith.  In  a  majority  of  tlir  cases  iliccdn. 
(litioiis  wliicli  lead  to  tin*  ohstructiou  arc  in  tlicnisclvcs  I'atal.  (use:  if 
cicatricial  occlusion  may  last  for  years.  A  patient  under  my  cai',.,  wli^, 
wiis  iK-rnnmently  jaundiced  I'or  nearly  three  yi-ars,  had  a  lihroid  ucclusidji 
of  the  ditet. 

The  (iuujiiiixix  of  the  nature  of  the  occlusion  is  often  very  dilliciih.  \ 
history  of  colic,  jaundice  of  varyin<f  intensity,  paroxysms  of  pain,  und  in- 
termittent  fever  point  to  j^all-stones.  In  cancerous  obstruction  ihc  tiuiinr 
mass  can  sometimes  be  felt  in  the  epipistric  refjjion.  In  eases  in  \vlii(  h 
the  lymi)h  glands  in  the  transverse  fissure  are  caneerous,  the  |iiiiii;ii\ 
disease  may  bo  in  the  pelvic  organs  or  the  rectum,  or  there  ni;iv  lnj  ;i 
limited  cancer  of  the  stomach,  which  has  not  given  any  synipldms.  In 
these  eases  the  examination  of  tla^  other  lymphatic;  glands  nmv  lie  nf 
value.  In  a  ease,  recently  under  observation,  with  jaundice  of  scvm 
weeks'  duration,  and  believed  to  be  catarrhal  (as  the  patient's  geiifial  imi- 
dition  was  good  and  he  was  said  not  to  have  lost  flesh),  a  small  nii(liil;ir 
mass  was  detected  at  the  navel,  which  on  removal  proved  to  he  scirrlms. 
Involvement  of  the  clavicular  groujts  of  lymj)h  glands  may  also  he  scrviir- 
able  in  diagnosis.  As  already  mentioned,  the  gall-bladder  is  oftcii  Inn 
little  enlarged  in  obstruction  of  the  common  duet,  (ireat  and  progressive 
eidargement  of  the  liver  with  jaundice  and  moderate  continued  fever  is 
more  commonly  met  with  in  cancer.  In  hypertro])hie  cirrhosis  a  similar 
condition  exists,  but  the  organ  is  smooth  and  there  is  rarely  jjrogressivc 
enlargement  while  under  observation. 

Treatment  of  Gall-stones  and  their  Effects. — In  an  attiuk 

of  biliary  colic;  the  j)atient  should  he  kej)t  under  morphia,  given  IiyjKHlcr- 
mically,  in  quarter-grain  doses.  In  an  agonizing  paroxysm  it  is  well  tn 
give  a  whitr  or  two  of  chloroform  until  the  morphia  has  had  time  to  iiil. 
Great  I'clief  is  experienced  from  the  hot  bath  and  from  fomentatidiis  in 
the  region  of  the  liver.  The  i)atient  should  be  given  laxatives  and  should 
drink  copiously  of  alkaline  mineral  waters.  Olive  oil  has  proved  usule.v 
in  my  hands.  When  taken  in  large  cjuantities,  fatty  conci-etions  are  passi'il 
with  the  stools,  which  have  been  regarded  as  calculi;  and  concretions  due 
to  eating  pears  have  been  also  mistaken,  particularly  when  associated  with 
colic  attacks.  Since  the  days  of  Durande,  whose  mixture  of  ether  ami 
turpentine  is  still  largely  used  in  France,  various  remedies  have  beon 
advised  to  dissolve  the  stones  within  the  gall-bladder,  none  of  which  aiv 
efficacious. 

The  diet  should  be  regulated,  the  patient  should  take  regular  exercise 
and  avoid,  as  much  as  possible,  the  starchy  and  saccharine  foods.  The 
soda  salts  recommended  by  Prout  are  believed  to  prevent  the  ooiiceiitra- 
tion  of  the  bile  and  the  formation  of  gall-stones.  Either  the  suipliateor 
the  phosphate  may  be  taken  in  doses  of  from  one  to  two  draclinis  daily. 
For  the  intense  itching,  powdering  with  starch,  strong  alkaline  batlij 


B''  4    1 


\ 


"It:: 


DISEASES  OF  TIIK   niLE-I'ASSAGRS. 


473 


(hot),  I  ilr.c.'irpin  liypodormiciilly  (gr.  |-j^),  atid  uiitipyrin  (^r.  viij),  niiiy 
lie  trit'il.     hilitliyol  atid  liit'oliii  (tintnictit  soiiu'tiiiics  "rives  rcliof, 

Kx|)n'ssi(>ii  of  fijall-stoiics  from  the  hladdcr  by  di^fital  iiiaiii|tiilati()n,  as 
icioniiiH'iidcd  l)y  (i(H)rgo  Ilarloy,  is  a  liif^ldy  irrational  prcKscdiirc,  not  to 
bo  followed.  So  long  as  gall-stones  remain  in  the  Madder  they  do  little 
or  no  linrin  in  a  great  majority  of  cases.  To  fnrcv  them  on  int(  the  duct 
i:)  to  rt'iidtM'  the  patient  liable  to  severe  (!olic  or  to  the  still  more  serioiH 
iliin;,'!'!'  of  j)ermaiieiit  obstruction, 

Wlifii  the  cystic  duct  is  occluded  and  the  gall-bladder  distended,  an 
ixploralory  puncture  may  be  made,  as  practised  by  the  elder  Pepper,  in 
1S,')7,  ill  11  case  of  empyema  of  the  gall-bladder,  atid  by  l<artholo\v  in  ISI'K, 
The  iniiictiire  may  be  made  either  to  draw  oil'  iluid  from  a  distended  blad- 
der or  to  cxitlore  for  gall-stones.  Aspiration  is  usually  a  .safe  procedure, 
tli(iiij,di  11  fatal  result  has  followed.  When  the  gall-bladder  is  distended 
and  |iliiiiily  imlpiible,  to  sound  for  stones  by  an  exploratory  puncture  is 
jiisliliiil)l(',  but  uud(M'  no  other  circumstatu'es,  "  The  easy  aJid  safe  method 
(if  sounding  for  impacted  stones,"  recommended  a  few  years  ago  by  a  Lon- 
don pliysician,  in  which  it  is  advised  to  thrust  a  sharj)  needle  six  inches 
IdiiLf  lictwoen  the  navel  and  the  margin  of  the  liver,  may  be  characterized 
lis  out!  of  the  most  extraordinary  operations  ever  advocated,  and  would 
liinl)iil)ly  always  prove  fatal,  as  in  the  ease  of  the  unhai)py  victim  u])on 
win  III)  il  WHS  practised, 

'I'lu'  surgiftal  treatment  of  gall-stones  has  of  late  years  made  rapid 
lirogri'ss.  'J'he  ojjeration  of  cholecystotomy,  or  opening  the  gall-bladder 
mid  rciiioving  the  stones,  which  was  advised  by  Sims,  has  been  remark- 
ably .successful,  i)articularly  in  the  haiuls  of  Lavson  Tait.  The  removal 
of  the  gall-bladder,  cholecystectomy,  has  also  been  practised  with  success. 
The  indications  for  operation  are  :  (a)  Repeated  atta(!ks  of  gall-stone  colic, 
of  great  severity  and  danger,  (b)  The  presence  of  a  distended  gall-bladder, 
ii.-s(iei!iteil  with  attacks  of  pain  or  with  fever.  Many  cases  of  obstruction 
<if  the  cystic  duct  with  moderate  distention  of  the  gall-bladder  produce 
little  or  no  inconvenience,  and  perfect  recovery  may  take  place  with  con- 
tnietiou  and  obliteration,  (r)  When  a  gall-stone  is  permanently  lodged  in 
the  einninoii  duct,  and  presents  the  group  of  symptoms  above  described. 
It  must,  however,  be  bonie  in  mind  that,  contrary  to  the  experiences  of 
Charcot  and  other  Freiich  writers,  three  of  my  cases  recovered — one  after 
persistence  of  the  condition  for  eight  months,  another  for  three  years ;  two 
died  of  the  eifects  of  the  prolonged  jaundice,  and  two  after  opcsration. 
I  he  question,  then,  of  advising  removal  in  such  cases  should  depend 
'iii'Kely  upon  the  personal  methods  and  success  of  the  surgeon  who  is 
iiviuliihle.  The  common  duct  has  been  explored  and  gall-stones  removed 
from  it.  The  operation  is  necessarily  much  more  serious  and  difficult 
tliiin  that  upon  the  gall-bladder. 


i;  f..' 


Hum 
4 1  f 

0''i  ill 


81 


474 


LISEASKS  OK  Tin:   DKiKSTIVE  SV.STEIM. 


IV.  CIRRHOSIS. 


i 


11  < 


%l: 


-.*'*,<•» 

..-!..'"( 


•i'l 


Definition. — A  chronic  disnisc  of  the  liver,  chiiruftcrizod  by  a  f,'ra(]uiil 
dostruction  of  livt'r-(!olls  iiiul  an  ovcrfjjrovvtii  of  coiimictivo-tissiu'  clcmcuts 
in  coiisiMiUfnco  of  wliich  the  or/,'un  Itccoint'S  hard  and  usually  small. 

Etiology. — The  discasi'  ((cciirs  niosl  frcciucntly  in  niiddlc-aLrid  iniilis. 
It  has  Ik-cii  H'^rardcd  as  ran*  in  chikUvn,  I'xci-pt  in  llu;  syphilitic  Inrm.  Imt 
rainier  Howard  colk'cU'd  (i;{  cases,  to  which  list  llatlield,  in  n  lurthcr 
Bcarch  of  the  literature,  has  been  alile  to  add  lilJ,  so  that  its  occiirreiKT  in 
early  life  is  more  coninion  than  lias  been  supposed. 

'I'lu'  followint,'  are  the  rcc(ii>iiized  factors  in  iiiducing  the  disease;  (n) 
AIco/kiL — 'i'he  abuse  of  spirits  is  the  coiuiuon  cause.  It  is  more  fri'(|iiciit 
'm  countries  in  which  strong  spirits  are  taken  than  in  those  in  wliieh  limit 
li({Uors  and  wines  are  used.  'I'he  change  results  from  the  irritative  cirtct 
of  the  stroiig  solution  of  alcolml  absorbed  from  the  stomach.  Tlie  fiiMJ 
oil  is  thought  to  be  the  oU'ending  material.  Similar  elTects  are  ddulitk^s 
produced  by  other  substances,  such  as  rich,  highly  seasoneil  l'(»u(ls,  or,  as 
has  bei'ii  suggested,  by  ])tomaines  and  other  alkaloids. 

{/'}  Si/p/t i[is. — We  have  already  considered  (under  8y|ihilis)  the  fouiis 
of  cirrhosis,  ditfiise  and  gummatous,  [)roduced  by  this  poison. 

(r)  Cyanolic  Cun(/esliu/i. — In  cases  of  chronic  disease  of  the  heart  and 
lungs  tholTvcr  is  in  a  condition  of  itersistent  venous  hyponemia,  in  (diix- 
quence  of  which  the  central  cells  of  the  liver  lobules  atrophy  and  tluiv  h 
hyperplasia  of  the  connective  tissue. 

{(I)  Mfilaria. — Sclerosis  of  the  liver  may  follow  prolonged  malarial 
poisoning.     In  this  country  it  is  very  rare. 

((')  Tti(icrcuh)si£. — We  ha.ve  already  referred  to  the  sclerotic  chanfrcs  in 
the  liver  produced  by  tuberculosis.  It  rarely,  if  ever,  indices  a  coiulitidii 
which  can  be  recognized  clinically. 

(/)  Smrh't  Fevrr. — IMie  fact  noted  by  Klein  that  in  scarlet  fever  th.'ir 
was  an  infiltration  W'ith  small  cells,  an  acute  interstitial  hepatitis,  gi'os  a 
clew  to  the  occurrence  of  some  of  the  cases  of  cirrhosis  of  the  liver  i:.  chil- 
dren. In  other  infectious  diseases,  too,  such  as  typhoid,  there  are  Incaliznl 
necrotic  areas  which  must  be  replaced  by  connective  tissue.  In  the  cir- 
rhosis of  early  life,  excluding  the  alcoholic  and  syphilitic  cases,  the  acute 
infectious  diseases  are  probably  the  important  antecedents. 

{(j)  Ridiets, — The  erdargement  of  the  liver  in  this  disease  is  assofiatcd 
with  increase  in  the  connective  tissue,  which  surrounds  the  i.idividiial 
lobules  ami  produces  changes  in  the  bile-ducts  (Ilodgben). 

[h)  Atithmcoms. — It  occasionally  happens  in  coal-miners  that  thooiir- 
bon  pigment  reaches  the  liver  in  large  quantities,  is  deposited  in  tlic  con- 
nective tissue  about  tht  j)ortal  canal,  and  may  lead  to  a  variety  of  cirrhosis 
which  has  been  described  by  Welch. 

In  animals,  artificial  obstruction  of  the  bile-passages  results  in  cirrhosis, 
but  in  man  there  may  be  persistent  stenosis  of  the  common  duct  or  ob- 


iR;3!la 


CIUIUIUSIS. 


47.-) 


strnctimi  witluKit  marked  iTifrcasc  in  the  enmu'ctivo  tissue.    The  onuses 
tthicli  iiiduci!  the  eirrliosis  wliicli  wo  meet  ut  llie  hedsido  aro  uleohol  and 

syiiliili-'. 

Morbid  Anatomy. — Pnieticully  du  the  post-inortein  table  we  aeo 
lirilidsis  ill  four  well-elianu'terized  t'drms  : 

(II)  The  Atmpliic  Cirrliasis  nf  L<n'niirr. — The  orj^'an  is  greatly  re- 
iliiird  ill  size  and  may  be  defurriicd.  'I'iie  wei<,dit  is  sometimes  not  more 
tli.iii  ;t  |><iiiiid  or  u  pound  and  a  iialf.  It  presents  numerous  ^M'anuia- 
tjdiis  nil  till'  surface;  is  lirm,  hard,  and  cuts  with  <,'reat  resistance.  'J'iie 
suiistiUice  is  seen  to  b(*  llliuTe  up  of  j^reenish-yelh)W  ishmds,  surrouiKh'd  by 
irniyisli-wliite  connective  tissue.  'I'liTs  yellow  appearance^  of  tiu(  liver  in- 
liiiicij  iiiU'iiiiec  to  jjive  it  the  name  of  cirrhosis. 

(h)  Fiif/i/  Cirr/iost's. — I']ven  in  the  atrophic  form  the  fat  is  increased, 
liut  in  typical  e.\anii»ics  of  tiiis  variety  the  organ  is  not  reduced  in  size, 
liiit  is  ciiliirm'd,  smooth  or  very  siij^ditiy  j,'ranular,  ana'inic,  yeUowish  white 
ill  iiildp,  and  resembles  an  (trdinary  fatty  liver.  Ft  is,  however,  lirni,  cuts 
with  resistance,  and  microscopically  shows  a  great  increase  in  the  coiincct- 
iw  tissue.  This  form  is  (piite  as  common  in  this  country  as  the  atrophic 
variity.     it  occurs  most  fre((iieiitly  in  beer-drinkers. 

{(■)  Ihipi'i'trapliir  ('irr/iosis. —  Knlargement  of  the  liver  occurs  in  the 
fiiiiv  st.igi!  of  the  ordinary  atrophic  cirrhosis,  but  the  increa.se  is  moderate 
1111(1  largely  due  to  liyiK^a'inia.  The  fatty  cirrhotit!  liver  is  also  large,  and 
may  niicli  a  hand's-hreadth  below  the  costal  nuirgin.  'I'ho  term  hy|)er- 
ti'iiiiliic  cirrhosis  should  be  restrictiul  to  the  form  described  by  French 
wrilfi's,  which  is  also  km)wn  as  hiliitnj  cirrhosis.  Unfortumitidy,  this  has 
Ih'cu  used  by  .some  writers  to  iiudude  as  well  the  ca.ses  in  whi(di  there  hay 
liciii  iicnnanont  oeclusioii  of  the  duct,  either  by  stricture  or  a  calculus} 
till'  induration,  however,  is  slight  under  the.se  circumstances  and  hyper- 
tmiijiy  very  rare.  Jt  seems  best  to  limit  the  terms  hiliary  and  /n/perfro/ihie 
ririiiosis  to  the  form  characttM'ized  by  permanent  enlargement  of  the  liver, 
;i  niaikeil  involvement  of  the  smaller  biliary  canaliculi,  and  retention  in 
an  unusuiil  degree,  in  comparison  with  atrophic  cirrhosis,  of  the  nuniher 
aiul  form  of  the  liver-cells,  in  spite  of  the  great  increase  of  the  lobular 
iiiiniective  tissue.  In  this  form  the  liver  is  greatly  etdarged  ;  in  one  of 
my  cases  it  weighed  seven  poiiiuls.  The  surface  is  smooth,  it  is  exceed- 
ingly tirni,  resists  cutting,  and  presents  on  section  a  deep  greenish-yellow 
I'llor.    All  of  my  cases  have  been  in  hard  drinkers. 

('/)  I'fn'/i('j)(ifiiis  ;  (flissnninn  Cirrhosis. — Tn  this  forrr  the  liver  18 
^.Tcatiy  reduced  in  size,  much  altered  in  shape,  and  everywhere  surrounded 
liy  a  tinu  grayish-white  membrane,  sometimes  of  semi-cartilaginous  con- 
sistt'iieo,  viirying  from  10  to  15  mm.  in  thickness^  This  fibrous  investment 
I'lm  be  stripped  off  readily,  and  the  liver  substance  may  look  almost  nor- 
"liil,  but  usually  shows  cirrhotic  changes.  The  capsular  thickening  may 
'•P  slight,  and  the  portal  connective  tissue  chiefly  involved.  The  capsule 
uf  the  spleen  is,  as  a  rule,  similarly  affected,  and  both  processes  are  asso- 


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47<{ 


DISEASES  OP  THE   DIGESTIVE  SYSTEM. 


ciaU-A  with  a  proliferative  peritonitis.     The  condition  \n  rr  ^=t  frofjueut  as 
a  rcrtult  of  alcohol,  but  occurs  also  in  instances  of  cyanotic  intlunilion. 

The  two  essential  elements  in  cirrhosis  are  destruction  of  livor-cclLs 
utid  obstruction  to  the  portal  circulation. 

.  In  an  autopsy  on  a  case  of  atrophic  cirrliosis  the  i)eritona;uni  is  usualh' 
found  to  contain  a  large  quantity  of  fluid,  the  membrane  is  opii(|iie,  and 
iht.Tc  is  chronic  catarrh  of  tlie  stdiiiach  and  of  the  small  intestines.  Tlie 
kidneys  are  sometimes  cirrhotic,  the  bases  of  the  lungs  may  be  imich  coni- 
prert.'fod  by  the  ascitic  fluid,  the  heart  often  shows  marked  degeiionitinii. 
and  arterio-sclerosis  is  usually  present.  A  remarkable  feature  is  the  asso- 
f;iation  of  acute  tuberculosis  with  cii-rhosis.  In  sev(!n  cases  of  my  series 
the  j.atients  died  with,  either  acute  tuberculous  peritonitis  or  acuto  tuber- 
culous }»leurisy.  Pitt  states  that  twenty-two  ajid  a  half  per  cent  of  the 
csmen  of  cirrhosis  dying  in  Guy's  Hospital  during  twelve  years  hud  acute 
tuberculosis. 

The  comt)cnsatory  circulation  is  usually  readily  demonstrated.  It  is 
carried  out  by  the  following  set  of  vessels :  (1)  The  accessory  ])ortal  system 
of  Sajjpey,  of  which  important  branches  pass  in  the  round  and  siis])ensorv 
ligaments  and  unite  with  the  epigastric  and  mammary  systems.  These 
vc'j«els  are  numerous  and  small.  Occasionally  a  large  single  vein,  wliieh 
may  attain  the  size  of  the  little  linger,  passes  from  the  hiliis  of  the  liver  in 
the  round  ligament,  and  joins  the  epigastric  veins  at  the  navel.  Although 
tlii.>»  has  the  i)osition  of  the  umbilical  vein,  it  is  usually,  as  Sajipcy  showed. 
a  para-umbilical  vein— that  is,  an  enlarged  vein  l)y  the  side  of  the  obliter- 
ated umbilical  vessel.  There  may  be  produced  about  the  navel  a  hufre 
hunch  of  varices,  the  so-called  caput  Medusas.  Other  branclus  of  this 
svHtem  occur  in  the  gastro-epiploic  omeritum,  about  the  gall-bladder,  and, 
moflt  importiint  of  all,  in  the  suspensory  ligament.  These  latter  form 
large  branches,  which  anastomose  freely  with  the  diaphragmatic  veins,  and 
n(i  unite  with  the  vena  azygos.  (2)  By  the  anastomosis  between  the  o'.soph- 
agf;al  and  gastric  veins.  The  veins  at  the  lower  end  of  the  (I'sopiiagus 
may  be  enormously  enlarged,  producing  varices  which  project  on  the 
mucous  membrane.  (3)  The  communications  between  the  hiemorrhoidal 
and  the  inferior  mesenteric  veins.  The  freedom  of  conmmnication  in  this 
direction  is  very  variable,  and  in  some  instances  the  ha-morrhoidal  veins 
are  not  much  eidarged.  (4)  The  veins  of  Retzius,  which  unite  the  ladiclos 
of  the  porta!  branches  in  the  intestines  and  mesentery  with  the  iiiferinr 
vena  cava  and  its  branches.  To  this  system  belong  the  whole  group  of 
retroperitoneal  veins,  which  are  in  most  instances  enormously  cnlarfjed, 
jmrticularly  about  the  kidneys,  and  wliich  serve  to  carry  off  a  coiisidorablo 
proportion  of  the  portal  blood. 

Symptoms. — (a)  Of  the  Atrophic  Form. — The  most  extreme  jifradLof 
atrof)hic  cirrhosis  may  exist  without  symptoms.  So  lonfj  as  the  rompen- 
i/t£orji  rircuhition  is  maintained  the  patient  may  suffer  little  or  no  iiu'on- 
▼eaience,    The  remarkahle"  efficiencv  of  this  collateral  circulation  is  well 


CIKRIIOSIS. 


477 


scon  ill  tlifirfo  rare  instances  of  permanent  obliteration  of  the  portal  vein. 
TIr' svinptoms  may  be  (livi<lc(l  into  two  groups — ()bstructive  and  toxic. 

Ohslnirtim: — The  ovei'lilling  of  the  blood-vessels  of  the  stomach  and 
intestine  loads  to  chronic  catarrh,  and  the  patients  sulfer  with  nausea 
anil  vomiting,  particularly  in  the  morning;  the  tongue  is  furred  and  the 
bowL'ls  are  irregular.  Ilannorrhage  from  the  stomach  may  be  an  early 
svm))t<ii(i ;  it  is  often  profuse  and  liable  to  recur.  It  seldom  proves  fatal. 
Tilt'  aiiioiiiit  vomited  may  be  remarkable,  as  in  a  case  already  referred  to, 
in  wliicli  ten  pounds  were  ejected  in  seven  days.  P'oUowing  the  ha?mate- 
mesis  nieliviia  is  common  ;  but  hajmorrhages  from  tlie  bowels  may  occur 
tor  several  years  without  haMnatemesis.  Enlargement  of  the  spleen  occurs 
from  tlio  ehronic  congestion.  Tlie  organ  can  usually  be  felt.  Evidences 
of  the  establishment  of  the  collateral  circulation  are  seen  in  the  enlarged 
cpiiliistric  and  mammary  veins,  n)ore  rarely  in  the  presence  of  the  ca2)ut 
Mctlusa'  and  in  the  develo2)ment  of  haMuorrhoids.  The  distended  venules  in 
the  lower  tiioracic  zone  along  the  line  of  attiichment  of  the  diaphragm  are 
not  specially  marked  in  cirrhosis.  The  most  striking  feature  of  failure  in 
the  compensatory  circulation  is  ascites,  the  effusion  of  serous  fluid  into  the 
peritoneal  cavity.  The  conditions  under  which  i\\h  occurs  are  still  ob- 
scure. Tlie  abdomen  gradually  distends,  may  reach  a  large  size,  and  con- 
tain as  niiu'h  as  15  or  30  litres.  (P^tlema  of  the  feet  may  precede  or  develop 
with  the  ascites.     The  dropsy  rarely  becomes  general. 

Jiiundice  is  usually  slight,  and  was  ])resent  in  only  35  of  130  cases  of 
cirrhosis  reported  by  Fagge.  The  skin  has  frequently  a  sallow,  slightly 
iiteroid  tint.  The  urine  is  often  reduced  in  amount,  c(m+ains  urates  in 
almiidance,  often  a  slight  amount  of  albumen,  and,  if  jaundice  is  intense, 
tube-easts.  The  disease  may  be  afebrile  throughout,  but  in  many  cases, 
as  shown  by  ('arrington,  there  is  slight  fever,  from  100°  to  102-5°, 

Exainiiiation  in  the  early  stage  of  the  disease  may  show  moderate  en- 
lari^eiiient  of  the  liver,  which  may  be  painful  on  pressure.  At  this  period 
tlie  patii'iit  may  come  under  observation  for  dys])epsia,  ha>matemesis,  slight 
jaiuulice,  or  nervous  symptoms.  Later  in  the  disease,  the  patient  has  an 
iiinnistakablc  hepatic  facies;  he  is  tliin,  the  eyes  are  sunken,  the  conjunc- 
tivii;  watery,  \\w.  nose  and  cheeks  show  distended  venules,  and  the  complex- 
ion is  n.,!!My  or  icteroid.  On  the  enlarged  abdomen  the  ves.sels  are  dis- 
tended, and  a  bunch  of  dilated  veins  may  surround  the  navel.  When 
iiuieh  iiiiid  is  in  the  peritonaeum  it  is  impossible  to  make  a  satisfactory  ex- 
iiM'inatioti,  but  after  withdrawal  the  area  of  liver  dulness  is  found  to  be 
diniinislied,  particuhirly  in  the  middle  line,  ami  on  deep  pressure  the  edge 
of  the  liver  can  be  detected,  and  occasionally  the  hard,  firm,  and  even 
I'liimilar  surface.  The  spleen  can  be  felt  in  the  left  liypochondriac  region, 
hxaniiiiation  of  the  anus  may  reveal  the  })resence  of  hiemorrhoids. 

Titxic  Sj/mpfomx. — At  any  stage  of  atrophic  cirrhosis  the  patient  may 
develop  cerebral  symptoms,  either  a  noisy,  joyous  delirium,  or  stupor, 
'■oina,  or  even  convulsions.     The  condition  is  not  infrequently  mistaken  for 


W  \  'If 


--.  I 


id'" 


478 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


ursBffip.  The  nature  of  the  toxic  agent  is  not  yet  settled.  Tlie  symptoms 
may  develop  without  jaundice,  and  cannot  be  attributed  to  cliolu'iniu,  uih! 
they  may  come  ou  in  hospital  when  the  patient  has  not  had  ukoliul  fir 
weeks. 

The  fatty  cirrhotic  liver  may  produce  symptoms  similar  to  tbosc^f  the 
atrophic  form,  but  it  more  frequently  is  latent  and  is  found  uccidi'iitnllv 
in  topers  who  liave  died  from  various  diseases.  The  greater  nunihci'df 
the  cases  clinically  diagnosed  tia  cirrhosis  with  enlargement  coino  in  tliis 
division. 

(b)  HyjjertropMc  or  biliary  cirrhosis  has  a  definite  and  (listimtivo 
symptomatology.  Tlie  liver  may  be  enlarged  for  months  or  cvi'ii  years, 
Jaundice  persists  for  some  tirue,  ou  which  jjoint  French  writers  hiy  gnat 
stTess.  It  may,  however,  come  on  acutely  with  the  other  syniptoiiis.  Jt 
is  intense,  like  an  obstructive  jaundice,  but,  as  u  rule,  the^stools  jire  liilf- 
staineil.  It  may  continue  for  a  k)ng  time  without  the  deveI(>j)iiK'iit  df 
other  syni})toms;  then  delirium  sets  in  and  all  the  features  of  an  ai  ute 
febrile  jaundice.  The  tongue  is  dry,  the  pulse  ra[)id,  tlie  teiiiporaliirc 
ranges  from  lO'l"  to  104°,  and  i)etechiie  occur  on  the  skin.  The  patient 
may  present  every  fei'.ture  of  acute  yellow  atrophy,  including  even  the 
convulsive  seizures.  The  attack  in  one  of  my  cases  proved  fatal  within 
ten  days;  in  another  it  was  prolonged  for  three  weeks.  Ascites  dcies  n«it 
develop).  The^  enlargement  of  the  liver  may  be  the  sole  diagnostic  erite- 
rion  o'rween  these  cases  and  acute  yellow  atrophy.  I  do  not  know,  linv- 
ever,  of  the  occurrence  of  leucin  or  tyrosin  in  the  urine  in  this  coiiditidii. 

{c)  The  perihepatitis  with  cirrhosis  cannot  be  distinguished  from  tiie 
ordinary  atrophic  form. 

Diagnosis. — With  ascites,  a  vrell-marked  history  of  aleoliolisin,  the 
hejiatic  facies,  and  lia^morrhage  from  the  stomach  or  bowels,  the  dia;'- 
nosis  is  rarely  doubtful.  If,  after  withdrawal  of  the  fluid,  the  s|ileeii  is 
found  to  be  enlarged  and  the  hVer  either  not  palpable  or,  if  it  is  en- 
larged, hard  and  regular,  the  ]>robabilities  in  favor  of  cirrhosis  are  very 
great.  In  the  early  stages  of  the  disease,  when  the  liver  is  increased  in 
size,  it  may  be  impossible  to  say  whether  it  is  a  cirrhotic  or  a  fatty  liver. 
The  differential  diagnosis  between  comtuon  and  s^hilitic  cirrliosisran 
sometimes  be  made.  A  marked  history  of  syphilis  or  the  existence  nf 
other  syphilitic  lesions,  witli^  great  irregularity  in  the  surface  or  at  the 
edge  of  the  liver,  are  the  points  in  favor  of  the  latter.  Thrombosis  (ir 
obliteration  of  the  portal  \ein  can  rarely  be  differentiated  In  the  casenf 
fibroid  transformation  of  the  portal  veil  which  came  under  my  observa- 
tion, the  collateral  circulation  had  been  established  for  years,  and  the 
symptoms  were  simply  those  of  extreme  portal  obstruction,  8U(  b  us  occur 
in  cirrhosis.  Thrombosis  of  the  portal  vein  is  frequent  in  cirrhosis  ami 
may  be  characterized  by  a  ra])idly  developing  ascites. 

Prognosis. — The  i)rognosis  is,  as  a  rule,  bad.  When  the  ctdliiteral 
circulation  is  fully  established  the  jjatient  may  have  no  symptoms  Mluit- 


CIRRnOSIS. 


479 


ever.  Three  cases  of  advanced  atrophic  cirrhosis  have  died  nnder  my  oh- 
pervatiou  of  other  aifections  without  presenting  during  life  any  syin[)toin8 
|i(iiiitiiig  to  disease  of  tlie  liver.  There  are  instances,  too,  of  eidargement 
,il'  tlic  liver,  slight  jaundice,  cerebral  symptoms,  and  even  ha'nuitemesis,  in 
wliicli  the  liver  becomes  reduced  in  size,  the  symptoms  disappear,  and  the 
patit'iit  may  live  in  comparative  comfort  for  many  years.  Then;  are  many 
cases,  too,  in  which,  after  one  or  two  tappings,  the  symjitoms  have  disap- 
peared aiul  the  i)atients  have  apparently  recovered. 

Treatment. — Ordinary  cirrhosis  of  the  liver  is  an  incurable  disease. 
MiUiy  writers,  speaking  of  the  curability  of  certain  forms,  show  a  lack  of 
apiircc'.ition  of  the  essential  conditions  ui)on  which  the  symptoms  depend. 
So  far  as  we  have  any  knowledge,  no  remedies  at  our  disposal  can  alter  or 
roiiiove  the  cicatricial  connective  tissue  which  constitutes  the  materia 
pirridtx  in  ordinary  cirrhosis.  On  the  other  hand,  we  know  that  extreme 
grades  of  contraction  of  the  liver  may  persist  for  years  without  symptoms 
when  tlie  compensatory  circulation  exists.  1'he  so-called  cure  of  cirrhosis 
means  the  re-establishment  of  this  compensation ;  and  it  would  be  as  un- 
reasonable to  speak  of  healing  a  chronic  valvular  lesion  when  with  digi- 
talis we  have  restored  the  circulatory  balance  as  it  is  to  speak  of  curing 
cirrhosis  of  the  liver  when  by  ta})ping  and  other  measures  the  compensa- 
tion lias  in  some  way  been  restored. 

The  patient  should  abstain  entirely  from  alcohol,  and,  if  possible,  should  • 
take  a  inilk  di.'t,  which  has  been  highly  recommended  by  Semnudiu—  In 
any  cas>.',  the  diet  should  ])e  nutritious,  but  not  too  rich.  Pleasures  should 
be  employed  to  reduce  the  gastro-intestinal  catarrh,  and  tlie  patient  should 
lead  a  (juiet,  out-of-door  life  and  keep  the  skin  active,.tlie  bowels  regular, 
and  the  urine  abundant.  In  non-syphilitic  cases  it  is  useless  to  give  either 
mercury  or  iodide  of  potassium.  When  a  well-niarked  history  of  syphilis 
exists  these  remedies  should  be  used,  but  neither  of  them  has  any  more 
influence  upon  the  development  of  a  new  growth  of  connective  tissue  in 
t!ic  liver  than  it  has  upon  the  progressive  development  of  a  scar  tissue  in 
a  k(d(iid  or  in  an  ordinary  developing  cicatrix.  The  ascites  should  bo 
tapjicd  early,  and  the  operation  may  l)e  rei)eated  so  soon  as  tlie  distention 
heciinies  distressing.  The  contiiuious  drainage  with  a  Southey's  tube  may 
lie  employed.  It  is  much  better  to  resort  to  tapping  early  if  after  a  few 
(lays'  trial  the  fluid  does  not  subside  rapidly  under  the  use  of  saline  jiurges. 
I'"n)ni  half  an  ounce  to  an  ounce  and  a  half  of  sulphate  of  magnesia  may 
iH'.iriveii  in  as  little  water  as  jwssiblo  half  an  hour  bffore  breakfast.  Elate- 
lium,  the  compound  jalap  powder,  or  the  bitartrate  of  potash  may  also  bo 
employed.  Digitalis  and  squills  are  often  useful.  In  the  syphilitic  cases 
or  when  syphilis  is  suspected  iodide  of  potassium  may  be  given  in  doses  of 
from  lifteon  to  thirty  drops  of  the  saturated  solution  three  times  a  day, 
aiid  mercury,  whicdi  is  conveniently  given  with  squills  and  digitalis  in  the 
form  of  Addison's  or  >.'iemcyer's  pill.  A  case  of  well-marked  sy])hilitic 
cirrhosis  with  recurring  ascites,  in  wliicli  tapping  was  resorted  to  ou  eight 


''■;-'x.^ 


Iti'i' 


'■  'K 


(  , :  f 


'  \i. 


tikr 


480 


DISEASES  OP  THE  DIGP^STIVE  SYSTEM. 


or  ten  occasions,  took  this  pill  at  JTitorvals  for  a  year  with  the  greatest  bene- 
fit, aud  subsequently  had  four  years  of  tolerably  good  health. 


V.  ABSCESS   OF  THE   LIVER. 


i'i 


i     f  3  ' 

— Ht  — '       —-^  ■ 


Etiology. — Suppuration  within  the  liver,  either  in  the  paroiichvniii 
or  in  the  blood  or  bile  passages,  occurs  under  the  following  condiijdns: 

(1)  'riic  tropical  abscess.  In  hot  elitnates  this  form  may  develop  idio- 
I)athically,  but  more  commonly  follows  dysentery.  It  frequc^ntlv  oeoiirs 
among  Europeans  in  India,  i)articularly  those  who  drink  alcohol  frcclvmul 
are  exposed  to  great  heat.  The  relation  of  this  form  of  abscess  to  dysen- 
tery is  still  under  discussion,  and  Anglo-Indian  practitioners  are  bv  ni> 
means  unanimous  on  the  subject.  Certainly  cases  may  develo])  witlidiit 
a  history  of  previous  dysentery,  and  there  have  been  fatal  cas;'s  without 
any  alfection  of  the  large  bowel.  In  this  country  the  largo  solitary  tropi- 
cal abscess  also  occurs,  oftenest  in  the  Southern  States.  In  Baltiiiinre  it 
is  not  very  infrequent,  as  may  be  judged  from  the  fact  that  during  two 
years  there  have  been  at  my  clinic  five  cases,  and  I  know  of  the  occurreiK  n 
of  three  or  four  additional  cases  during  this  time  in  the  city. 

The  relation  of  this  form  of  abscess  to  the  amoeha  coli  has  boon  cnrc- 
fully  studied  by  Kartulis  and  exhaustively  considered  in  a  monograpli  liv 
Councilman  and  Lafleur,  The  descriptions  and  illustrations  of  tluso 
authors  are  most  convincing  as  to  the  direct  etiological  association  of  this 
organism  with  liver  abscess.  Clinically  the  patient  may  have  aiiHeba  vuli 
in  the  stools  and  well-marked  signs  of  liver  abscess  without  nuu'kod  symp- 
toms of  dysentery  and  even  with  the  foeces  well  formed. 

(2)  Traunuitism  is  an  oc(;asional  cause.'  The  injury  is  generally  in  the 
hepatic  region.  Two  instances  have  come  under  my  notice  of  it  in  hnike- 
men  who  were  injured  while  coupling  cars.  Injury  of  the  head  is  not  in- 
frequently followed  by  liver  abscess. 

(3)  Embolic  or  pya'mic!  abscesses  arc  the  most  numerous,  and  may  de- 
velop in  a  general  '  yannia  from  any  cause  or  follow  foci  of  suppuration  in 
the  territory  of  i.Ue  jxirtal  vessels.  Tiio  infective  agents  may  roach  the 
liver  through  the  hepatic  artery,  as  in  those  cases  in  which  the  ()ri,ffiiial 
focus  of  infection  is  in  tlie  area  of  the  systemic  circulation  ;  though  it  may 
happen  occasionally  that  the  infective  agent,  instead  of  i)iissing  tlinnijrii 
the  lungs,  reaches  the  liver  through  the  inferior  vena  cava  and  tlu^  liopatii' 
veins.  A  remarkable  instance  of  multi[)le  al)S(!esses  of  arterial  origin  was 
alforded  l)y  the  case  of  aneurism  of  the  hepatic  artery  reportoil  l)y  l!i  .-s 
and  myself.  Infe(,'tion  tiirougli  the  portal  vein  is  much  more  (■(minioii. 
It  results  from  dysentery  and  other  ulcerative  affections  of  tlio  bowels, 
appendicitis,  ocicasioually  aftc'r  typhoid  fever,  in  rectal  affections,  uiul  ni 
abseessc:5  in  the  pelvis.  In  these  eases  the  abscesses  are  multiple  ami,  as  a 
r-ilc,  witliin  the  branches  of  the  portal  vein— suppurative  pylephlebitis. 


ABSCESS  OF  THE  LIVER. 


481 


(4)  A  not  uncommon  cause  of  suppuration  k  inflammation  of  the  bile- 
passairt'S  caused  by  gall-stones,  more  rarely  by  parasites — suppurative  cho- 
langitis. 

In  some  instances  of  tuberculosi.<«  of  the  liver  the  affection  is  chielly  of 
the  liili'-iUicts,  with  the  formation  of  multiple  tuberculous  abscesses  con- 
tiuniiig  a  bile-stained  i)us. 

(,"i)  Foreign  bodies  and  parasites.  In  rare  instances  foreign  bodies, 
such  as  M  needle,  may  pass  from  tlie  stomach  or  gullet,  lodge  iu  the  liver, 
1111(1  cxcilo  an  abscess,  or,  as  in  several  instances  which  have  been  I'cported, 
a  foreign  body,  such  as  a  needle  or  a  fish-bone,  may  jierforate  a  branch  or 
the  portal  vein  itself  and  induce  extensive  pylephlebitis.  Echinococcus 
cvsts  frequently  cause  supjiuration ;  the  })enetration  of  round  worms  into 
the  liver  less  commonly ;  and  most  rarely  of  all  the  liver-fluke. 

Morbid  Anatomy. — (a)  Offhe  Solilari/  or  'Trajiiral  Abscess. — This 
is  not  always  single  ;  there  may  be  two  or  even  more  large  af)S('ess  cavities, 
1'iUii.niig  in  size  from  an  orange  to  a  (;hild"s  head.  The  largest-sized  ab- 
scess nuiy  contain  from  three  to  six  litres  of  pus  and  involve  more  than 
three  fourths  of  the  entire  organ.  In  "Waring's  statistics,  sixty-two  per 
cent  of  tile  eases  were  single.  The  abscess  in  nearly  seventy  per  cent  of 
tlie  cases  was  in  the  right  lobe,  more  toward  tlio  convexity  than  the  con- 
cave side.  In  long-standing  cases  the  abscess-wall  may  be  lirm  and  thick, 
but,  as  a  rule,  the  cavity  possesses  no  definite  limiting  membrane,  and  sec- 
tinn  of  the  wall  shows  an  internal  layer,  grayish  in  color,  shreddy,  and 
iiKidc  up  of  necrotic  liver  substance,  pus-cells,  aiul  amu'ba' ;  a  middle 
laver,  brownish  red  in  color;  and  an  external  zone  of  hypera'niic  liver  tis- 
sue. The  pus  is  often  reddish  brown  in  color,  closely  reseiidjling  anchovy 
sauce.  In  other  instances  it  is  grayish  white,  nuicoid,  and  may  be  rpute 
ireaniy.  The  odor  is  at  times  very  peculiar.  In  one  instance  it  had  the 
sour  smell  of  chyme,  though  no  connection  with  tlu^  stomach  was  f(mnd. 
Ill  a  recent  case  of  amcebie  dysentery  there  were  multi^jle  miliary  abscesses 
Ml  the  liver,  all  of  which  contained  amu'ba?. 

The  bacteriological  examination  of  the  contents  show  that  as  a  rule 
the  pus  is  sterile  (Kartulis).  The  termination  of  this  form  of  abscess  may 
be  iis  follows,  as  noted  in  Waring's  300  cases :  Remained  intact,  fifty-six 
])er  cent;  opened  by  operation,  sixteen  per  cent;  jierforated  the  right 
pleura,  nearly  five  per  cent;  ruptured  into  the  right  lung,  nine  per  cent; 
ruptured  into  the  peritonaeum,  Ave  per  cent;  ruptured  into  the  colon, 
nearly  three  })ercent;  and  there  were  in  addition  instances  which  rujit- 
ui'ed  into  the  hepatic  ami  l)ile- vessels  and  into  the  gall-bladder. 

{!>)  Of  Septic  and  Pi/(eiiiic  ^ibscesses. — These  are  always  multiple, 
thouirh  oecasiomdly,  following  injury,  there  may  l)e  a  large  solitary  collec- 
tion of  pus. 

In  sti[)purative  pylephlebitis  the  liver  is  uniformly  enlarged.  The  eap- 
!<«lo  may  Ijc  smooth  and  the  external  surface  of  the  organ  of  normal 
appeuruiiee.     In  other  instances,  numerous  yellowish-white  points  appear 


if  I 


^K 


482 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


boiicatli  tlie  capsule.  On  section  there  arc  isolated  pot-kets  of  pus,  eitlier 
liaviiijf  a  round  outline  or  in  some  ])laces  distinctly  dendritic,  ainl  fidm 
these  the  pus  maybe  squeezed.  They  look  like  small,  solitary  alisofssos 
but,  on  ])ro])in<f,  are  found  to  communicate  with  the  portal  vein  and  t , 
represent  its  l)raiu'hes,  distended  and  su])puratin^.  The  entire  jKiruil  hv,-- 
tem  within  the  liver  may  be  involved  ;  sometimes  territories  an;  cut  oil  by 
thrombi.  The  suppuration  may  extend  into  the  main  branch  or  vwn  inti 
the  mesenteric  aiul  gastric  veins.  The  pus  may  be  fetid  and  is  often  bile- 
etained  ;  it  may,  Innvever,  be  thick,  tenacious,  and  laudable.  In  s:i|)|iiii;i- 
tive  cholangitis  there  is  usually  obstruction  by  gall-stones,  the  ducts  aiv 
greatly  distended,  the  gall-bladder  eidargcd  and  full  of  pus,  and  [h 
branches  Avithin  the  liver  are  extremely  distended,  so  that  on  scctinu  then. 
is  an  a])iiearance  not  unlike  that  described  in  pylephlel)itis. 

Snjjpuration  about  echinococcus  cysts  may  be  very  extensive,  fdviiiiiL' 
enormous  abscesses,  the  characters  of  which  are  at  once  recogiuzid  liv  tlio 
remnants  of  the  cysts. 

Symptoms. — («)  0/  the  Larf/e  Solifari/  Ahsrrss. — In  tlio  troiic,.; 
there  arc  iiistaiu;es  in  which  the  abscess  a])pcars  to  bo  Intent  iind  to  n;ii  ;i 
course  without  definite  symptoms,  and  death  nuiy  occur  suddeidy  frnm 
rupture. 

Fever,  pain,  enlargement  of  the  liver,  and  the  developmer.t  of  a  fo^t'c 
condition  are  the  important  symptoms  of  hepatic  abscess.  The  tcuipi  n- 
ture  is  elevated  at  the  outset  and  is  of  an  intermittent  or  s.ptic  type.  It 
is  irregular,  an<l  may  remain  normal  or  even  subnormal  f ;  r  a  few  diiy, ; 
then  the  patient  has  a  rigor  and  the  temperature  rises  to  K  ;)°  (ir  liiclur. 
Owing  to  this  intermittent  character  of  the  fever  the  cases  are  u?  ually,  in 
this  latitude,  mistaken  for  malaria.  The  fever  may  rise  every  aftinnMH! 
■without  a  rigor.  Profuse  sweating  is  common,  particularly  wluii  \hv 
patient  falls  asleep.  In  chronic  cases  there  may  be  little  or  no  fever.  At 
the  time  of  Avriting,  there  is  in  oiic  of  my  wards  a  patient  witli  liwr 
abscess  which  has  perforated  the  lung  who  still  coughs  up  pus,  br.t 
■whose  tem]-)crature  has  been  normal  for  weeks.  The  pain  is  varir.lilc,  ar.d 
is  usually  referred  to  the  back  or  shoulder;  or  there  h  a  didl  a(lii!i;(  sen- 
sation in  the  right  hypochondrium.  When  turned  on  the  left  side,  the 
patient  often  complains  of  a  heavy,  dragging  sensation,  so  that  lie  usually 
prefers  to  lie  on  the  right  side;  at  least,  this  has  been  the  case  in  a  )uaj(.i'- 
ity  of  the  instances  which  have  come  under  my  observation.  I'aiii  nn 
pressure  over  the  liver  is  usually  present,  imrticularly  deep  pressure  at  the 
costal  margiii  in  the  nipple  line. 

The  enlargement  of  the  liver  is  most  marked  in  the  right  lobe,  aud.  i;> 
the  abscess  (^avity  is  usually  situated  more  toward  the  ujiper  than  tlie  u;.- 
der  surface,  the  increase  in  volume  is  upward  and  to  the  right,  luit  down- 
ward, as  in  cancer  and  the  other  affections  producing  cnlargenieut.  Pn- 
cuasion  in  the  mid-sternal  and  jiarasternal  lines  may  show  a  normal  limit. 
At  the  nipple-line  the  curve  of  liver  duluess  begins  to  rise,  and  i:;  tlie  laid- 


ABSCESS  OF  THE  LIVER. 


•483 


iixillarv  it  may  roach  the  fifth  rib,  wliilc  bcliiTid,  near  the  spine,  the  area 
of  (liiiiu'ss  may  be  ahnost  on  a  level  with  tlie  anj^ie  of  the  wapula.  Of 
(oinse  there  are  instances  in  wliich  this  clianietei'islic  feature  is  not  i)res- 
cnt,  iis  wlien  the  abscess  occupies  the  left  lobe.  The  enlargement  of  the 
liver  may  be  so  great  as  to  cause  bulging  of  the  right  side,  and  the  edge 
iiiav  project  a  hand's-breadth  or  more  Ik'Iow  the  costal  margin.  In  such 
iiistiiiircs  the  surface  is  snujotli.  Palpation  is  painful,  and  there  may  bo 
liviniliis  on  deep  inspiration.  In  some  instances  fluctuation  nuiy  be  dc- 
toctcd.  Adhesions  nuiy  form  to  the  abdominal  wall  aiul  the  abscess  may 
pdint  l)elow  the  margin  of  the  ribs,  or  even  in  the  epigastric  region.  lu 
maiiv  cases  the  appearance  of  the  patient  is  suggestive.^  The  skin  has  a 
sallow,  slightly  icteroid  tint,  the  face  is  i)ale,  the  complexion  nuukly,  the 
coiijnnctivie  are  infiltrated,  and  often  slightly  bile-tinged.  There  is  in  the 
faiii'S  and  in  the  general  ai)pearance  of  the  patient  a  strong  suggestion  of 
the  fxisteiuse  of  abscess.  There  is  no  internal  affection  associated  with 
suii]tiiration  which  gives,  I  think,  just  the  same  hue  as  certain  instances 
of  ahscoss  of  the  liver.  Marked  jaundice  is  rare.  Diarrhu'a  may  be  jjresent 
and  may  give  an  imi)ortant  clew  to  the  nature  of  the  case,  particularly  if 
aiii(i'ba3  are  found  iu  the  stools.     Constipation  may  occur. 

Remarkable  and  characteristic  symptoms  arise  when  the  abscess  in- 
vades the  lung.  The  extension  may  occur  through  the  diaphragm,  with- 
out artiial  rupture,  and  with  the  ])roduction  of  a  purulent  pleurisy  and 
invasion  of  the  lung.  In  four  cases  of  this  kiiul,  which  have  been  under 
(m.servatiou  recently,  the  i)atients  gradually  develo[)ed  a  severe  cough, 
usually  of  an  aggravated  and  convulsive  character,  there  were  signs  of  in- 
volvement at  the  base  of  the  right  lung,  defei'tive  resonance,  feeble  tubular 
breathing,  and  increase  in  the  tactile  fremitus;  but  the  most  characteristic 
t'eature  was  the  presence  of  a  reddish-brown  expectoration  of  a  brick-dust 
e(;l(ir,  resembling  anchovy  sauce.  This,  which  was  noted  originally  ])y 
Budd,  was  present  in  our  cases,  ami  in  addition  I?eese  and  Lafleur  found 
iu  all  (una'hcB  coU  identical  with  those  wdiich  exist  in  the  liver  abscess  and 
iu  the  stools.  They  are  present  in  variable  numbers  and  display  active 
auui'bic  movements.  The  brownish  tint  of  the  expectoration  is  due  to 
blood -pigment  and  blood-corpuscles,  and  there  may  be  orange-red  crystals 
of  lui'iuatoidin. 

The  abscess  may  perforate  externally,  as  mentioned  ah'cady,  or  into  the 
stomach  or  bowel;  occasionally  into  the  pericardium.  '^Fhe  duration  of 
this  form  is  very  variable.  It  may  run  its  course  ami  prove  fatal  in  six 
or  eight  weeks  or  may  persist  for  several  years. 

The  })rognosis  is  serious,  as  the  mortality  is  more  than  fifty  per  cent. 
The  death-rate  has  been  lowered  of  late  years,  owing  to  the  greater  fear- 
lessness with  which  surgeons  now  attack  these  cases. 

(/')  Of  the  Pywmic  Alrcess  and  Svppnrative  Pi/lcpJiIehifis. — Clinically 
these  conditions  cannot  be  separated.  Occurring  in  a  general  pyaemia, 
110  special  features  may  be  added  to  the  case.     When  there  is  suppuiation 


''    g^jBp8j 

ii 

if 

'4m 

B$3 

1 

484 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


4#  ~ 


within  the  portal  voin  the  liver  is  U'.iforinly  eiilargctl  und  tender,  tiiiiii;.'h 
pain  may  not  be  a  niari<e(l  feature.  There  is  an  irreguhir,  sei>tic  IVvcr 
and  the  coJii])Iexion  is  muddy,  sonietiines  distinctly  ieteroid.  Tiie  rcatiins 
are  indeed  those  of  pya'mia,  phis  a  slii^ht  ieteroid  tinge,  and  an  eiilnrircd 
and  painful  liver.  The  latter  features  aloim  are  }>eeuliar.  The  sweats 
chills,  ])rostration,  and  fever  have  nothing  distinctive. 

Diagnosis. — Abscess  of  the  liver  nuiy  be  confounded  with  iiitiiinit- 
tont  fever,  a  common  mistake  in  malarial  regions.  l*ra('tically  an  inter- 
mittent fever  which  resists  (|uinine  is  not  nudarial.  Laverau's  orpinisms 
are  also  absent  from  the  blood.  When  the  al)scess  bursts  into  tlie  pK'ura 
a  right-sided  em])yema  is  produced  and  jierforation  of  the  lung  nsually 
follows.  When  the  liver  absciess  has  been  latent  aiul  dysenteric  synijitnms 
not  marked,  the  conditioji  may  be  considered  empyema  or  abscess  of  the 
luug.  In  su(th  cases  the  anchovy-sauce-like  color  of  the  pus  and  tlio 
preseiu'e  of  the  amu^bte  will  enable  one  to  make  a  definite  diagnosis,  as 
lias  been  done  in  cases  by  Lafleur.  Perforation  externally  is  readily  rccdj:- 
nized,and  yet  in  an  abscess  cavity  in  the  ejjigastric  region  it  may  be  dillicult 
to  say  whether  it  has  ])r()ceeded  from  the  liver  or  is  in  the  abdominal  wall. 
"When  the  abscess  is  large,  and  the  adhesions  are  so  firm  that  the  livor 
does  not  descend  during  inspiration,  the  exploratory  needle  does  not  make 
an  up-and-down  movement  during  aspiration.  In  an  instance  of  this 
kind  whicih  I  saw  with  Ifearn  at  the  I'hiladelphia  iros])ital,  all  the  feat- 
ures, local  ami  general,  seemed  to  point  to  abscess  in  the  abdominal  wall, 
but  the  operation  revealed  a  large  })erf()rating  abscess  cavity  in  the  left 
lobe  of  the  liver.  The  diagnosis  of  suppurating  echinococcus  cyst  is 
rarely  possible,  except  in  Australia  and  Iceland,  where  hydatids  are  so 
common.  In  the  oidy  case  which  has  come  under  my  observatiou,  the  in- 
numerable tumors  scattered  throughout  the  abdomen  and  the  great  size  u( 
the  liver  led,  not  unnaturally,  in  spite  of  the  occurrence  of  septic  syiiiii- 
toms,  to  the  diagnosis  of  cancer. 

Perhaps  the  most  important  affection  from  which  suppuration  within 
the  liver  is  to  be  separated  is  the  intermittent  hepatic  fever  associated  with 
gall-stones.  Of  the  cases  reported  a  majority  have  been  considered  due  to 
sup])uration,  and  in  two  of  my  cases  the  liver  had  been  re])eatedly  a>(."iato(l. 
Post-mortem  examinations  have  shown  conclusively  that  the  high  fever 
and  chills  may  recur  at  intervals  for  yeiirs  without  suppuration  in  the 
ducts.  The  distinctive  features  of  this  condition  are  paroxysms  of  fever 
with  rigors  and  sweats — which  may  occur  with  great  regularity,  but  wliioh 
more  often  are  separated  by  long  intervals — the  deepening  of  the  jauiulioe 
after  the  paroxysms,  the  entire  apyrexia  in  the  intervals,  and  the  mainte- 
nance of  the  general  nutrition.  The  tiine  element  also  is  important,  as  in 
some  of  these  cases  the  disease  has  lasted  for  several  years.  Finally,  it  is 
to  be  remembered  that  abscess  of  tlie  liver,  in  temperate  climates  at  least. 
is  invariably  secondary,  and  the  primary  source  must  be  carefully  soiiirht 
for,  either  in   dysentery,  slight   ulceration   of   the   rectum,  supi)u rating 


NEW  GIIOWTIIS   IN  TIIK   LIVER. 


485 


luiMiiorrlioids,  ulcer  of  tlio  stotnacli,  or  in  suppurative  diseases  of  otlier 
parts  of  tlie  boily,  particularly  in  tiie  skull  or  in  the  Ijoiu's. 

The  presetuie  of  a  leucocytosis  is  a  luost  important  feature  in  all  forms 
of  .suppuration  in  the  liver. 

In  suspected  cases,  whether  the  liver  is  enlar<.fed  (jr  not,  exploratory 
aspiration  nuiy  be  performed  without  risk.  'Die  needle  may  be  entered  in 
the  anterior  axillary  line  in  the  lowest  interspace,  or  in  the  seventh  inter- 
s|)iK'i'  in  the  mid-axillary  liiu',  or  over  the  centre  of  the  area  of  dulnoss 
iH'liiiul.  The  patient  should  be  2>lii<'i'd  under  ether,  for  it  nuiy  be  neces- 
sary to  nuike  several  deep  punctures.  It  is  not  well  to  use  too  small  an 
aspirator.  No  ill  elTects  follow  tliis  procedure,  even  though  blood  may 
leak  into  the  peritoneal  cavity.  Extensive  suppuration  nuiy  exist,  and  yet 
bf  missed  in  the  aspiration,  particularly  when  the  branches  of  the  portal 
vein  are  distended  with  pus. 

Treatment.  —  I'yiemic  abscesses  and  suppurative  pylej)hlebitis  are 
iiivaiialjly  fatal.  Treves,  however,  rej)orts  a  case  of  ]»ya!mic  abscess  fol- 
lowiiiji  ajipendicitis  in  which  the  patient  recovered  after  an  exploratory 
operation.  Surgical  measures  are  not  justified  in  these  cases,  uidess  an 
abseess  shows  signs  of  pointing.  As  the  abscesses  associated  with  dysen- 
tery are  often  single,  they  alford  a  reasomible  hope  for  operation.  If, 
however,  the  patient  is  expectorating  the  pus,  if  the  general  condition  is 
triiod  and  the  hectic  fever  not  marked,  it  is  best  to  defer  operation,  us 
numy  of  these  instances  recover  spontaneously.  The  large  single  abscesses 
otTer  the  best  chance  for  operation.  The  general  medical  treatment  of 
the  cases  is  that  of  ordinary  septicaamia. 


VI.    NEW   GROWTHS    IN    THE    LIVER. 

These  may  be  cancer,  either  primary  or  secondary,  siiruuma,  or  angioma. 

Etiology. — Cancer  of  the  liver  is  third  in  order  of  frequetu;y  of  in- 
ternal cancer.  It  is  rarely  i)riinary,  usually  secondary  to  can<!cr  in  other 
organs.  It  is  a  disease  of  late  adult  life.  A(!cording  to  Leichtcnstcrn, 
over  iifty  per  cent  of  the  cases  occur  between  the  fortieth  and  the  sixtieth 
years.  It  occasit)nally  occurs  in  children.  Women  arc  attacked  less  fre- 
(|iu'ntly  than  men.  It  is  stated  by  some  authors  that  secondary  cancer  is 
more  common  in  women,  owing  to  the  freqiuMu-y  of  cancicr  of  the  uterus. 
lleiidity  is  believed  to  have  an  inlluence  in  from  fifteen  to  twenty  per 
cent. 

In  many  cases  trauma  is  an  antecedent,  and  cancer  of  the  bile-passages 
IS  associated  in  many  cases  with  gall-stones.  Cancer  is  stated  to  be  less 
conunon  in  the  tropics.  Its  relative  proportion  to  other  diseases  nuiy  be 
judged  from  the  fact  that  among  the  first  three  thousand  patiimts  admit- 
ted to  the  wards  of  the  Johns  Hopkins  Hospital  there  were  seven  cases  of 
cancer  of  the  liver. 


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480 


DISEASES  OF  THE   DKJESTIVE  SYSTEM. 


1 


{  v,'it 


'  Lii 


Morbid  Anatomy. — Tliu  follitwing  forms  of  new  growths  (k(ui-  in 
till)  livor  luul  liiivu  ii  clinical  iinportaiui' : 

Cancer. — (1)  PrinKirij  rdii/rr,  nl'  wliicli  three  forms  may  he  wvik'. 
iiized.* 

{ii)  The  ?H(fssii'e  w we;*,  which  causes  ^reat  enlargement  uiid  ow  vcMou 
shows  ii  uniform  mass  of  new  growth,  which  oe('Ui)ies  a  large  imriion  (f 
the  organ.  It  is  grayish  while,  usually  iu)t  softened,  and  is  al)i'ii|iil\  (jiu- 
lined  from  the  contiguous  liver  sul)stance. 

(/>)  yinlutar  cdiirrr,  in  which  the  liver  is  oceui)ie(l  l)y  nodular  masses, 
some  large,  some  small,  irregularly  scattered  throughout  the  organ.  I'su- 
silly  in  one  region  there  is  a  larger,  perhaps  llrmer,  oldi'r-looking  luass 
wliicli  indicates  the  j)rimary  sciit,  and  the  nunu'rous  nodules  are  sccdiiilurv 
to  it.  This  form  is  much  like  the  secondary  cancerous  involvement,  ix- 
cept  that  it  seldom  reaches  a  large  size. 

{(•)  The  thinl  is  the  remarkable  and  rare  variety,  (vr «(■<?;•  toil/i  cirr/insis, 
■which  forms  an  anatomical  picture  perfectly  uni([ue  and  at  lirst  very 
puzzling.  The  liver  is  not  nnicli  enlargcil,  rarely  weighing  more  than  two 
and  a  half  or  three  kilogrammes.  The  surface  is  grayish  yellow,  stuililcl 
over  with  nodular  yellowish  masse-;,  resembling  tlu!  projections  in  an  (nili- 
nary  cirrhotic  liver.  On  section  the  cancerous  nodules  are  seen  scatttivd 
throughout  the  entire  organ,  varying  in  diameter  from  three  to  ten  er 
more  millimetres  and  surnmnded  with  fibrous  tissue. 

Histologically,  the  primary  cancers  are  epitlieliomata — alveolar  ami 
trabecular.  The  character  of  the  cells  varies  greatly.  8ome  varieties  iiir 
polymorphous;  others  small  polyhedral;  and  others  again  contain  giant 
cells.  In  rare  instances,  as  in  one  described  by  (Jreenlield,  the  cells  arc 
cylindrical.  The  trabeiailar  form  of  epithelionui  is  also  kiujwn  as  adenoma 
or  adeno-carcinoma. 

(•■i)  Sccnndar;/  Cancer. — The  organ  is  usually  enormously  eiilarired, 
and  may  weigh  twenty  pounds  or  more.  The  cancerous  nodules  pi'oject 
beneath  the  capsule,  and  can  bo  felt  during  life  or  even  seen  through  the 
thin  abdominal  walls.  They  are  usually  disseminated  equally,  though  in 
rare  instan(x>s  they  may  bo  confined  to  one  lobe.  The  consisteiu'c  of  tlio 
nodules  varies;  in  some  cases  they  are  firm  and  hard  and  those  on  the 
surface  show  a  distinct  umbilication,  due  to  the  shrinking  of  the  tihrous 
tissue  in  the  centre.  These  sui)erficial  cancerous  masses  are  still  some- 
times spoken  of  as  "  Farre's  tubercles."  ^lore  frequently  the  masses  are 
on  section  grayish  white  in  color,  or  ha^morrhagic.  Kupture  of  lilood- 
vessels  is  not  uncommon  in  these  cases.  In  one  specimen  there  was  an 
enormous  clot  beneath  the  capsule  <  !'  the  liver,  together  with  lueinorrhagc 
into  the  gall-bladder  and  into  the  peritonanim.  The  secondary  cancer 
shows  the  same  structure  as  the  initial  lesion,  and  is  usually  either  an  iilve- 
olar  or  cylindrical  carcinoma.     Degeneration  is  common  in  these  second- 

*  Ilanot  and  Gilbert,  fitudes  sur  les  Maladies  du  Foie,  Paris,  1888. 


^! 


NEW  (IROWTIIS   IN  TIIR   LIVKR. 


4H7 


ftrv^M'owtlui;  tliiis  tlio  liyiiliiic  tniiisfoniiiitioii  iimy  coiivort  Iiirfjo  uivas  into 
;i(lcii.-<',  dry,  gniyisli-yt'llow  iimss.  Kxtciisivo  ii reus  of  futty  (k'ginicnitioii 
Mi;iv  iMciir,  ^olorosis  is  not  uiicoininon,  iiiul  li!i'iuorrlia;^os  arc  frc)f|uc'nt. 
SiipiHinition  soiiiotiiiit's  follows. 

(D)  ('(fiirrr  iif  f/ir  /li/c- /'iissdi/rs. — Much  attention  lias  l)i'(Mi  frivcn  to 
tills  (if  latf,  anil  Zeiikor,  Musst>r  ami  Atniis  have  recently  puhlished  ex- 
haust i\i'  papers  on  the  snhject.  In  100  cases  collectetl  hy  Musser  the 
liiiiri'  proportion  (3  to  1)  were  in  feniules.  Jaundice  was  ])resent  in  sixt}'- 
iii;ii'  per  cent,  and  in  ahout  the  same  pen-entaj^c  there  was  a  tumor  in  the 
iv/u\n  of  the  gall-bladder.  Courvoisier  has  collected  lOO  cases,  of  which 
So  were  in  men  and  IT  in  women.  The  association  of  cancer  of  the  ])ile- 
p;i!«S!ifjes  with  calculi  lias  long  heoi  recognized,  and  they  are  present  in  at 
li'iist  >iv\i'n  eighths  of  all  cases.  The  fundus  of  tlie  gall-hladder  is  usually 
involved  iirst.  The  ])rocess  may  extend  to  the  comnion  or  hepatic  ducts, 
and  invasion  of  the  contiguous  structures  is  common.  The  ducts  may  bo 
allVi'ti'd  [)riniarily. 

Sarcoma. — Of  primary  sarcoma  of  the  liver  very  few  cnses  hiivo  been 
i'i'|i(irte(l.  Secondary  sarcoma  is  more  frequent,  and  many  examples  of 
lyin[ilio-sarcoma  and  niyxo-sarcoma  are  on  record,  less  frecjueiitly  glio- 
sarcitnia  or  the  smooth  or  striped  myoma. 

The  most  important  form  is  the  melano-surcoma,  which  develops  in 
tlie  liver  secondarily  to  sarcoma  of  the  vyo  or  of  the  skin.  Vt-ry  i-arely 
inclaun-sarcoma  develojjs  i)rimarily  in  the  liver.  Of  the  re[)orted  cases 
llaiiot  excludes  all  but  one.  In  this  form  the  liver  is  greatly  enlarged,  is 
(■ithcr  uniformly  infiltrated  with  the  cancer,  which  gives  the  cut  surface 
the  appearance  of  dark  granite,  fir  there  are  largo  nodular  masses  of  a 
(Kep  black  or  marbled  color.  There  are  usually  extensive  metastases,  and 
in  some  instances  every  organ  of  the  body  is  involved.  Xodules  of  melano- 
siu'L'oina  of  the  skin  may  give  a  clew  to  the  diagnosis. 

Other  Forms  of  Liver  Tumor. — One  of  the  commonest  tumors  in  the 
liver  is  the  angioma,  \\hich  occurs  as  a  small,  reddish  body  the  size  of  a 
v.alinit,  and  (insists  simjily  of  a  series  of  dilated  vessels.  Occasionally  in 
I'liildrcii  aiigiomata  have  developed  and  produced  large  tumors. 

Cysts  are  occasionally  foiind  in  the  liver,  either  single,  which  arc  not 
vwT  uncommon,  or  multiple,  when  they  usually  coexist  with  congenital 
'■ystic  kidneys. 

Symptoms. — It  is  often  impossiljlc  to  differentiate  primary  and  sec- 
luulary  cancer  of  the  liver  unless  the  primary  seat  of  the  disease  is  evident, 
as  in  till!  case  of  scirrhus  of  the  breast,  or  cancer  of  the  rectum,  or  of  a 
tumor  in  the  stomach,  which  can  be  felt.  As  a  rule,  cancer  of  the  liver  is 
associated  Avith  progressive  cidargcment ;  but  there  are  cases  of  jirimary 
iiiMlular  cancer,  and  in  the  cancer  with  cirrhosis  the  organ  may  not  be 
enlarged.  Gastric  disturbance,  loss  of  appetite,  nausea,  and  vomiting  are 
fi'oiiueut.  Progressive  loss  of  flesh  and  strength  may  be  the  first  symp- 
toms.   Pain  or  a  sensation  of  uneasiness  in  the  right  hyi)ochondriac  region 


.:'^. 


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488 


DISKASKS  OF  TIIH    DKIKSTIVK  f-YSTKM. 


rimy  !«>  ])r('S('iit,  hiil,  ciioriutiiix  ciiliir^'i'dicnt  of  the  liver  iiuiy  occur  uiihout 
tlio  Hli^'Iitcst  piiiii.  .Jaiiiidicc,  which  is  j»r('scnt  in  at  h-ast  om-  hah"  df  the 
cases,  is  usually  ol"  iiKMh'nitc  exU'iit,  utih-ss  the  cnnitiioii  duct  is  (mi  hidiil. 
Ascites  is  rare,  excej)t  in  tlie  t'urni  of  eaiicor  with  cirrhosis,  in  whirh  tin. 
clinical  picture  is  tliat  of  the  atrophic  form.  Pressure  hy  (lodujc^  (in  tie 
portal  vein  or  extension  of  tlu;  cancer  to  the  |»eritoniV'Uin  nuiy  also  iiidiicc 
ascites. 

Inspection  sliows  tlio  ul)doinen  to  he  disteiidcfl,  partieidarly  in  ihc 
upper  /one.  In  late  st,a;^'cs  of  the  disease,  when  einaciati  -n  is  uiiirkcd. 
the  cancerous  nodules  can  he  plainly  seen  hciieath  the  skin,  and  in  rare 
instances  even  the  und)ilications.  'i'he  superlicial  vi'ins  arc  eidarjjfcd,  Ou 
j)al]»ation  the  liver  is  fcdt,  a  hand's-hreadth  or  more  helow  the  costal  niarfjiii, 
descending,' with  each  inspiration.  The  surface  is  usually  irre^'ular,  iiiul 
may  present  lar;,'e  jiiasses  or  smaller  nodular  hodies,  (dthcr  rounded  or 
with  <'entral  depressions.  In  instances  of  dilTuse  infiltration  the  liver  aiav 
be  greatly  eidarged  and  ])resent  a  perfectly  smooth  surface.  The  ^n'dwth 
is  j)rogressive,  and  the  edge  of  the  liver  may  nitinuitely  exteiul  below  the 
lev(d  of  the  nav(d.  Although  g<'ncrally  uniform  and  ])roducing  cnlarLre- 
ment  of  th(i  whole  organ,  occasionally,  when  the  tumor  develops  from  tin 
left  l(d)e,  it  may  form  a  solid  mass,  which  occupies  the  epigastric  rcgiim, 
By  percussion  the  outline  can  he  accurately  limited  and  the  itrogressivo 
growth  of  tumor  estimated.  'I'he  si)leen  is  rarely  eidaiged.  Pyrexia  is 
present  in  many  eases,  usually  a  continuous  fever,  ranging  from  liHf  to 
10*^°;  it  maybe  intermittent  with  rigors,  'i'his  uuiy  l)e  associated  wiili 
the  cancer  alone,  or,  as  in  one  of  my  cases,  with  supituration.  (Kdeina  of 
the  feet,  from  ani«mia,  usually  supervenes.  Cancer  of  the  liver  kills  in 
from  three  to  fifteen  mouths. 

Diagnosis. — The  diagnosis  is  easy  when  the  liver  is  greatly  eidaririMl 
and  the  surface  nodular.  The  smoother  forms  of  diffuse  carcinoma  may 
at  first  be  mistaken  for  fatty  or  amyloid  liver,  but  tlie  presence  of  jaun- 
dice, the  rapid  enlargement,  and  the  more  marked  cachexia  will  usually 
sufKce  to  dilTerentiate  it.  Perhaps  the  most  ])uzzling  conditions  oeeiir 
in  the  rare  cases  of  enlarged  amyloid  liver  wit'.i  irregular  gummata.  The 
large  echinococcus  liver  n^ay  present  a  striking  sinnlarity  to  oareiiuuua, 
but  the  projecting  nodules  sire  usually  softer,  tlio  disease  lasts  much  longer, 
and  the  cachexia  is  not  marked. 

Hypertrophic  cirriiosis  may  at  first  be  mistaken  for  carcinoma,  as  the 
jaundice  is  usually  deep  and  the  liver  very  large ;  but  the  absence  of  a 
marked  cachexia  and  wasting,  and  tbe  painless,  smooth  character  of  the 
enlargement  are  points  against  cancer.  When  in  doubt  in  these  cases, 
aspiration  may  be  safely  performed,  and  positive  indication  may  be  gained 
from  the  materials  so  obtained.  In  large,  rapidly  growing  secoiulary 
cancers  the  superficial  rounded  masses  may  almost  fluctuate  and  these 
soft  tumor-like  projections  may  contain  blood.  The  form  of  cancer  with 
cirrhosis  can  scarcely  be  separated  from  atrophic  cirrhosis  itself.     Perhaps 


PATTY   lAVmi. 


4S}) 


the  Wintiiij?  is  inoro  extreme!  uiul  iimrc  rapid,  hut  tlio  jaundice  iiiid  the 
tisciti's  art'  i(leuti<'ul.  Mclaiio-wirconm  causes  jjfreat  eniar^'cnuMit  of  tho 
uriMii.  'i'licre  are  freciui'iitly  symptoms  of  involvement  of  oMier  viscera, 
;H  tlir  liiiij,'s,  kidneys,  or  spleen.  Secoii(hiry  tumors  may  (h'velop  on  llie 
sLiii.  A  ^cry  important  symptom,  not  present  in  all  eases,  is  melannria, 
till'  passiij,'i(  of  a  very  (Iark-eolori'(l  urim*,  wliicli  may,  however,  when  first 
viiiilnl,  1)1'  quite  norimil  in  color.  'IMh'  existence  of  a  melano-sarcoimi  of 
the  evi',  or  the  history  of  hiindness  in  one  eye,  with  snhsecpient  extirpa- 
fidii,  limy  indicate  at  once  the  true  luiture  of  the  hepatic  eidar;jfenu'nt. 
TJic  siioiidary  tumors  may  develop  Honu^  time  after  the  extirpation  of  tlio 
eve,  iis  in  a  case  under  the  care  of  J.  ('.  Wilson,  at  the  IMiiladelphia  Ilns- 
pil.il,  i>i',  iis  in  a  ease  under  Tyson  at  the  sanui  institution,  the  patient 
iii;iv  ha\c  a  sarcoma  of  tin*  choroid  which  had  never  caused  any  syiup- 
tdiiis.  Triiuary  cancer  of  the  ^fall-l)ladder  can  rarely  ho  diaj.?nosed.  It 
limy  he  fjfreatly  dilated  and  readily  palpahle.  Occasionally  tumors  of  the 
kiiliicy  or  a  tumor  of  the  transverse  colon  may  he  confounded  with  it. 

The  fmi/iiinif  must  lie  entirely  symptomatic — allayiniif  the  pain,  re- 
lii'viii^'  the  gastric  disturbance,  and  meeting  other  symptoms  as  they  arise. 


VII.  FATTY   LIVER. 

Two  dilTerent  forms  of  this  condition  are  recognized — the  fatty  infil- 
tratiiin  and  fatty  degeneration. 

latty  inliltration  occurs,  to  a  certain  extent,  in  normal  livers,  since 
till'  cells  always  contain  minute  globules  of  oil. 

In  fatty  degeneration,  which  is  a  nnudi  less  common  condition,  the 
protiiplasni  of  the  liver-cells  is  destroyed  and  the  fat  takes  its  place,  as 
sirii  ill  ciises  of  malignant  jaundice  and  in  jihosjihorus  poisoning. 

Fatty  liver  occurs  under  the  following  conditions :  {a)  In  a.ssociation 
with  g(!ii(!ral  oliesity,  in  which  case  the  liver  appears  to  be  one  of  the 
stiiri'-lidiist'S  of  the  excessive  fat.  {/j)  In  conditions  in  wliich  the  oxi(hi- 
tioii  |ii()(oss('s  are  interfered  with,  as  in  cacliexia,  profound  anajmia,  and  in 
phthisis.  Tho  fatty  infiltration  of  the  liver  in  lieavy  drinkers  is  to  be 
attriliutcd  to  the  excessive  demand  made  by  the  alcohol  upon  the  oxygen. 
('■)  I'ortain  poisons,  of  which  jihosphorus  is  the  most  characteristic,  pro- 
iliu'c  an  intense  fatty  degencratioji  with  necrosis  of  the  liver-cells.  The 
\»n>un  of  acute  yellow  atrophy,  whatever  its  nature,  acts  in  the  same  way. 

Tho  fatty  liver  is  uniformly  increased  in  size.  The  edge  may  reach 
lii'low  the  level  of  the  navel.  It  is  smooth,  looks  pale  and  bloodless ;  on 
>  I'tiDu  it  is  dry,  and  renders  the  surface  of  the  knife  greasy.  The  organ 
may  weigh  many  pounds,  and  yet  the  specific  gravity  is  so  low  that  the 
entire  organ  floats  in  water. 

The  symptoms  of  fatty  liver  are  not  definite.  Jaundice  is  never  pres- 
ent; the  stools  may  be  light-colored,  but  even  in  the  most  advanced  grades 


im 


.    .1  ,1.11 

!  11 


I- 


1. 


1 


F  .fninT'    1 


I'M 


400 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


H    ->(,t|f 


th«!  hilo  is  Htill  fonneil.  Signs  of  portal  oltstruction  are  raro.  TTmmor- 
rhoids  are  not  very  infrequent.  Altogetli  r,  the  symptoms  are  ill-dctinod 
and  chiefly  those  of  the  disease  with  whieli  tlie  (h-geiieration  is  assdciaUil. 
Incases  of  great  ohesity,  the  itliysical  examination  is  iinctTlaiii ;  hut  in 
phthi.-fis  and  cachectic  conditions,  the  organ  can  be  felt,  greativ  ('iilar<f('il 
Hmr)Oth,  and  painless.  Fatty  livers  are  among  tlie  largest  met  with  at  the 
^Kidside. 


Vm.  AMYLOID  LIVER. 

The  waxy,  lardaceous,  or  amyloid  liver  occurs  as  ])art  of  a  general 
degeneration,  associated  witli  cachexias,  particularly  when  the  result  uf 
long-standing  supi)uration. 

In  practice,  it  is  found  oftenest  in  the  prolonged  su])puratiou  of  tiilicr- 
cnlous  disease,  either  of  the  lungs  or  of  the  ])ones.  ^'ext  in  order  of  fre- 
quency are  the  cases  associated  with  syphilis.  Here  there  may  be  ulcera- 
tion oi  the  rectum,  with  which  it  is  often  cfjiniccted,  or  (;hronic  disease  of 
the  hone,  (»r  it  may  be  i>resent  when  there  are  no  suppurative  cliaiigos.  It 
is  found  oC(!asionally  in  rickets,  in  ])rolonged  convalescence  from  the  infec- 
tious fevers,  and  in  the  cachexia  of  cancer. 

The  amyloid  organ  is  large,  and  may  attain  diniensions  e(|iiallo(l  only 
by  that  of  the  cancerous  organ.  Wilks  speaks  of  a  liver  weighing  four- 
teen pounds.  It  is  solid,  firm,  resistant,  on  section  auaMiiic.  aiul  has  u 
Hemitranslucent,  inliltrated  ap])earaiu^e.  Stained  with  a  dilute  solution  nf 
inline,  tlie  areas  infiltrated  with  the  amyloid  matt(;r  assunu'  a  rich  inaho^ 
any-brown  color.  The  precise  nature  0/  tbis  change  is  still  in  (jucstioii. 
It  first  attacks  the  capdlaries,  usuidly  of  the  median  zoim  of  the  lobules, 
and  sul>ser|uently  the  interlobular  vessels  and  the  coniu'ctive  tissue.  The 
cells  are  but  little  if  at  all  affected. 

Th«!re  are  no  characteristic  symptomsi  of  this  condition.  .Faundiie 
does  not  occur ;  the  stools  may  be  light-colored,  but  the  secretion  of  bile 
p<THists.  The  physical  examination  shows  the  organ  to  be  uniformly  en- 
larged and  paiidc'ss,  the  surface  smooth,  the  edges  rounded,  and  the  euii- 
KJstence  greatly  iiu'reased.  Sometimes  the  edge,  even  in  very  great  cnlarjie- 
mcnt,  is  sharp  and  hard.  The  spleen  also  nuiy  be  involved,  but  there  an 
no  evidences  of  portal  obstruction. 

The  flifff/iwsis  of  the  condition  is,  as  a  rule,  easy.  Progressive  ami 
^eat  enlargement  in  connection  with  suppuration  of  long  sfandini,'  or 
with  syphilis,  is  almost  always  of  this  nature.  In  rare  instances,  however, 
the  amyloid  liver  is  reduced  in  size. 

In  hiikwmin  the  liver  may  attain  considerable  size  and  be  smooth  ami 
uniform,  resembling,  on  y)hysical  examination,  the  fatty  organ.  Tin-'  blood 
condition  at  once  indicates  the  true  nature  of  the  case. 


m 


ANOMALIES!   IN    FORM    AND    POSITION   OF  TIIK    LIVER. 


491 


IX.    ANOMALIES    IN    FORM    AND    POSITION    OF   THE 

LIVER. 

Ill  transposition  of  the  viscera  tlie  riglit  lol)e  of  the  orj^im  may  ocoiipy 
the  lift  side.  A  coninion  and  important  anomaly  is  tlie  tilting  forward  of 
the  nr<:ati,  so  that  the  long  axis  is  vertical,  not  transverse.  Instead  of  tlu? 
edge  of  the  right  lobe  presenting  just  below  the  costal  margin,  a  consider- 
iiblc  [lortioTi  of  the  snrfaee  of  the  lobe  is  in  contact  witii  the  abdominal 
p;ni(tcN  and  the  edge  may  be  felt  as  low,  perhaps,  as  the  navel.  This  an- 
teversion  is  apt  to  be  mistaken  for  enlargement  of  the  organ. 

'riie  "  lacing"  liver  is  met  with  in  two  chief  types.  In  one,  the  anterior 
portion,  cliielly  of  the  right  lobe,  is  greatly  prolonged,  and  may  reach  the 
transverse  navel  line,  or  even  lower.  A  shallow  transverse  groove  sepa- 
rates the  thin  extension  from  the  main  portion  of  the  organ.  The  peri- 
tniieal  elating  of  this  groove  may  be  fibroid,  and  in  rare  instiinces  the  de- 
foriiied  portion  is  connected  with  the  organ  by  an  almost  tendinous  mem- 
lirane.  Tlie  liver  may  be  com])ressed  laterally  and  have  a  ])yraniidal  shape, 
ami  the  extreme  left  border  and  the  hinder  margin  of  the  left  lobe  may  be 
Miiii'h  folded  and  incurved.  The  projecting  portion  of  the  liver,  extending 
lew  i;.  the  right  Hank,  may  be  mistaken  for  a  tunmr,  or  more  frequently 
for  a  movable  right  kidney.  Its  continuity  with  the  liver  itself  may  not 
be  evident  on  pal|)ation  or  on  ])ercussion,  as  coils  of  intestine  may  lie  in 
front.  It  descends,  however,  with  inspiration,  and  usually  the  margin 
can  be  traced  (continuously  with  that  of  the  left  lobe  of  the  liver.  The 
greatest  dillicidty  arises  when  this  anonuUous  la{)pet  of  the  liver  is  either 
iiafiirally  very  thick  ami  united  to  the  liver  by  a  very  thin  membrane,  or 
wiien  it  is  swollen  in  conditions  of  great  congestion  of  the  organ. 

The  other  principal  type  of  lacing  liver  is  quite  dilTerent  in  shape.  It 
is  thick,  broader  above  than  below,  and  lies  almost  entirely  above  the  trans- 
verse line  of  the  cartilages.  There  is  a  narrow  groove  just  above  the  an- 
terior biirder,  which  is  placed  more  transversely  than  nornud.* 

Movable  Liver. — This  rare  condition  has  received  much  attention  of 

lute,  and  .1.  K.  (Iraham,  in  a  recent  paper,  lias  collected  seventy  reported 

eases  from  the  literature.     In  a  very  considerable  number  of  these  there 

has  lieen  a  mistaki'U  diagnosis.     A  slight  grade  of  nu)bility  of  the  orgHti  is 

foiiiid  in  the  pendulous  abdomen  of  enteroptosis,  ami  after  rc[)eatcd  ascites. 

The  organ  is  so  connected  at  its  posterior  nnirgin  with  the  inferior 

vena  cava  and  diaphragm  that  any  great  mobility  from  this  point  is  im- 

pfissihle,  except  on  the  theory  of  a  meso-heiiar  or  congenital  ligamentous 

iiiiioii  liotween  these  structures.     The  liganuMits,  however,  may  be  greatly 

relaxed  (the  suspensory  T'o  centimetres,  and  the  triangular  ligament  4  ccn- 

tinietres.  in  one  of  Leni)e''s  cases)  ;  and  when  the  patient  is  in  the  erect 

I'listiire  the  organ  tnay  droj)  down  so  far  tluit  its  upper  surface  is  entirely 

ihIiiu-  the  costal  margin.     The  condition  is  rarely  met  with  in  men  ;  fif'y- 

"ix'  of  the  eases  were  in  women. 

Sec  1*.  Hertz,  Abtiormitilloii  in  der  Lagc  uiid  Form  der  Biiutiliorgaiie,  Berlin,  iy04. 


•(:" 


I  '     : 


11.,'  W 


492 


DISEASES  OP  THE  DIGESTIVE  SYSTEM. 


-: 


m 


IX.   DISEASES  OF  THE  PATs'CREAS. 

Normal  conditions  of  the  organ  must  not  be  mistaken  for  disease.  It 
is  often  hard,  and  with  very  distinct  lobulation.  Atro])hy  is  oonunnn  in  old 
age  and  in  wasting  diseases.  Microscopically,  the  changes  of  self-digestion 
must  not  be  mistaken  for  coagulation-necrosis. 


I.   HvCMORRHAGE. 

Of  late  years  much  attention  has  been  j)ai(l  to  this  condition,  wliidi 
may  prove  rapidly  fatal  and  has  important  medico-legal  bearings.  F.  \\, 
Draper*  has  reported  five  cases,  in  all  of  which  death  occurred  either  .sud- 
denly or  after  a  very  short  illness.  The  symptoms  are  thus  brielly  sum- 
marized by  Prince : 

"  The  patient,  who  has  previou.sly  ])een  perfectly  well,  is  suddenly  taken 
with  the  illness  which  terminates  his  life.  .  .  .  When  the  hii'imrrhagc 
occurs  the  patient  may  be  quietly  resting  or  ])ursuing  li.  lu  '  <tceupa- 
tion.  The  pain  which  ushers  in  the  attack  is  usually  vei\  e*  .  l,  uiid  lo- 
cated in  the  upper  part  of  the  abdomen.  It  steadily  increases  in  severitv, 
is  sharp  or  ]H'rhai)S  colicky  in  character.  It  is  almost  from  thf  first  ac- 
companied l)y  nausea  and  vomiting;  the  latter  becomes  fre(ineiii  and  ob- 
stinate, but  gives  no  relief.  The  patient  soon  becomes  anxious,  restless, 
and  depressed  ;  he  tosses  about,  and  only  with  difbculty  can  hi'  resti'ained 
in  bed.  The  .surface  is  cold,  and  the  forehead  is  covered  with  acnjd  sweat. 
The  pul.se  is  weak,  rapid,  and  sooner  or  later  imt)er(;ej)tible.  The  alulo- 
men  becomes  tender,  the  tenderness  being  located  in  the  upper  part  of  the 
abdomen  or  ei)igastrium.  Tympanites  is  sometimes  marked.  The  tem- 
perature in  most  cases  is  either  normal  or  below  normal.  The  bowels  aif 
apt  to  be  constipated.  'I'hese  symptoms  continue  without  relief;  those 
which  are  most  striking  being  the  ])ain,  vomiting,  an.xiousness,  re.stles.- 
uess,  and  the  state  of  collapse  into  whi(di  the  ])atient  soon  falls." 

Post  mortem,  the  pancreas  is  found  uniformly  iiiHltrated  with  1j;^i 
Death,  as  Zenker  suggests,  is  probably  due  to  shock  through  the  soliir 
plexus. 

The  ha;morrhago  may  occur  in  connection  with  cancer  of  tli(>  orjjaii. 
The  blood  may  be  effused  into  the  lesser  peritona3um,  or,  if  fmui  .lie  tail, 
about  the  spleen  and  left  kidney,  forming  an  enormous  hscniatouia. 


•  Transactions  of  the  Association  of  American  Physicians,  vol.  i. 


ACUTE  PANCREATITIS. 


II.  ACUTE   PANCREATITIS. 


498 


{a)  Acute  HsBinorrhagic  Pancreatitis.— The  admiriiblo  stiulics  of  Fitz* 
liave  crvstiillizod  our  knowledge  on  tliis  subject,  and  broiiglit  the  alleetion 
\ntliiii  the  scope  of  the  diagnosticdau.  A  majority  of  the  cases  occur  in 
piTsoiis  over  tliirty.  Many  of  the  ]>atients  liad  been  addicted  to  ah^ohol, 
iind  iiiiiiiy  had  Kuifored  from  attacks  of  indigestion,  occasionally  with  severe 
pains  and  vomiting. 

Murhid  Amttomy. — 'Y\\g  pancreas  is  found  enlarged,  and  the  interlobu- 
lar tissue  infiltrated  with  blood,  and  perhaps  with  clots.  In  some  instances 
tho  coiitigiiou!^  tissues  may  also  be  ha'morrhagic!,  and  the  whole  may  form 
11  lai'j^H',  linn  mass,  situated  at  the  upper  and  back  part  of  the  abdominal 
cavity.  The  root  of  the  mesentery,  the  mesocolon,  and  the  omentum 
may  also  show  ha!morrhages ;  tho  other  organs  may  be  practically  normal. 
In  most  instances  there  can  be  seen  about  the  lobules  areas  of  opaque  white 
tissue,  and  upon  the  omentum  and  mesentery  similar  opaque,  white  specks, 
which  will  be  referred  to  subsequently  as  the  fatty  necrosis  of  Balser.  In 
s[i()ts  tho  gland-cells  may  also  be  found  necrotic,  while  there  may  be  cases 
showing  a  marked  increase  in  the  fibrous  tissue. 

The  .•<i/m}i/oms  of  this  coiulition  are  remarkable.  The  attack  sets  in 
with  viok'iit  pain  in  the  abdomen,  usually  in  the  upper  left  zone,  but  in  some 
instances  it  is  general.  Kausea  and  vomiting  are  present,  and  usually  con- 
stipation, 'rynipanitic  distention  of  the  abdomen  is  of  frecpient  occurrence. 
Fever  may  he  jiresent,  but  is  an  iiu-onstant  symptom.  There  may  be  early 
ilelii'iniM.  ColIa{)se  symptoms  supervene,  and  death  ocrcurs  usually  from  the 
second  to  the  fourth  day,  or  even  earlier.  The  swelling  and  intiltration  in 
the  region  of  the  pancreas  necessarily  involve  the  cadiac  [)lexus,  and  the 
stretidiiiig  of  the  nerves  may  at  count  for  the  agoiuzmg  i)ain  and  the  sud- 
den collapse.  In  a  case  whi(di  I  have  reported  the  semilunar  ganglia 
were  swollen,  the  nerve-cells  indistinct,  and  there  was  an  interstitial  infil- 
tration of  round  cells.  The  Pacinian  corpuscdes  in  tiie  neighborhood  of 
the  pimcreas  were  enormously  swollen  and  codematous. 

A  (/ui(/)iosi)i  of  intestinal  obstruction  or  of  acute  perforative  peritonitis 
is  usually  made.  A  correct  diagnosis  was  made  in  one  case  by  Fitz,  and 
the  jiossibility  of  the  ])resence  of  this  condition  nnist  be  c(»nsidered  in  all 
ahdoiiiinal  cases  which  come  on  suddenly  with  intense  pain  in  the  epi- 
pastrie  region,  vomiting,  and  distention  of  the  abdomen.  Perforation  of 
a  .|ilic.  ulcer  or  jterforation  from  gall-stones  might  jjroduce  similar 
sym|itonis,  but  the  previ(ms  history  would  give  important  indications.  In 
the  ease  in  wlindi  the  diagnosis  was  made  by  Fitz,  the  patient  was  sud- 
denly seized  with  severe  ])ain  in  the  epigastrium,  followed  by  vomiting 
and  prostration.  The  abdomen  was  distended,  temperature  slightly  ele- 
vated, and  the  bowels  were  constipated.     Tlu;  diajifnosls  lay  between  ob- 

•  Middleton-Goklismitli  Lecture.  New  York  Medical  Record,  vol.  i,  1889. 


H 


494 


DISEASES  OF   THE  DIGESTIVE  SYSTEM. 


struction,  jjorforative  peritonitis,  aiul  acute  pancreatitis.  IjiiparotDiny  was 
pert'i >!•!»<."<  1,  but  no  obstruction  I'ound.  The  autopsy  slioweil  ucutu  luuiuor- 
rhagio  pancreatitis. 

The  cases  are  stated  to  be  uuiformly  fatal,  but  recovery  may  (Kcur  ji^ 
shown  by  a  case  which  was  admitte;!  to  the  .Jolins  Hopkins  Il(».s)iital. 
Symptoms  (jf  obstruction  ol"  tlie  bi)wels  iiad  j  ersisted  for  three  or  lour 
days,  the  ai)(h)meu  was  distiuided,  tender,  and  very  painful.  I  saw  tln' 
l)atient  on  admission,  concurred  in  the  diagn(  his  of  ])robabh'  obstruction, 
and,  as  the  condition  was  serious,  ordered  liim  to  be  transferred  at  oiicti  u, 
tlie  operating-room.  Tlie  coils  were  distended  and  injected,  and  the  pcii- 
toneal  cavity  contaiiujd  a  snudl  amount  of  bloody  serum.  No  ohstrurlidii 
was  found,  but  in  the  region  of  the  pancreas  and  at  tlio  root  of  tlie  lueson- 
tery  there  was  a  dense,  thick,  indurated  mass  and  tliere  were  areas  of  fat- 
necrosis  in  botli  mesentery  and  omentum.  The  patient  recovered,  and  now, 
five  years  later,  remains  well. 

'I'he  literature  of  the  past  few  years  shows  that  this  alTection  is  iniich 
nic.  c  ,ent  than  has  been  sujjposed.     It  has  a  very  important  cliiiiwil 

and  ni.       o-legal  bearing. 

A  point  of  interest  is  the  relation  of  tha /(ff-necroais  to  pancreatie  dis- 
ease. The  areas  are  found  in  the  interlobular  pancreatic  tissue,  in  tlie 
mesentery,  in  the  omentum,  and  in  the  abdominal  fatty  tissue  generally. 
In  the  pancreas  the  lobules  are  seen  to  be  separated  by  a  dead-white  in'- 
crotic  tissue,  which  gives  a  remarkable  ap])earance  to  the  section.  In  the 
abdominal  fat  the  areas  are  usually  not  larger  than  a  pin's  head  ;  they  at 
once  attract  attention,  and  may  be  mistaken,  on  superficial  exaniiiiation. 
for  miliary  tubercles  or  neoplasms.  They  may  be  larger;  instances  have 
been  reported  in  which  they  were  the  size  of  a  hen's  egg.  On  section  they 
have  a  soft,  tallowy  consistence.  LangeVhans  has  shown  that  tliis  sub- 
stance is  a  jombination  of  lime  with  certain  fatty  acids.  They  may  lie 
crusted  with  lime,  and  in  a  man,  aged  eighty,  who  died  of  BrigliiV  dis- 
ease, I  found  the  lobules  of  the  i)ancreas  entirely  isolated  by  areas  of  fatty 
lu^crosis  with  (extensive  deposition  of  lime  salts.  There  is  no  neees.sirv 
etiological  relation  between  disease  of  the  pancreas  and  disseiuinatt'd  fatty 
necrosis  of  the  abdomen.  Cases  have  been  found  acjcidentally  iti  lapanit- 
omy  for  ovarian  tumor  and  in  instances  in  which  the  pancreas  has  beep 
normal.  They  may  be  found  in  thin  persons.  The  buctarium  cdll  com- 
inui/e  was  present  in  two  cases,  with  diphtiuM'itic  colitis,  examined  by 
Welch,  though  in  most  cases  the  areas  of  necrosis  are  sterile.  Langer- 
hans  produced  fat-necrosis  by  injecting  extract  of  pancreas  into  the  fatty 
tissue  of  a  dog;  and  llildebrand  has  shown  experimentally  that  the  fat- 
necroses  are  caused  by  the  pancreatic  juice,  and  by  the  ferment,  not  the 
trypsin. 

(b)  Suppurative  PancreatLlis. — Of  twenty-two  cases  analy// d  hy  I'itz. 
the  majority  occurred  in  adidts  und(>r  forty  years  of  age;  seventeen  were 
males.     Anatomically,  there  may  be  a  diiluse  sujjpuration  thrGiighoiit  the 


CHRONIC   PANCREATITIS. 


495 


nrffiin,  wliich  is  studdod  with  small  abscesses.  In  other  instances  tlie 
iibsci'ss  cavity  is  large,  anil  the  pancreas  is  converted  into  an  irregular 
cvst  lilled  with  creamy  pus.  In  more  chronic  cases  the  abscess  may  bo 
ciiciuiiscribed  and  the  contents  cheesy.  Communications  sometimes  oc- 
nir  with  the  duodenum,  or  the  abscess  may  burst  into  the  peritoniBum. 
Altlimigh  tlie  di-case  is  usually  chronic,  it  begins  with  epigastric  pain, 
voinitiug,  and  sometimes  prostration.  There  is  irregular  i'ever,  and  death 
may  necur  in  three  or  four  weeks.  In  more  chronic  cases  there  is  very 
slight  fever  or  oidy  occasional  paroxysms.  The  disease  may  persist  for 
wtrks,  months,  or  even  for  a  year. 

'I  iic  synijitoms  are  indefinite  and  the  condition  could  scarcely  be  made 
(lilt  (luring  life.  Tenderness  exists  in  the  epigastrium,  or  may  at  times 
extend  to  the  left  and  be  quite  sha'-ply  localized  over  the  position  of  the 
jiiuicreas,  but  a  circumscribed  tumor  is  rai'e.  Fat-necrosis  is  not  often 
fuiuid  post  mortem  in  these  cases. 

('•)  Gangrenous  Pancreatitis.— Fitz  has  collected  fifteen  cases.  The 
pancreas  may  be  converted  into  a  dark,  slate-colored,  stinking  mass,  or  it 
may  lie  nearly  free  in  the  omental  cavity,  attjiched  only  by  a  few  shreds  of 
tihroiis  tissue.  Complete  secpiest  ration  of  the  organ  is  not  uni;ommon. 
It  niav  be  discharged  as  a  slouch  from  tlie  bowels,  and  in  two  cases 
ill  which  this  hap[)ened  recovery  took  i)lace.  As  a  rule,  acute  ])erito- 
iiitis  fdUows.  Iliumorrhagic  jumcreatiti.s  may  precede  or  be  associated 
with  it.  Death  occurs  with  symptoms  of  collapse,  conmumly  in  from  ten 
to  twenty  days.  Disseminated  fat-necrosis  is  usually  preseiit.  In  some 
instances  the  totally  or  partially  sequestrated  orgaii  may  be  in  a  large 
ahscess  cavity,  which  may  form  a  palpable  tumor,  lying  usually  just  above 
nr  lo  the  left  of  the  umbilicus.     In  two  instances  of  this  nature  operation 


I   I 


It 


and  ( 


raiuage  have  been  followed  bv  recovery. 


III.    CHRONIC    PANCREATITIS. 

Tlie  organ  is  firmer  an<l  smaller  than  normal,  the  interstitial  connect- 
ive tissue  is  increased,  and  there  is  more  or  less  change  in  the  secreting 
structures.  A  special  interest  has  been  aroused  lately  in  this  affection,  as 
it  lui'^  liccn  fre(]uently  found  in  diabetes.  There  nuiy  be  marked  pigmen- 
tary changes;  a  similar  condition  has  been  found  in  the  liver.  Degenera- 
tiiiii  of  the  glandular  elements  is  present  in  these  cases.  The  sclerosis  may 
hi' associated  with  calculi  in  the  ducts.  An  interstitial  lipoma  may  cause 
great  wasting  of  the  lobules. 


■i'ft  f'iU 


IV.   PANCREATIC  CYSTS. 

'I'licK' commonly  result  from  the  imj)action  of  calculi ;  either  biliary, 
li'ilginir  at  the  orilice  of  the  common  duct,  or  pancreatic,  within  the  duct 
I'f  Wiisung.      Obliteration  of  the  duct  may  also  result  from  cicatricial 


490 


DISKASES  OF  THE   DIGESTIVE  SYSTEM. 


contraction  and  occasionally  from  displacement,  pjighteen  cases  of  cvsts 
of  the  pancreas  have  been  collected  by  Senn.  An  injury  has  luvccdcd 
the  onset  of  the  disease ;  but  in  many  cases,  as  shown  by  Jordan  Llovd, 
the  fluid  is  in  the  lesser  pcritona-uin  (see  lomlizcd  pcritonilis).  T|i(. 
chief  symptoms  are  tumor  in  the  epigastric  region,  usually  niiMliun,  or 
sometimes  to  one  side.  When  large,  it  has  occupied  the  whole  ;iiH|(jiiiiii;i| 
cavity,  and  in  such  instances  the  diagnosis  of  ovarian  tumor  1ms  iisuullv 
been  nuide.  The  tumor  may  develop  rapidly,  or  may  be  cLnjuic  uiid  last 
for  many  years.  In  some  instances  the  tumor  attained  a  large  size  witliin 
a  few  weeks.  Pain  is  not  necessarily  present.  Fatty  diarrluea  did  not 
exist  in  any  of  the  cases.  The  stools  may  be  clay-colored,  copious,  luij 
putrescent. 

The  diagnosis  of  the  condition  is  extremely  diflicult,  yet  it  seems  to 
have  been  made  in  7  of  the  18  cases.  Aspiration  should  Ije  made  to 
determine  the  nature  of  the  lluid.  This  has  varied  considerably,  l)ut  most 
frequently  has  been  brownish  or  chocolate-colored.  In  oidy  0  of  tlie  1? 
cases  in  which  the  nature  is  meiUioned  was  the  fluid  of  a  clear  serous 
character.  It  presents  some,  at  least,  of  the  characters  of  pancreatic  lluid, 
and  can  emulsify  fat  and  convert  starch  into  sugar.  The  tumor  foruied 
by  a  pancreatic  cyst  "lies  in  or  near  the  epigastrium,  and  causes  protru- 
sion, at  first,  of  the  upper  part  of  the  abdomen.  It  usually  appears  in  the 
left  hypochondrium,  between  the  costal  cartiliiges  and  the  median  line; 
more  rarely  it  is  felt  in  the  vicinity  of  the  navel.  It  is  globular,  roistani, 
not  elastic,  smooth,  usually  changing  its  jiosition  somewiuit  with  the 
movements  of  the  diaphragm,  and  possessing  a  slight  degree  of  lateral 
motion"  (Fitz). 

V.  CANCER. 


ili'H'MWiii 


.1,  '  f  ' 


This  is  usually  scirrhus,  and  may  be  primary  or  secondary.  It  is  not 
common,  as  may  be  judged  by  the  analysis  by  Segre,  who  found  in  Il,4!ii 
autopsies  only  132  tumors  of  the  pancreas,  127  of  which  were  careinonuita, 
2  sarcomata,  2  cysts,  and  1  syphiloma.  In  only  12  of  the  cases  oi  eareino- 
ma  was  the  disease  limited  to  the  gland.  The  head  is  commonly  atlected, 
and  the  disease  may  be  limited  to  this  part  or  extend  to  it  from  the  stom- 
ach or  intestines. 

The  symi)toms  are  variable,  and  a  diagnosis  is  not  often  jiossilde. 
There  may  be  stearrhoni,  though  it  is  to  be  remembered  that  fatty  iliar- 
rluwa  is  not  invariably  associated  with  disease  of  the  pancreas.  Clay-col- 
ored, greasy,  and  loose  stools  may  be  present,  with  undigestec'  food,  as 
noted  by  T.  J,  Walker  as  a  symjitom  of  obstruction  of  the  pauereatie 
duct.  Diabetes  may  coexist.  Although  the  head  of  the  pancreas  <an  be 
felt  in  very  thin  persons,  the  tumor  masses  can  ra.rcly  be  ])alpattd.  In 
the  analysis  of  137  cases  by  Da  Costa,  in  only  13  was  the  tumor  recognized 
by  palpation.     The  general  symjjtoms  are  those  of  internal  carcinoma. 


i^sjiJH 


PANCRKATIC  CALCULI. 


497 


Progressive  emaciation,  loss  of  strongtli,  and  (ly.sj)cpsia  are  present.  Tliere 
ispiiiii  in  the  (■pi<,'astriiun,  somctinu's  paroxysmal.  When  the  head  of  the 
paiicnas  irf  involved  jautulioe  is  almost  invariably  jx-escnt. 

Tlu!  disease  can  scarcely  ever  l)e  distiiignislu'd  from  cancer  in  the 
pyloric  zone  with  involvement  of  the  glands  in  the  hilus  of  the  liver.  The 
niovulilc  character  of  the  pyloric  tumor  and  the  absence  of  the  hydro- 
chloric acid  in  the  vomit  are  valuabli!  points.  Tnmor  of  the  transverse 
cdloii  is  more  su|)erficial  and  movable,  is  often  associated  with  temporary 
iibstruclion,  and  there  may  be  hiemorrhage  from  the  bowels.  In  a  case 
with  progressive  emaciation,  epigastric  i)ain,  and  deep-seated,  immobile 
tumor,  with  the  presence  of  fatty  and  greasy  stools  and  the  gradual  devel- 
iipiiu'iit  of  jaundice,  the  diagnosis  of  cancer  of  the  pancreas  is  ])robable. 

As  the  wasting  proceeds  the  aortic  pulsation  is  transmitted  with  great 
forco  through  the  pancreas  and  transverse  colon,  and  when  a  tumor  is 
present  the  diagnosis  of  aneurism  nniy  be  nuide ;  but  in  the  latter  the 
s;i('  hiis  not  an  np-and-down  jerking  i)ulsation,  l)ut  is  distensilc.  Tn  doubt- 
ful tumors  in  this  region  the  examination  should  also  be  made  in  the  knee- 
elbow  position. 

Of  other  new  growths  in  the  pancreas,  tubercle  may  be  mentioned  as 
iiraro  occurrence;  a  few  cases  of  .syphiloma  have  been  (lescrii)ed. 

The  treatment  of  new  growths  in  the  pancreas  is  entirely  symptomatic. 

VI.  PANCREATIC  CALCULI. 

Concretions  are  occasionally  met  with  in  the  pancreatic  ducts  leading 
ti)  great  dilatation  and  to  atroj)hy  of  the  gland  structure.  They  are  often 
numerous,  and  are  either  round  in  shape,  or  rough,  spinous,  and  coral-like. 
They  are  usually  white,  often  of  an  opaque  white  in  color,  and  are  com- 
posed chielly  of  carbonate  of  ]ime.  When  in  large  numbers  they  cause 
.-erioiis  dilatation  of  the  ducts  with  atro])hy  of  tlie  gland  tissue,  sometimes 
greiit  cystic  dilatation,  rarely  abscess. 

The  symptoms  of  pancreatic  calculi  are  not  definite.  In  the  majority 
of  instances  they  are  met  with  acci'lentally.  There  are  cases,  however,  in 
whieli  the  disease  is  suggested  by  fatty  stools  and  the  presence  of  glyco- 
suriii.  possibly  certain  obscure  forms  of  colic  may  be  caused  V)y  their 
[ireseiice,  and  Minnich  has  reported  a  case  in  which,  after  an  attack  of 
i!olic,  calcidi  composed  of  calcic  carbonate  and  phosphate  were  passed  in 
the  stools. 


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ww^ 


498  DISEASES  OF  THE   DIGESTIVE  SYSTEM. 


X.  DISEASES   OF  THE   PERITONyEUM. 

I.  ACUTE  GENERAL  PERITONITIS. 

Definition. — Acute  iiiilainmation  of  the  poritormnim. 

Etiology. — Till!  condition  miiy  lu'  priniary  or  secondary. 

{(I)  Primary,  Idiopathic  Peritonitis.— Considering  liow  freqncntly  tlic 
pleura  and  periciirdinni  are  i)riinarily  intlanied  the  rarity  of  i(lii)|>iitlii( 
inflannnatioii  of  the  peritona-nm  is  somewhat  remarkable.  It  may  follow 
cold  or  exj)o.sure  and  is  then  known  as  rheumatic  peritonitis.  Xd  iiistiinco 
of  the  kind  has  come  under  my  notice.  OccasioiuUly  in  Hriohi'.s  disfii* 
acute  peritonitis  develops  as  a  terminal  event. 

(/v)  Secondary  Peritonitis  is  due  to  extension  of  inflammation  from,  or 
l)erforation  of  one  of  the  organs  covered  by  the  peritonuMun.  rcritoiiitis 
from  extension  may  follow  inflammation  of  the  stomach  or  iiitcstinos. 
extensiv((  ulceration  in  tlu'se  parts,  cancer,  acute  suppurative  inllanmiiition,. 
of  the  spleen,  liver,  pancreas,  retroperitoiu-al  tissues,  and  the  pelvic  viscera 

Perforative  jieritonitis  is  the  most  comnu)n,  following  external  wouikLs 
perf(U"ati()u  of  ulcer  of  the  stomach  or  bowels,  perforation  of  the  i^all- 
bladder,  abscess  of  the  liver,  s[)leen,  or  kidiu'ys.  Two  importaiU  causi's; 
are  a])pendicitis  and  snp]>nrating  inihuumation  about  the  Fidlo[)ia!i  tulii'S 
aud  ovaries.  There  are  instauces  in  which  peritonitis  has  followed  niptiire 
of  an  apparently  normal  Graafian  follicle. 

The  peritonitis  of  sei)tica3mia  aud  pyicmia  is  almost  invariably  tlic  re- 
sult of  a  local  process.  An  exceedingly  acute  form  of  peritonitis  iiiay  lui 
cau.sed  by  the  development  of  tubercles  on  the  membrane. 

Morbid  Anatomy.— In  recent  cases,  on  opening  the  abdomen  the 
intestinal  coils  are  disteiuled  and  glued  together  by  lymph,  and  the  jien- 
tona?um  ])reseuts  a  ])atchy,  sometimes  a  uuiform  injection,  'i'he  exmlii- 
tion  maybe:  (a)  Fibrinous,  with  little  or  no  fluid,  except  a  few  luiekets 
of  clear  serum  between  the  coils.  (/>)  Sero-fibi'iuous.  The  coils  are  cov- 
ered with  lymph,  and  there  is  in  addition  a  large  amouut  of  a  yellowisli, 
sero-fd)riuous  fluid.  In  instauces  in  winch  the  stomach  or  intestine  is 
perforated  this  may  be  mixed  with  food  or  fa'ces.  (r)  I'urnlcnt,  in  wliich 
the  exudate  is  either  thin  and  greenish  yellow  in  color,  or  o[)a<|ne  while 
aud  (U-eamy.  (iJ)  Putrid.  Occasionally  in  })uerpcral  aud  perforative  peri- 
tonitis, jiarticularly  wlien  the  latter  has  been  caused  by  cancer,  the  exudate 
is  thin,  grayish  green  in  color,  and  has  a  gangrenous  odor,  (r)  Ibemor- 
rhagic.  This  is  sometimes  found  as  an  admixture  in  cases  of  acute  jieri- 
tonitis  following  wounds,  and  occurs  in  the  cancerous  and  tubereiilons 
terms. 

The  amount  of  the  effusion  varies  from  half  a  litre  to  twenty  or  thirty 
litres.     There  are  probably  essential  differences  between  the  various  liiiuts 


ACUTE  CiEXKUAI.   PKiaTONlTIS. 


400 


of  iioritniiitis,  and  l)iu;t('riol()<jy  is  ItcyiiuiiiiL'  to  i^qvc  ns  vsiluublo  iiiforiiiii- 
tidii  oil  this  point.  Mii(!ii  worlv  lias  been  done  hiU'ly  ni)(»n  \\\v.  sul)ji'rt, 
till'  most  inii)ortant  1)V  'Pavel  ami  Lanz.  Of  59  I'ases  oxainined  by  tliein, 
the  streptooociMis  pyoirenes  was  fmiiid  alime  in  ;i(),  in  association  in  !.">  ; 
tlir  liacilliis  eoli  comiimnis  alone  in  !.").  in  assoidation  in  Kl;  the  staphylo- 
ciK'cus  alone  in  'i,  in  asso(;iation  in  (» ;  the  piienniocoi'cns  in  coniljinatiou 
ill  •>;  cases.  In  a  majority  of  instances  of  peritonitis  from  [icrl'oratioii  tho 
Ijiicilliis  eoli  eomnnmis  is  present,  usnally  in  pnre  eulinre.  Welch  has 
I'liuiid  it  also  in  j)erilonitis  due  to  idceratioii  of  the  intestines  without  p(!r- 
fvratioii.  In  a  very  interestiii;j;  eti.se  in  my  wards  of  a  yoiiiiii'  woman  a^ed 
t'lLditceii,  with  contracted  kidney  iind  nra'iina,  there  was  an  acntc^  jieri- 
tnnitis,  from  whieli  Flexner  isolated  the  protens  viilj^aris  in  pure  enltnre. 
Twe  eases  iiave  been  reported  by  Mexner  in  which  the  piieiimocoecus 
iikme  was  present.  Of  other  organisms  which  liave  been  found  may  bo 
niciitioned  tho  bacillus  pyocyaiieiis,  the  anthrax  bacillus,  and  the  bacillus 
ju'iuijeiies  capsiilatiis. 

Symptoms.  —In  the  perforative  and  septic  ciises  the  onset  is  marked 
by  chilly  feelings  or  an  actual  rigor  with  intense  j)ain  in  thealxlomeii.  In 
tvjilinid  I'ever,  when  the  sensoriiiin  is  beiiuiid)ed,  the  on.set  may  not  be 
iioiiced.  The  pain  is  general,  and  is  usually  intense  and  aggravated  by 
iiidveiiients  and  pressuie.  A  position  is  taken  which  relieves  the  tension 
(if  the  al)dominal  muscles,  so  that  the  patient  lies  on  the  back  with  the 
tliiudis  drawn  np  and  the  shoulders  elevated.  The  greatest  jniin  is  usually 
lii'lmv  the  umbilicus,  but  in  jjcritoiutis  from  perforation  of  the  stomach 
jiiiiii  may  be  referred  to  the  back,  the  chest,  or  the  shoulder.  The  respira- 
tii  II  is  suj)erticial — costal  in  type — as  it  is  painful  to  use  the  diaj)hragni. 
i'ur  the  same  reason  the  action  of  coughing  is  restrained,  and  even  the 
iiiiivcments  necessary  for  talking  are  linuted.  In  tliis  early  stage  the  sensi- 
tiveness may  be  great  and  the  abilomimd  muscles  are  often  rigidly  con- 
tnicled.  If  tiie  ])atient  is  at  perfect  rest  the  jtain  nniy  he  very  slight,  and 
tliiTc  are  instances  in  which  it  is  not  at  all  marked,  and  may,  imleed,  be 
ubjeiit. 

The  abdomen  gradmdly  becomes  distended  and  tetiseand  is  tympanitic! 
on  iicrciission.  The  pulse  is  rapid,  small,  and  hard,  and  often  has  a  peculiar 
wii' ■  ([iiality.  It  rauges  from  110  to  I'AK  The  temperature  may  rise  rap- 
idly afli'r  the  chill  and  reach  10-1°  or  lU.-)°,  but  the  siibse(|uent  elevation  is 
iiioi.erate.  In  some  very  severe  ca.ses  there  may  l)e  no  fever  throughout, 
llu'  tongue  at  first  is  white  and  moist,  but  subseciuently  boe()mes  dry  iind 
oftuii  red  and  fissured.  \'omiting  is  an  early  and  })romiiu'nt  feature  ami 
i-'iiiisc's  great  pain.  The  contents  of  the  stomai'h  are  first  ejected,  then 
ytllouish  and  bile-stiuned  fluid,  ami  finally  a  greenish  aiul,  in  rare  in- 
sliiiKes,  a  brownish-black  Ii(pnil  with  slight  fa'cal  odor.  The  bowels  may 
bf  loose  at  the  onset  and  then  constipation  follows.  Freipient  nucturition 
iiiiiy  i)i;  present,  less  often  retention.  The  urine  is  usually  scanty  and 
iiiglieulored,  and  contains  a  large  quantity  of  indicau. 


)) 


1  1 


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500 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


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Tlio  iipiH'iiriUicc!  of  tlio  puficnt  wlicn  tlu'sc  syniptoiiis  liiivc  fiillv  ilovol- 
oped  is  vory  cliiinictoristic.  'Vho  tacc  is  pinched,  tiie  eyes  are  siuiktii,  and 
tho  expression  is  very  anxious.  'I'iic  constiint  vomiting  of  fluids  causes  u 
wasted  iipjx'iinince,  and  the  iiands  sometimes  ju'esent  the  washci'-Wdiimn's 
slvin.  J'lxci^pt  in  cholera,  we  si'e  tlie  Jlippocratic  facies  more  IVciincntlv 
in  tins  tlian  in  any  other  disease— "^^  s/iarp  nose,  /ki/Idio  ci/i's,  .  ulldpsiil 
tetuplen  ;  the  cars  ro/i/,  f(j,//riici('il,  fuiil  llii'ir  lo/irs  tiinicd  (ml  :  llo'  skin 
about  the  forehead  fieiuy  rov(/h,  distended,  and  parrlied  ;  the  cnhir  i<f  Ikr 
trhdle  face  Iteinij  liro/eii,  hlack\  liritl,  ar  tead-ea'ured.^''  There  are  oiu'  or 
two  additional  j)oints  about  the  alidomeii.  The  tympany  is  usuully  ex- 
cessive, owiiif^  to  the  (fnnit  relaxation  of  the  walls  of  the  intestines  liv  in- 
flammation and  exudation.  'I'he  splenic  dulness  may  be  obliteniteil,  the 
diaphra<jjm  puslmd  up,  and  the  a})ex  beat  of  the  lieart  dislocated  to  the 
fourth  interspace.  'I'he  liver  dulness  may  be  "(reatly  reduced,  or  may,  in 
tlie  mammary  line,  be  obliteratiMl.  it  has  been  claimed  that  this  is  a  iljs. 
tinctive  feature  of  ])erforative  peritoiutis,  Imt  on  several  occasions  1  h:ive 
been  able  to  demonstrate  that  the  liver  dulness  in  the  middle  ami  maiii- 
niary  line  was  obliterated  by  tym])anites  alone.  In  the  axillary  line,  dii 
the  other  hand,  the  liver  dulness,  though  diminished,  may  persist.  I'litiiinu- 
})eritona'um  following  perforation  more  certainly  obliterates  the  lu'|iatie 
dulness.  hi  such  ciisos  the  fluid  effused  produces  a  dulness  in  the  hitenil 
m^ion;  but  witii  gas  in  the  peritonu-'um,  if  the  i)atieut  is  turned  mi  the 
left  side,  a  clear  note  is  heard  beneath  the  seventh  and  eighth  ribs. 

Klfusioiv  of  fluid— ascites — is  usually  present  except  in  some  acute, 
rapidly  fatal  cases,  'i'lie  flanks  are  dull  on  percussion.  The  dullness  may 
bo  movable,  though  this  depends  altogether  upon  the  degree  of  adhcsinii.s. 
There  may  be  cjiisiderable  effusion  without  either  movable  diilnis.s  or 
fluctuation.  A  fi'iction-rub  may  be  present,  as  first  pointed  out  by  Ih'ight, 
but  it  is  not  nearly  so  common  in  acute  as  in  clironic  peritonitis. 

Course. — The  acute  diffuse  peritonitis  usually  terminates  in  death. 
The  most  intense  forms  may  kill  within  thirty-six  or  forty-eight  Ikuus; 
more  commonly  death  results  in  four  or  five  days,  or  the  attack  may  bo 
prolonged  to  eight  or  ten  days.  Tiie  pulse  becomes  irregular,  the  heart- 
sounds  weak,  the  breathing  shallow,  there  are  lividity  with  jiallor,  a  cold 
skin,  with  high  rectal  temperature — a  group  of  symptoms  indicating 
profound  failure  of  the  vital  functions  for  which  (Jee  has  revived  the  old 
term  Upothyniia.  Occasionally  death  occurs  with  great  suddenness,  owing, 
possibly,  to  paralysis  of  the  heart. 

Diagnosis. — In  tyiiical  cases  the  severe  pain  at  onset,  the  distention 
of  the  abdomen,  the  tenderness,  the  fever,  the  gradual  developiiieiit  of 
effusion,  collapse  symptoms,  and  the  vomiting  give  a  characteristic  pittnre. 
Careful  inquiries  should  at  once  be  made  concerning  the  previous  cdnili- 
tion,  from  which  a  clew  can  often  be  had  as  to  the  starting-point  of  the 
trouble.  In  young  adults  a  considerable  proportion  of  all  cases  depends 
upon  perforating  appendicitis,  and  there  may  be  an  account  of  previous 


ACUTE  GENERA li  I'EUlTONlTrS. 


501 


iittiicks  of  piiin  in  the  iliiie  roj,'i()ti,  or  of  coiistipiitioii  iiltorniitinj?  witli  diiir- 
ili(ia.  Ill  woiiu'ii  tlic  most  fr('(|iu'iit  ciitiscs  arc  siipiiiirutivc  proccssc's  in 
till'  julvic  viscora,  (.'itlitT  associalt'd  with  salpiii;,nt.i.-!,  al)scc's.v(>s  in  tln^  broad 
li'Miiii'iits,  or  acuti'  puerperal  infection.  IVrforation  of  j.^astrie  ulcer  is 
iiiurc  eonunon  also  in  wonu'ii.  It  is  not  always  easy  to  determine  tho 
cuiiM'.  Many  cases  eomt;  under  ohservation  for  the  lirst  time  with  tho 
alMlniiirii  distended  and  tender,  and  it  is  impossihU?  to  make  a  satisfactory 
cxiiiiiiiiation.  In  such  instances  the  pelvic,  organs  should  be  examined 
witli  tile  greatest  care.  In  typhoid  fi'vcr,  if  the  patient  is  eonseious,  tho 
.sudiicii  onset  of  pain,  the  developnu'ut  of  great  meteorism,  and  the  uggni- 
viitimi  of  tlie  general  symptoms  indicate  clearly  what  luis  happened. 
When  the  patient  is  in  di'i'p  I'oma,  on  the  other  lumd,  the  j)erforation  may 
lie  overlooked.  Tho  following  conditions  uro  most  apt  to  be  mistaken  for 
lu'iite  peritonitis: 

{(i)  Ariife  I'Jnfcro-roIiiis. — Here  tlie  pain  and  distention  and  tlio  sen- 
sitiveness on  pressure  may  lu'  marki'd.  The  pain  is  more  colicky  in  chur- 
lictcr,  the  diarrho'a  is  more  fre<|uent,  and  t!  ".  collapst;  is  nu)re  extreme. 

(//)  77ir  S(i-r((U<'d  Ili/sfrrintI  /'rri/oiii/ls. — This  has  deceived  tho  very 
fleet,  as  almost  every  feature  of  genuine  peritonitis,  even  tho  collapse,  may 
he  siiindated.  The  cmset  may  be  sudden,  with  severe  pain  in  the  abdornen, 
teiiilcrness,  vomiting,  diarrho'a,  ditVii"iliy  in  mi(^turition,  and  the  charac- 
teristic decubitus.  Even  the  temperature  nuiy  be  elevated.  There  maybe 
reiurreni-e  of  the  attack.  A  case  lias  been  reported  by  Hristowe  in  which 
foiu'  attacks  occurred  within  a  year,  and  it  was  not  until  s^K'cial  hysterical 
livinptiinis  developed  that  the  true  nature  of  the  trouble  was  sns])ected. 

(r)  O/tsfrurfion  of  the  bonwl,  as  already  mentioned,  may  simulate  jjcri- 
timitis,  Ixith  having  pain,  vomiting,  tympanites,  and  constipation  in  com- 
mon, it  may  for  a  couple  of  (hiys  really  be  impossible  to  make  a  diagnosis 
in  the  al)sence  of  a  satisfactory  history. 

{(1)  Jiiipfiirc  of  an  itbdonutial  (nieun'sm  or  embolism  of  tlie  superior 
mcscKteric  artenj  may  cause  symptoms  whicl>  simulate  peritonitis.  In  the 
lattL'r,  sudden  onset  with  severe  pain,  the  collapse  symptoms,  frequent 
vomiting,  and  great  distenti(m  of  the  abdomen  may  be  present. 

('•)  1  have  already  referred  to  the  fact  tliat  acute  ha^morrhagic  pan- 
ercatitis  may  be  mi.staken  for  peritonitis.  Lastly,  a  ruptured  tubal  preg- 
luuK-y  may  resemble  acute  peritonitis.  A  ])atient  was  admitted  to  my 
wards  in  an  enfeebled  coTulition,  with  a  thready  jnilse,  distended  and  ten- 
der alxlomen,  aiul  signs  of  fluid.  The  attack  had  conu^  -..w  suddenly  four 
day.s  before,  when  she  had  been  in  jjcrfect  health.  She  looked  pale,  tho 
blood  count  was  taken  and  found  below  three  millions  per  cubic  centi- 
motro,  with  leucocytosis,  a  condition  rather  indicating  antBuiia  from  hicm- 
oirha^o.  The  abdomen  was  tapped  with  a  fine  aspirator  needle  and  a 
Moody  thiid  withdrawn.  The  diagnosis  of  probable  ruptured  tubal  preg- 
nancy was  made  and  the  patient  was  transferred  to  the  gynajcological  de- 
partment, where  laparotomy  was  performed  and  the  ruptured  tube  removed. 


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DISKASES  OF  TIIK   DIOKSTIVK  SYSTEM. 


II.  PERITONITIS   IN    INFANTS. 


Peritonitis  iimy  <»cciir  in  llic  I'n'liis  tis  a  (•(iiiscijiiciicc  of  sv|iliilis,  and 
may  lead  tctconstrictinn  of  ilic  IkiwcI  liy  liliroiis  udlKv-idiis. 

In  liic  iii'\v-I)(»rn  a  septic  |iei'itniiitis  may  extend  rntui  an  inlliuiicd  iuu\. 
l)isteidiiin  nf  tlie  alwionien,  sliirid  swelling,' and  redness  alxint  tlie  CdnKuiiil 
not  inrre(|nently  jaundice  are  present.  It  is  an  nncoininon  event,  mul 
e.xisted  in  only  four  of  lifty-one  iidanis  dyin;;  of  inilainnuition  of  llieconl 
and  s('|)tie.i'rnia  ( Knii^fe). 

Dnrin;;  eliildliodd  peritonitis  develops  from  causes  similar  to  tiiose  nf. 
feeling'  the  adult.  Perforative  appendicitis  is  common.  Peritonitis  fol- 
lowin;;  Idows  or  kicks  o»i  the  ahdomen  ocrurs  more  fre(|uently  at  this 
period.  In  hoys  injury  while  phiyini:  foot-hall  may  lie  followed  liy  (liU'iisc 
peritordtis.  A  rai'e  causo  in  children  is  exti'nsioii  thron^jh  the  diaphni^rm 
from  an  empyema.  There  are  on  recoid  instances  of  pei'itoiutis  oecurriii:.' 
in  several  children  at  the  same  school,  and  it  has  heeii  attrihnteil  to  •<c\vci'- 
jjas  poisonin;;.  It  was  in  iiivesti^atin<;  an  cpideiiuc  of  tins  kind  at  the 
Watidswortli  sfdntol,  in  London,  that  Anstie  received  the  ])ost-mort('ra 
wound  of  whieii  lie  died. 


III.   LOCALIZED  PERITONITIS. 


)  m 


1.  Subphrenic  Peritonitis. — The  i;cneral  peritoiKcum  e  'r  tliorisht 

and  left  iohe.s  of  the  hvi'r  may  he  involved  in  an  extension  Irom  the  jdi'uni 
of  suppurative,  tulx'i'culous,  or  cancerous  processes.  In  various  alTcctidiis 
of  the  liver — cancer,  ahscess,  hydatid  di-sease,  and  in  alTections  of  the 
gall-hladder — the  intlamnuition  may  l)c  localized  to  the  periton;euiii  nivrr- 
intr  the  upper  surface  of  the  organ.  These  forms  of  localized  suhpiironic 
jteritonitis  in  the  greater  sac  are  not  so  important  in  reality  as  tlie.-c  wliieh 
occur  in  the  lesser  peritonieum.  'IMie  anatonncal  relations  of  this  struc- 
ture are  as  follows  :  It  lies  hehind  and  helow  the  stomach,  the  (riisfn- 
hepatic  omeiitun),  and  the  anterior  layer  of  the  great  omeiituin.  Its 
lower  limit  forms  the  npper  layer  of  the  transverse  nieso-colon.  On  cither 
side  it  reaches  from  the  hepatic  to  the  sjtlenic  flexures  of  the  colon,  and 
from  the  foramen  of  Winslow  to  the  hilus  of  the  spleen.  Behindit  ("(n- 
ers  and  is  tightly  adherent  to  the  front  of  the  pancreas.  Its  ujiper  limit 
is  formed  hy  the  transverse  fissure  of  the  liver,  by  that  portion  of  the 
diaphragm  which  is  covered  hy  the  lower  layer  of  the  right  lateral  liira- 
ment  of  the  liver,  and  the  lolnis  Spigelii  lies  bare  in  the  cavity.  The 
foramen  of  Winslow,  through  which  the  lesser  communicates  with  the 
greater  peritona.Hini,  is  readily  closed  by  intlammation. 

Inflammatory  processes,  exudates,  and  ha'inorrhages  may  be  cniiilmil 
entirely  to  the  lesser  peritonanim.     The  exudate  of  tuberculous  peritouitis 


I,()('AM/,i:i)    I'KItlTONITIS. 


no.*} 


iii;iv  In'  coiilliird  to  it.  PiTfonitionH  (if  ccrdiiii  piirts  of  tlio  slomncli,  of 
t|i(>  iIiiimIchuiii,  iiMil  of  III*' ciiloii  tiiay  (>\i'il(>  iiil1aiiiiii:ilion  in  it  alone;  iiiul 
in  Mirioiis  atVi'ctioiis  of  llic  iiaiicrcas,  parliciilarly  trauma  and  jurniorrliaf,'*'. 
till'  ilTiision  into  till)  sac  lias  often  been  confoiintlfd  witli  cyst  of  this 
()r;.';iii.  "  I'atlioloj^ical  distention  of  tlie  lesser  iteritoiiiemn  irivt's  rise  to 
ji  imnur  in  tlio  left  liypoidiondriac,  epiiraslric,  and  utnliilical  I'cLjions  of 
ii  seiiii'wiiat  cliaiMcteristii'  shape,  hnt  wlucli  appears  to  vary  from  time 
to  liiiii'  in  f(trin  and  size,  accordinif  to  tlic  conditions  of  the  overlyiii",' 
stoiMiirh  ;  for  when  th(^  viscns  is  fnll  of  li(piid  c((iiteiits  it  increases  tho  area 
of  the  tumor's  iliiliH'SH,  while  it  makes  its  ontlines  less  delinahle  hy  pal- 
patiuii,  and  if  tli(>  stomach  is  distended  with  jjas  the  dull  area  heeomes 
rc'SDiiaiit  and  apparently  tin;  tumor  may  disappear  alto^jether.  The  colon 
always  lies  below  the  tumor  atid  never  in  front  of  or  ubovu  it,  us  is  the  case 
in  kidney  eidar«,'emeiit  "  (Jordan  Lloyd). 

Special  mention  must  bo  made  of  tlic  remarkable  form  of  snb- 
plireiuc  abscess  eontainiitfj  air,  which  may  simulate  closely  pneiimit- 
tlidrax,  ami  hence  was  called  by  licydeii  /'i/ii-piii'iiiii(i//i(int.''  Knh/i/irrin'fiis. 
Till'  ail't'ctioii  has  been  thoroiiffhly  studied  of  lat(i  years  by  Sehourleii, 
MaMiii,  Melt/.cr,  atid  l>i'i;  Dickinson.  In  14"-i  out  of  \'tO  recorded  cases 
the  cause  was  kiu)wn.  In  a  few  instances,  as  in  one  reported  by  Meltzer, 
the  subphrenic  abscess  seemed  to  have  followed  pneiimoiua.  I'yothorax 
is  an  occasional  cause.  Hy  far  the  most  fretpient  condition  is  jrastric 
ulcer,  wliich  occurred  in  SO  of  the  cases.  Duodenal  ulcer  was  the  (^aiise 
in  six  i)or  cent.  In  about  ten  per  v.out  of  the  cases  the  appendix  was  the 
startiuir-point  of  the  abscess.  Cancer  of  the  stomach  is  an  occasional 
ciiuse.  Other  rare  causes  are  trauma,  which  was  jjresent  in  one  of  my 
cases,  perforation  of  hepatic  or  renal  abscess,  lesions  of  the  spleen,  abscess, 
anil  cysts  of  the  i)ancreas. 

In  a  majority  of  all  the  oases  in  wdiioh  the  stomach  or  duodenum  is 
IH'rfonileil — sometimes,  indeed,  in  the  cases  following  trauma,  as  in  (Jose 
-?  of  my  series — the  abscess  contains  air. 

The  sym{)toms  of  subphrenic  abscess  vary  very  considerably,  depending 
a  ;;o(](i  (leal  upon  the  priimiry  cause.  The  onset,  as  a  rule,  is  abruj)t, 
particularly  when  due  to  perforation  of  a  gastric  ulcer.  There  are  severe 
liaiu.  vomiting,  often  of  bilious  or  of  bloody  nuiterial ;  respiration  is  em- 
barrasseil,  owing  to  the  involvement  of  the  diapiiragni ;  then  the  con- 
stitutional symptoms  develop  associated  with  sui)puration,  chills,  irregu- 
lar fever,  emaciation.  Subsequently  perforation  may  take  place  ijito  the 
pleura  or  into  the  lung,  with  severe  cough  and  abuiulant  purulent  ex- 
pectoration. 

The  coiulitions  are  so  obscure  that  the  diagnosis  of  subphrenic  ab- 
scess is  not  often  made.  The  perihepatic  abscess  beneath  the  arch  of 
the  diaphragm,  whether  to  the  right  or  left  of  the  suspensory  ligament, 
when  it  does  not  contain  air,  is  almost  invariably  mistaken  for  empyema. 
^\hen  a  pus  colJectiou  of  any  size  is  in  the  lesser  pcritoiiajum,  the  tumor 


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DISEASES  OP  TFIK   DIGESTIVE  SYSTEM. 


in  formfn]  wliicli  lias  the  characters  already  mentioned  in  a  quotation  from 
Mr.  .Jordan  f^loyd. 

The  most  remarkahk'  featr.res  arc  those  which  are  siipcradilfd  wlieu 
thf!  alwcess  cavity  contains  air.  Here,  on  the  rifjiil  side,  when  the  ahiJcess 
u  in  the  greater  pei-itonanini,  above  tiie  riji:ht  lobe  of  the  liver,  tlic  (][■{. 
jihra^m  may  be  jnished  iij)  to  the  level  of  the  second  or  third  rili,  ami 
the  jihysical  signs  on  percussion  and  auscultation  are  tho.se  of  jiiuunio- 
thorax,  particularly  the  tympanitic  resonance  and  the  movable  iliihuss. 
The  liver  is  usually  greatly  depressed  aiul  there  is  bulging  on  the  right 
ni<](\  Still  more  obscure  are  the  cases  of  air-containing  itbscesses  diu'  to 
I>erforation  of  the  stomach  or  duodenum,  in  which  the  gas  is  coiitiiiiuMl 
in  thf»  lesser  peritona>um.  Here  the  diaphragm  is  pushed  uj)  and  tliorc 
are  xigns  of  pueumothora.x  on  the  left  side.  In  a  large  majority  of  all 
the  cases  wliich  follow  })erforation  of  a  gastric  idcer  the  effusion  lies  be- 
tween the  diajihragm  above,  the  sjjleen,  stomach,  and  the  left  lolie  of  tlio 
Hv»T  hcdow. 

The  prognosis  in  cases  of  subphrenic  abscess  is  not  very  hopeful.  Of 
the  csijfcs  on  record  about  20  })er  cent  oidy  have  recovered.  Of  ! ho  live 
canon  which  have  come  under  my  observation,  three  recovered  after 
ojHTation. 

'i  Appendicular. — The  most  frequent  cause  in  the  male  of  localized 
|K;ritonit.is  is  inllammation  of  the  appendi.x  vermiformis.  The  sit  nation 
varies  with  the  ])osition  of  this  extremely  variable  organ.  The  adhesion, 
jMrrforafion,  aiul  intraperitoneal  iibscess  cavity  may  be  within  the  pelvis. 
or  to  the  left  of  the  median  line  in  the  iliac  region,  in  the  lower  lijrlit 
quadrant  of  the  umbiliral  region — a  not  uncommon  situation— or,  (4 
courae,  most  frequently  in  the  right  iliac  fos.^a.  In  the  most  coiiunon 
)<itiiatiori  the  localized  abscess  lies  upon 'the  psoas  mus(de,  bor.iidcd  by 
the  ca-cum  on  the  right  and  the  terminal  portion  of  the  ileum  and  its 
mewntery  in  front  iind  to  the  left.  In  many  of  these  cases  the  limitation 
i»  perfect,  arul  jiost-mortem  records  show  that  c()mi)lete  healing  may 
take  p'l.ice  with  the  obliteration  of  the  api)endi.\'  in  a  mass  of  linn  scar 
ti.HHne. 

3.  Pe'vic  Peritonitis. — The  most  frequent  ctuise  is  innammation  almiit 
the  uterus  and  Fallopian  tubes.  Puerperal  septicivmia,  goimrrhoa.  and 
tuberculosis  are  the  usual  causes.  The  tubes  arc  the  starting-point  in  ii 
majririty  of  the  ca.ses.  The  fimbria'  become  adherent  and  (d()S<dy  iinittcd 
to  the  ovary,  and  there  is  gradually  produced  a  condition  of  thickening  of 
the  parts,  in  whicdi  the  individtud  organs  are  scarcely  recogjiizaldc.  Th 
fiilxrs  are  dilated  and  fdled  with  (dieesy  nuitter  or  pus,  and  there  in  y 
b<'  small  abscess  cavities  in  the  broad  ligaments.  Rupture  of  on<'  of  tl  s=»' 
may  cause  general  peritonitis,  or  the  membrane  may  be  involved  l)y  oxaii- 
sion,  as  in  tuberculosis  of  these  parts. 


CHRONIC   PERITONITIS. 


IV.  CHRONIC  PERITONIT!S. 


505 


Tlio  following  varieties  may  be  reeogrizod  :  {<i)  Local  adhesive  perito- 
nitis, a  viTV  common  condition,  which  occurs  ])artieiiliirly  abo  L  '.c  spli'cn, 
form  in:,' adhesions  between  the  capsule  ami  the  diaphragm,  about  the  liver, 
less  fn'(iuontly  about  the  intestines  and  mesentery.  I'oi  t^  of  thickening 
or  puckering  on  the  peritonaeum  occur  sonu'tiitu^s  with  m:i'  ii  of  the  coils 
or  fibrous  bands.  Tn  a  iiu.jority  of  such  cases  the  condition  is  met  a('<i- 
(k'Utallv  post  mortem.  Two  sets  of  8ymj)t()ms  may,  however,  be  caused 
bv  thi'S(!  adhesions.  \^'hen  a  fibrous  band  is  attached  in  such  a  way  as 
to  form  a  loop  or  snare,  a  coil  of  intestine  may  pass  through  it.  Thus, 
of  the  2')'y  cases  of  intestinal  obstruction  analyzed  by  Fit:^,  tj."5  were  due  to 
this  cause.  The  second  group  is  less  serious  and  comprises  cases  with 
persistent  abdominal  pain  of  a  colicky  character,  sometimes  rendering  life 
miserable.  Instances  of  this  kiiul  have  been  successfully  operated  upon 
liv  lloinans  and  II.  A.  Kelly. 

(//)  Diffuse  Adhesive  Peritonitis. — This  is  a  consequence  of  an  acute 
int!;uiiin;ition,  either  simple  or  tuberculous.  The  peritoiueum  is  obliter- 
ritcd.  ih\  cutting  through  the  abdominal  wall,  the  coils  of  intestines  are 
uniforndy  matted  together  and  can  neither  be  separated  from  each  other 
nor  can  the  visceral  and  parietal  layers  bo  distinguished.  There  nuiy  be 
thirkcniiig  of  the  layers,  and  the  liver  and  sjileen  arc  usually  involved  in 
tlio  iidhesions. 

(r)  Proliferative  Peritonitis. — Apart  from  cancer  and  tubercle,  which 
liroduct'   typical   lesions  of  chronic   peritonitis,   the   most   characteristic 
form  is  that  which  may  be  described  uiuler  this  heading.     Tlie  essential 
iiiuitomical  feature  is  great  thickening  of  the  peritoneal  layers,  usually 
without  much  adhesion.     The  cases  are  sometimes  fouiul  with  cirrhosis  of 
the  stomacli.     In  one  instaiice  I  found   it  in  connection  with  a  cirrhotic 
I'ondition  of  the  ctvcum  and  the  first  part  of  the  colon.    In  the  inspection 
iif  a  rust'  of  tliis  kind  there  is  usually  nuiderate  efi'usion,  more  rarely  exten- 
sive ascites.     The  peritonaeum  is  opaque-white  in  color,  and  everywhere 
ihiikeiuMl.  often  in  2)atches.     The  omentum  is  usually  rolled  and  forms  a 
thirkoiu'd  mass  transversely  placed  between  the  stonuich  and  the  colon. 
l"he  poritoiiivnim  over  the  stomach,  intestines,  and  nu'sentery  is  sometinu's 
LTCilly  thickened.     The  liver  aiul  spleen  nuiv  simply  be  adherent,  or  there 
is  a  condition  of  chronic  perihepatitis  or  pe-isplenitis,  so  that  a  layer  of 
linn,  almost  gristly  connective  tissue  of  fntu  one  ftmrth  to  half  an  inch 
m  tliickuoss  encircles  these  organs.     I''sually  the  volume  of  the  liver  is  in 
'I'liseijiieiu'c  greatly  reduced.     The  gastro-hepatic  omentum  may  be  con- 
''trictid  liy  this  new  growth  and  the  calibre  of  the  portal  vein  much  nar- 
■■"Wril,     A  serous  effusion  may  be  present.     On  account  of  the  adhesions 
which  forui,  the  peritonre^um  may  be  divided  into  three  or  four  dilferent 
j!ic?,  us  is  luore  fully  described  under  the  tuberculous  ])erit()nitis.    In  these 
tiiises  the   ii\testines  are  usually  free,   though  the  mesentery   is  greatly 


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DISEASES  OP   THE   DIGESTIVE  SYSTEM. 


shortened.  Tliore  are  instimces  of  eliroiiic  peritonitis  in  wliieh  tlic  him. 
entery  is  so  sliortened  Ijy  this  proliferative  elianfj;e  that  the  intestines  Umn 
a  ball  not  larger  than  a  cocoa-nut  situated  in  the  middle  line,  and  allcr  re- 
moval of  the  exudation  can  be  felt  as  a  solid  tunujr.  The  intestinal  wall 
is  greatly  thickened  and  the  mucous  membrane  of  the  ileum  is  thrown 
into  folds  like  the  valvuliu  conniventes.  This  i)roliferative  i)eritoniti,s  j.s 
found  frequently  in  the  subjects  of  chronic  alcoholism. 

In  all  forms  of  chronic  peritonitis  a  friction  may  be  felt  usually  in  the 
upper  zone  of  the  abdomen. 

In  some  instances  of  chronic  peritonitis  the  membrane  presents  luuiicr- 
ous  nodular  thickenings,  which  may  be  mistaken  for  tubercles.  Tlicv 
may  be  scattered  in  numbers  on  the  membranes,  and  it  may  he  extruiiiclv 
difHcult,  without  the  most  careful  microscopical  examination,  td  dftcr- 
mine  their  nature.  J.  F.  I'ayne  has  described  a  case  of  this  son  associ- 
ated with  disseminating  growths  throughout  the  liver  which  were  not 
cancerous.  It  has  been  suggested  that  some  of  the  cases  of  tuberculous 
peritonitis  cured  by  operation  luive  been  of  this  nature,  but  histoloi^iciil 
examination  would,  as  a  rule,  readily  determine  between  the  conditions. 
Miura,  in  Japan,  has  reported  a  cas;'  in  which  these  iu)dules  containcj  tlic 
ova  of  a  parasite. 

{(/)  Chronic  HaBmorrhagic  Peritonitis.— Hlood-staincd  clTusidns  in  the 
peritonanim  ocruir  ])arti;'ulirly  in  cancerous  and  tubenailous  disease.  Thciv 
is  a  form  of  chronic  inlhi.mmation  aiiahigous  to  the  hiemorrhagic  pacliynicii- 
ingitis  of  the  l)rain.  it  was  described  lirst  by  N'irchow,  and  is  localized 
most  commoniy  in  the  ])elvis.  Layers  of  new  connective  tissue  form  on 
the  surface  of  tlie  peritonivum  with  large  wide  vessels  from  which  h.cinor- 
rhage  occurs.  This  is  repeated  from  time  to  time  with  the  i'orniation  of 
regular  layers  of  Inemorrhagic  etfusion.  It  is  rarely  dill'use,  more  com- 
monly circumscribed. 


V.   NEW  GROWTHS   IN  THE   PERITON>EUM. 


S        -        V 

•-•: 

'  I 

\ 

m- 

!l 

1 

nl 

m 

lii 

m 

(a)  Tuberculous  Peritonitis.— This  luia  already  been  coD8iden>(|. 

{(/)  Cancer  of  the  PeritonEBum. — .\lthougli  as  a  rule  secondary  to  dis- 
ease of  the  stomach,  liver,  or  pelvic  organs,  cases  of  ])rimary  cancer  an 
o(u'asionally  found.  Secoiulary  maligmmt  peritonitis  occur,  in  coniu'ctinii 
with  all  forms  of  cancer.  It  is  usually  characterized  by  a  luiniher  of 
round  tumors  scattert'd  over  the  entire  j)eritonivuni,  sometimes  small  iiiid 
miliary,  at  others  large  and  nodular,  with  puckered  centres.  The  dini'iise 
most  commoidy  starts  from  the  stomach  or  the  ovaries.  The  omciitiiin  is 
indurated,  and,  as  in  tuberculous  peritonitis,  forms  a  nniss  wliicdi  lies 
transM'rsely  across  the  upjjcr  portion  of  the  abdomen.     I'riniary  inalii:- 

iKint  disease  of  the  pcritona'um  is  extremely  rare.     Colloid  has  ini'ed, 

forming  enormous  masses,  which  in  one  case  weighed  over  one  hundred 


ASCITES. 


507 


nnniidrJ.  Cancer  of  this  membrane  spreads,  either  by  the  detaohment  of 
.^niiill  particles  vvhieh  are  carried  in  tlie  lymph  currents  and  by  the  move- 
iiiiMits  to  distant  parts,  or  l)y  contact  of  opposinfj  surfaces.  It  occurs  more 
fnijihiitly  in  women  than  in  men,  and  more  commonly  at  the  later  ])eri()d 
(if  litV. 

The  (lidfjnosis  of  cancer  of  the  peritonanim  is  easy  witli  a  history 
of  II  local  malijj^naiit  disease;  as  when  it  occurs  with  ovarian  tumor  or 
with  oaiicer  of  the  pylorus.  In  cases  in  which  there  is  no  evidence  of 
a  iiriiiiary  lesion  the  diagnosis  may  be  doubtful.  The  clini(,'al  picture  ia 
usuallv  that  of  chronic  ascites  with  prog^ressive  emaciation.  There  may 
i)o  110  IVver.  If  there  is  mncdi  etfusion  nothinif  definite  can  be  felt  on  ex- 
iiiiiiiiatidn.  After  tappinjf,  irrc<rular  nodules  or  the  curled  omentum  may 
be  t'l'lt  lying  transversely  across  the  up])cr  porti(m  of  the  abdomen.  Vn- 
fid'tiiiiately,  this  tumor  upon  which  so  much  stress  is  laid  occurs  as  fre- 
quently in  tuberculous  peritonitis  and  may  be  present  in  a  ty|)ical  manner 
ill  ehi'onie  proliferative  form,  so  that  in  itself  it  has  no  special  diagnostic 
value.  Multiple  nodules,  if  large,  indicate  cancer,  jtartieularly  in  jiersons 
al)  ivo  middle  life.  Nodular  tuberculous  peritonitis  is  most  fre(|uent  in 
cliililreii.  The  presence  about  the  mivel  of  secondary  nodules  and  indu- 
rated masses  is  more  common  in  cancer.  Inflammation,  supi)'.iration,  and 
tlie  discharge  of  pus  from  the  navel  rarely  occur  except  in  tuberculous 
ilisiasc.  Considerable  enlargement  of  the  inguinal  glands  may  be  present 
ill  raiHcr.    The  nature  of  the  fluid  in  cancer  and  in  tuliercle  mav  be  mutdi 


:illKi', 


It  may  lie  ha'morrhagic  in  both;  more  often  in  the  latter.     Tl 


le 


iiistojogieal  examination  in  cancer  may  show  large  multinucdear  cells  or 
LTdUps  of  cells — the  sprouting  cell-groups  of  Funlis — wliiidi  are  extremely 
suLfirestive.  The  colloid  cancer  may  jiroduce  a  totally  dillerent  jiicture; 
iiistr.iil  of  iiseitic  fluid,  the  abdomen  is  ii|iic(l  by  the  semi-solid  gehtti- 
uoiis  suhstauce,  and  is  firm,  not  fluctualin- 

And,  lastly,  there  are  instances  of  echiiiococii  in  tlie  {)eritnjia'um  wliidi 
muv  siiiiulate  cancer  very  closely.  I  have  reporleii  ,i  case  of  this  kind,  in 
which  the  enlarged  liver  and  the  innumerable  nodular  luuascs  in  the  peri- 
■miia'uiii  naturally  led  to  this  diagnosis. 


VI.   ASCITES    {fli/drn-prrifompum). 

Definition. — The  accumulation  of  serous  fluid   in  the   pcrit.   ,eal 

iiivilv. 

Etiology. — (1)  Local  Causes. — (n)  Chronic  ijiflammation  o1  the  peri- 
'"naMiin,  cither  simple,  cancerous,  or  tuberculous.  (/))  Portal  obstruction 
11"  the  terminal  branches  within  the  liver,  as  in  cirrhosis,  or  by  compressicm 
"' the  Vein  in  the  gastro-hepatic  omentum,  either  by  proliferative  perito- 
'iitis,  hy  new  growths,  or  by  aneurism,  (r)  Tumors  of  the  abdom(Mi.  The 
Miliil  griiwth.s  of  the  ovaries  may  cause  considerable  ascites,  which  nuiy 


•  iji  i 


'liW 


'."^'i^M 


u 


508 


DISEASES  OP  TUE  DIGESTIVE  SYSTEM. 


"^  'm 


completely  mask  tlie  true  condition.    The  enlarged  spleen  in  loukaMiua 
less  commonly  in  malaria,  may  be  associated  with  recurring  ascites. 

(2)  General  Causes. — The  ascites  is  ])art  of  a  general  drojjsy,  tlu'  re- 
suit  of  mechanical  elfects,  as  in  heart-disease,  chronic  emphysema,  and 
•cirrhosis  of  the  lung.  In  cardiac  lesions  the  effusion  is  sometiiius  con- 
fined to  the  peritonanim,  in  which  case  it  is  due  to  secondary  eliiiiif^fcs  in 
the  liver,  or  it  has  beeii  suggested  to  be  connected  with  a  faihirc  df  tlie 
suction  action  of  this  organ,  by  wliich  the  peritonaeum  is  kept  dry.  Asciti's 
occurs  also  in  the  drojjsy  of  liright's  disease,  and  in  hydrajniic  states  of 
the  blood. 

Symptoms. — A  gradual  uniform  enlargement  of  the  abdonicn  is  the 
characteristic  syni])tom  of  ascites.  The  })liysical  signs  are  usually  distinct- 
ive, (a)  Jnspecfmi. — According  to  the  amount  of  fluid  the  abddiiien  is 
protuberant  and  flattened  at  the  sides.  With  large  elfusions,  the  skin  is 
tense  and  may  ])rcscnt  the  linca;  albicantes.  Frequently  the  navt'l  itself 
and  the  parts  about  it  arc  very  prominent.  In  numy  cases  the  sujifi'liciii! 
veins  are  enlarged  and  a  plexus  joining  the  manumiry  vessels  can  lie  swn. 
Sometimes  it  can  be  determined  by  pressure  on  these  veins  that  tlic  ( iir- 
rent  is  from  below  upward.  In  some  instances,  as  in  thrombosis  or  olilit- 
eration  of  the  portal  vein,  these  superficial  abdominal  vessels  may  be  ex- 
tensively varicose.  About  the  navel  in  cases  of  cirrhosis  there  is  oecu- 
sionally  a  large  bunch  of  distended  veins,  the  so-called  caput  Mediisa\ 

{b)  Palpftfion. — Fluctuation  is  obtained  by  placing  the  fingers  of  one 
haml  u])on  one  side  of  the  abdomen  and  by  giving  a  shar]»  tap  on  the  op- 
posite side  witli  tlie  other  hand,  when  a  wave  is  felt  to  strike  as  a  (iolinite 
shock  against  the  applied  fingers.  Even  com])aratively  small  (|uaiitities  of 
fluid  may  give  this  fiuctuation  shock.  ,  When  the  abdominal  walls  are 
thick  or  very  fat,  an  assistant  may  place  the  edge  of  the  hand  or  a  piece 
of  card-board  in  the  front  of  the  abdomen.  A  different  prncedui'o  is 
adopted  in  jialpating  for  the  solid  organs  in  case  of  ascites.  Instead  of  plac- 
ing the  hand  fiat  upon  the  abdomen,  as  in  the  ordinary  method,  the  pads 
of  the  fingers  only  are  })laced  lightly  upon  the  skin,  and  then  by  a  sudden 
depressicm  of  the  fingers  the  fiuid  is  disi)laced  and  the  solid  orpin  or 
tumor  may  be  felt.  By  tliis  method  of  "dipping"  or  displacenii'iit,  as  it 
is  called,  the  liver  may  br  felt  behtw  the  costal  margin,  or  the  sjileen,  or 
sometimes  solid  tumora  of  the  omentum  or  intestine. 

(c)  Percussion. — In  the  dorsal  position  with  a  moderate  quantity  of 
fluid  in  the  peritonanim  the  fianks  are  dull,  while  the  umbilical  ami  epi- 
gastric regions,  into  which  the  intestines  float,  are  tym])aniti('.  'i'liis  area 
of  clear  resonance  may  have  an  oval  outline.  Having  ol)tained  tlie  lateral 
limit  of  the  dulness  on  one  side,  if  the  patient  then  turns  on  the  oiijiosito 
side,  the  fluid  gravitates  to  the  dei)endent  part  and  the  uppermo.st  flunk  i? 
now  tympanitic.  In  moderate  effu  ons  this  movable  dnlness  cliaiiL'c^ 
greatly  in  the  different  postures.  Small  amounts  of  fluid,  probably  under 
a  litre,  would  scarcely  give  movable  dulness,  as  the  pelvis  and  the  renal 


ASCITES. 


509 


regions  liold  a  considerable  qtiantity.  In  such  cases  it  is  best  to  place  the 
piiticiit  in  the  knee-elbow  position,  Avlien  a  dull  note  will  be  determined  at 
the  most  dependent  portion.  By  careful  attention  to  these  details  mis- 
takes lire  usually  avoided. 

Tlio  following  are  among  the  conditions  which  may  be  mistaken  for 
droiisv;  Ovarian  tinnor,  in  which  the  sixv.  develoj)S,  as  a  rule,  unilaterally, 
tliouj,'h  when  large  it  is  centrally  placed.  The  dulness  is  anterior  and  the 
ri'soiiiince  is  in  the  flanks,  into  which  the  intestines  are  pushed  by  the  cyst. 
Exaiiiiiiation  per  vaginam  may  give  important  indications.  In  those  rare 
instances  in  which  gas  develoi)S  in  the  cyst  the  diagnosis  may  be  very  diffi- 
cult. SuccusHion  has  been  obtained  in  such  (fases.  A  disfended  hhtddvr 
may  reach  above  the  umbilicus.  In  such  instances  some  urine  dribbles 
awav,  and  suspicion  of  ascites  or  a  cyst  is  occasionally  entertained.  I  once 
saw  a  trucliar  thrust  into  a  distended  bladder,  which  was  su2)posed  to  be 
an  (ivariau  cyst,  and  it  is  stated  that  John  Hunter  tapped  a  bladder,  sup- 
posing' it  to  be  ascites.  Such  a  mistake  should  be  avoided  by  careful 
oatlu'lei'ization  prior  to  any  operative  procedures.  And  lastly,  there  are 
larjjc  pancreatic  or  hydatid  cysts  in  the  abdomen  which  may  simulate 
ascites. 

Xaliire  of  Oie  Ascitic  Fluid. — I'^suidly  this  is  a  clear  serum,  light  yel- 
low ill  the  ascites  of  an.Tmia  and  Bright's  disea.se,  often  darker  in  color  in 
cirrhosis  of  the  liver.  The  specific  gravity  is  low,  seldom  more  than  I'OIO 
or  lOf").  In  the  fluid  of  ovarian  cysts  the  specific  gravity  is  high,  l-O^O  or 
over.  It  is  albuminous  and  sometimes  coagulates  spontaneously.  Ilannor- 
rhniric  ctl'usiou  usually  occurs  in  cancer  and  tuberculosis,  and  occasionally 
in  cirrhosis.  I  have  already  referred  to  the  instances  of  ha;morrhagic  effu- 
sion in  coiniection  with  ruptured  tubal  ])regnancy.  A  chylous,  milky  ex- 
mhitc  is  occasionally  found.  Busey  has  collected  thirty-three  cases  from 
the  literature.  There  are,  as  Quincke  has  pointed  out,  two  distinct  varie- 
ties, a  fatty  aiid  a  chylous,  which  may  be  distinguished  by  the  microscope, 
as  in  the  former  there  are  distinct  fat-globules.  These  cases  have  been 
sometimes  connected  with  peritoneal  or  mesenteric  cancer.  In  the  true 
ihylons  ascites  the  fluid  is  turbid  and  milky.  In  some  of  the  cjises,  as  in 
Whithi's,  ii  perforation  of  the  thoracic  duct  has  been  found.  The  condL 
tion  iloes  not  necessarily  follow  obliteration  of  the  thoracic  duct.  Mild 
I'raijes  of  chylous  ascites,  which  are  occasionally  found  clinically,  may  bo 
due  to  the  fact  that  the  patient  upon  a  milk  diet  has  a  permanent 
lipicinia,  such  as  is  ]iresent  in  young  animals  and  in  diabetics,  in  whom 
the  lii|uor  sanguinis  is  always  fatty.  Under  such  circumstances  an  exu- 
'lato  may  contain  enough  of  the  molecular  base  of  the  chyle  to  ])roduce 
tarhi.lity  of  the  fluid.  Some  of  the  cases  have  been  associated  with 
filariasis. 

Treatment  of  the  Previous  Conditions.  —  («)  Acute  Peri- 
tonitis. i{cst  is  enjoined  upon  the  patient  by  the  severe  ))ain  which  fol- 
'"ws  the  slightest  movement,  and  he  should  be  propped  in  the  position 


?■ 


n 


?1 


ipll 


•m 


1h 


)   ' 


,-ii 
W 


If 


h  « 


no 


DISEASES  OF  THE  DIGESTIVE  SYSTEM. 


wliicli  gives  liim  greatest  relief.  For  the  pain  morphia  should  be  iiijcettd 
liypodennieally  in  full  doses.  In  an  adult  it  is  better  to  give  a  third  or 
lialf  a  grain  at  once,  and  subsecpiently  at  intervals  rej)eat  it  in  Miialicr 
doses,  as  are  necessary.  The  action  of  the  drug  should  be  carel'iillv 
watched  ami  the  ])atient  should  not  be  allowed  to  ])ass  into  sucl)  a  dcirnr 
of  unconsciousness  that  he  cannot  be  aroused.  1'he  respiration  ami  tin.' 
condition  of  the  pu[)ils  also  give  valuable  information.  The  ainouul  nf 
opium  which  has  been  given  in  certain  instances  is  remarkal)le,  and  iiidj- 
cates  a  tolerance  of  the  drug.  The  doses  given  by  the  late  Aloiizo  Clurk, 
of  New  York,  may  be  truly  termed  heroic.  Austin  Flint  notes  that  a 
2)atient  under  the  care  of  this  physician  took  "  in  the  first  twenty-four 
hours,  of  opium  and  the  sulphate  of  morphia,  a  quantity  e(iuivalciit  to  Im; 
grains  of  opium  ;  in  the  second  twenty-four  hours  she  took  V,i  irruiiis; 
on  the  third  day,  230  grains;  on  the  fourth  day,  1:20  grains;  on  the  lil'ih 
day,  54  grains;  on  the  sixth  day,  22  grains;  (jii  the  seventh  day,  IS  grains; 
after  which  the  treatment  was  suspended."  It  is  unnecessary  to  use  tlicM' 
enormous  doses,  as,  even  when  the  pain  is  most  intense,  from  a  third  to 
u  half  grain  of  morphia  every  few  hours  will  usually  keep  the  iiaticiit 
thoroughly  under  the  inlluence  of  the  drug.  In  a  robust,  strong  patiriit, 
seen  at  the  outset,  twenty  leeches  ap])lied  over  the  abdomen  will  give  great 
relief. 

Local  api)lications — either  hot  tur])entine  stupes  or  cloths  wrung  out 
of  ice-water — may  be  laid  u})on  the  abdomen.  The  patients  souK'tiiiiis 
declare  that  they  are  greatly  relieved  by  the  latter. 

The  question  of  the  use  of  purgatives  in  peritonitis  hiis  of  laic  liccn 
warmly  discussed.  Lawson  Tait  and  other  gyna'cologists  have  used  tlic 
saliiu!  [)urges  with  the  greatest  beiu'lit  in  post-operation  peritonitis.  Tlic. 
retically  it  appears  correct  to  give  salines  in  concentrated  form,  whiili 
cause  a  rapid  and  profuse  exosmosis  of  serum  from  the  intestinal  vessels. 
relieving  the  congestion  and  reducing  the  oedema,  which  is  one  imiiurtaut 
factor  in  causing  the  meteorism.  It  is  also  urged  that  the  increased  peri- 
stalsis ]>revents  the  fornnition  of  adhesions.  In  reading  the  reports  of  thise 
successful  cases,  one  is  not  always  convinced,  however,  that  peritonitis 
actually  existed.  Still,  in  cases  of  acute  peritonitis  due  to  exteiisimi  er 
following  operation  or  in  septic  conditions  the  judgment  of  many  canful 
men  is  decidedly  in  favor  of  the  use  of  salines.  I  cannot  speak  fnmi  pi'i- 
sonal  exi>erience  on  this  (piestion.  The  majority  of  cases  of  ))eiitoiuti> 
which  come  under  the  care  of  the  physician  follow  lesions  of  the  ahdoiiiiiiiil 
viscera  or  are  due  to  perforation  of  ulc^r  of  the  stomach,  the  ileum,  or  tln' 
upi)endix.  In  such  cases,  particularly  in  the  large  group  of  appemlix  cases. 
to  give  saline  purgatives  is,  to  say  the  least,  most  injudicious  frcatiueiit. 
The  safety  of  the  patient  lies  in  the  restriction  of  the  peristalsis  and  tlie 
localization  of  the  inflammation,  for  which  purpose  opium  aloiu'  i^  "I 
service.  In  these  instances  rectal  injections  should  be  employed  In  relieve 
the  large  bowel.     No  symptom  in  acute  peritonitis  is  more  serious  than 


ASCITES. 


511 


tl\r  tviiipanitcs,  and  none  is  more  ditticiilt  to  meet.  The  use  of  the  long 
tiilic  iiiul  injections  containing  turpi'iitinc  may  l)o  triod.  Drugs  by  the 
inouili  cannot  l)e  retained. 

K(ir  tlio  vomiting,  ice  and  small  quantiticf^  of  soda  water  may  lu^  cm- 
plovcil.  The  patient  shinilil  bo  fed  on  milk,  but  if  the  vomiting  is  dis- 
tiissiiig  it  is  best  not  to  attempt  to  give  food  by  tiie  mouth,  but  to  use 
sniall  nutrient  enemata.  In  all  cases  of  [)eritonitis  it  is  best  to  have  a  sur- 
•n'on  in  consultation  early  in  the  disease,  as  the  (|uestion  of  operation  may 
conic  up  at  any  moment.  1  have  already  mentioned  (he  conditions  under 
wliirh  laparotomy  is  indicated  in  })erforative  rppendicitis.  'i'he  acute 
iiiuTlont  cases,  particularly  those  in  which  the  m  -.'ptococci  occur,  usually 
(lie;  but  although  the  results  of  operative  interference  in  this  form  have 
iKit  as  vet  been  very  brilliant,  the  condition,  we  must  remember,  is  almost 
licjx'less,  and  too  ofteii  tnere  has  been  unnecessary  delay  in  calling  in  sur- 
irjcal  aid.  In  the  acute  forms  of  tnberculous  peritonitis  oj)eration  appears 
t(p  l)f  nion^  hopeful,  but  they  are  not  always  successful. 

{/i)  Chronic  Peritonitis. — For  the  cases  of  chronic  ])rol iterative  i)eri- 
tdiiitis  very  little  can  be  done.  The  treatment  is  practically  that  of  ascites. 
In  all  these  forms,  when  the  distention  becomes  extreme,  tiip])ing  is  indi- 
catcil.  The  treatment  of  tuberculous  peritonitis  has  fallen  largely  into 
the  hands  of  tiic  surgeons,  and  the  results  in  many  cases  are  very  good. 
Accdrding  to  the  statistics  of  Maurange,*  of  Tl  cases,  28  survived  the 
(ipeiation  for  more  than  a  year.  Of  'Z('>  additional  cases  which  I  have  col- 
Itrtcd,!-  l-t  were  dead  at  the  time  of  the  report.  Within  two  years  and 
thrci'  months  there  were  six  operatiojjs  performed  at  the  Johns  Hopkins 
lliKpital  in  tuberculous  peritonitis,  with  four  recoveries. 

('•)  Ascites. — The  treatment  depeiuls  sonunvhat  on  the  nature  of  the 
(•as(>.  In  cirrhosis  early  and  repeated  tajiping  may  give  time  for  the  estab- 
lislmicnt  of  the  collateral  circulation,  and  temporary  cures  have  followed 
this  procedure.  Permanent  drainage  with  Southey's  tube,  incision,  and 
washing  out  the  peritona'um  have  also  ])een  ])ractised.  In  the  ascites 
of  hciu't  and  renal  disease  the  cathartics  are  most  satisfactory,  ])articularly 
tlir  liitartrate  of  potash,  given  alone  or  with  jalap,  and  the  large  doses  of 
salts  given  an  hour  before  breakfast  with  as  little  water  as  possible.  These 
soiiictimos  cause  rapid  disappearance  of  the  effusion,  but  they  are  not  so 
successful  in  ascites  as  in  pleurisy  with  effusion.  The  stronger  cathartics 
may  sometimes  be  necessary.  The  ascites  formbig  part  of  the  general 
anasarca  of  Uright's  disease  will  receive  consideration  under  another  section. 

*  Paris  Thesis,  1889. 

t  On  Tuberculous  Peritonitis,  Johns  Hopkins  llospitul  Reports,  IbQO. 


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SECTION  IV. 
DISEASES   or   THE   RESPIRATORY   SYSTEM. 


I.  DISEASES  OF  THE  NOSE. 
I.  ACUTE  CORYZA. 

Acute  catarrhal  inflanmiation  of  the  upper  air-passa^fcs,  popularly 
known  as  a  "  catarrh  "  or  a  "  cold,"  is  usually  an  independent  alluction, 
but  may  })rooede  the  development  of  another  disease. 

Etiology. — It  prevails  most  extensively  in  the  changeable  weatlier  of 
the  spring  and  early  winter,  and  may  occur  in  ei)idemic  form,  many  cases 
developing  in  a  community  witiiin  a  few  weeks.  These  outbreiiks  arc 
very  like,  though  loss  intense  than  the  epidemic  influenza,  cases  of  wiiieli 
may  begin  Avith  symptoms  of  ordinary  coryza.  The  disease  probaMy  de- 
pends upon  a  micro-organism.  Irritating  fumes,  such  as  those  of  iodine  or 
ammonia,  also  may  cause  an  acute  catarrh  of  the  nose. 

Symptoms. — The  patient  feels  indisposed,  perhaps  chill},  has  slijilit 
headache,  and  sneezes  frequently.  In  severe  cases  there  are  pains  in  tlio 
back  and  limbs.  Tliere  is  usually  slight  fever,  the  temperature  rising  to 
101°.  Th3  pulse  is  quick,  the  skiu  is  dry,  and  there  are  all  the  features  of 
a  feverish  attack.  At  first  the  mucous  membrane  of  the  nose  is  swollen, 
"  stuffed  up,"  and  the  patient  has  to  breathe  through  the  mouth.  A  thin, 
clear,  irritating  secretion  flows,  and  makes  the  edges  of  the  nostrils  sore, 
The  mucous  membrane  of  the  tear-ducts  is  swollen,  so  that  the  eyes  weep 
and  the  conjunctiva)  are  injected.  Witli  the  nasal  catarrh  there  is  slight 
soreness  of  the  throat  and  stiffness  of  the  neck;  the  pharynx  looks  red 
and  swollen,  and  sometimes  the  act  of  swallowing  is  painful.  The  larynx 
also  may  be  involved,  and  the  voice  becomes  husky  or  is  even  lost.  If  the 
inflammation  extends  to  the  Eustachian  tubes  there  may  be  imiiairment 
of  the  hearing.  Owing  to  the  swelling  of  the  nasal  mucosa,  the  sense  of 
smell  and,  in  part,  the  sense  of  taste  are  lost.  In  more  severe  cases  there 
are  bronchial  irritation  and  cough.  Occasionally  there  is  an  outlireak  of 
labial  or  nasal  herpes.  Usually  within  thirty-six  hours  the  nasal  secretion 
becomes  turbid  and  more  profuse,  the  swelling  of  the  mucosa  subsides,  the 
patient  gradually  becomes  able  to  breathe  through  the  nostrils,  and  within 


CHRONIC  NASAL  CATARRH. 


513 


four  or  five  days  tlio  symptoms  disiippeur,  with  the  exception  of  the  in- 
crcusL'd  discharge  from  the  nose  and  upper  j)luirynx.  Tliore  are  rarely 
uiiv  liud  clTetits  from  a  siiuplc  coryza.  Whuii  the  attacks  arc  freciuoutly 
rept'iilrd  the  disease  may  become  chronic. 

Tiie  diagnosis  is  always  easy,  but  caution  must  be  exercised  lest  the 
initial  catarrh  of  measles  or  severe  influenza  should  be  mistaken  fo"  the 
siniplr  coryza. 

Treatment. — Many  cases  arc  so  mild  that  the  patients  are  able  to  be 
iihoiil  and  to  attend  to  their  work.  If  there  are  fever  aiid  constitutional 
dislurbancc,  the  patient  should  be  kept  in  bod  and  should  take  a  simple 
h'wr  mixlure,  and  at  night  a  drink  of  hot  lemonade  and  a  fidl  dosi'  of 
Dover's  powder.  Many  ])ersons  lind  great  benefit  from  the  Turkish  bath. 
Fur  the  distressing  sense  of  tightness  and  ])ain  over  the  frontal  sinuses, 
encaino  is  very  useful  and  sometimes  gives  immediate  relief.  The  four- 
per-ccnt  solution  may  be  injected  into  the  nostrils,  or  cotton-wool  soaked 
in  the  solution  may  be  inserted  into  them.  Later,  the  snulT  recommended 
bv  Ferrier  is  advantageous,  composed,  as  it  is,  of  nu)rphia  (gr.  ij),  bismuth 
( 3  iv),  acacia  powder  (  3  ij).  Tiiis  may  occasionally  bo  blown  or  snuffed 
into  the  nostrils.  The  fluid  extract  of  hamamelis,  "snuffed  "  from  the 
liiiiiil  every  two  or  three  hours,  is  mueh  better.  Coryza  is  rarely  serious  in 
itself,  but  renders  the  subject  more  susceptible  to  other  affections.  The 
attacks  should  therefore  never  be  slighted,  and  in  young  children  and  in 
the  ul(i  especitil  care  should  be  taken  during  convalescence. 


II.  CHRONIC  NASAL  CATARRH 

(lihifiitis  simpler ;  lihiintis  hypurtruphica;  Rhinitia  atrophica). 

In  simple  chronic  catarrh  there  is  increased  irritability  of  the  mucous 
membrane,  particularly  of  the  erectile  tissue  on  the  septum  and  turbinated 
bones.  There  is  a  tendency  to  fre(iuent  stop[)age  of  one  or  both  nostrils 
and  the  patient  very  easily  catches  cold.  The  secretion  is  at  first  clear 
unil  afterward  thick  and  tenacious.  The  sense  of  sinell  is  not  specially 
ilisturlkMl  at  this  stage.  With  the  mirror  the  mucous  membrane  looks 
congested  and  swollen  and  the  veins  may  be  distended. 

In  hypertrophic  rhinitis,  which  is  usually  a  sequel  of  the  former  con- 
dition, tile  nasal  passages  arc  obstructed,  chielly  by  enlargement  of  the 
lower  tur!)inated  bodies  and  swelling  of  the  nuicous  membrane  of  the  sep- 
tiuu.  Very  often  there  is  hypertrophy  of  the  adenoid  tissue  in  the  vault 
of  the  pharynx  and  of  the  mucous  membrane  about  the  orifices  of  the 
Fustachian  tubes.  The  two  conditions  frequently  go  together  as  ex- 
pressed in  the  designation,  chronic  naso-pharyngeal  catarrh.  The  symp- 
toms i.f  this  hypertrophic!  rhinitis  nniy  be  local  or  general. 

Tile  most  important  local  symptom  is  the  obstruction  of  tlie  passage  of 
air  through  the  nostrils,  so  that  the  patients  become  mouth-breathers. 


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DISKASES  OF  THE  IIESPIIIATOUY  SYSTEM. 


Diiriiii;  tlic  tliiy  tlii.-t  tiiiiy  not  1)0  very  disfrcssiiiij,  liiit  at  iiij^lif  the  mouth 
and  throat.  ;,'('t  cxtrciiu'ly  dry  and  llic  shu'p  is  disturhcd.  'I'lic  Vdicc  1,,,. 
comos  iiasid  in  (|iiaiity  and  in  advanct-d  cases,  when  tlio  Knstacliiaii  tuluK 
ai'(!  ()bstrn((t('d,  tluMV  may  lie  dcafni'ss.  It  slionld  over  Ih*  Ixn'n.'  in  inind  Sv 
tli(>  pnictitidncr  that  u  very  Iarj,'i'  itroportion  of  all  cases  of  deafness  oriiri. 
iiate  in  chroinc  naso-pharyn^'cal  cataiTli.  'I'he  ,<,'eneral  symptoms  in  tlicsc 
cases,  ])artienlarly  in  children,  are  of  the  ^ii'catest  importance,  and  liavc 
been  eonsi(lere(|  more  fidly  nnder  chronie  i)haryngeal  catarrli  and  iihiuiIi. 
breathinj;.  Snilice  it  hero  to  say  that  there  is  produced  in  children  Mclmr- 
ncteristic  facies,  associated  often  with  mental  dnlness  and  ehanj^fes  in  the 
form  of  the  thorax. 

Atrophic  r/iitii/is,  which  is  also  known  under  the  names  coi'vzm  \\i\ih 
and  ozaniii,  may  he  a  secpience  of  the  hypertrophic  form.  Oziciia  is  (inl\  a 
symptom,  and  is  met  with  in  many  ulcerative  conditions  of  the  nostrils, 
particularly  as  a  result  of  syphilis,  foreiirn  bodies,  caries  and  necrosis  of 
the  hones,  and  <^danders.  J-'ortunatcly,  the  atroi)hie  form  by  no  nu'ar.^ 
necessarily  follows  the  liyi)ertro])hie  stajre.  'I'he  cases  are  much  more  fre- 
quent in  women  than  in  men,  and  usually  occur  early  in  life.  The  imicdiis 
membrane  is  thin  and  covered  with  <rrayish  crusts  wbi<'li,  when  rcinovtd, 
show  a  slightly  excoriated  t^urface,  but  true  ulcers  are  rarely  seen.  The 
erectile  tissue  is  completely  atrojdiied  by  a  process  of  slow  eonnective-tissuf 
growth,  or,  as  J.  \.  Mackenzie  calls  it,  a  cirrhosis.  The  mucous  nii'in- 
brane  of  the  pharynx  is  usually  dry  ami  glazed. 

The  synijitoms  are  most  distinctive,  owing  to  the  horrible  odor  Avhioh 
comes  from  the  nose,  and  of  which,  fortunately,  the  patient  is  liim.-i'lf 
unconscious,  because  the  sense  of  smell  is  lost.  The  secretion,  which  is 
puriform,  dries  and  forms  large  crusts,  which  are  dislodged  by  pirkiniror 
whiidi  gradually  fall  off.  The  cause  of  the  offensive  odor  has  liccii  iiiiicli 
discussed — whether  it  is  due  to  a  sjiecial  organism  or  to  .specially  favoniliJc 
conditions  for  the  growth  and  dcvelo[tment  of  the  germs  of  ]iutrof!icti(iii, 
Probably  the  latter  view  is  correct. 

The  trcatmeut  of  hypertroidiic  rhinitis  consists  in  the  thorough  ilciuis- 
ing  of  the  nasal  i)assages,  the  removal  of  tlu^  jdiaryngeal  growths,  ami  the 
reduction  of  the  hypertrophied  nasal  mucosa.  It  is  best  to  use  a  ^iinple 
douche,  in  order  to  keep  the  niendirane  at)solutcly  (dean.  The  liiiiniui;- 
liam  nasal  douche  is  the  most  simjjle  aiul  satisfactory,  and  may  lie  lilicil 
with  alkaMne  and  antiseptic  or  deodorizing  solutions.  One  of  the  inn-* 
satisfactory  is  the  bicarbomite  of  soda  (IJ  dra(dim),  listerine  (<!  dracliiiis). 
and  water  (1  ounce,').  Operative  })rocedures  are  necessary  in  a  iiiajori;} 
of  the  cases,  ami  the  ])ractitioner  shoidd  early  call  to  his  assistance  tlir 
specialist.  It  is  sad  to  think  of  the  misery  which  has  been  cut  liltil  iipt*" 
thousands  of  people  owing  to  neglect  of  nuso-pharyngeal  catarrh  I'V 
parents  and  physicians. 

I'he  treatment  of  atrophic  rhinitis  comes  more  properly  under  tiic 
special  monographs. 


AUTUMNAL  CATAHIin. 


III.  AUTUMNAL  CATARRH  (//-»//  Firer). 


515 


i 


All  allVcliuii  di'  llio  iipiit'T  iiir-itiissiijj:('s,  often  associated  with  iistlmiatio 
iitt;iiks,  duo  to  the  action  of  certain  stimuli  14)011  ji  hyj)erseiisitivo  iniuious 
iiiciiiliraiie. 

This  alVection  was  first  (leserilie(l  in  ISl!)  l)y  I?ostoci\,  who  caMed  it 
ciihirr/nis  ti's/iriis.  ^forrill  Wyiiian,  oi'  ('anihrid^'e,  Mass.,  wrote  a  niono- 
^-.■;i|ili  on  the  subject,  and  descrilx'd  two  I'oi-iiis,  the  ".lune  cold,"  or  "rose 
niM,"  which  conies  on  in  the  sjirini,',  iiiid  the  autumnal  form  which,  in 
this  (•oimtrv,  does  not  develo})  until  Aii^fust  and  Septemher,  and  never 
iM'i'sisls  alter  a  severe  frost.  Ulakley  studied  its  coniii ction  witli  the  pol- 
len (if  various  jrrasses  and  llowers.  'l"he  late  (ieor^'e  M.  Heard  made 
iiiaiiv  careful  ohservations  on  the  disease,  riitil  riKjeiitly  this  form  of  ca- 
lanii  was  l)elieved  to  result  exclusively  from  the  action  of  certain  irritants 
mi  ilie  mucous  memlirane  of  thi'  nose,  particularly  the  pollen  of  plants, 
wliii  li,  as  the  experiments  of  l?lakley  showed,  play  an  imiiortant  role  in 
till'  disease.  Other  enianatioiif  also  may  induce  an  attai'k,  as  in  the  ease 
(if  the  late  .\iistiii  Flint,  who  was  liahle  to  coryza,  or  even  asthma,  if  ho 
sl('|it  (111  a  certain  sort  of  feather  pillow  'I'his,  howi'Vi-r,  is  only  <»n(f  factor 
ill  the  disease.  A  second,  nmst  important  one,  was  discovered  in  the  coii- 
ilitidii  of  the  nasal  mui'inis  memhrane  in  these  eases.  N'oltolini,  of  JJreslau, 
ill  is;  1.  observed  the  euro  of  a  case  of  asthma  hy  the  removal  of  a  nasal  ]ioly- 
)m>,  Since  that  date  the  observations  of  Hack,  in  (Jermany,  and  ])articu- 
liiiiy  iif  Daly,  of  Pittsburi;;  lloe,  of  Koidu'ster;  .John  N.  ^fackenzie,  of 
15iiltiiinii'e ;  and  Harrison  Allen,  of  I'hiladidphia,  have  demonstrated  the 
iissdcialioii  of  asthmatic;  attacks  with  nasal  disease.  Daly  discovered  that 
ill  a  liirire  proportion  of  the  cases  of  hay  asthma  there  was  local  disease  of 
the  imicous  naMubraiu'  of  the  nose,  the  cure  of  which  rendered  tlie  pa- 
liciil  insusceptible  to  conditions  previously  excitinj;  the  attacks.  This  lias 
lii'i'U  abundantly  coidirmed.  Still  identical  lesions  exist  in  many  |KU)ple 
wild  never  suffer  with  the  disease,  so  that  there  must  be  a  third  factor,  a 
iicindtic  constitution.  In  the  etiolofiy  of  hay  fever,  then,  these  three  ele- 
iiicnis  ])revail — a  nervous  constitution,  an  irritable  nasal  mucosa,  and  the  f 
stiiiiidiis. 

The  disease  atfects  certain  families,  ])articularly,  it  is  said,  those  with  a 
iK'iir(ili(,'  taint.  The  peculiarity  may  occur  thron<:h  several  fjeiu'rations. 
It  i.-  1  ( rtaiiily  more  eomuKm  in  the  United  States  than  in  Eiiniju',  and 
iiiuili  more  comnH)n  in  the  United  States  than  in  Canada.  The  I'nited 
^taii  ~  Hay  Fever  Association  now  numbers  th.ousands  of  mendiers. 

I'ucllers  in  cities  are  more  subject  than  residents  in  the  country.  The 
sinictural  pe'^iiliarities  of  the  nasal  mucous  nu'mbrane  are  those  of  hyper- 
t"''>plii(;  rliiintis.  Harrison  Allen  states  that  the  inferior  turbinated  bones 
li<'  Well  above  the  floor  of  the  nostrils,  which  renders  the  mucous  mem- 
l)i'aiii'  more  liable  to  irritation  from  inhaled  substances.  Deflection  of  tlie 
^^^'ptuiu,  hypertrophy  of  the  soft  parts,  and  excessive  hypera)sthesia,  so  that 


II  J' 


510 


DISKASKH  OF  THE   IlKSPIUATOUY  SYSTKM. 


m. 


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tho  nicro  toudi  witli  a  probo  may  bo  HufVu-U'iit  to  iiuluco  an  iittii<  k,  nro 
coiniiioii  coiHlitinns. 

Symptoms. — 'i'hoso  arc,  in  a  majority  of  tlio  cases,  very  lik(^  tlidse  ,,f 
ordinary  coryza.  I'hcn'  may,  however,  Ijc  much  more  lieadache  ami  dis- 
tress,  and  some  patients  l)ccoinc  very  low-spirited.  ('ou<,'h  is  a  cniiiin,,), 
symptom  and  may  be  very  distrcssin;,^.  I'aroxysms  (»f  asthma  may  dcvi  1,,-. 
so  iilie  as  to  be  indistinguishable  from  the  ordinary  l)ronehial  rnrin  The 
two  conditions  imiy  inilecil  alternate,  the  patient  liavinj,'  at  one  time  a'l 
attack  of  common  hay  fever  and  at  another,  under  .similar  eireuiii-iaiiccs, 
an  attaek  of  bronchial  asthma.  Of  the  immediate  excitin^f  causes  of  the 
attack,  un(iuestio!i:dily  in  a  majority  of  the  cases  eominj,'  on  in  the  antiunii 
there  i.s  an  association  with  the  presence  (»f  judlen  in  the  atmosplicic,  Imt 
this  is  only  one  of  a  host  of  exciting  causes.  In  certain  persons  tlic  imr- 
oxysms  may  develoj)  at  any  season  from  sudden  chanjics  in  the  tempt  ru- 
ture.  An  attack  may  even  come  o)\  throu<rh  association  of  ideas.  The 
"Well-known  ex[)criment  of  ,].  >,'.  .Nfackeiizie,  of  inducing;  an  attack  in  ;i 
8Uscoi)tiblc  i)erson  by  olTcrinj;  her  an  aililicial  rose  to  smell,  strikincK 
illustrates  the  neurotic  element  in  the  disease. 

Treatment. — 'I'his  may  l)c  comjirised  under  three  lu-ads  :  First,  since 
the  disease  appears  in  nuiiiy  instances  to  be  a  form  of  chronic  nenmsis, 
remedies  which  imj)i()ve  the  stal)ility  of  the  nervous  system  may  be  oiii- 
ployed — such  as  arseinc,  ])hosphorus,  and  strychnia.  Second,  iliinatir. 
DwelK'rs  in  the  cities  of  the  Atlantic  sea-I)oard  and  of  the  Central  States 
enjoy  complete  immunity  in  the  Adirondacks  and  \Vhite  ^fountains.  As 
a  rule  the  disease  is  a^^jiravated  by  residence  in  agricultural  districts.  '[].■ 
dry  mountain  air  is  unquestionably  the  best ;  tliere  are  cases,  however,  w!;'eli 
do  well  at  tho  seaside.  Third,  the  thorough  local  treatment  of  the  nose. 
})articularly  the  destruction  of  the  vessels  and  sinuses  over  the  sensitive 
areas. 


IV.  EPISTAXIS. 


Etiology. — Bleeding  from  the  nose  may  result  from  local  or  ccnsti- 
tutional  conditiojis.  Among  local  causes  may  be  mentioned  tniuuKilisiii, 
picking  or  scratching  the  nose,  new  growths,  ami  the  presence  of  fnrcijrn 

bodies.     In  chronic  nasal  catarrh  bleeding  is  not  infrecpient.     The  1>1 1 

may  come  from  one  or  both  nostrils.  The  flow  may  be  profuse  after  mi 
injury,  but  is  soon  checked  and  is  very  rarely  fatal.  Occasionally  jirofuso 
and  fatal  luemoi-rhage  occurs  as  a  result  of  injury  to  the  skull.  In  a  re- 
markable case  of  this  kind,  coming  on  some  weeks  after  tho  receipt  of  the 
injury,  I  found  that  there  had  been  a  fracture  across  the  si)hcn(iiil  bone 
and  an  erosion  had  taken  ])lace  into  the  carotid  artery,  just  where  it  runs 
clo.sest  to  the  sphenoidal  slmises.  Tho  young  man  had  completely  rectn- 
ered  from  the  effects  of  the  injury,  and  the  fatal  haemorrhage  took  place  a.s 
he  was  stooping  over  to  wash  his  face. 


EPISTAXIS. 


517 


Among  poncrnl  conditions  with  which  noso-hh'oding  is  nssooiatod,  tho 
folliiwiii;:  lire  tlu;  niost  imiiortiint, :  It  occtirH  with  groat  fre(|iu'ncy  in  grow- 
iiij;  I'liildivM,  purticiihirly  iiliout  iho  age  of  jjiiborty ;  more  frt'ciiieiitly  in 
llu'  il.'Iicjito  than  in  tiio  .strong  and  vigorons. 

Kpistaxis  la  a  very  common  event  in  i)crsons  of  so-called  plethoric 
li!il)il.  It  i«  stated  sometimes  to  precede,  or  to  indicate  a  liabiiity  to, 
ujiDiiIfxy,  but  this  is  very  doubtful. 

In  veiu»us  engorgement,  due  to  heart  or  pulmonary  disease,  e])istaxis  ia 
iKit  ((iir.mou  and  there  nuiy  be  a  most  extreme  grade  of  cyanosis  without 
its  (tccurrenco.  In  balloon  and  mountain  aaceusions,  in  the  very  rarelif(l 
utii>iis|iiii're,  hu'inorrhage  from  tlie  nose  is  a  common  event.  In  luemo- 
hliiliii  llie  nose  ranks  lirst  of  the  naicous  membranes  from  whieii  bleeding 
arises.  It  occurs  in  all  forms  of  chronic  anivmias.  It  precedes  the  onset 
(ifcirtiiin  fevers,  more  |)articnlarly  typhoid,  with  which  it  seems  associated 
ill  a  special  manner.  Vicarious  epistaxis  has  been  described  in  cases  of 
suiiiire->i()n  of  the  menses.  Lastly,  it  is  said  to  be  brought  on  by  certain 
psveliical  impressions,  l)ut  the  observations  on  (his  jioint  are  not  trust- 
Wditliy.  'IMie  blood  in  epistaxis  results  from  capillary  oozing  or  diapedesis. 
The  mucous  mend)ram!  is  deeply  coiigested  and  there  may  be  small  ecehy- 
inoses.  The  bleeding  area  is  usually  in  the  respiratory  portion  of  one  nos- 
tril mill  upon  the  cartilaginous  septum. 

Symptoms. — Slight  luemori'liagi'  is  iu)t  associated  with  any  special 
t'ealiu'es.  WluMi  the  bleeding  is  protracted  the  patients  have  the  more 
Si  rjuus  manifestations  of  hws  of  blood.  In  tho  slow  drip[)ing  which  takes 
jilace  in  some  instances  of  hicmopliilia,  there  may  be  fornu'd  a  remarkable 
liliiiM.l  tumor  projecting  from  one  nostril  and  extending  even  below  tho 

mnlltll. 

l)eath  from  ordinary  ei)istaxis  is  very  rare.  The  more  blood  is  lost, 
the  greater  is  tho  tendency  to  clotting  with  spontaneous  cessation  of  tho 
bleeiiiug. 

The  iHiignosis  is  usually  easy.  One  point  oidy  need  be  mentioned ; 
namely,  that  bleeding  from  the  posterior  nares  occasionally  occurs  during 
sleep  and  the  blood  trickles  into  the  ])harynx  and  may  be  swallowed.  If 
viiiiiiteil,  it  nuiy  be  confounded  with  luenuitemesis ;  or,  if  coughed  up,  with 
lia'iiKiptysis. 

Treatment. — In  a  majority  of  the  cases  the  bleeding  ceases  of  itself. 
\aiious  simple  measures  may  be  employed,  such  as  holding  the  arms 
above  the  head,  the  ai)plication  of  ice  to  the  nose,  or  the  injection  of  cold 
01'  hot  water  into  the  nostrils.  Astringents,  such  as  zinc,  alum,  or  tannin, 
may  he  used ;  ai\d  the  old-fashioned  an'l  sometimes  successful  remedy,  a 
cubwel),  may  be  introduced  into  the  nostrils.  If  the  bleeding  comes  from 
an  ulcerated  surface,  an  attempt  should  be  nuide  to  ap])ly  chromic  acid  or 
to  cauterize.  If  the  bleeding  is  at  all  severe  and  obstinate,  the  posterior 
nares  sliould  bo  plugged.  Ergot  may  be  given  internally  or  hypodermi- 
cally. 


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Mi  l^  Jiff  J   ■■ 


518  DISEASES  OP  THE   RESPIRATOKY   SYSTEM. 


II.  DISEASES   OF  THE   LAliYXX. 

I.  ACUTE  CATARRHAL   LARYNGITIS. 

Tlii.^  mny  conio  on  as  ill!  indcpciideiit  iilTcctidii  or  in  associiilinn  witli 
gonfral  catarrh  of  the  upper  respiratory  i)assa;res, 

Etiology. — Many  cases  are  due  to  catciiiii;?  cold  or  to  ovmix'  of  tlic 
voice;  others  devtdop  in  con.XMiueMce  of  the  inhalation  of  irritatiiii:  ;:ii.-is. 
It  »nay  orrcnr  in  the  general  catarrh  associatecl  with  influenza  ami  iinn^lis. 
Very  severe  larynj^iti*  is  excited  by  li'auniatisni,  either  injuries  fi-dm  uiili- 
oiit  or  the  lod<finent  of  foreign  bodies.  It  may  he  caused  l)y  tlie  actidii  nf 
very  hot  li«|uids  or  corrosive  poisons. 

Sympt'  tus. — 'I'here  is  a  sense  of  tickling  referred  to  llic  larynx; 
tlic  cold  air  irritates  and,  owing  to  the  increased  sensihility  of  the  iiuicoiis 
nierrd>rane,  the  act  of  ins])iralioii  may  Ik-  ))aiufuh  There  is  a  drv  ri.ii-'ii, 
and  the  voice  is  altered.  At  hrst  il  is  simply  husky,  hut  soon  phdii;  limi 
iM'Comes  painful,  and  finally  the  voice  may  he  c(»iupletely  lost.  In  adults 
the  respirations  are  not  increased  in  frciiiieiicy,  hut  in  (diildrcii  dv-piiiia 
ij<  not  uiK-omnion  and  may  occur  in  spasmodic  attacks.  If  inudi  udcini 
aceoni|)atiies  the  inllamnuitory  swelling,  there  may  he  urgent  dyspnua. 

'I'he  laryngoscope  shows  a  sw(dlcn  and  lumclicd  nnicous  tncnduaiic  i.f 
the  larynx,  ]»artieuhirly  the  ary-e[)iglottidean  folds.  'I'he  vocal  cdnis 
have  lost  tlieir  smooth  and  shining  appearance  and  are  rc(ldcncd  ami 
HWollen.  Tiicir  mobility  also  is  greatly  impaire<l,  owing  to  the  iidiltiatiim 
of  the  adjoining  mucous  membraiu>  and  "'"  the  muscles.  A  slight  iniiiniii 
cxiirlation  covci's  the  parts.  'IMie  constitutional  symptoms  are  nut  severe. 
There;  is  rarely  much  fever,  and  in  many  cases  the  patit'  it  is  not  sciiiii:>ly 
ill.  Occasionallv  eases  come  on  with  greater  intensity,  tlf  cough  is  very 
di.itressing,  deglutition  is  painful,  and  (here  iiay  be  urgent    lyspuiea. 

Diagnosis. — There  is  rarely  any  dilliculty  in  determining  the  nalme 
of  a  ease  if  a  satisfactory  laryngoscopie  exaiiination  can  l)e  made.  'I'lC 
wverer  forms  may  simulate  o'detna  of  the  glottis.  When  the  loss  (  i  \iiiec 
in  marked,  the  case  may  he  mistaken  for  one  of  itcrvous  api.iiHa.  hut  the 
laryngoscope  would  decide  the  »|U(>stion  at  once.  .Much  moi'c  Jitlieidt  is 
the  diagnosis  of  acute  larvngi'.is  in  (diildrcn,  ])articularly  in  the  ven 
young,  in  wliom  ir  is  so  hard  to  make  a  jiroper  examination,  l-'mm  (inii- 
nary  laryngismus  it  is  to  be  disti';f,niishe(|  by  the  presence  of  fever,  tl\i' 
rnrKh>  of  onset,  and  ])articularly  the  I'oryza  and  the  ])revious  syinptom:^  nf 
hoarscTU'Ss  or  lo.ss  of  voice.  ^letubraiHtu  i  laryngitis  Jiiay  at  iirst  he  (|niti' 
impossible  to  diTerentiate,  hut  in  a  majority  of  cases  of  this  aircctiun  liierc 
are  j>atcli('3  on  the  pharynx  and  early  swelling  of  the  cervical  glands.  Tho 
«yni[itoms,  too,  are  nnudi  more  severe. 

Treatment. — Rest  of  the  larynx  shonh'.  he  enjoined,  so  far  a-  plio- 
nai'.',>n  ia  eoiieerned.     In  eases  of  any  severity  the  ])atient  slutuld  le  kept 


n<:DEM  ATOUS  TiARYXGITIS. 


519 


ill  lii'ii,  Tlic  room  sliniild  bo  ii';  fui  ov(M\  toinporatiirc  and  tlio  air  .saturated 
wiili  moisture.  Euriy  in  the  disease,  if  there  is  much  fi'Ver,  aeouiie  and 
cil'Mte  of  potasli  can  bo  given,  and  for  tiie  irritating  painful  eougli  a  full 
(li>sr  (if  Dover's  })o\vder  at  niglit.     An  ice-hag  externally  ufleu  gives  great 

relief. 

II.    CHRONIC    LARYNGITIS. 

Etiology. — The  eases  nsually  follow  rejK'ated  acuti*  attaeks.  The 
iiiii-l  roninion  eau.ses  are  overuse  of  the  voice,  ])artii'ularly  in  persons 
wIkw  occupation  necessitates  shouting  in  the  open  air.  The  con- 
stMiit    inhalation   of    irritating   sui)stan(;es,   as    tohacco-sinoki-,    may    also 

I'UlIM'  it. 

Symptoms. — The  voice  is  usually  hoarse  and  rough  and  in  .^I'Vero 
cMM'S  iiinv  he  almost  lost.  There  is  nsually  very  little  [lain  ;  only  tlu'  un- 
]»lr;isiiit  -^cnse  of  tickling  in  the  larynx,  which  causi's  a  frcipiciit  desire  to 
i'nii:.di.  With  the  hirgyngo.scope  the  mucous  mcmhranc  look,-  swollen,  hut 
nniili  less  I'eil  than  in  the  acute  condition.  In  association  with  the  granu- 
liir  plianiigitis,  the  nuicous  glands  of  the  epiglottis  and  of  the  ventricles 
iiKiy  he  involved. 

Treatment. — The  nostrils  should  he  carefully  examineil,  since  in 
si'iiii'  instances  chronic  laryngitis  is  associated  with  and  even  dependent 
11)1(111  iiiistruction  to  the  free  passage  of  air  through  the  nost'.  Local  appli- 
iiitiiiii  must  he  made  directly  to  tlu'  larynx,  either  with  a  hrush  or  hy 
means  (if  a  spray.  Among  tlie  remedies  most  rccommendc'l  are  the  solu- 
timis  (if  nitrate  of  silver,  chlorafc  of  potash,  pcrchhu'ide  of  /.inc.  and  tannic 
acid.     Insiilllalions  of  hismuth  are  sometimes  n.^eful. 

.\',i(iiig  (lii'tM'Mons  to  he  given  are  the  avoidance  of  lieated  rooms  and 
IdiKl  speaking,  and  abstinence  from  t(»baceo  and  alcohol.  The  throat 
slidiild  not  lie  too  much  mut11ed,and  nuiruing  and  evening  the  neck  siiould 
111'  siionged  with  cold  water. 


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III.    CEDEMATOUS    LARYNGITIS. 

Etiology. — (Kdema  of  the  glottis,  or,  more  correctly,  of  the  struet- 
mvs  which  form  the  glottis,  is  a  very  .serious  alTcetion  which  is  met  with 
(")  as  a  rare  se(jiicnee  of  ordinary  acute  laryngitis,  whetlu'r  due  to  I'old  or 
!o  the  a[)plicalion  of  irritants.  (//)  In  chronic  diseases  of  the  larynx,  as 
sy|)liilis  or  tubercle,  (r)  In  severe  inllammatory  di.-^eases  like  diphllni'ia, 
ill  erysipelas  of  the  neck,  and  in  various  forms  of  cellulitis,  (d)  Occii- 
Miiiially  in  the  ueute  infectious  di.seas(>s — scarlet  fever,  typhus,  or  typlntid. 
hi  Hright's  di.sease,  either  acute  or  ehro'  ic,  tlu're  may  be  a  rapidly  ih-vel- 
ifi,-  ii'dema. 

Symptoms. — There  is  dyspmra,  iji(.Teasing  in  intensity,  so  that  with- 
in an  iiiiiir  or  two  the  condition  becomes  very  si'rioiis.  There  is  .sometimes 
nuirkcl  stridor  in  respiration.     The  voice  becomes  husky  and  disa]>pears. 


kX 


''.5    J- 


520 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


H 


The  laryngoscope  shows  enormous  swelling  of  the  cpi^^'lottis,  wliii  h  can 
sometimes  be  felt  with  the  finger  or  even  seen  when  the  tongue  is  >tniiijf]y 
depressed  with  a  spatula.  The  ary-epiglottidean  folds  are  the  seat  of  the 
chief  swelling  and  may  almost  meet  in  the  middle  lino.  Occasioiutllv  the 
oedema  is  l)elu\v  the  true  cords. 

The  diagnosis  is  rarely  ditruudt,  inasmueh  as  even  Avithout  the  lurvii- 
goscope  the  swollen  epiglottis  can  be  seen  or  felt  with  the  iing(  r.  The 
disease  is  very  fatal. 

Treatment. — An  iee-bag  should  1)0  placed  on  the  larynx  iiiid  the 
patient  given  ice  to  suck.  If  the  symptoms  are  urgent,  the  throat  should 
be  sprayed  with  a  strong  solution  of  cocaine,  and  the  swollen  cpiir|,)t)is 
scarilicd.  If  relief  does  not  follow,  tracheotomy  should  immedi;it(l\  he 
})erformed.  The  high  rate  of  mortality  is  due  to  the  fact  that  this  (i[HTd- 
tion  is  as  a  rule  too  long  delayed. 

IV,    SPASMODIC   LARYNGITIS  {Laryngismus  Hiridulm). 

Spasm  of  the  glottis  is  met  with  in  many  affections  of  the  larynx,  hut 
there  is  a  special  disease  in  children  which  lias  received  the  above-iuoii- 
tioned  names. 

Etiology. — A  i)urely  ium-vous  alTection,  without  any  inflaiiiiiiaturv 
condition  of  the  larynx,  it  occurs  in  children  between  the  ages  of  six 
months  and  three  years,  and  is  most  commonly  seen  in  connection  with 
rickets.  It  is  also  associateil  with  tetany.  Often  the  attack  comes  on 
when  the  child  has  been  crossed  or  scolded.  Mothers  ♦iomctiiiics  i'mII  tlic 
attacks  "  imssion  fits  "  or  attacks  of  "holding  the  breath."  It  wa 
posed  at  one  time  that  they  were  associated  witli  enlargement  i 
thymus,  and  they  therefore  received  the  n.-ime  of  llnpnif  dslhina. 

The  actual  condition  of  the  larynx  during  a  paroxysm  is  a  si)asiii  of  tin- 
adductors,  but  the  precise  nature  of  the  inllueiices  causing  it  is  not  ret 
known,  whether  centric  or  rellex  from  peripheral  irritation.  The  diswisi' 
is  not  so  comuKdi  in  America  as  in  Enghmd. 

Symptoms. — Tiie  atta(dis  may  come  on  either  in  the  night  or  in  tin 
day  ;  often  just  as  the  child  awakes.  There  is  no  cough,  no  hoarseiii'ss, 
but  the  res})iration  is  arrested  and  the  child  struggles  for  breath,  the  fu't- 
gets  congested,  and  then,  with  a  sudden  relaxation  of  the  spasm,  the  air 
is  drawn  into  the  lungs  with  a  high-pitcheil  crowing  sound,  whit  li  has 
given  to  the  alb'ction  the  name  of  "  (diihl-crowing."  ('onvul>ioiis  may 
occur  during  an  attack  or  there  may  be  carjio-pedal  spasms.  Death  may, 
but  rarely  does,  occur  during  the  attack.  "With  the  cyanosis  the  spasm 
relaxes  and  respiration  begins.  The  attacks  may  recur  with  gn  at  fiv- 
quency  tiironghout  the  day. 

Treatment. — The  gums  should  be  carefully  examined  and,  it'  swnh 
len  and  hot,  freely  lanced.  The  bowels  should  lie  carefully  re^ridatcd 
and  us  these  children  are  usually  delicate  or  rickety  nourishing  diet  and 


iip- 
the 


TUBERCULOUS  LARVNGITIS. 


521 


rod-liver  oil  should  be  given.  By  far  the  most  satisfantory  method  of 
tiviitiiH'iit  is  the  cold  spoiiijiiif,'.  In  severe  cases,  two  or  three  times  a  day 
till' child  sliould  be  placed  in  u  warm  l)ath  and  tlie  back  and  chest  thor- 
oiiglilv  sponi^'ed  for  a  minute  or  two  with  cold  water.  Since  learning  this 
practice  from  Kinger,  at  the  University  Hospital,  I  have  seen  numy  cases 
in  which  it  i)roved  successful.  It  may  be  employed  when  the  child  is  in 
;i  parfixysm,  though  if  the  attack  is  severe  and  the  lividity  is  great  it  is 
iiiucii  better  to  dash  cold  water  into  the  face.  Sometiuu'S  the  introduc- 
tion (if  tlic  linger  far  back  into  the  throat  will  relieve  the  sjiasm. 

Spasmodic  croup,  believed  to  be  a  functional  sj>asm  of  the  muscles  of 
the  liU'Viix,  is  an  ulTection  seen  most  comnu)nly  between  the  the  ages  of 
two  and  five  years.  According  to  Trousseau's  description,  the  child  goes 
tjlicd  well,  and  about  midnight  or  in  the  early  morning  hours  awakes  with 
(Impressed  breathing,  harsh,  eroupy  cough,  and  i)erhaps  some  huskiness  of 
voice.  The  opjtression  and  distress  for  a  tinu?  are  very  serious,  the  face  is 
coii!,'c>te(l,  and  there  arc  signs  of  approaching  cyanosis.  The  attack  passes 
olf  abruptly,  the  child  falls  asleep  and  awakes  the  next  morning  feeling 
porfectly  well.  These  attacks  may  he  repeated  for  several  nights  in  suc- 
ccs-iiiii,  and  usiuilly  cause  great  alarm  to  the  jmrents.  Whether  this  is  cn- 
tirclv  a  t'uiK'tional  spasm  is,  I  think,  doubtful.  There  are  instances  in 
which  the  cliild  is  soininvhat  hoarse  through  the  day,  and  has  slight  ca- 
tiriiial  symptom3  and  a  brazen,  eroupy  cough.  There  is  })robably  slight 
catarrhal  laryngitis  with  it.  These  cases  are  not  infrequently  mistaken 
for  true  croup,  and  parents  are  sonu'times  unnei-essarily  disturbed  by  the 
sM'ious  view  which  the  physician  takes  of  the  ease.  Too  often  the  j^oor 
chilli,  deluged  with  <lrugs,  is  longer  in  recovering  from  the  treatment  than 
he  would  be  from  the  disease.  To  allay  the  spasm  a  whifT  of  chloroform 
iiiiiy  he  administered,  which  will  in  a  few  moments  give  relief,  or  the  child 
may  he  ]>hu'ed  in  a  hot  bath.  A  ])rompt  enu'tic,  smdi  as  zinc  or  wine  of 
ipwae,  will  usually  relieve  the  spasm,  and  is  specially  indicated  if  the  child 
has  overloaded  the  stomach  through  the  day. 


k 


V.    TUBERCULOUS    LARYNGITIS. 

Etiology. — Tubercles  may  develop  priuutrily  ii\  the  laryngeal  niu- 
cii>a.  hut  ill  the  great  majority  of  cases  the  atfection  is  secondary  to  pul- 
iiioiiary  tuberculosis,  in  which  it  is  met  with  in  a  varial)le  proportion  of 
fioiii  eighteen  to  thirty  per  cent.  liaryngitis  may  oc<'ur  very  early  in 
piiliiKiiiary  tuberculosis.  There  may  be  well-marki-d  involvement  of  the 
laiyiix  with  signs  of  very  limited  trouble  at  one  ajiex.  These  are  cases 
"hich,  ill  my  experience,  run  a  very  unfavorable  course. 

Morbid  A.natomy.— The  mucosa  is  at  first  swollen  and  prestuits 
^altered  tubercles,  which  seem  to  begin  in  the  neighborhood  of  the  lilood- 
vcssi'k  By  their  fusion  small  tuberculous  masses  arise,  which  caseate  and 
84 


522 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


liiiiilly  ulcerate,  leaving  shallow  irregular  losses  of  substance.  1'lic  nlnpps 
are  usually  (covered  with  a  grayish  exudation,  and  tliere  is  a  gericial  iluLk- 
ening  of  the  mucosa  about  them,  which  is  particularly  marked  upon  tho 
arytenoids.  The  ulcers  may  erode  the  true  cords  and  finally  destiov  them, 
and  jKis^ing  deeply  may  ciiuso  perifhondritis  with  necrosis  and  oic.i.iuiuillv 
exfoliation  of  the  cartilages.  The  disease  may  extend  laterally  ami  luvulvo 
the  j)harynx,  and  downward  over  the  mucous  membrane  coveriiiff  tlie 
cricoid  cartilage  toward  tho  oesophagus.  Above,  it  may  reach  tlic  |Mi>Uiior 
■wall  of  the  pharynx,  and  in  rare  cases  extend  to  the  fauces  and  tonsils. 
The  epiglottis  may  be  entirely  di'stroyed.  There  are  rare  insliiiiccs  in 
which  cicatricial  changes  go  on  to  such  a  degree  that  stenosis  of  the  larviix 
is  induced,  a  renuirkablo  specimen  of  which  I  saw  some  years  ago  with 
J.  Solis-Cohen. 

S3niiptomS. — The  first  indication  is  .'(light  huskiness  of  the  voice, 
which  finally  deepens  to  hoarseness,  and  in  advanced  stages  there  may  be 
complete  loss  of  voii'C.  There  is  something  very  suggestive  in  the  eaily 
hoarseness  of  tuberculous  hiryngitis.  My  attention  has  frefpiently  kru 
directed  to  the  lungs  sinqdy  by  the  (pudity  of  the  voice. 

The  cough  is  in  part  due  to  invdlvenu'iit  of  the  hirynx.  Eai'iy  in  tin- 
disease  it  is  not  very  troublesome,  but  when  the  ulceration  is  extensive  it 
becomes  husky  and  iiied'eetual.  Of  tlu'  symptoms  of  laryngeal  tuhereu- 
losis,  none  is  nu)re  aggravating  than  the  dysphagia,  which  is  met  with  jiar- 
ticularlv  when  the  e[)iglottis  is  involved,  and  when  the  ulceration  has 
extended  to  the  jiharynx.  There  is  no  more  distressing  or  painful  coiiiiili- 
oation  in  jdithisis.  In  instaiu'es  in  which  the  e[»iglottis  is  in  great  part 
destrityi'd,  with  eai'h  atleinpt  to  take  food  there  are  distressing  paroxysms 
of  cough,  and  even  of  suffocation. 

AVith  the  laryngoscope  there  is  seen  early  in  the  disease  a  pallor  of  tin' 
mucous  mend)rane,  which  also  lodks  thickened  and  inliltrated.  paiticiilarh 
that  covering  the  arytenoid  cartilages.  Tho  tuberculous  ulcers  arc  veiv 
characteristic.  They  are  lii'oad  and  shallow,  with  gray  bases  and  ill-defined 
outliiu's.  The  vocal  cords  arc  infiltrated  and  thickened,  and  ulcrratiou  is 
very  common. 

The  diagnosis  of  tuberculous  hiryngitis  is  rarely  ditlicult,  as  it  i-;  usu- 
ally ass(iri;itcd  with  well-marked  i)ulmonary  disease.  In  case  of  iloiiht 
some  of  the  secretion  from  the  base  of  an  ulcer  should  be  reniovid  anl 
e.xamined  for  bacilli. 

Treatment. — I'hysicians  pay  scarcely  sufTieient  attention  to  tin' 
laryngeal  comjdications  of  consumption.  The  ulcers  should  lie  spravi  1 
and  kei)t  thoroughly  cleansed.  Solutions  of  tannic  acid,  nitrate  oi'  sihir. 
or  sul|)hide  of  zinc  nniy  be  cmitloyed.  The  insutllation,  two  or  tlm  e  tinus 
a  day,  of  a  powder  of  iodoform,  with  morphia,  after  thoroughlv  cKansin;' 
the  ulei-rs  with  a  spray,  relieves  the  pain  in  a  majority  of  the  eases.  ('"• 
caine  (four  per  cent  solution)  applied  with  the  atomizer  will  ofiiii  enalili' 
tho  patient  to  swallow  his  food  comfortably.     There  are,  howe\ei,  distress 


SYI'IIILITIC  LARYNGITIS. 


523 


inff  Ciisos  of  extensive  liirviigoal  iuid  ithiirynffoiil  ulooration  in  which  even 
lociiiiii'  loses  its  fjood  etTects.  Wlieii  the  ei)i,irh)ttis  is  lost  the  (iiHiciilty  in 
swulli'winjr  hecntiu'S  very  fri'eut.  Wolfenden  states  that  this  may  l)e  obvi- 
iittMi  if  the  putii'iit  han,<rs  iiis  liead  over  the  side  of  the  bed  and  sucks  milk 
throii^li  :i  rubber  tubing  from  a  mug  placed  ou  the  floor. 

VI.    SYPHILITIC    LARYNGITIS. 

Svphilis  attaeks  tlie  larynx  with  great  frequency.  It  may  result  frotu 
tlu'  iiilierited  disease  or  be  a  secoiulary  or  tertiary  manifestation  of  the  ao- 
(Hiiri'ii  t'lirm. 

Symptoms. — In  seeon(hiry  syjdiilis  there  is  occasionally  erythema  of 
tlic  larynx,  wiiicdi  may  go  on  to  detlnite  catarrh,  but  has  nothing  charac- 
teristic. The  process  may  proceed  to  the  forniation  of  superlicial  whiti-^li 
ulcers,  usually  symmetrically  idaeed  on  the  cords  or  ventricular  bands. 
Miicdiis  patches  and  condylomata  are  rarely  seen.  The  symptoms  are 
]inieiiially  those  of  slight  loss  of  voice  with  laryngeal  irritation,  as  in  the 
>iin|ili'  catarrhal  form. 

The  tertiary  laryngeal  lesions  are  tiunu'rous  and  very  serious.  True 
L'Uiiimata.  varying  in  size  from  the  head  of  a  pin  to  a  small  nut,  develop 
ill  the  sul)inucous  tissue  most  commonly  at  the  base  of  the  e])iglottis. 
They  Li'd  tlirough  the  changes  charactcistic  of  these  structures  and  may 
either  l»rcak  down,  j)roducirig  extensive  and  deep  idceration,  or — and  this 
is  more  characteristic  of  syphilitic  laryngitis — in  their  healing  form  a 
lilii'dii-  li~-uc  which  shrinks  and  produces  stenosis.  The  ulceration  is  apt 
t(i  extend  deeply  and  involve  tlu-  cartilage,  inducing  lu'crosis  and  exfolia- 
tion, and  even  lia'morrhage  from  erosion  of  the  arteries.  (Edcuia  may 
>iiililonly  jirove  fat:d.  The  cicatrices  which  follow  the  sclerosis  of  the 
L'lnnniata  ov  the  healing  of  the  uh^'rs  proiliice  great  deformity.  The  epi- 
;'lottis.  t'nr  instance,  niiiy  l)e  tied  down  to  the  i)hary?igeal  wall  or  to  thu 
ejiiLTlottii'  t'olds,  or  ev(Mi  to  the  tongue  ;  and  eventually  a  steiu>sis  results, 
Hhieji  may  necessitate  tracheotomy. 

Till'  laryngeal  symptoms  of  inherited  syphilis  have  the  usual  course  of 
these  le-ious  aud  appear  either  early,  within  the  first  five  or  six  months,  or 
after  luilierty;  most  commonly  in  the  former  period.  Of  Td  cases,  .1.  N". 
Maekeiizie  found  that  (!:5  occnrre(l  within  tlu^  lirst  year.  The  guminatoiis 
iiitiltrMtion  leads  to  idceration,  most  commonly  of  the  e])iglottis  atid  in 
the  ventricles,  and  Ww  process  may  extend  deeply  ami  involvi;  the  carti- 
liii.'!'.    Ciiatricial  contracticm  may  also  occur. 

The  diagnosis  of  sy])hilis  of  the  larynx  is  rarely  difticidt,  since  it  occurs 
'  niiwt  enininoiily  in  coniu^ction  with  other  symptoms  of  the  disease. 

Treatment. — 'i'he  administration  of  constitutional  remedies  is  the 
niovt  iiii|iortant,  and  under  mercury  and  iodide  of  potassium  the  local 
^viii|il(iiiis  nniy  rapidly  be  relieved.  ''I'he  tertia.T  laryngeal  manifestations 
i'lvalwaw  serious  and  dillicult  to  treat.     The  deep  ulceration  is  specially 


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524 


DISEASES  OF  THE   RESPIRATORY   SYSTEM. 


hard  to  combiit,  mid  tin*  oicatrization  may  lU'cyssitatc  trucliootoinv,  or  the 
grtiduul  dilutulioii,  as  practised  by  Schroetter. 


III.  DISEASES  OF  THE   P.ROXCIII. 


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I.    ACUTE   BRONCHITIS. 

Acute  catarrhal  inliainniation  of  tho  bronchial  mucous  nionibraiu'  i>  a 
very  coinnum  disease,  rarely  serious  in  iiealthy  adults,  l)ut  very  fatal  iu  tlir 
ohl  and  in  tho  young,  owing  to  associated  pulmonary  complications.  It  is 
bilateral  and  atVects  either  the  larger  and  medium  size<i  tidu's  dp  tlir 
sniiiller  bronclii,  in  which  case  it  is  known  as  capillary  bronchitis. 

AVe  shall  siteak  oidy  of  the  former,  as  the  latter  is  part  and  parcel  i.f 
broncho-ptu'umonia. 

etiology. — Acute  bronchitis  is  a  commo!i  seqiu'ucc  of  cati'iiiiiLT  cnltl, 
and  is  often  nothing  more  than  the  extension  downward  of  an  unliiKirv 
coryza.  It  occurs  most  fre(piently  in  the  chatigeal)le  weather  nf  caih 
spring  and  late  autumn.  Its  association  with  cold  is  well  indicatcil  U 
the  popidar  expression  "  cold  on  the  chest."  It  nuiy  prevail  as  an  i.'iii- 
demic  apart  from  inlluenza,  of  which  it  is  an  important  feature. 

Acute  bronidiitis  is  associated  with  many  otiier  affections,  iiotalilv 
measles.  It  is  by  no  nutans  rare  at  the  onset  of  typhoid  fever  and  malaria. 
It  is  present  also  in  asthma  and  whooping-cough.  Tho  brom-hitis  nf 
Bright's  disease,  gout,  and  heart-disease  is  usually  a  chronic  furni.  1; 
attacks  persons  (»f  all  ages,  but  most  frecpieutly  the  young  and  the  nM. 
There  are  individuals  wiio  liave  a  special  disposition  to  bronciiial  catarrli. 
and  the  sliirhtest  exposure  is  a[tt  to  bring  on  an  attai-k.  I'erson.s  who  iivi 
an  out-of-door  life  are  usually  less  subject  to  the  di.sease  than  those  wli" 
follow  sedentjii'y  occui)ations. 

The  atfection  is  prol)alily  mlcrobie,  though  we  have  as  yet  no  (Icliiiii' 
evidence  upon  this  ])oint. 

Morbid  Anatomy. — The  mucous  mend)rane  of  the  ti^aelica  i.ii'i 
bronchi  is  reddened,  c()ngest(Hl,  and  covered  with  mucus  and  niU(n-|iiiN 
whii'li  nniy  be  seen  oozing  from  the  snmller  bronchi,  sonu'  of  wliicli  aiv 
dilated.  The  finer  changes  iu  tiic  mucosii  consist  in  des(|uaniatiiiii  nf  tli 
ciliated  epithelium,  swelling  and  ledema  of  the  submiicosa,  and  inlllti'utieii 
of  the  tissue  with  leucocytes.     The  mucous  glands  are  much  swollen. 

Symptoms. — The  symptoms  of  an  ordinary  "cold"  aceonipai)\  tin' 
onset  of  an  acute  bronchitis.  The  coryza  exteiuls  to  tho  tubes,  and  may 
also  affect  the  larynx,  protlucing  h()arsenes.s,  which  in  many  eases  is  niarkoii. 
A  chill  is  rare,  but  there  is  invariably  a  sense  of  oppression,  with  Ih'Uvi- 
ness  and  languor  anil  pains  iu  the  bones  and  back.  In  mild  eases  tlniv  \i 
scarcely  any  fever,  but  in  severer  forms  the  range  is  from  KH    to  l"'' • 


ACUTE  BRONCHITIS. 


52; 


Thi!  liviiiiohinl  symptoms  set  in  with  a  fooling  of  tip^htnoss  nnrl  rawnoss 
beiioiitli  tlio  sternum  and  a  sensation  of  oj)j)rossion  in  the  chest.  The 
lounh  is  roiif,'!!  at  Hrst,  cuttin<,'  and  sore,  anil  often  of  a  rin<fin<if  eliaraeter. 
it  I'diiies  on  in  paroxysms  which  rack  a!ul  distress  the  patient  extremely. 
nuiiiiir  the  severe  spells  the  pain  may  be  very  intense  beneath  the  sternum 
iiul  aliii'j,'  the  attachments  of  the  diaphra<;m.  At  first  tlie  cou<rh  is  dry, 
but  in  ii  few  days  the  secretion  becomes  muco-purulent  and  al)undant,  and 
tiimllv  |iurulent.  With  the  looseninj;  of  the  cou<jh  great  relief  is  experi- 
(iiicd.  The  sputum  is  made  up  largely  of  pus-cells,  with  a  variable  nund)er 
iif  the  large  round  alveolar  cells,  many  of  which  ci)ntain  carbon  grains, 
whil''  nthcrs  have  u]i<lergone  the  myelin  degeneration. 

J'/ni^inil  Sftjiif^: — The  respiratory  movements  are  not  greatly  increased 
in  frftjiieiicy  unless  the  fever  is  high.  There  are  instances,  however,  in 
which  the  breathing  is  rajiid  and  when  the  smaller  tubes  are  involved 
there  is  dyspiuea.  On  palpation  the  bronchial  fremitus  may  often  be  felt. 
(In  auscultation  in  tiie  early  stage,  piping  sibilant  rales  are  everywhere  to 
lie  heard.  They  are  very  changeable,  and  a[)pear  and  disappear  with  cough- 
in;r.  With  the  relaxation  of  the  bronchial  membranes  and  the  greater 
iihiiuiiiiuco  of  the  secretion,  the  rales  change  and  become  mucous  and  bub- 
lilinir  iu  (|uality. 

The  rnursc  of  the  disease  depends  on  the  conditions  under  which  it 
ilevelops.  In  healthy  adults,  by  the  end  of  a  week  the  fever  subnides  and 
'lie  cdugh  loosens.  In  another  Avoek  or  ten  days  convalescence  is  fully 
established.  In  young  children  the  chief  risk  is  in  tiu*  extension  of  the 
[iroccss  (lowjiward.  In  measles  and  whoo[)iiig-cough,  the  ordinary  bron- 
'liial  catarrh  is  very  apt  to  descend  to  the  (inor  tubes,  which  beronu' di- 
!;itc(l  and  plugged  with  muco-pus,  inducing  areas  of  collapse,  and  finally 
liroiii'lid-inu'iinionia.  This  extension  is  indicated  by  changes  in  the  phvsi- 
(■\\\  siirus,  Usually  at  the  base  the  rales  are  subcrepitant  and  nutuerous 
iiml  there  may  be  areas  of  defective  resonance  and  of  feel)]e  or  distjint  tu- 
liiilar  lireatliiug.  In  the  aged  and  debilitated  there  are  similar  dangers  if 
the  imieess  extends  from  the  larger  to  the  smaller  tubes.  In  old  age  the 
liriincliial  mucosa  is  less  capable  of  expelling  the  mucus,  which  is  njore 
ajit  to  sag  to  the  dependent  parts  and  induce  dilatation  of  the  tubes  with 
extension  of  the  inflammation  to  the  contiguous  air-cells. 

riic  ilifiijnosis  of  acute  bronchitis  is  rarely  diflicult.  Althonsrh  the 
mode  of  onset  may  be  brusque  atid  jterhaps  simulate  i)neumonia,  yet  the 
alisenee  of  dulness  and  blowing  breathing,  ami  the  general  character  of 
the  bi'oiicliial  intlammation,  renders  the  diagnosis  simple,  'i'he  complica- 
tion of  l)r(iiicho-pnoumonia  is  indicated  by  the  greater  severity  of  the  symp- 
ti'nis.  partietdarly  the  dyspncea,  the  defective  color,  and  the  physical  signs. 

Treatment. — In  mild  cases,  household  measures  suffice.  The  hot 
f"ol-b;iih,  or  the  warm  bath,  a  drink  of  hot  lemojia(le,and  a  mustard  plas- 
ter on  the  chost  will  often  give  relief.  For  the  dry,  racking  cougu,  the 
-v!ii|itoin  most  complained  of  by  the  patient,  Dover's  powder  is  the  best 


¥' 


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520 


DISKASKS  OP  THE  KESI'IUATOIIY  SYSTEM. 


•.•fn 


h'-u  '^i|f-^ 


remedy.  It  is  a  popular  l)elu'f  that  quinine,  in  full  doses,  will  rlicok  ^j, 
onc!oining  cold  in  the  chest,  but  this  is  doubtful.  Jt  is  a  coniinoii  ciisftdiii 
when  persons  feel  the  approach  of  u  cold  to  take  a  Turkish  lijitli,  aiid 
though  the  tightness  and  oppression  may  be  relieved  by  it,  there  is  in  a 
majority  of  the  cases  great  risk.  Some  of  the  severest  cases  of  iii<iii(liitis 
which  1  have  seen  have  followed  this  initial  'I'urkish  bath.  ISo  ilimht,  if 
the  jKM'son  could  go  to  bed  directly  from  the  bath,  its  action  Udiild  W 
benelicial,  but  there  is  great  risk  of  catching  additional  "cold"  in  jr,,!,,,, 
home  from  the  bath.  IJelief  is  obtjiined  from  the  uiij)leasaiit  sense  df 
rawness  by  keeping  the  air  of  the  room  saturated  with  moisture,  ami  in 
this  dry  stage  the  old-fashioned  mixture  of  tin;  wines  of  antinioiiv  hihI  ipc- 
cacuanha  with  litjuor  ammonii  acetatis  and  nitrous  etlief  is  iiseiiil.  If 
the  pulse  is  very  rapid,  tincture  of  aconite  may  be  given,  ]>arti(iiliirly  in 
the  case  of  children.  For  the  cough,  when  dry  and  irritating,  opium 
should  be  freely  used  in  the  form  of  Dover's  ]iowder.  Of  course,  in  ijn' 
very  young  and  the  aged  care  must  be  exercised  in  the  use  of  opiiun,  ]»ai- 
ticularly  if  tlie  secretions  arc  free  ;  but  for  the  distressing,  irritjitive  e(»ii<.'|i, 
which  keeps  the  patient  uwake,  no  remedy  can  take  its  ])lace.  As  the  e(iii<rh 
loosens  and  the  expectoration  is  more  abundant,  the  patient  beconies  ninrc 
comfortable.  In  this  stage  it  is  customary  to  ply  the  patient  with  ex|nc- 
torants  of  various  sorts.  Though  useful  occasionally,  they  should  ikiI  W 
given  us  a  matter  of  routine.  A  mixture  of  squills,  ammonia,  and  sene;';i 
is  a  favorite  one  with  many  ))ractitioners  at  this  stage. 

In  the  acute  bronchitis  of  children,  if  the  amount  of  secretion  is  krirc 
and  difficult  to  expectorate,  or  if  then^  is  dyspno.'a  arul  the  c(dor  he^'iiis 
to  get  dusky,  an  emetic  (a  tablespoonful  of  ipecac  wine)  shoukl  be  given 
at  once  and  repeated  if  necessary. 


II.    CHRONIC   BRONCHITIS. 


Etiology. — This  affection  may  follow  repeated  attacks  of  iiciite  hron- 
chitis,  but  it  is  most  commonly  niet  with  in  chronic  lung  ailVctions,  lienri- 
disease,  g<mt,  and  remd  disease.  It  is  frequent  in  the  aged  ;  tlie  yeiiiiL' 
rarely  arc  affected.  Climate  and  season  have  an  imi)ortant  iiitlnenee.  It 
is  the  winter  cough  of  tlio  old  man,  which  recurs  with  regularity  iis  tin' 
weather  gets  cold  and  changeable. 

Morbid  Anatomy. — The  bronchial  mucosa  presents  a  greiit  variety 
of  changes,  depending  somewhat  upon  the  disease  with  whiih  <  hreiiir 
bronchitis  is  associated.  In  some  cases  the  mucous  membrane  is  very 
thin,  so  that  the  longitudinal  bands  of  elastic  tissue  stand  out  jinmiineiitly. 
The  tubes  are  dilated  and  the  muscular  and  glandular  tissues  are  .itnipliH'i 
and  the  epithelium  is  in  great  part  shed. 

In  other  iiistances  the  mucosa  is  thickened,  granular,  and  intiltniteil 
There  may  be  ulceration,  particularly  of  the  mucous  follicles.     ItioiK'liiiil 


CHRONIC  BRONCHITIS. 


527 


(lihitiilions  aro  not  uiicominou  and  oniphyscnia  is  a  constant  aecompani- 

iiifiit- 

Symptoms. — In  the  form  mot  with  in  old  men,  associated  with  oni- 
nliysi'nia,  {^'oiit,  or  hoart-disease,  tho  eliit'f  symptoms  are  as  follows :  Short- 
mss  (if  l)ri'iith,  which  may  not  ho  noticoahlo  excopt  on  exertion.  'I'he 
piiliciits  "  pull'  and  hlow  "  on  f,'oin<;  up  hill  or  up  a  flight  of  stairs.  This  is 
line  lint  so  much  to  tho  chronic  Ijronchitis  ilsi'lf  as  to  associated  emphysenui 
DifMii  to  cardiac  weakness.  They  complain  of  no  [)ain.  Thecou<,'h  is  varia- 
hlr,  (  hiuigiii<?  with  the  weather  and  with  the  season.  Durinj^  the  summer 
tlu'V  iiiiiy  remain  free,  ))ut  each  succeeiliM<;  winter  the  couj^h  comes  on  with 
severity  and  persists.  There  may  ho  only  a  spell  in  the  mortiin<r,  or  the 
cliief  distress  is  at  nij^ht.  Tho  spntum  in  chronic  hroiudiitis  is  very  varia- 
lili'.  Ill  (;ases  of  the  so-called  dry  catarrh  there  is  no  expectoration.  Usu- 
iiHv.  iiowever,  it  is  ahundant,  muco-purulent,  or  distinctly  purnlent  in 
cliiirarter.  There  aro  instances  in  which  tho  patient  coii<,d»s  up  for  years 
a  thin  tliiid  s])utum.     There  is  rarely  fever.     The  fjeneral  health  may  he 

c; 1  and  the  disease  may  present  no  serious  features  apart  from  tho  lia- 

liility  to  induce  emphysema  and  hronchiectasy.  In  many  cases  it  is  an 
iiiciirahle  atTection.  Patients  im])rovo  an<l  the  cou<jh  disappears  in  tho 
suiuiiKT  time  oidy  to  return  durinjf  the  winter  months. 

Physical  Signs. — The  chest  is  usually  distendeil,  the  movements  aro 
liiiiitrd,  and  the  condition  is  often  that  which  we  see  in  emphysema.  Tho 
IH'ivussion  note  is  clear  or  hyperresonant.  On  auscultation,  expiration  is 
pnijoiiired  and  wheezy  and  rhonchi  of  various  sorts  are  heard — sonn?  liij;h- 
jiitt  lit'd  and  piping,  others  deep-toned  and  snoring.  Crepitation  is  oom- 
nmii  at  tho  hases. 

Clinical  Varieties. — The  desci-iption  Just  given  is  of  the  ordinary 
iliidnic  hi'onchitis  which  occurs  in  connection  with  emphysema  and  heart- 
(iisi'ase  and  in  many  elderly  men.  There  are  certain  forms  wdiich  merit  spe- 
cial description  :  (a)  On  several  occasions  I  have  met  with  a  form  of  rhrnuir, 
liniHr/ii/is,  particularly  in  women,  which  ccmies  on  between  the  ages  of 
twenty  and  thirty  and  nniy  continue  indefinitely  without  serious  impair- 
iiu'iit  of  the  health.  In  one  case,  a  lady  of  fifty,  with  a  phthisical  family 
history,  began  to  cough  when  she  was  twenty-five,  and  since  then  has  had 
inure  or  less  cough  every  day  without  intermission.  It  has  not  seriously 
iiii|iaiivd  her  health,  though  she  has  never  been  strr^-'''.  Once  or  twice 
she  has  had  attacks  of  eczema.  Tho  cough  is  clnefly  in  the  morning,  is 
iipt  t(;  he  brought  on  by  too  nuich  conversation,  and  is  quite  nulej)endent 
"f  the  weather.  Tho  daily  a-nount  of  expectoration  is  not  great,  rarely 
ludie  than  from  four  to  six  ounces.  It  is  muco-purulent  in  character. 
IIk'  examination  of  tho  chest  is  negative — no  emphysenui,  no  rales.  I 
liavc  met  several  such  instances  whi(.'h  seem  to  form  a  tyjie  of  cdironio 
bronchitis,  though  it  is  dinicult  to  say  upon  what  the  condition  depends. 

(b)  Hronchorrhoea. — Excessive  bronchial  secretion  is  met  with  under 
several  conditions.    It  must  not  bo  mistaken  for  the  profuse  expectoration. 


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528 


DISEASES  OP  THE  KKSPIRATOUY  SYSTEM. 


of  brotiflilor'tusy.  Tlu'  socrotinn  may  l)o  very  liquid  and  watory — hronchor. 
rhd-a  .srrtisit.  More  (toniinonly,  it  in  imnilmt  tlunijj;li  tiiiii,aiul  with  "Tfcn- 
isli  (tr  ycllow-^frci'ii  niasson.  It  may  hi'  thick  and  iiiiifonii.  'I'his  |iri)fii>e 
hronchial  seoretioii  is  usually  a  manifestation  of  chronic  hrom  hitis  mni 
may  lead  to  dilatation  of  tlio  tubes  and  idtimatdy  to  fetid  hrmirhiiis  i„ 
the  yoiinfi:  the  condition  may  persist  for  years  without  impaiiintnt  of 
health  and  without  apparently  damaf;in<f  the  lunj^s. 

(r)  I'uh'id  lii'iinchHis. — Fetid  expectoration  is  met  with  in  coniicftjon 
with  l)ronchiectasi8,  pinjirene,  ahscess,  or  with  decomposition  of  secretions 
within  phthisical  cavities  and  in  an  empyenui  which  has  perforati  d  the 
lun<;.  'I'hcre  are  instances  in  which,  ai)art  from  any  of  these  states,  the 
expectoration  has  a  fetid  character.  The  sputa  are  ahundant,  u.-imllv 
thin,  grayish  white  in  color,  and  they  separate  into  an  upper  "tluid  laver 
ca2)ped  with  frothy  nuicus  aiul  a  thick  sediment  in  which  may  soinetinics 
be  found  dirty  yellow  nuisses  the  size  of  peas  or  beans — the  so-called  ])it- 
trich's  plugs.  The  allection  is  very  rare  apart  from  the  above-nictitidiied 
conditions.  In  severe  cases  it  leads  to  changes  in  the  bronchial  walls, 
j)neumonia,  aiul  often  to  abscess  or  gangrene.  Metastatic  brain  abscess 
has  folluwed  i)utrid  bronchitis  in  a  certain  number  of  cases. 

{(l)  Dfji  Ciifarr/i. —  ('ir/iirr/ie  aw  of  Laeiniec  is  a  not  uncommon  form, 
charactv.'rized  by  ])aroxysms  of  coughing  of  great  intensity,  with  little  or 
no  expectoration.  It  is  usualb  met  with  in  elderly  pers(ms  with  ein])liy- 
sema,  and  is  one  of  the  most  ol>.>tinate  of  all  varieties  of  bronchitis. 

In  England  the  damp  cold  of  the  unwarmed  houses  is  responsilile  in 
great  part  for  the  prevalence  of  chronic  bronchitis  among  the  aged  and 
weak.  An  equable,  warm  temjjcrature  is  of  the  first  importance  to  all 
persons  prone  to  the  disease. 

Treatment. — By  far  the  most  satisfactory  method  of  treating  the 
recurring  winter  bronchitis  is  change  of  climate.  Kemoval  to  a  sdutliern 
latitude  may  ])revent  the  onset.  Southern  France,  southern  {'iililmiiia, 
and  Florida  furnish  winter  climates  in  which  the  subjects  of  clironie 
bronchitis  live  with  the  greatest  comfort.  All  cases  of  prolonged  bronchial 
irritation  are  benefited  t)y  change  of  air. 

The  lirst  endeavor  in  treating  a  case  of  chronic  bronchitis  is  to  ascer- 
tain, if  possible,  whether  Jiere  are  constitutional  or  local  aifections  witli 
which  it  is  associated.  In  many  instances  the  urine  is  found  to  be  liiuldy 
acid,  perhaps  slightly  albuminous,  and  the  arteries  are  stiif.  In  the  form 
associated  with  this  condition,  sometimes  called  gouty  bronchitis,  the  at- 
tacks seem  related  to  the  defective  remd  eliuunation,  and  to  this  condition 
the  treatment  should  be  first  directed.  In  other  instances  there  are  lieart- 
disease  and  emphysema.  In  the  form  occurring  in  old  men  much  may  be 
done  in  the  way  of  prophylaxis.  Septuagenarians  should  read  ( )liver  \\  en- 
dell  Holmes's*  "Do  Senectute"  with  reference  to  the  care  of  the  health. 


*  Over  the  Tea-cups,  Boston,  1800. 


BRONrillKm'ASUI, 


521) 


Tlitrc  is  no  doubt  tlmt  with  prudence  oven  in  our  chanfjoabit'  winter 
weather  much  may  he  done  to  prevent  the  onset  of  elironi(!  Ijronehitis. 
Woollen  underjrartuents  should  l)e  used  and  especial  eare  should  he  taken 
ill  the  spriufj  months  not  to  change  them  for  lighter  ones  l)efore  the  warm 
wi'iither  is  established. 

Cure  is  seldom  elTected  by  niedieijud  remedies.  There  arc  instances 
ill  which  iodide  of  potassium  acts  with  remarkable  benetit,  and  it  should 
al\v;i\s  l)e  given  a  trial  in  cases  of  paroxysmal  bronchitis  of  obscure  origin. 
W'hvu  the  secret iiu  is  excessive  muriate  of  ammonia  and  senega  are  useful. 
Stiiiii,  .ting  expectorants  are  contraiiulicatt'd.  When  the  heart  is  feeble, 
the  ci)ud)ination  of  digitalis  and  strychnia  is  very  beneficial,  'riirpentine, 
the  old-fashioned  remedy  so  warmly  recommeiideil  by  tlui  I)uhlin  physi- 
ciiiiis,  has  in  many  quarters  fallen  undeservedly  into  disuse.  I'repMi'utioiis 
of  tar,  creasote,  aiul  tcreheue  are  sometimes  uscfid.  Of  other  halsamic 
remedies,  saiulal-wood,  the  compound  tincture  of  benzoin,  copaiba,  balsam 
of  reiii  or  tolu  may  be  useil.  Tidialations  of  eucalyjttus  and  of  the  spray  of 
ipeaciianlui  wine  are  often  very  useful.  If  fetor  l)e  present,  carbolic  acid 
in  the  forui  of  spray  (ten  to  twenty  per  cent  solution)  will  lessen  tlic  odor, 
or  thymol  (1  to  1,000).  In  full  blooded  men,  when  venous  engorgement 
exists  and  shortness  of  breath,  the  abstraction  of  twenty  to  thirty  ounces 
of  blood  will  ulTord  prompt  relief. 

III.    BRONCHIECTASIS. 

Etiology. — Dilatation  of  the  bronchi  occurs  under  tlio  following 
coiiditiuns  ;  (1)  As  a  congenital  defect  or  anomaly.  Such  cases  are  ex- 
tiviiH'ly  rare,  commonly  unilateral,  (irawitz  has  described  the  condition 
as  ljr)iic/iii'c/(tsis  2(nii'ei'sulis.  Welch  has  met  an  instance  in  a  young 
jrirl.  (2)  In  connection  with  inflanunation  of  the  broiudii,  jtarticnlarly 
whfii  this  leads  to  weakness  of  the  walls  with  the  accumulation  of  secre- 
tion. Tiider  this  category  come  tlu^  dilatation  met  with  in  (dironic  bron- 
chitis: and  emphysema,  the  dilated  bromdii  iu  (dironic  phthisis,  in  the 
catarrhal  pneunumias  of  children,  and  particularly  the  dilitation  whidi 
results  from  the  preseiux^  of  foreign  bodies  iu  the  air-tubes  or  from 
pressure,  as  of  an  aneurism  on  otie  Vironchus.  (3)  In  extreme  contraction 
of  the  lung  tissue,  whether  due  to  interstitial  pneumcuiia  or  to  compres- 
sion hy  pleural  adhesions,  broiudiial  dilatation  is  a  common  though  not 
a  constant  accompaniment. 

UiKiuestionably  the  weakening  of  the  bronchial  wall  is  the  most  impor- 
tant, jtmljably  the  essential,  factor  in  inducing  l)roi\«diicctasy,  since  the  wall 
is  then  not  able  to  resist  the  pressure  of  air  in  severe  spells  of  coughing 
and  in  straining.  In  some  instances  the  nu're  weight  of  the  accumulated 
secretion  may  be  sufficient  to  distend  the  terminal  tubides,  as  is  seen  in 
coiniin -sion  of  a  bronchus  by  aneurism. 

Morbid  Anatomy. — Two  chief  forms  are  recognized — the  cylin- 
dricul  and  the  saccular — which  may  exist  togetlier  in  the  same  lung.    The 


'li 


''  »;;■ 


5:50 


DISKASKS  OP  TIIK   HKSI'IIIATOIIY   SYSTKM. 


|!f  h  I' 


i/ffrTfTii 


1/  \''  '  ! 


lit 


I!       '  f 


'^ 


'M    H 


.}  r.. 


If 


-  ,i  »    <  I 


\, 


condition  iimy  1)0  <,'eiuTiil  (»r  pnrtial.  I'liivcrsal  bntiichii-ctiiHis  is  .ilwuvn 
iiiiiliiU'ral.  It  o<'('urs  in  riirt'  con^^ciiital  ciisi's  and  is  occasionally  sr.  n  n<  ^ 
8C(|Uciico  of  interstitial  )iMciinionia.  'I'lic  i-ntiiv  Ijnnicliial  tree  i-  ii|ii(.. 
K(!iite<l  l»y  a  scries  of  surcuii  o|K'iiiii<j  one  into  tiie  other.  'I'lie  u,,l|>  inc 
sniootli  and  possihly  witliont  ulceration  or  erosion  except  in  the  d>|H  ii(|,.|,t 
parts.  Tilt!  lining'  ineinhrane  ot'  the  sa<'cnli  is  nsiially  smooth  ainl  liIImih. 
ing.  'I'he  dilatations  may  form  lar;re  cysts  immediately  lienmili  tlu' 
l)leiira.  Intorvciiiinj,'  hetwei'n  the  sacmli  is  a  denKc  cirrhotic  luiiLr  tissiu;. 
'I'he  partial  dilatations — the  saccidar  and  cylindrical — are  coniiiinii  in 
clironic  jjhthisis,  particularly  at  the  apex,  in  chronic  pleurisy  at  the  Imsf. 
and  in  emphysema.  Here  the  dilatation  is  more  commonly  c\  liiiilriruj, 
soMU'times  fusiform.  The  bronchial  mucous  nu-mbrane  is  nun  li  in. 
volved  and  somi'times  there  is  a  narrowing  of  the  lumen.  Oc(  asiciiiiillv 
out!  nuH'ts  with  a  sinjrle  saccular  bi'onchiectasy  in  connection  with  cliriiiiir 
bronchitis  or  emphysema.  Some  of  these  h»ok  like  simple  cysts,  with 
smooth  walls,  witluait  fluid  contents. 

Jlistolotfically  the  liroiichi  which  arc  the  seat  of  dilatation  -hnu  im- 
])ortant  chan<,'es.  In  th((  larj^'c,  smooth  dilatations  the  cylimlrical  is  ii- 
l)laced  l)y  a  pavement  epithelium.  The  nmscular  layer  is  strrtdic  I,  atn.- 
l)liied,  and  the  fibres  separated  ;  the  clastic  tissue  is  also  much  stn'tclud 
and  separated.  In  the  larj^e  saccular  bronebiectasies  tnd  in  some  of  \\\v 
cylindrical  forms,  due  to  retained  secretions,  the  linin,ir  Jnembranc  is  ulcer. 
fttcd.  The  contents  of  some  of  the  larger  bronchiectatic  cavities  arc  Imr- 
ril)ly  feti(b 

Symptoms.  —  In  the  limited  dilatations  of  ]tbthisis,  enijtliyscnia,  iiml 
chronic  broncdiitis,  the  sym|)toms  are  in  j^reat  part  those  of  the  oriiriiial 
disease,  and  the  condition  often  is  not  suspecttMJ  during'  life. 

In  extensive  saccular  bronchiectasy  the  characters  of  the  coimii  ;iii(i 
expectoration  are  distinctive.  'I'he  [)atient  will  jiass  the  j^reatir  [lait 
of  the  day  without  any  couj^li  and  then  in  a  severe  paroxysm  will  biiiifr 
up  a  large  (juantity  of  s])utum.  Sometimes  ebango  of  the  position  will 
bring  on  a  violent  attack,  jtrobably  due  to  ♦he  fact  that  some  nf  tin 
secreti(m  flows  from  the  dilatation  to  a  normal  lube.  The  daily  s|i(ll  (if 
coughing  is  usually  in  the  morning.  The  expectoration  is  in  niaiiv  in- 
stances very  characteristic.  It  is  grayish  or  grayish  brown  in  color,  lliiid. 
})urulent,  with  a  ])eculiar  acid,  sometimes  fetid,  odor.  Placed  in  a  .diiir;'.! 
gla.ss,  it  se])arates  into  a  thick  graindar  layer  below  and  a  thin  nuicnid  in- 
tervi'ning  layer  above,  which  is  capped  by  a  brownish  froth.  .Microscniii- 
eally  it  consists  of  pus-corpuscles,  often  largo  crystals  of  fatty  acids,  wliirh 
are  sometimes  in  enormous  nund)ers  over  the  field  and  arraniT'tl  ii' 
bunches.  Ilsematoidin  crystals  are  sometimes  present.  Elastic  liluis  aiv 
seldom  found  except  when  there  is  ulceration  of  the  bronchinl  "all-. 
Tubercle  bacilli  are  not  })resent.  In  some  eases  the  ex])ectoration  is  vdv 
fetid  and  has  all  the  characters  of  that  described  under  fetid  bmin  liitis. 
Nummular  expectoration,  such  as  conies  from  phthisical  cavitis..-.  is  r.ot 


BUONCHIAL  ASTHMA. 


>;ji 


conininn.  TTu'iiiorrliiifro  may  oci'iir,  hut  in  tny  cxpcriciicc  it  lias  liccn  rare. 
Ali-irsH  of  tilt!  Iiniiii  lias  in  a  IVw  instances  {'(dlowi'd  tiu*  lironcliicctasis. 
Klininiatoid  utTt'ctions  may  (l*-v('Iii|i  ((ii'i'lianlt). 

I'lu'  diai/tidnis  is  not  possiltlc  in  a  larjic  iniinltcr  of  tlii'  cases.  In  tlio 
e\t(  iisivo  .sac(!ulatc(l  forms,  unilateral  und  associiated  with  interstitial  pneii- 
iiiiiiiia  or  chronic  plenrisy  the  diaiTHosis  is  easy.  'I'lu're  is  contraction  of 
till'  side,  \vhi(di  in  some  instances  is  not,  at  all  extreme.  The  cavernous 
HJiTiis  may  ho  (diiefly  at  the  ha.se  und  may  vary  according;  to  the  condition 
of  ilic  cavity,  whether  full  or  empty.  There  may  lie  the  most  ex({uisito 
uiii|>lioric  phenonu'nu  and  loud  resonant  rales.  Tlu' condition  persists  for 
vi'iiis  and  is  not  inconsistent  with  toleraiily  active  life.  The  patients  fre- 
(|ii('iit,ly  show  dij^ns  of  marked  (iirdtarrassnu-nt  (d'  the  pulmonary  circula- 
timi.  There  is*  cyanosis  .on  exertion,  the  tinj.'er-tip8  are  cdulilu'd,  and  the 
nails  iinturved,  A  (Mtndition  very  ditlicidt  to  distin<fuisli  from  hronchiec- 
tiisy  is  a  limiteil  pleural  cavity  communicating;  with  u  hronchus. 

Treatment. — .Medical  treatment  is  not  satisfactory,  since  it  is  impos- 
.sililc  to  heal  the  cavity.  I  have  practised  the  injii  tion  of  antiseptic  fluids 
ill  siiine  instances  with  honelit.  Intratracheal  injections  have  heeii  very 
wiiriiily  recommended  of  lute.  With  u  suitahic;  syringe  a  druclim  nuiy  be 
injected  twice  u  day  of  the  following  .solution  :  Menthol  10  [uirts,  jjuaia- 
cdl  "J  parts,  olive  oil  SIS  parts.  In  suitable  cases  druinajj;e  (d"  the  cavilii'S 
iiiiiv  be  attempted,  particularly  if  the  patient  is  in  fairly  ^ood  condition. 
I'm-  the  fetid  .secretion  turpentine  may  be  given,  or  terebene,  and  iiihala- 
tiuiis  u.sed  of  curboli(5  acid  or  thymol. 


.ti 


I ,  iij 


M 


■  I, 


, ; 


I'li 


IV.    BRONCHIAL   ASTHMA. 

Asthma  is  a  term  wlii(di  has  been  applied  to  various  (Miulitions  associ- 
ated with  dyspnu'a — hence  the  names  canliac  and  renal  a.sthma — but  its 
use  should  bo  limited  to  the  affection  known  us  bronchial  or  .s[»usmodio 
aslhnia. 

Etiologfy. — All  writers  afrrcc  that  there  is  in  a  niujority  of  cases  of 
liroiiiiiial  asthma  a  strong  neurotic  element.  Many  regard  it  as  a  neu- 
rosis in  which,  according  to  one  view,  spasm  of  the  bronchial  mus(de.s, 
aci'onliiig  to  the  other,  turgescence  of  the  niucosa,  results  from  disturbed 
iiiiurvation,  pneumogastric  or  vaso-motor.  Of  the  numerous  theories  the 
following  are  the  most  imiiortant  : 

(1)  That  it  is  due  to  soas^n  of_  tjiii  brouchial.  iLlUfii'les^  a  theory  which 
ims  perhaps  the  largest  number  of  adheri'iits.  The  original  experiments 
of  (',  ,1.  H.  Williams,  upon  which  it  is  largely  ba.sed,  have  not,  however, 
hiTii  coidirmed  of  late  year.s. 

C^')  That  the  attack  is  due  to  swelling  of  the  bronchial  mucous  niem- 
bnviie — lluctionary  hyperu3mia  (Truube),  vuso-niotor  turgescence  (Weber), 
diU'ase  hyperannic  swelling  (Clurk). 

(•i)  That  in  many  cases  it  is  a  special  form  of  inflammation  of  the 
smaller  bronchioles — bronchiolitis  exudativa  ((>arschmunn).     Other  theo- 


;tii 

''    -hi 


-r* 


^1  k'  |>     '?' 


'PIPP 


532 


DISEASES  OF  THE   RESPIIUTORV    SYSTEM. 


«.A.ii^ia..jaaji 


rios  which  may  he  niontioned  are  that  the  attack  depends  on  spasm  of  the 
diai»hra<rm  or  on  it  Ilex  spasm  of  all  the  inspiratory  niuseles. 

As  alrcj'.dy  mentioneij,  the  so-ealled  hay  fever  is  an  atfeetion  Avliidi  Ims 
many  resemhlances  to  bronchial  asthma,  with  which  the  attacks  niiiv  iiltcr- 
nate.  In  the  suddenness  of  onset  and  in  many  of  tlieir  fciitures  these  ills- 
cswcs  liavc  tlie  same  orijrin  ami  differ  otdy  in  site,  as  sn<r^este(l  liv  Sir 
Andrew  Clark  and  now  <jenerally  acknowled^fe(|  liy  specialists.  .Making 
dne  allowance  for  anato?!iical  dilTerences,  if  the  structural  chan<res  ncinr- 
rinjr  in  the  nusal  mucous  memhrane  duriiif;  an  attack  of  hay  fever  were  to 
(X'rur  also  in  various  parts  "'  the  hronchi.d  mucosa,  their  presence  the'' 
would  atTord  a  complete  and  adc'piate  explanation  of  the  facts  oh,..-,  .d 
duriiij^  a  jjaroxysm  of  bronchial  asthma  (Clai'k).  With  this  statenieiit  I 
fully  ajrrcc,  but  the  observations  of  Curschniaiin  have  directed  atteutinn 
toafcsitiin^  in  asthma  wliich  has  been  ne<rlected  ;  namelv,  that  in  a  nm- 
jority  of  the  cases  it  is  associated  with  an  exudation,  such  as  niiiriit  lie 
Hiipposj-d  to  come  from  a  turiresccnt  juucosa  and  wliicli  is  of  a  very  charac- 
tcri.-tie  anil  jieculiar  charact;'r.  The  hypera'inia  and  swelling'  of  the  imi- 
crwa  and  the  extrenudy  viscid,  tenaeious  mucus  explain  well  the  hiiidraiuo 
to  in.-(pii..:ion  and  expiration  and  also  the  (|uality  of  the  r/iles. 

Some  ^jfcneral  facts  with  reference  to  etiolo^ry  may  be  nicntioued.  'Yhc 
afTccfion  sometimes  runs  in  families,  partii'ularly  those  with  irritable  iiml 
lUMLible  nervous  syst.'ins.  The  attack  may  be  ass(»ciated  with  neiiralui;! 
or,  na  Suiter  mentions,  even  alternate  with  e])ilepsy.  Men  arc  luori'  fiv- 
rpir-ntly  affect. •(!  than  women.  The  disease  often  bcfrins  in  cliildlioiM'  ;.,i(l 
H.Mietimcs  lasts  until  old  a<fc.  One  of  its  most  strikinjjf  peculiarities  is  tlir 
Ijimiri'  and  c'ctraordinary  variety  of  circumstances  wliieli  at  times  iinliicc 
u  paroxysm.  Amonj:^  these  local  conditiiins  climate  or  attnosplicre  arc 
most  inij)ortant.  A  pi'rson  may  be  free  in  the  city  aiul  iiivariably  siillVr 
from  an  attack  when  he  ^'oes  into  the  country,  or  into  one  special  part  nf 
the  country.  Su(di  ca:-vs  are  by  no  means  uncommon.  Hrcatbiiifr  the  air 
of  a  particular  room  or  a  dusty  iitmosphere  may  brin<r  on  an  attack. 
Odors,  particidarly  of  flowers  and  of  hay,  or  <'i')anations  from  animals,  as 
the  horse,  dr>f;,  or  cat,  may  at  one.'  cause  an  outbri-ak.  Fri<.dit  or  \  iolciit 
i-inotion  of  any  sort  may  Ijrinir  on  a  paroxysm.  I'terine  and  o\ariaii 
troubles  were  formerly  thoui^ht  to  induce  atta<'ks  and  nuiy  do  so  in  ran' 
instances.  Diet,  too,  has  an  important  influence,  and  in  persons  subject  to 
the  disease  .severe  paroxysms  may  he  induced  l)y  overloadintr  the  stomacli. 
or  by  taking;  certain  articles  of  lood.  ('hroni(!  cases,  in  wliicdi  the  attack.-^ 
recur  year  after  year,  urailually  become  as.snciated  with  ejn])hy.sema.  ami 
ifvery  fresh  "cold  "  induces  a  paroxysm.  And  lastly,  many  case.-,  of  Imui- 
chial  asthma  are  associated  with  alTcctions  of  th'  nose,  particular! \  with 
hy|KTtropliic  rhinitis  and  nasal  polypi.  Accordini,'  to  some  specialist-  ef 
lar^'c  exjterience,  all  cases  of  bronchial  asthma  have  soine  affection  of  tlio 
li|»per  air-;)as.sa<,'es,  but  1  am  convinced  from  personal  observatif.ii  tliat 
this  id  erroneous.     .Still  physicians  must  acknowledge  the  debt  whi(  h  we 


BRONCHIAL   ASTHMA. 


583 


owt  to  Voltolinl,  Hack,  Duly,  Roe,  and  others  wlio  liavo  shown  the  close 
connection  which  exists  between  alleetions  of  the  naso-phurynx  and  many 
cui-cs  of  broncliial  asthma. 

Brii'lly  stated  tliiMi,  l)rnM('hial  asthma  is  a  neurotic  alTcction,  character- 
ized i»v  iiypera'mia  and  tur^esciiuH'  of  the  nuictisa ol"  tlir  smaller  lironchiul 
tiilics  and  a  peculiar  exudate  of  mucin,  'i'lu'  attacks  may  l>c  dui'  to  direct 
irriliition  of  the  bronchial  mucosa  or  may  In-  induced  n'tlc.x'y,  1)V  irritation 
(if  the  nasal  mucosa,  and  indirectly,  too,  by  reilcx.  inlhieiices,  from  sLom- 
iicli,  intestines,  or  frenital  ort^ans. 

Symptoms.  —  Premonitory  sensations  precede  some  attacks,  such  as 
chills'  feeling,  a  sense  of  tijj^htness  in  the  eiiesl,  tlatulenee,  i>assii<rc  of  a 
larirc  ((uantity  of  nrine,  or  jLjreat  depression  of  spirits.  Nocturnal  attacks 
lire  common.  After  a  few  hours'  sleep,  the  patient  is  arousi-d  with  a  dis- 
trc<<in,<:  sense  of  w'ant  of  breat''  ami  a  feclin;j;  of  jjrreat  oppression  in  the 
chest.  Soon  the  respiratory  elVu:  is  become  violent,  all  the  accessdry  mus- 
cles are  broui^ht  into  play,  and  in  a  few  minutes  the  jtatiiMit  is  in  a  par- 
oxvsiu  of  the  most  iiitensc  dyspiuea.  'I'he  face  is  pale,  the  expression 
aiixiiuis,  speech  is  impossible,  and  in  s[»ite  of  the  most  strenuous  insi>ira- 
terv  clforts  very  little  air  enters  the  lunjfs.  Expiration  is  prolonj^eil  and 
also  wheezy.  The  number  of  respirations,  however,  is  luit  uiuch  increased. 
The  astiimati(!  tit  may  last  from  a  few  minutes  to  several  hours.  When 
severe,  the  si>;ns  of  defective  aeration  soon  appear,  the  fa  -e  bec(»mes  be- 
dewed with  sweat,  the  pulse  is  small  and  ipiick,  the  extremities  j^et  cold, 
and  just  as  the  patient  seems  to  lie  at  his  \»orst,  the  breathinfr  bcjrins  to 
fret  easier,  ami  often  with  a  paroxysm  of  couLrhinjr  relief  i  ■  (ditained  and 
he  sinks  exhausted  to  sleep,  'i'he  relief  may  be  but  li'tiiporary  and  a  sec- 
01.  I  attack  may  s(»on  conu'  on.  In  a  majority  of  the  cases  evi-n  in  the 
intervals  Itetwecn  the  asthmatic  fits  the  respiration  is  sonn-what  embar- 
ra-S(d.  The  con<jh  is  at  first  very  ti^ht  and  dry  ami  the  expectoration  is 
expelled  witii  the  <ireatest  ditliculty. 

The  physical  sitjns  durinjij  an  iittack  are  very  characteristic.  On  in- 
speetjnn  the  thorax  looks  enlarired,  barrel-sliapeil,and  is  lixeil,  the  amount 
(if  e\pansioji  l)einj^  alto<iether  disproportionate  to  the  intensity  of  the  iii- 
spiralory  movement.s.  'i'he  diaphra.iini  is  lowered  and  mo\(s  but  sliLfhtly. 
Inspiriition  is  short  and  (Hi'ck,  expiration  prolon,<.''c(l.  I'ercussion  may  m)t 
reveal  any  six-cial  diifcreiice,  but  there  is  sometinu's  mai'kc(l  hyperrcso- 
iiaiiee,  jiarticularly  in  cases  wdii(di  have  had  rcpeate(l  attacks. 

t>;i  auscultation,  with  inspiration  and  expiration,  there  are  ininimer- 
iihle  sibilant  and  sonorona  nlles  of  all  varieties,  pipinsr  and  hi-xh-pitcduMl, 
lowjiitclied  ami  grave.     Tjater  in  the  attack  there  are  moist  rales. 

The  spiifiiiii  in  bronchial  asthma  is  (|uitc  distinctive,  unlike  that  whudi 
'"•eiii's  ill  any  other  atfcction.  Karly  in  the'atta(dv  it  is  bnaijiht  up  with 
iTi'e.it  ditliculty  and  is  in  the  form  of  rouii(le(l  jrelatiiious  nni.sses,  the  so- 
failed  "y>('/7f'.« "  of  Laennec.  Tlnmirh  ball-like,  (hey  can  be  unbdded  and 
rt'ally  represent  moulds  in  mucus  of  the  snuiller  tubes.     The  entire  expec- 


■■{,'!■■ 


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iri''  ... 


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If  "v 


i 


r.*>- 1  J 


a..  :- 


fil 


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u 


tPlWi 


■/  .-viii 


534 


DISEASES  OP  THE   IlESPIRATORY  SYSTEM. 


tonition  itiiiy  bo  i!iiulo  up  of  these  rfoniewlmt  triiiislueoiit-lookiiijif  inllcts 
floating  ill  a  small  (|iiaiitity  oi'  thin  niiicus.  Some  of  them  are  <i|i;(i|ii(.. 
Often  witii  the  naked  eye  a  twisted  spiral  eharacter  can  be  seen,  paiticn. 
larly  if  the  sputum  is  spread  on  a  glass  with  a  black  background.  Mien,. 
8eo])i('alIy,  many  of  these  pellets  have  a  spiral  structure,  which  niMlci'.s 
them  among  the  most  remarkable  bodies  met  with  in  s[»utum.  It  i-  nut 
a  little  curious  that  they  should  have  been  j)ractically  overlookcil  until 
des(!ril)ed  a  few  years  ago  by  Curschmann.  Tndcr  the  micrusc.i|i,.  th,. 
spirals  an^  of  two  forms.  In  one  then'  is  simply  a  twisted,  spii'iillv  ur- 
rangetl  mucin,  in  which  are  entangled  cells,  derived  probably  fnun  the 
smaller  bronchi  and  alveoli,  (.'fteii  in  all  stages  of  fatty  dcgeiiciiitinii. 
The  twist  may  be  loose  or  tight.  The  second  form  is  much  more  |iiinli,ir. 
In  the  centre  of  a  tightly  coiled  skein  of  nnu'in  ilbrils  with  .i  few  si  attcnMl 
cells  is  a  Hlament  of  extraordinary  clearnes-'  and  transliiccncv,  prulpulilv 
composed  of  ti'ansforiiu'd  niiiciii.  As  Curschmann  suggests,  these  -pinils 
are  doubtle-^s  fornu'd  in  tliv'  liner  bronchioles  and  constitute  the  iiKiihict 
of  an  acute  lironchiojitis.  It  is  dilTicult  to  explain  tluur  spiral  luitmv.  1 
do  not  know  of  any  observations  uixm  the  cour.se  of  the  currents  ppMhired 
by  the  ciliated  epithelium  in  tin  hroiu-hi,  but  it  is  (piite  jiossihle  th;it  their 
H<'tion  may  be  rotatory,  in  wlii'-h  case,  particularly  when  condiiiiei!  with 
spasm  of  tile  hroiiejiial  muscles,  it  is  |M»s#(il)lc  to  conceive  that  the  iniieii- 
forjucil  in  the  tube  nuglit  be  conipelleil  to  assume  a  •'piral  form.  Witliiii 
two  or  three  days  'iie  sputum  changes  entirely  in  <liaracter;  it  he(  n'ii<'S 
niuco-purulent  and  Cursehmanirs  spirals  are  no  longer  to  be  foiind.  'I  luy 
occiir  in  all  instances  of  tnu-  bronchial  asthma  iti  the  early  jK-riod  of  the 
attack.  There  are,  in  addition,  in  niai\y  cases,  tin-  |H»iiit*-d.  octiili'Jnil 
erystiils  descrilu'd  by  Leyden  and  soinetiuuvs  called  .istlnna  (-rystaU.    Tin  y 

arc  identical  with  the  crystals  found   in  the  sertu-n  and   in  the  M I  in 

leuka'uua.  At  one  time  they  were  suppo.sed,  by  their  irritating  eliarneiiT, 
to  induce  the  {laroxysms. 

The  citursr  of  the  disease  is  very  variable.  In  severe  attacks  tlie  piir- 
oxNsnis  recur  for  three  or  four  nights  or  even  more,  aJid  in  the  intervals 
and  during  the  day  there  may  be  wheezing  and  cough.  Karly  in  the  .liseasi' 
th  ■'  patient  may  be  free  in  the  morning,  without  cough  or  nuich  distress, 
and  the  attacks  may  appea''  at  first  to  be  of  a  purely  nervous  c|i;ii;ii  ter, 
In  the  long-staniling  cases  emi»hysi'iM  i  almost  invariahly  develops,  aiii! 
while  the  pure  astliinatic  fits  diminish  in  frcipuMicy  the  chrotnc  brondiitiH 
and  sluu'tncss  of  breath  b"conu'  agirravated. 

We  have  no  knowledge  of  the  morbid  aiuitomy  of  true  asthma.  I'ealli 
during  the  attack  is  unkno'An.  In  long-standing  cases  the  lesinii-  iuv 
those  of  chroiHc  ])ronehitis  and  emphysema. 

Treatment. — The  astlimatic  attack  usually  demands  inimediiiie  and 
prompt  treatment,  and  remedies  should  be  administered  whii-h  expericnco 
has  .shown  are  capable  of  relieving  the  condition  of  the  bronch,.d  unieosu. 
A  few  whitfs  of  chloroform  will  produce  prompt  though  temporary  nla.xa- 


FIBRINOUS  BRONCHITIS. 


535 


tioii.  In  a  child  with  very  severe  attaeks,  resisting  all  tlie  usual  reiuedieiJ, 
the  iicatJneiit  hy  fhloroforni  j^ave  itimicdiate  and  liiially  perniaiieiit  relief. 
rnl(  s  (if  nitrite  of  aniyl  may  be  hrolven  on  tlie  hand  ken  liief  or  from  two 
to  livf  ilnips  of  tlie  solution  nuiy  be  ))lace(l  upon  eotton-wool  and  iulialed. 
Streii.u  stimulants  ^'wim  hot  or  a  dose  of  spirits  of  elilorofonn  in  hot 
ttlii-ky  will  sometimi's  induee  relaxation.  More  permanent  relief  is  given 
liv  the  hypoilermie  injeetion  of  morphia  or  of  morphia  and  eoeaine  (M»m- 
liiticd.  In  obstinate  and  rejjoatedly  recurring  attacks  this  has  pmved  a 
vprv  satisfactory  plan,  'i'he  sedative  antispasmodics,  such  a*-  belladonna, 
iK'iitiiine,  stramonium,  and  lobelia,  may  be  jriven  in  solution  or  used 
ill  the  form  of  cigarettes.  Nearly  all  the  popidnr  remedies  either  in 
this  form  or  in  jiaslilles  contain  some  ])lant  of  the  order  .soUtnaceic^  with 
nitrate  or  chlonito  of  [lotash.  Excellent  cigarettes  are  now  manufactured 
and  a>tlniiatics  try  various  sorts,  siiiee  one  form  benelits  one  ]iatient, 
aiiiitln  r  form  another  patient.  Nitre  paper  nuide  with  a  strong  .suluficin 
iif  nitrate  of  potash  is  very  serviceable.  Filling  a  room  with  the  funu-s 
(if  this  |iaper  prior  to  retiring  will  sometinu>s  ward  ntl'  a  nocturnal  attack. 
I  lia\e  known  several  i)atient.s  to  whom  tobacco  smoke  iidialed  was  ipnte 
as  |inteiit  as  the  prcparcil  eigarettes. 

The  use  of  compressed  air  in  the  pneumatic  cabinet  is  very  bi'nelicial ; 
owgen  inhalations  may  be  also  tried.  In  preventing  the  recurrence  of 
till'  attaeks  there  is  no  remedy  so  useful  as  iodide  of  potassium,  \vhi(di 
siiiiietiiiies  acts  liki' a  «peciti<'.  From  ten  to  twenty  grains  three  times  a 
(lav  is  usually  sulhcicMit. 

Particular  attention  should  be  paid  to  the  liet  of  a^■Illmatic  patient.s. 
A  rule  Which  exp»'rience  generally  compels  them  to  make  is  to  fake  tho 
Ik  aw  UK  als  in  the  early  part  of  the  day  and  not  retire  to  bed  before  gas- 
trie  (I  gcslion  is  e(implete(|.  As  the  attacks  are  oft"n  induce(l  by  Hatu- 
li'ii'V.  t!ie  carbohydrates  should  not  be  allowed.  ColTee  is  a  more  suitable 
ilniik  than  tea.  In  respect  to  (dimate  it  is  very  diflictdt  to  lay  down  rules 
fnv  a-llniiatics.  The  patients  are  often  inindi  lietter  in  the  citv  tlian  in 
till'  eoinitry.  The  high  and  dry  altitudes  are  certainly  more  beneficial 
than  llie  sea-shore  ;  but  in  protracted  cases,  with  emphysema  as  a  ■*ccondiiry 
(diniilication,  the  raret  d  air  of  high  altitiules  is  not  advantageous.  In 
ymiiig  persons  I  havt^  known  a  residence  for  six  months  in  Florida  or 
soiuluru  California  to  lie  followed  iiy  prolonged  freedom  from  attj*»*s. 


V.   FIBRINOUS   BRONCHITIS. 

.\n  nente  (^ir  (di'onic  ulTeotion,  (duiracterized  by  the  formation  in  cer- 
tain ut'  th.e  bronchial  tulios  of  fibrinous  casts,  which  are  expelled  in  parox- 
ysm- of  dyspmea  and  cough. 

In  several  diseases  librinons  moulds  of  tlu^  bronchi  are  formed,  as  in 
flilititiieiia  and  croup  (with  extension  into  the  trachea  and  bronchi),  in 


m'!rr 


1 1 'il'j'leiff'fM 


>nc 


DISEASES  OP  THE  RESPIRATORY  SYSTEM. 


(  ;^ 


li 


pru'u  moil  ill,  and  ot'casioiially  in  phthisis — conditions  wliidi,  howcvi  r.  have 
nothini^  to  do  witli  true  fibrinous  bronchitis.  Tiu'sc  casts  arc  not  tn  ln' 
conf(»tnid('(l  with  tlic  bhxjd-casts  which  occur  occasioiuilly  in  li;i'iiin|  ivsis. 

Etiology.  — Notliiuf,'  is  known  of  its  causation.  It  occurs  uhjic  fpc. 
(|Ucnll\'  ill  iMidcs.  It  is  met  with  at  all  jK-riods  of  life,  but  is  more  cniiiiiKtii 
between  the  aj^es  of  twenty  and  forty.  It  has  been  known  to  attack  stvtial 
members  of  the  same  family.  Cases  have  been  described  occurring'  tn^rctlior 
as  if  (lu(!  to  some  endi'mic  intlueiice  (I'ichini).  The  cases  are  riire,  |i;uticMi- 
larly  iu  hospital  j>ractice.  The  attacks  occur  most  commouly  in  ijic 
spi"  ip;  nu)nths.  An  association  with  tubercilosis  has  Ijcen  fre(|uently  \u  tcil. 
Model,  ill  an  article  from  Biiumler's  clinic,  states  that  tuberciilnsis  wns 
])resent  in  ten  of  twenty-one  po.st-mortems.  It  has  been  met  with  also  in 
connection  with  skin-diseases,  such  as  pemphi<fus,  impetifio,  and  Iici'ikn, 
The  attacks  appeared  to  be  related  in  some  eases  to  the  meiistnial  imikkI, 
Several  instances  have  l)een  described  with  lieart-disease,  but  it  .s^oiiis 
l)robabli'  that  in  all  these  conditions  the  connection  was  not  causal. 

Symptoms. — Acute  cases  are  rare.  They  may  set  in  with  liiirli 
fevers,  ri^tii's,  severe  paroxysms  of  coujrh,  and  perhaps  with  ha'nio|itvsi>. 
Tlie  clinical  picture  ri'sembles  acute  bronchitis,  and  only  the  e.\|pi'.Isiiiii 
of  the  mciiibiaiious  casts  fjives  the  eluiracteristic  features  fo  tlic  case.  It 
is  much  more  serious  than  the  chronic  form  and  fatal  termiiia  ion  is  iidt 
uncommon.  N.  S.  I)avis  has  rcportctl  two  fatal  cases.  In  some  uf  the 
acute  cases  there  has  )»eeii  atl'cctioii  of  the  tonsils,  and  it  is  possible  that 
the  disease  may  ha\('  iiceii  truly  di]ihtheritic  in  character  and  diie  tn  ex- 
tension of  the  membrane  into  the  trachea  and  bronchi.  The  casts  in  tluse 
cases  arc  not  only  more  exti-nsive,  but  they  also  do  not  j)resent  the  lami- 
nated structure  characteristic  of  true  plastic  lironchitis. 

A  patient  may  have  a  sinjrle  attack  without  any  recurrence,  but  in  tlit 
chronic  form  the  attacks  come  on  at  varyiiifr  int  rvals  and  the  disease  iiiiiy 
last  for  ten  or  even  twenty  years.  Instances  are  on  record  in  which  the 
]iaroxysms  have  occurred  at  definite  intervals  for  many  mouths.  The  at- 
tacks may  recur  weekly  or  a  pi'riod  of  a  year  or  iikh'c  may  iiitcrveu(>.  Tiic 
onset  is  marked  by  bronchitic  symptoms,  not  necessarily  with  fever.  The 
eoujjrh  becomes  distressinji  and  paroxysmal  in  character  ;  the  sputa  iii;ty  he 
blood-stained  ami  the  patient  brinj,'s  up  rounded,  ball-like  masses,  whjili. 
when  disciitun.irlctl,  are  found  to  be  jnoulds  of  bronchi  ;  the  lueuinrrliajri' 
may  be  profuse.  In  oiu'  of  the  two  cases  which  I  have  seen  it  iiivarialily 
accompanied  the  attack,  and  the  whitis'i  dendritic  casts  of  the  tube  wen' 
always  entaujrled  in  the  blood  and  clots.  I'rjrent  dyspn(ea  and  evjMiosis 
may  be  present  in  severe  atta<'ks.  The  /i/ii/sii\;/  sitfus  are  those  ot  a  <rwri- 
bronchitis.  It  may  occasionally  be  jioss'ble  to  determine  the  weidv 
sn])pressed  breath  sounds  in  the  ulTected  territory  and  there  may  be  I'iit 
expansion  or  even  retraction  of  the  chest  wall  in  ii  correspondinjir  »''':i,  hut 
this  is  ill  reality  very  dillicult,  and  twice  prior  to  the  expuNion  i>l  ih'' 
casts  1  failed  to  determine  by  physii-al  examination  the  allected  re::i<iti. 


sy   ■ 


CIRCULATORY  DISTURBAXCKS  IN  THE  LUNGS. 


537 


tlusc 
liiiiii- 

ill  tin; 

sc  limy 
h  tho 

'he  lit- 
'i'lic 
The 

llKiy  lie 
whirll, 

ivrliiifi'' 
iriiilily 

'     WflT 

Miiosis 

-cMTl' 

.(•lit 

r,.:|,  bill 

.)i'  the 
inn. 


As  rnontioiuMl,  the  casts  aiT  usually  roU'd  up  and  inixnl  with  mucus  »>r 
lijodil.  When  unravelled  in  water  tliey  jiresi'iit  a  complete  mould  of  u 
sfcoiiilary  or  tertiary  hroiiclius  with  its  ramiliculions.  The  size  of  the  cast 
iii.iv  \;iiy  with  difrerent  attacks,  but,  iis  has  often  been  noticcil,  the  form 
aiiii  -izi'  may  lie  identical  at  each  attack  as  if  precisely  the  same  bronchial 
uivii  was  involved  i-ach  time.  The  casts  are  hollow,  laminated,  the  si/.e  of 
the  lumen  varying,'  with  tho  number  and  thickness  of  the  lamina".  Some- 
times they  are  almost  solid.  Transver-ic  sections  show  a  beautiful  concen- 
tric arranffcini'iit.  The  librin  a)»j)ears  in  jilaces  to  retain  its  fibrillary 
-tnutiire  ;  in  others,  as  in  diphtheritic  membrane,  it  has  undergone  the 
hviiliiie  transformation.  liCiicocytcs  are  imiu'dded  in  the  meshes.  In  the 
cfiitre,  particularly  in  the  smaller  casts,  it  is  not  uncommon  to  sec  ulveolai* 
i'|iitlieliiim  with  numerous  carbon  panicles.  Leyden's  crystals  are  some- 
tiiius  found  and  occasionally  Curschmann's  spirals. 

Tile  patl'.ology  of  'he  disea.se  is  obscure.  The  membrane  is  identical 
with  that  to  which  the  term  crouiious  is  applied,  and  the  ob.scurity  relates 
not  .-II  iiiiicli  to  the  tiicchanisiii  of  the  production,  which  is  probably  tho 
siiiiie  as  ill  other  mucous  surfai'cs,  as  to  the  curious  limitation  of  the  alTec- 
tidii  to  ceitain  bronchial  territories  and  tl.  "  remarkable  recurri'iice  at  stated 
or  iiTcuMilar  intervals  throughout  a  pi'riod  of  many  years, 

111  the  acute  cases  the  tnuttiucnt  should  be  that  of  ordinary  acute  bron- 
ihiti-.  We  know  of  nothiiij,'  which  can  prevent  tho  recurroucc  of  tho 
iitlurks  ill  the  chronic  form.  In  the  uncomplicated  oases  there  is  rarely 
iiiiv  danger  during  the  ])aro.\ysm,  even  though  the  symptoms  may  be  most 
ili.-tressiiig  and  the  dys])nu'a  and  cough  very  severe.  Inhalations  of  ether, 
stfuiii,  or  atomized  lime-water  aid  in  the  scp  ir;;ti'>n  of  the  membranes. 
riliicar|)iiie  might  be  n.seful,  as  in  some  instanc  >  it  increases  the  bronchial 
Mirction.  '{'he  eniploymcnt  of  emetics  may  lie  necessary,  and  in  sonio 
tascss  they  are  eU'ective  in  promoting  the  removal  of  tho  cststs. 


TV.   DISE.VSES   OF   TlIK    LrXGS. 

I.  CIRCULATORY   DISTURBANCES   IN  THE   LUNGS. 

Cougestion. — There  am  two  forms  of  congestion  of  the  lungs— a<'livn 
mill  ]i:i.-sivc. 

(1)  Artive  rntif/esfinn  of  the  /.^//^//.v.— Much  dniil)t  and  confusion  still 

t'xi>t  on  this  subject.     Frencii  writers,  following  Woillez,  regard  it  a,-^  an 

i'lili'iMiiilent  iirimary  all'cction  (iiKihidir  dr  IlVwV/rO.  and  in  their  diction- 

:ini'>  and   text-liooks   allot  much  space    to   it.      English    and    American 

•""li'Ts  more  correctly  regard  it  as  a  .symptomatic  alTcction.     Active  Ihix- 

i"ii  tn  the  lungs  occurs  Avith  incroa.sod  action  of  the  heart,  and  when  very 

•i'>t  ;iii  or  irritating  substances  arc  inhaled.     In  diseases  which  intorfora 
So 


538 


DISEASES  OF  THE   RESPIRATORY  SYSTEM. 


b  ' 


lociilly  with  tlio  rirciilatioii  the  (•.•iiiillarics  in  th(>  u(lja(;i'iit  uiiaiTocfcil  por- 
tions may  l)o  fjroatly  distiiiidnl.  'I'lic  iniiKirtjinci',  how(!Vcr,  of  this  cillai. 
enil  tUixioii,  iis  it  is  callod,  is  prolwibly  i-xa^'i^'cratini.  In  a  wlui'.r  scrii's  of 
piilinoiiury  alTcctioiis  Mu'It  is  this  associated  coiigcstioii — in  inicuiiiDiiiii, 
brou'-liitis,  pliMirisy,  and  tiiltcntulosis. 

Tlie  symptoms  of  ai'tivi'  (Mnijjcstion  (.f  the  luug^  arc  by  no  iiii'ans  ddi. 
nito.  Tlio  dosiTijition  given  liy  Woillez  and  by  other  l^'reiich  writers  is 
of  an  iilfection  wiiicji  is  diHicidt  to  rc-ogni/.e  from  anomalous  or  larvjil 
forms  of  pneumonia.  The  <  hief  symptoms  deseribed  are  initial  eliill,  piiin 
in  till!  side,  dyspmiM,  moderate  couirli,  and  lemperatnr((  from  IdP  u,  pi;;". 
The  ])hysi('ul  signs  arc  defective  resonance,  feeble  breathing,  soMi(tim('f» 
bronchial  in  cliaracter,  and  tine,  rales.  A  majority  of  clinical  plivsiciaiis 
would  iindonbte(lly  class  such  cases  under  inflaniination  of  the  Iuiil".  In 
many  epidemics  the  abnormal  and  larval  forms  are  specially  prcMdctit. 
This  is  no  doubt  tho  cojiditioii  to  which  Porclier,  of  Charlcstowu,  ciijlul 
attention  a  short  linu?  ago  as  u  "  hitherto  undescribed  affection  of  the 
lungs." 

The  occurrence  of  an  intense  and  ra[Mdly  fatal  congestion  of  the  luiiir, 
following  extreme  heat  or  vuUl  <»r  soinetinics  violent  I'xertion,  is  rccogiiizcil 
by  some  authors.  Uenforth,  the  oarsman,  is  siiid  to  hn\e  dic<l  from  tlii-^ 
causo  during  the  race  at  Halifax,  l-euf  has  described  cases  in  wliicli.  in 
association  willi  drnnkcniics.-.  exposure,  and  cold,  death  occurred  suddciilv, 
or  within  twenty-four  hours,  ami  the  only  lesion  found  has  liecu  ai>  ex- 
trenu>,  almost  ha'morrbagic,  congr-stion  of  the  lungs.  It  is  by  no  laciins 
certain  that  in  these  cases  death  really  occurs  fn»ni  pulmonary  coiigostinu 
in  the  absence  of  sjiecilic  stateiiuMits  with  reference  to  tlu*  coronary  ;ir- 
tcries.  Several  times  in  sudden  death  from  disease  (tf  these  vessels  I  liavc 
seen  great  engorgement  of  the  lungs  though  not  the  extrcriie  grade  'imii- 
tioned  ])y  Tjcuf.  I  liavc  no  |)er.-ionaI  knowledge  of  cases  sueh  as  lie 
descril)es. 

('i)  /'(issirf  Ctniftrsflnih — Two  forms  of  this  may  he  rocogni/.ed,  tlif 
mechanical  and  the  hypostatic. 

{<t)  Mechanical  eongesti^m  occui's  whemncr  there  is  an  obstacle  U>  (lie 
return  of  the  blood  to  the  heart.  It  i>!  a  cotnmon  event  in  many  alfeetieih 
of  the  left  heart,  Tlu^  lungs  are  voluminous,  russet  brown  in  color,  cut- 
ting and  tearing  with  great  resistanc".  On  section  they  show  at  iirst  ;i 
brownish-i'cd  ti'ige,  and  then  the  cut  surface,  expf)sed  to  the  aii",  bcccriic- 
n.])idly  of  a  vivid  red  c< dor  from  oxidation  of  the  abundant  lui'Tn<  .ddiiii. 
This  is  the  condition  known  as  hrnit'ii  iiulurnfiun  of  the  lung.  Ili.-tolop- 
cally  it  is  charach'rized  b\  (a)  great  distention  of  the  alveolar  caiii'luricH; 
(/8)  increase  in  the  conneetive-tissue  elements  of  the  lung;  (y)  tlic  pn's 
ence  in  the  alveolar  walls  of  manv  .-(dls  containing  altere(|  b|ood-|i;j-ii('tit 
{h)  in  the  alveoli  mimerons  epithelial  ceils  containing  blood-pigmcnt  in 
all  shiges  of  alt<'ration,  \\hi(d»  are  also  found  in  great  nund)ers  in  tin. 
sputum. 


CIRCULATORY   DISTURBANCES   IN  THE   LUNUS. 


r)3i) 


It.  (X'casioiiiilly  'iiii|i)U'iis  tlmt  tliir<  incctliiiiiical  liyiHTH'iiiia  of  the  lung 
r('siiii> ''■'""  pnisi-iin- ui  tiiiiiors.  So  loii^' as  (•()iii[H'iisati<iii  is  inaiutaiiu'd 
tlic  iiu'i'liaiiical  t'<i?ij^csti(iii  df  the  liiHj,'  in  iH'art-discase  doi-s  not  itrodiico 
,inv  >sini»l<»nis,  l)ut  witli  cnrrclilcfl  heart  ai-tioii  the  I'lij^orjji'tnt'nt  ln-conu'S 
iiiarkt  il  and  then!  air  (i\>itini.'a,  I'ougli,  and  e.\]ii'ctonition,  witii  tlic  cliar- 
,iitrii.>li('  alvx'olar  ct'lls. 

(//)  llvi»<>.stalic  coiij^'t'stinn.  In  fcvi'is  ami  adynaniir  states  ;^'i'ncrail_v  it 
is  vi'iv  cDinnntn  to  lind  the  l)asrs  of  tlic  inn;rs  (Iccply  con^rcstcHl,  a  condi- 
tion nidiiccd  jiartly  l)y  tlic  cll'cci  of  ffravitv,  the  |iaticnt  lyinij  rccnnilicnt 
ill  (lilt!  posture  for  u  hmi;  time,  hut  chiclly  hy  \veal\ened  heart  action. 
That  it  is  not  an  elfei't  of  jfravity  alone  is  shown  hy  tlie  fact  tiiat  a  hcviilliy 
111  rsnii  may  remain  in  l»ed  an  iiidclinite  time  without  its  oceiirrence.  'I'ho 
tciMi  hvpostatit;  (!on<^esti()!i  is  apiiiied  to  it.  'I'iie  posterior  jiarts  of  tiio 
luiiir  arc  (hirk  in  cojoi' and  eii^.'or^ri'd  with  i»lood  and  seritni ;  in  soino  in- 
>t;iiiccs  to  siicji  a  tlcifree  that  (he  alveoli  no  Ioniser  contain  air  and  portions 
(if  the  liiii;(  sink  in  water.  'I'lie  term  sj)h'iiiuiliini  and  hypostatic;  piieii- 
iiiiinia  have  been  j^iveii  t'»  these  advanced  <,fr.ides.  It  is  a  e.ininion  alTec- 
liuM  ill  protracted  cases  of  typhoid  fever  and  in  lonj^  dehilitatinjj  illnesses, 
ill  ascites,  nieteorism,  and  ahdoininal  tumors  the  bases  of  the  liinijs  may 
lie  (iiiiipresseil  and  eoiiirested.  In  this  connection  must  he  tnentioned  the 
I'liiiii  of  passive  coiiirestion  met  with  in  injury  to,  and  or<,'anic  disease  of, 
till'  liraiii.  In  cerebral  apo[ilexy  th.'  bases  of  the  liin^js  are  deeply  cn- 
L'<ir;;(i|.  iHit  ipiit;'  airless,  but  heavy,  and  on  section  drip  with  blood  and 
smiiii.  I  have  twici'  seen  this  conditiini  in  an  extreme  jrraih'  throiiLdioiit 
till' liiiij^s  in  death  from  morphia  poi-oninji;.  In  .some  instances  the  liinj; 
tissue  has  a  blackish,  gelatinous,  inliltrateil  ap])earance,  almost  like  dilfuse 
liiiliiiiiiiary  apoploxy.  Occasionally  this  congestion  is  most  markeil  in.  and 
iVfii  cditiiied  to,  the  heiniplegic'  siih'.  In  prolonged  coma  the  hypostiitio 
niiiL'c>tinii  may  be  associated  with  patclu  -  of  consolidation,  due  to  tho 
asiiiialinii  iif  portions  of  food  into  tlie  air-passages. 

The  symptoms  of  hypostatic  congestion  ari'  not  at  all  characteristit^ 
mill  the  condition  has  to  be  sought  for  by  careful  examination  of  the  bases 
iif  the  lungs,  wh'  n  slight  dutiiess,  feeble,  sometimes  blowing,  breathing 
ami  lii|iii(l  riiles  can  be  detected. 

The  trcahnnil  of  congestion  of  the  lungs  is  usually  that  of  the  condi- 
tinii  uiili  which  it  is  associated.  In  the  iiiteii.se  pulmonarv  I'ligorgenieiit, 
Aliiiji  may  possibly  oecnr  primarily,  and  which  is  met  with  in  heart-diseasD 
aiiil  1  iiiphysema,  free  blceiling  should  be  practisetl.  l-'roiii  twenty  to  thirty 
|'un(■l•^  of  hliiiid  should  lie  taken  from  the  arm,  and  if  the  blood  does  not 
t'liw  fii vly  and  the  condition  of  the  [latieiit  is  desperate,  uspirutioii  of  the 
I'lLrht  nurii'le  may  be  performed. 

(Elema. —  In  all  forms  of  intense  congestion  of  the  lungs  there  is  a 
'raiiMiihiimi  of  serum  from  the  engorged  capiilarie.s  chietl\  into  the  air- 
'"11n  'hi*  also  into  the  alveolar  walls.  Not  tmly  is  it  very  freipient  in  con- 
;.'wtiiiii.  hut  also  with  inllammation,  with  new  growths,  infarcts,  ami  tuber- 


\. 


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1 


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i 


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1,9. 


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if- 


If 


t",:! 


'"si-, 


■JiLL^ 


540 


PISRASES  OF  TIIK   UESPIUATnUY  SYSTEM. 


H'\': 


I   ) 


•i»i! 


I    4'  ^'^'^ 

¥    1  i5'  '  '■' 

*     /      V  ' 

t'^l'u  'J.  « 


,.''f 


,1'   ! 


^1 


1.?  ' 


i   1 


ck\s.  AVliPii  limittMl  to  tln'  ncifjliborlKHMl  of  iiii  nlToctcd  part,  the  namo 
collatoral  d-dt'ina  is  soniotiiiics  applicil  to  it.  (Jciioral  o'deiiia  (trciirs  nndci- 
conditions  very  similar  to  tliosc  met  witli  in  coiip'stioii.  It  i.s  very  (irtcn, 
no  doiilit,  a  terminal  event,  occurring:  witli  tlie  deatli  airmiy.  It  is  seen  in 
typical  form  in  the  eaeliexias,  in  deatii  from  an:emia,  also  in  cln-diiir 
liriizlit's  disease,  disease  of  the  heart,  ami  cerebral  atl'eclions. 

The  (edematous  \uu<;  is  ln'avy,  looks  watery,  pits  on  prossuro,  anil  liom 
the  cut  surface  a  lar^e  fimmtity  of  clear  and,  in  cases  of  coii^'estion.  lilocilv 
serum  flows  freely;  the  tissue  may  even  have  u  p'latiiious,  inliltratid  n|i- 
])earance.  T\n'  coiulition  is  much  mori'  common  at  tiic  hases,  hut  it  iniiv 
exist  throu<;hout  the  entire  lung.  The  ])athol(t<fy  of  j)ulmonary  (edeiiiti  is 
not  always  clear.  'J'wo  fuetors  usually  jirevail  in  extreme  eases — iiiciciiscd 
tension  within  the  j)ulmonary  system  and  a  dilutetl  blood  plasma.  The 
increased  tension  alone  is  net  eajjablc  of  produciuff  it.  The  ex|ieriiiu'iits 
of  Welch  seem  to  indicate  that  the  essential  factor  lies  in  a  dispriiportiiiii. 
ate  weakness  of  the  left  ventricle,  so  that  the  blood  accumulates  in  tlir 
lun;^  capillaries  until  transudation  occurs,  a  view  which  sat isfactorilv  ex- 
plains certain  cases,  ])artir'ularly  the  terminal  O'deuuis. 

'i'he  si/))ipf(iitis  of  (jvlema  of  the  lunj^s  are  often  oidy  an  a<r,i:ravaliiin  of 
those  already  existinir,  aiul  are  due  to  the  jtrimary  disease,  whether  cur- 
diac.  renal,  or  gciu'ral.  There  arc  usually  increasing  dysjnuea  and  coii<:li. 
and  on  examination  there  nuiy  be  defective  resonance  and  large  li(|inil  n'llos 
at  the  bases.  There  are  cases  in  which  the  o  dema  comes  on  with  groiit 
euddcniH'ss,  and  in  chronic  Iiright's  disease  it  may  prove  rapidly  fatal. 

Tn  the  cases  of  so-called  iidlammatory  o'dcina  fevt'r  is  always  present. 
and  often  si_gns,  more  or  less  markcil,  df  pneumouia. 

The  frcdfiiirnf  of  (edema  of  the  lung  is  practically  that  of  the  coiidi- 
tions  with  which  it  is  associated.  In  the  acute  cases  active  catharsis.  mihI 
if  there  is  cyanosis,  free  venesection  should  be  resorted  to. 

Pulmonary  Hasmorrhage. — This  occurs  in  two  iovn\fi~-Iirt)iirhii-iii(h 
mnuary  InvmorrluKjo^  souu'times  called  brnnchorrhagia,  in  which  tlic  \\V»\\ 
is  poured  out  into  the  brotudii  and  is  expectoi'aled,  aiul  jiuhniDifirji  up"- 
ph'.ri/  or  ])neumorrhagia,  in  which  the  lueinorrhagc  takes  place  into  tlii' 
air-cells  and  the  lung  tissue. 

1.  />r(>Nr/in-/)iiJ>n(i)iifri/  /[(rniorrJiiri/p  ;  lf(rmopfi/sifi. — Sjiittingdr  Mih"!. 
to  "wliicdi  the  term  Inemoplysis  should  be  restricted,  results  from  a  viuirty 
of  conditions,  among  whi(  h  the  following  are  the  most  important :  I*')  In 
young  healthy  jjcrsons  ha-moptysis  may  occur  without  Avarning,  ami  iifti-r 
continuing  for  a  few  days  disappear  and  leave  no  ill  triucs.  Tlurc  iimy 
bo  at  the  time  of  the  attack  no  physical  signs  indicating  pulmonary  ilista>i' 
In  such  cases  good  health  may  be  j)reserve(l  for  years  and  uc  fiirtln'i' 
troidjle  occur.  These  cases  are  not  very  uncommon.  In  Ware's  iiiiiior- 
tant  contribution  to  this  subject,*  of  3S(i  cases  of  lui'moptysis  tiultil  iu 


*  Oti  Iliumoptysis  as  a  Symptom,  by  .Idlui  "NViiro,  !M.  D. 


CIliCL-LATOllY   DISTI'UUAXCKS  IX  TIIH   LrXUS. 


541 


private  praftico  C3  recovorc'(l  aiid  iiiiluioiiiiry  disi'iiso  did  not  Hnl)S(M|iu'ntly 
iliivclfip  in  tlicin.     I  know  three  |irot'essi(iiial  n.en  who  liiid  hu'inoptysis  us 
slmlt'iits,  iind  who  now,  ill  perioils  of  from  llt'tceii  to  ei^^hteeii  years  siibsu- 
(iiifiillv,  remain  in  perfect  health.     (/>)  lla-moptysis  in  pulmonary  Inliercu- 
jo.-is.  So  fri'fpiently  an-  tliese  eoiiditions  assoeiiited  that  in  tiie  lay  mind  spit- 
tiiimif  blood  and  consnmption  are  almost  synonymous.     Tlu^  llippoeratic 
.iuliniisin, "  From  a  spittin;;  of  hlood  there  is  a  sj)ittinjf  of  ])iis,"  is  ri'peated 
thniiij:liiiiit  the  literatni'e  of  more  than  twenty  centiirii's.     It  oeeiirs  eilher 
oarly  in  the  disease,  l)efore  there  are  any  obvious  physical  si;,Mis,  or  after  the 
(lcvelo)nnent  of  well-marked  local  lesions.    L'ii({uestional)ly  in  a  majoiity  of 
the  eases  in  which  subseijuent  to  ha'mo[itysis  phtlii>is  occurs  tultercles  wero 
iih'iiidv  jiresent  in  the  hin<f.     The  ha'morrhaj,'e  is  broiu-hial  and  associated 
with  a  limited  f(»cus  of  disease.     When  the  jmlmonary  lesion  is  more  ad- 
vaiiifil  the   laenioiitysis  ri'sults  cither   from   erosion  of  a  branch  of  tho 
[luliiiouary  artery  or  from  rupture  of  an  ani'urismal  dilatation  of  the  same. 
(r)  In  connection  with  certain  iliseascs  of  the  lnn<r,  as  pneumonia  (in  tho 
initial  stajjc)  and  cancer,  (k*  asionally  in  ^aULjrcne,  abscess,  and  bronchiecr- 
tasis,  ha'nioptysis  occurs.     {(/)   lla'uuiptysis  is   nul   with  in   many  heart 
alleitions,  particularly  mitral   lesions.     It  may   be  profuse  and   recur  at 
intervals  for  years.     {<■)   In  ulci-rative  alTections  of  the  larynx,  trachea,  or 
bronchi.     Sometimes  tho  ha-moi^rhago    is   profuse   and    ra[iidly   fatal,  a8 
when  an  idcor  erodes  a  larsj;e  1)ranch  of  tho  pulmonary  artery,  an  accident 
which  I  have  known  to  happen  in  a  case  of  chronic  bronchitis  with  em- 
liliysonia.     (/)  Aneurism  is  an  occasional  canso  of  Incnioptysis.     It  may 
lie  sudden  and  rai)idly  fatal   when   the  sac  hursts  into  tho  air-passaijfes. 
Slight  bleeding  may  continue  for  weeks  or  even  longer,  dm;  to  j)rcssure  on 
the  nuicous  nuMnbrano,  erosion  of  tho  lung,   or  in  some  cases  the  sac 
'' wc'-ps ''  through  tho  exposed  lamina;  of  lilirin.     (;/)  Vii'arious  lia'mor- 
rhag',  which  Oi'curs  in  rare  instances  in  cases  of  interruiited  menstruation. 
The  instances  are  well  authenticated.     Flint  mentions  a  case  which  he 
had  had  under  ol)servation  for  four  years,  and  Hippocrates  refers  to  it  in 
thi'  aphorism,  "  IIa'mo[)tysis  in  a  woman  is  renu>vi'd  l)y  an  oruiition  of  tho 
inmsrs."    Periodical  ha'nioptysis  has  also  lieen  met  with  after  the  removal 
of  both  ovaries.    Kven  fatal  ha'mori'hagc  has  oi'currcd  from  the  lung  during 
iiit'n>lruati()n  when  no  lesion  was  1'nund  to  account  for  it.     (//)  There  is  a 
fiiriii  of  recurring  lia'inoptysis  in  arthritic  sulijects  to  which  Sir  Andrew 
riaik  has  called  special  attention  and  which  also  is  described  by  French 
writers.     The  cases  occur  in  pers(»ns  over  fifty  years  of  ago  Avho  usually 
pivsiMit  signs  of  the  arthritic  diathesis.     It  rarely  leads  to  fatal  issue  and 
subsides  without  inducing  pulmonary  (dianges.     (/)  lla-moptysis   recurs 
sonutimes  in  malignant  fevers  and  in  purpura  Inomorrhagica.    Lastly,  there 
is  etuleiuic  hannoptysis,  due  to  the  Distomuia  Wrs/rrmaiiiii  in  tho  bron- 
chial tubes,  an  afTeclion  which  is  conlined  to  parts  of  ('hina  and  Japan. 

Symptoms. — lia'inoptysis  sets  in  as  a  rule  suddenly.     Often  with- 
out warning  the  patient  experiences  a  warm,  aaltish  taste  as  tho  mouth 


ir 


mi^ii^  r 


I  '   ! 


"*     . 


•1.  f^. 


542 


DISKASKS  OV  TIIK   IJKSIMIJATOIIV  SYSTKM. 


fills  with  lilood.  ('oii;fliiii,i:  is  iisiially  imliiccd.  Tlicrc  iiiiiy  )ii'  unlv 
uii  oiiiicn  (»r  sii  Itrnii^'iit  up  Itffort'  the  liI»T(liii;f  stups,  op  tin-  Mciiliin^r 
limy  coiitiiii-.c  I'dT  (liiys,  tlic  luitiriit  liriii;^iii,ir  up  siuiili  (piuiililics.  In  .tlifr 
iiisfsiiici's,  particularly  when  a  lai'j;*'  vcsrst-l  is  cnnlcd  or  a?i  an('Ui'i>iii  lnirstH, 
the  aiiiount  i  larirr,  and  the  patient  after  a  feu  attempts  at  ediiL'liin" 
hIiows  si^Mis  (if  siill'dcatinn  and  death  is  prodiieed  hy  iniindatinii  df  th,. 
hniiichial  system.  i''atal  ha'inorrlia<,'e  may  even  ovi-nv  inid  a  larp'  i;i\it\ 
in  a  patient  dehilitated  hy  phthisis  without  the  prndurtinn  df  liieiiKiplvsis, 
I  dissected  a  ease  <if  this  kind  at  the  IMiiladelphia  Hospital.  'I'lie  Moim] 
from  the  lnnj,'s  jieiiei'ally  has  characters  which  rciidi'r  it  readilv  ili-tin- 
^'iiishalile  from  the  l)l()iid  which  is  vomited,  it  is  alkaline  in  ivik  lidu. 
fnithy,and  mixed  with  niucns,  and  when  enajiiilalion  occurs  air-liidiM(>  suv 
]>rcscnt  in  the  clot,  lilood-imtulds  of  the  smaller  hroiudii  are  sojuetiiiics 
seen,  raticiitsean  usuallv  tell  wlictlier  the  Mood  has  lieeii  hroii^rln  |||,l,y 
(•ou,Lrhiii,Lr  or  hy  vomiting',  and  in  a  majority  <d'  cases  the  history  j,d\e.«  iin- 
jiortant  iii(li(.'ations.  In  paro.xysiiial  lia-moptysis  eoimected  with  iiicn^tniiil 
(listurhances  tl'c  pruetitioiier  shoidd  see  that  the  Mood  is  actually  .niiMJi,.,] 
lip,  since  d('<'e[>lioii  may  he  practised.  Naturally,  the  patient  is  at  lii-i 
alarmed  at  the  occurrence  of  hieedin:,',  hut,  unless  very  profuse,  a<  wlun 
due  t(»  rupture  of  an  aortic  aneurism  in  a  pulmonary  cavity,  the  tlaii^oT  i« 
rarely  immediate.  The  attacks,  however,  are  apt  to  recui'  for  a  ftu  (|;iv« 
and  the  sputa  may  remain  Idood-tinp'il  for  a  loii^jer  period.  In  tlir  j.'n';it 
majority  of  I'a.ses  the  ha'mori'ha;j:e  ceases  spontaneously.  It  should  )»■  n'- 
meml)ere(l  that  some  of  the  hlood  may  In'  swallowed  and  produce  vumit- 
injr,  and,  after  a  (lay  or  two,  the  stools  may  r>e  dark  in  c(dor.  It  is  not 
Well  dni'iiiLr  an  attnck  of  Iweiiioptysis  to  examine  the  (diest.  It  «;i-  fnr- 
inerly  thought  that  ha'morrhaj^e  exorcised  a  prejudicial  I'll'ccI  and  r\(iliil 
inllammatioii  of  the  luiitrs,  hut  this  is  not  often  the  case. 

('.')  /'iiliiiii/niri/  Apd/ilf'.ri/ ;  lln'iii'irrlnniif  ////W/v7.--!n  this  cuiiililion 
the  hlood  is  elTiised  into  the  air-colls  and  interstitial  tissue.  It  is  r;nvl\ 
indeed  dilTiise,  hreakinir  the  iiareiichyma  as  the  hrain  tissue  is  hinkeii  in 
oerehral  apoplexy.  Sometimes,  in  disease  of  the  hrain,  in  se]itii'  cniiili- 
tions,  and  in  the  mali^niant  forms  of  fevers,  the  liinir  tissue  is  iiiiireraih 
iiililtrate(l  with  hlood  and  has,  on  section,  a  hlaek,  (jcdalinous  appe.iritiicc 

As  a  rule,  the  luoniorrhajj^o  is  limited  and  results  from  the  hlockiiiir 'if 
a  hraiieh  of  the  jailnionary  artory  either  hy  a  throinlms  or  an  emliMlus. 
The  condition  is  most  common  in  chronic  heart-disease.  AltlioiiL'li  the 
jtulmonary  arteries  are  terminal  one.s,  hlockin^  is  not  always  followed  I)} 
infarction  ;  partly  hooiiuso  the  wide  capillaries  furni.sh  suflieienf  iuiastn- 
inosis,  and  ]tartly  hociiuso  tho  hroiichial  vcs.sels  may  kooj)  up  the  linulii- 
tion.  The  infarctions  are  ohielly  at  tho  jieriphory  of  the  lun^^  ;i-U!illy 
weclire-shaped,  with  tho  1-ise  of  the  wedjre  toward  the  surface.  W  In"  "t'- 
coiit,  they  are  dark  in  color,  hard  and  (inn,  and  look  on  sectitm  likf  '"' 
ordinary  blood-clot,  firadual  (dianijos  \io  on,  and  tho  color  Iiecojiu's  a 
red<liah  brown.     The  jdcura  over  an  infarct  is  usually  inflamed.     A  mi- 


^k4  • ' 


CIRCUI.ATORY   DISTL'UHANCES  IN   TliK   LUNOS. 


543 


rros<'(tpi<'!il  Hoctioii  shows  tlin  air-cells  to  ]>v  disU'inlfil  with  rod  blood-cor- 
iiusilfs,  which  may  also  he  in  the  alveolar  walls.  'Die  infarcts  are  usually 
niulliple  and  \ar}  in  siz»!  I'mni  a  walnnt  to  an  orange.  Very  lar^'e  onea 
iiiiiv  involve  tlio  greater  part  of  a  lol)e.  in  tlio  iirtury  [)assiii;.'  to  thu 
iilTccicd  territory  a  throinlnis  or  an  cniiiohis  is  found.  The  glohular 
tliroinhi.  formed  in  the  ri;,dit  anricnlar  appendix,  play  an  important  part 
ill  the  prodiK^tion  of  Inemorrlia^nc  infarction.  In  many  catics  the  sounui 
(if  the  tMuholus  cannot  ho  discovered,  and  the  infarct  nniy  have  resulted 
fidin  thrond)osis  in  tho  pulmonary  artery,  hut,  as  hefon-  mentioneo,  it  is 
iidl  iid'i'e<|U(!iit  to  lind  total  ohstructinn  of  a  larp'  hranch  of  a  pulmonary 
iirlerv  without  haunorrhajxe  into  the  corresponding'  hin;.;  area.  'I'he  fur- 
ther iiislory  of  an  infarction  i.-  variai>le.  It  is  possiljle  that  in  some  in- 
stances the  eirc-ulation  is  re-i'stahlisheil  and  liie  hlood  removed.  ^loro 
(■(iiiiiiiuidy,  if  tlio  patient  lives,  the  usual  chan;^es  j^o  on  in  the  extiavasjitevl 
l)li)()d  and  idtinuitelya  pij,'menled,  puckeri'd,  liiu'oid  patidi  rcsidts.  Slou^di- 
iii;(  may  occur  with  the  formation  of  a  cavity.  Occasionally  jxanjireno 
i'csmIIs.  Inai-a.se  at  tho  University  Hospital,  l'hiladelj)hia,  a  gaugronuus 
iiif  in  t  ruptured  and  produced  fatal  |)neumothora.\. 

Tho  Ki/nipfoDis  of  |)ulmoiiary  apoplexy  arc  hy  no  nu-aiis  deliiiit*'.  Thu 
coudilion  may  he  suspected  in  chronic  iicarl-diseas"  when  haemoptysis 
oi'i'iirs,  j)articularly  in  mitral  stenosis,  hut  the  idci'din;^  may  he  ilue  to  tho 
extreme  en<i;or<:;oment.  When  tlm  infarcts  are  very  hirge,  and  {Kirtic.ularly 
ill  the  lower  lohe,  in  wliioli  thoy  most  commonly  occur,  tliorc  may  he  signs 
111' (•ipnsnli(hitii>n  with  hlowiii<f  I)rcathiiig. 

Treatment  of  Pulmonary  Heemorrhage.— In  the  treatment 
of  lueiiioptysis  it  is  important  lo  reinemlier  the  condition  of  tho  piilmo- 
iiiiry  <ireidalion  and  tho  nature  of  tho  lesions  associated  with  tho  liaenior- 
rliage. 

The  pressure  within  the  pulmonary  artery  is  con.-i  h fahly  less  than  that 
in  the  aortic  .system.  W  v  have  as  yet  very  imperfect  knowledge  of  tho 
oireaiiista.ux'S  whi(di  inlhu-noe  tho  lesser  circulation  in  man.  Rosoarchos, 
purtinihirly  those  of  Bradford,  indicate  that  the  system  k  under  vaso- 
niolor  control,  Imt  our  knowledgo  of  tho  muiual  relations  of  ju'ossuro  m 
the  aorta  aiul  in  tho  pulmonary  artery,  under  varying  conditions,  is  still 
very  imperfect.  Kxpiu-iments  with  drugs  seem  to  show  that  llu're  may  ho 
an  inlhienee  on  systemic  hlootl-pressure  without  any  on  tho  pulmonary, 
ami  th(!  pressure  in  tho  ono  may  risi'  while  it  falls  in  the  other,  or  it  may 
rise  and  fall  in  l)oth  together.  In  .Viulrew's  llarveian  Oration  those  rela- 
tions are  thoroughly  descrihed,  and  a  statemi'iit  is  math",  hased  on  lirad- 
foid's  experiments,  as  to  tho  action  on  the  pulmf)iuiry  hlood-pro.ssuro  of 
man^  •  the  drugs  omployed  in  hionutjitysis.  'J'hus  ergot,  the  remedy 
pinii  i.|.s  ino^t  commoidy  used,  causes  a  distinct  rise  in  the  pulmonary 
bloiii  -Miessnre,  while  aconite  ])roduces  a  dciinite  fall. 

Til  •  an:itomical  condition  in  luenioptysis  is  either  hypera.'niia  of  the 
bronehial  miioosa  (or  of  tho  lung  tissue)  or  a  perforated  artery.     In  the 


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DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


latter  case  the  patient  often  passes  rapidly  ])eyon(l  treatment,  thougli  there 
are  instances  of  tlie  most  profuse  hannon-liiige  whicli  must  liave  eoiiic  ffoui 
a  perforated  artery  or  a  ruptured  aneurism  in  wliicli  recovery  has  occurred. 
Practically,  for  treatment,  we  should  separate  those  cases,  as  the  rcruedios 
which  would  he  applicable  in  a  case  of  congested  and  bleeding  nuicosu 
would  be  as  much  out  of  i)lace  in  a  case  of  luvmorrhage  from  ruptured 
aneurism  as  in  a  cut  radial  artery.  When  the  blood  is  brought  up  in 
quantities — in  mouthfuls  at  a  time — it  is  almost  certain  either  tlmt  an 
aneurism  has  ruj)tured  or  a  vessel  has  been  eroded.  In  the  instances  in 
which  the  sputa  are  blood-tinged  or  Avhen  the  blood  is  in  smaller  ([uanti- 
ties,  bleeding  comes  by  diai)edesis  from  hypera,miic  vessels.  In  such  cases 
the  ha'morrhage  may  bo  beneficial  in  relieving  the  congested  blood-vessels. 

The  indications  are  to  reduce  the  frequency  of  the  lieart-l)eats  and  to 
lower  the  blood-pressure.  By  far  the  most  important  measure  is  absolute 
quiet  of  body,  such  as  can  only  be  secured  by  rest  in  bed  and  seclusion. 
In  the  majority  of  cases  of  mild  hamioptysis  this  is  sufficient.  Even 
when  the  patient  insists  upon  going  about,  the  bleeding  may  stop  spon- 
taneously. The  diet  should  be  light  and  unstimulating.  Alcohol  should 
not  be  iised.  The  patient  may,  if  he  wishes,  have  ice  to  suck.  Sniall 
doses  of  aromatic  sulphuric  acid  may  be  given,  but  unless  the  bleeding 
is  protracted  styptic  and  astringent  medicines  are  not  indicated.  Fur 
cough,  which  is  always  present  and  disturbing,  oi)ium  should  ])e  freelv 
given,  and  is  of  all  medicines  most  serviceable  in  hannoptysis.  Digitalis 
should  not  be  used,  as  it  raises  the  blood-pressure  in  the  pulmonary  artery. 
Aconite,  as  it  lowers  the  pressure,  may  be  used  when  there  is  mucdi  vascu- 
lar excitement.  Ergot,  tannic  acid,  and  lead,  which  are  so  much  eiu- 
ployed,  have,  I  believe,  litt!>  or  no  influence  in  hamioptysis.  Ergot,  aceoi>l- 
ing  to  Bradford,  produces  distinct  rise  in  the  pulmoiuiry  blood-])rc.ssure. 
One  of  the  most  satisfactory  means  of  lowering  the  blood-pressure  is  purga- 
tion, aiid  when  the  bleeding  is  protracted  salts  may  be  freely  given.  In 
profuse  haMnoptysis,  such  as  comes  from  erosion  of  an  artei'y  or  the  rupt- 
ure of  an  aneurism,  a  fatal  result  is  common,  and  yet  post-mortem  evi- 
dence shows  that  thrombosis  may  occur  with  healing  in  a  rupture  of  con- 
siderable size.  The  fainting  induced  by  the  loss  of  l)lood  is  proliably  tlu' 
most  enicient  means  of  promoting  thrombosis,  and  it  was  on  this  priiiciplf. 
that  formerly  patients  were  bled  from  the  arm,  or  from  both  arms,  as  in 
the-case  of  Laurence  Sterne.  Ligatures,  or  Esmarch's  bandages,  idaeed 
around  the  legs  may  serve  temporarily  to  check  the  bleeding.  The  iee- 
bag  on  the  sternum  is  of  doubtful  utility.  In  a  protracted  case  Cayley  in- 
duced pneumothorax,  but  without  effect. 

Briefly,  then,  we  may  say  that  cases  of  haemorrhage  from  rupture  of 
aneurism  or  erosion  of  a  blood-vessel  xisually  jirove  fatal.  The  fainting 
induced  by  the  loss  of  blood  is  beneficial,  anu,  if  the  patient  can  he  kept 
alive  for  twenty-four  hours,  a  thrombus  of  sufficient  strength  to  prevent 
further  bleeding  may  form.     The  chief  danger  is  the  iuuudutiou  of  the 


PNEUMONIA. 


545 


bronchial  system  with  the  blood,  so  tlmt  while  the  hfemorrhage  is  profuse 
till'  cough  should  be  oncouruged.  Opium  should  not  tliou  be  used,  and 
stimulants  should  be  given  witli  caution. 

Ill  the  otlicr  gi'oup,  in  wliich  the  lui'morrhage  comes  from  a  congested 
area  and  is  limited,  tlie  patient  gets  well  if  kept  absolutely  quiet,  and 
fiitul  haMUorrhage  proliably  neve,  occurs  from  this  source.  Rest,  rechic- 
tioii  of  !.he  blood-pressure  by  minimum  diet,  purging,  if  necessary,  and  the 
administration  of  opium  to  allay  the  cough  are  tlie  main  indications. 


II.    PNEUMONIA 

(Lobar,  Croupous,  or  Fibrinous  Pneumonia  ;  Pneumonitis  ;  Lung  Fex'er.) 

Definition. — An  infectious  disease  caused  by  the  viirracoccui^  Ian- 
ceohifus  (pneumococcus,  diplococcus  pneumonia^),  which  excites  a  local 
inflammation  in  the  lungs,  and,  by  its  toxines,  constitutional  disturbance 
of  varying  intensity.  The  fever  terminates  abruptly  by  crisis.  Secondary 
infective  processes  are  common. 

Etiology. — Pneumonia  is  one  of  the  most  wide-spread  of  acute  dis- 
eases. Hospital  statistics  show  that  the  ratio  to  other  admissions  is  in  the 
proportion  of  twenty  to  thirty  per  thousand. 

It  ])revails  at  all  ages.  Cliildren  are  quite  as  susceptible  to  it  as  adults, 
and  it  is  the  special  enemy  of  old  age.  ^lales  are  more  fr  'quently  affected 
tl'.au  females.  Dwellers  in  cities  and  persons  whose  occupations  arc  as- 
sociated with  exposure,  hardship,  and  cold  are  most  liable  to  the  disease. 
Contrary  to  the  general  rule  in  infectious  diseases,  newcomers  and  immi- 
grants seem  less  susceptible  than  the  native  inhabitants.  Deliilitating 
causes  of  all  sorts  render  individuals  more  susceptible.  Alcoholism  is  per- 
haps the  most  potent  predisposing  factor.  Persons  Aveakened  by  disease 
are  especially  prone  to  it ;  thus  wo  find  many  cases  in  connection  with 
chronic  Bright's  disease,  diabetes,  the  chronic  affections  of  the  nervous 
system,  and  protracted  fevers.  One  importaiit  predisposing  cause  is  a  pre- 
vious attack.  Xo  acute  disease  recurs  with  such  irequcncy.  Instances 
are  on  record  of  individuals  who  have  had  ten  or  more  attacks. 

Climate  does  not  appear  to  have  much  influence.  The  disease  pre- 
vails equally  in  cold  and  in  hot  countries,  but  it  is  stated  that  on  this 
continent  it  is  more  prevalent  in  the  Southern  than  in  the  Northern 
States.  More  important  is  the  influence  of  season.  StaHstics  everywliere 
show  that  more  persons  are  attacked  from  December  to  May  than  in  the 
summer  and  autumn.  Seitz's  large  statistics  of  5,005  cases  in  ^lunich 
give  3'^  per  cent  in  winter,  36-8  jier  cent  in  spring,  15  3  per  cent  in  sum- 
mer, and  15-7  per  cent  in  autumn.  Seibert  gives  February  and  March 
for  New  York.  Bell's  statistics  of  the  Montreal  General  Hospital  show 
practically  the  same  distribution,  but  ','.  is  worth  noting  that  during 
January,  the  coldest  month  of  the  year,  in  which  the  mean  temperature 


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540 


DISEASES  OF  THE   RESPIRATORY  SYSTEM. 


for  ten  years  was  l.'J-To"  F.,  tlie  percentage  was  eoniparatively  low.  Jaim- 
ary,  however,  is  a  iiioiith  with  very  slight  variations  in  tenijierature,  and  it 
seeJMS  that  the  sudden  changes  characteristic  of  March,  April,  and  Muv 
are  the  important  climatic  factors  which  predis[)ose  to  i)neuiiu)iiia.  I[,.r. 
ringham  ])laces  the  "pneumonia  season"  in  London  from  the  (.inl  df 
March  to  the  end  of  June. 

Of  otiier  factors,  cold  has  been  thought  to  be  one  of  the  nutst  iniiKir- 
tant,  !uid  for  years  was  regarded  as  the  elVicient  cause  of  the  disease'.  L'li- 
doubtedly  the  disease  sometimes  promptly  follows  a  sudden  cliilliiif  or 
wetting,  but  in  a  large  majority  of  casos  no  such  history  can  be  obtaiiiud. 

J'neumonia  follows  ti'aunuitism  'vith  great  fre(juen('y,  more  partini- 
larly  injury  of  the  chest.  Litten  has  called  special  attention  to  this  cvn- 
tifsifui-piu'iimonia. 

A  change  of  oi)inion  has  of  late  taken  place  as  to  the  luiture  of  piieii- 
inonia,  whicli  is  now  almost  universally  regarded  as  a  specific  infectious 
disease,  depending  upon  a  micro-organism.  Among  gem-ral  eircuiii- 
stances  favoring  this  view,  is  the  occurrence  of  i)neumonia  in  rpidonif. 
form,  a  fact  recognized  by  Laennec  and  by  Grisolle.  Many  liuiise  cj)!- 
deniics  have  been  described  within  the  past  twenty  years.  ()n  several 
occasions  I  have  known  two,  three,  and  even  four  jK-rsons  udniitteil  to 
hospital  from  the  same  house.  In  1887  I  saw,  with  Graham,  of  Toronto, 
a  local  outbreak  in  whicli  three  members  of  a  family  were  consecutively 
attacked  with  the  most  nudignant  pneumonia.  There  are  instances  mi 
record  in  which  as  many  as  ten  residents  in  one  house  have  been  attacked, 
Of  late  years  numy  epidemics  in  towns  have  been  reported.  Still  iimro 
striking  arc  the  epidemics  which  have  been  described  in  i)risons  and  gar- 
risons, of  whicli  one  of  the  most  remarkable  is  that  reported  by  W .  B. 
Hodman,  of  Frankfort,  Kentucky.  In  one  year  there  occurred  in  a  prison 
population  of  735,  118  cases,  with  25  deaths.  The  prison  was  much  over- 
crowded at  the  time.  Similar  epidemics  have  been  described  in  Europe. 
At  the  penitentiary  at  Amberg,  from  the  1st  of  January  to  the  1st  nf 
June,  there  were  IGl  cases  of  pneumonia,  with  a  mortality  of  over  twenty- 
eight  per  cent. 

The  micrococcusi  Jnnccolafus  [diplococcui^  jnn'ionaiiia')  of  Fraenk(4  is 
now  believed  by  competent  authorities  to  be  the  specific  agent  of  the  dis- 
ease. It  is  identical  with  the  micrococcus  which  Pasteur  aiul  Steri-herg 
found  in  the  saliva  of  certain  individuals  and  which  produces  septicemia 
in  the  rabbit.  It  occurs  occasionally  in  the  nose,  the  larynx,  and  the 
Eustachian  tube.  According  to  Xetter's  observations,  it  is  ])resent  in  the 
buccal  secretion  in  twenty  per  cent  of  healthy  persons.  It  persists  for 
months,  or  even  years,  in  the  saliva  of  persons  who  have  had  i)neuiiioni;i. 
The  researches  of  Fraenkel,  Weichselbauni,  Gamaleia,  and  others  show  that 
it  is  by  far  the  most  constant  organism  in  pneumonia,  and  that  it  ncciirs 
in  the  secondary  processes  of  the  disease,  such  as  jileurisy,  endocarditis, 
pericarditis,  and   meningitis.     In   ten   cases  recently  examined  at  the 


PNEUMONIA. 


547 


patlinlogioal  liibnratory  of  the  Jolins  Hopkins  TTo.spitiil  by  my  rolloiitriio 
Wtk'h,  tliis  or,ijiinisiii  was  present  in  all ;  in  six  as  ]»ure  cultures  in  the 
lunjr,  in  four  together  with  pus  organisms.  In  the  sputum  it  may  be 
domotistrated  by  treating  the  ordinary  cover-glass  ])rei)arati()ns  with  gla- 
ciiil  iU'otic  acid  and  then,  without  washing  off  the  acid,  dropping  on  aniline 
oil  and  gentian-violet,  which  is  to  be  poured  otT  and  renewed  two  or  three; 
tiiiios.  The  organism  is  seen  to  be  a  somewhat  elliptical  lance-shaped 
coccus  occurring  in  pairs,  hence  the  term  diplococcns.  It  is  usually  eu- 
cajisulated. 

According  to  the  dominant  view,  pneumonia  is  an  infective  disease 
oiuised  by  this  diplococcus,  which  has  its  scat  of  election  in  and  produces 
its  chief  effects  on  the  lung,  and  which  can,  under  favoring  circumstances, 
invade  otlier  parts  of  thf  '  idy — the  pleura,  meninges,  and  endocardium. 
This  microbe  may  possibly  attack  these  parts  without  the  intervention  of 
iiitlaiinnation  of  the  lung,  as  it  has  been  found  in  meningitis  and  pleurisy 
iiulcjtendent  of  pneumonia.  It  is  a  wide-spread  organism,  at  times  pres- 
ent, as  before  stated,  in  the  buccal  secretions  of  healthy  persons.  It  is  not 
iinpnibiible  that  the  various  predisposing  causes,  such  as  cold,  exhaustion, 
ami  (U'bility,  lower  the  vitality  and  render  the  individual  susceptible,  thus 
cliaiiging  the  character  of  the  tissue-soil  so  that  the  virus  can  grow  and 
jiroihice  its  specitic  etTects. 

On  this  view,  pneumonia  may  be  regarded  as  a  local  disease,  produced 
by  iiilialation  of  the  diplococci,  which  induce,  by  their  toxines,  as  in  other 
local  diseases,  such  as  erysipelas  and  diphtheria,  constitutional  disiurbance 
of  varying  degrees  of  intensity,  liy  the  further  invasion  of  the  jjarasites 
a  piicumococcus  septicuMuia  may  be  produced,  with  secondary  infective 
processes  in  other  organs.* 

Recently  from  Leyden's  clinic  very  interesting  studies  have  been  issued 
by  the  brothers  Klemperer  on  the  production  of  immunity  and  npon 
the  cure  of  pneujnonia.  Immunity  is  readily  ol)taincd  in  animals  either 
by  subcutaneous  or  intravenous  injections  of  large  quantities  of  the  fil- 
tered bouillon  cultures,  or  by  the  injection  of  the  glycerine  extract.  The 
iiinnuuity,  though  rarely  lasting  more  than  six  months,  was  transmitted 
to  the  olfspriug  born  within  this  period.  Still  more  interesting  are  their 
observations  upon  tlie  cure  of  the  cxperiment.illy  produced  disease.  They 
found  that  the  serum  and  fluids  of  the  l)ody  of  an  animal  which  had  been 
rendered  immune  had  the  property  not  only  of  jiroducing  immunity 
when  introduced  into  the  circulation  of  another  snsce]itil)le  animal,  but 
actually  of  curing  the  disease  after  infection  had  been  in  progress  for 
some  time.  In  infected  .  nimals  with  a  body  temperature  of  from  40"  to 
•il°  C,  the  fever  fell  to  normal  in  twenty-four  hours  aftci-  the  injection  of 
serum  of  another  animal  which  possessed  immunity.     They  believe  that 

*  Sie  on  tlic  question  of  etiology  the  elaborate  essay  of  Wells,  Journal  of  the  Amer- 
ican Medical  Association,  1889. 


1 1     ' 


t 
h 


ill 


,  t     'Au 


II" 'i: 


.548 


DISEASES  OP  THE  RESPIRATORY  SYSTEM. 


tlio  pnonmopoccus  produces  a  poisonous  albumin  (pneumotoxin)  whioh 
when  introduced  into  the  circulation  of  an  animal  causes  ek'vati<iii  df 
temperature  and  the  subsequent  production  in  the  body  of  a  ^ulistiuico 
(antipneumotoxin)  which  jiossesses  the  power  of  neutralizing  the  jioisdii- 
ous  albumin  which  is  formed  by  the  bacteria.  In  man  they  hoM  tli:it 
durini^  the  pneumonic  process  there  is  a  constant  absorption  into  the  cir- 
culation of  this  r)oisonous  albumin  i)roduced  bv  tlie  bacteria  in  tlic  iiiii<rs 
This  continues  until  eventually  the  same  antidotal  substance  is  iirodnciMl 
in  the  circulation  that  has  been  seen  to  occur  experimentally.  It  is  ilu'u 
that  the  crisis  occurs.  The  bacteria  are  neitlier  destroyed  ii.-r  is  tliiir 
power  to  produce  the  poisonous  albumin  lessened;  but  the  third  f;ictor, 
the  antitoxic  clement,  now  exists  and  neutralizes  the  toxic  suljstaiiccs  as 
they  are  produced.  'I'hey  demonstrated  that  the  serum  of  the  blood  df 
patients  after  the  crisis  of  pneumonia  contained  the  antitoxic  suh.stance 
and  was  capable,  in  a  fair  number  of  cases,  of  curinp  the  dis(>ase  when  in- 
jected into  infected  animals.  Tliey  have  made  prclitniuary  ohserviitiuiis 
upon  patients  with  a  view  of  inducing  the  crisis  by  the  injection  of  the 
blood  serum  of  persons  convalescent  from  pneumonia,  and  which  conse- 
quently contains  the  antitoxic  body.  In  six  cases  of  pneumonia  the  clfect 
of  the  injections  was  favorable.  The  general  results  of  expeiimciital 
work  has  confirmed  these  observations ;  but  no  satisfactory  progress 
has  been  made  in  establishing  a  rational  serum-therapy  for  the  disease 
in  man. 

Morbid  Anatomy. — Since  the  time  of  Laennec,  pathologists  liiive 
recognized  three  stages  in  the  inflamed  lung — engorgement,  red  hejiatiza- 
tion,  ami  gray  liepatization. 

In  the  stage  of  engorfjciunit  the  lung  tissue  is  deep  red  in  color,  finiicr 
to  the  touch,  and  more  solid,  and  on  section  the  surface  is  bathed  with 
blood  and  serum.  It  still  cre])ivates,  tlumgh  not  so  distinctly  as  healthy 
lung,  and  excised  portions  float.  The  air-cells  can  be  dilated  hy  in- 
sufflation from  the  bronchus.  :Microscopical  examination  shows  the 
capillary  vessels  to  be  greatly  distended,  the  alveolar  epithelium  swollen. 
and  the  air-cells  occupied  by  a  variable  number  of  blood-corpusc  los  and 
detached  alveolar  cells.  In  the  stage  of  red  hvpafizaiion  the  lung  tissue 
is  solid,  firm,  and  airless.  If  the  entire  lobe  is  involved  it  looks  volumi- 
nous, and  shows  indentations  of  the  ribs.  On  section  the  surface  is  dry. 
reddish  broAvn  in  color,  arul  has  lost  the  deeply  congested  a]>];earan(e  of 
the  first  stage.  One  of  the  most  remarkalde  features  is  the  friability;  in 
striking  contrast  to  the  healthy  lung,  which  is  torn  with  ditliculty,  a 
hepatized  organ  ean  be  readily  broken  by  the  finger.  Careful  iiis]Hrtioii 
shows  that  the  surface  is  distinctly  granular,  the  granulations  represent- 
ing fibrinous  plugs  filling  the  air-cells.  The  distinctness  of  this  appeiir- 
ance  varies  greatly  with  the  size  of  the  alveoli,  which  are  about  O-lo  mm.  m 
diameter  in  the  infant,  0-1.5  or  0-10  in  the  adult,  and  from  0-20  to  0-25  in 
old  age.     On  scraping  the  surface  with  a  knife  a  reddish  viscid  serum  is 


PNEUMONIA. 


i49 


removotl,  contuiniiifj  sniiill  gnimiliir  inasacs.  The  sniullor  l^roiiclii  often 
contain  fibrinous  plujff!.  If  tlu'  hinj^' lias  l)et'n  r(.'niovc'<l  before  tlio  liciirt, 
it  is  nut  nncoMiinon  to  find  solid  moulds  of  clot  lillinjf  the  I dood -vessels. 
Mier(isco})ie;dly,  tlie  air-cells  are  seen  to  be  ocHUipied  by  coa<;ulatc(l  fibrin 
in  the  meshes  of  Avhich  are  red  blood-cor[)useles,  ixdyniiclear  leiicocyti's, 
[iiul  alveolar  epithelium.  The  alveolar  walls  are  infiltrated  and  leucocytes 
are  seen  in  the  interlobidar  tissues.  f!over-glas,s  iireparations  from  the 
exudate,  and  thin  sections  show,  as  a  rule,  the  diplococci  already  rel'erred 
to  many  of  which  are  contained  within  cells.  Stai>hylocoeci  and  slre[)- 
tocoeci  nuiy  also  he  seen  in  some  eases.  In  the  stage  of  (jvan  lupuliuitiun 
the  tissue  has  changed  from  a  reddish-brown  to  a  grayish-white  color. 
The  surface  is  moister,  the  exudate  obtained  on  scraping  is  nutre  turbid, 
the  granules  in  the  aciin  are  less  distinct,  and  the  lung  tissue  is  still  more 
friable.  Histologically,  in  gray  hei>atization,  it  is  seen  that  the  air-cells 
arc  densely  filled  with  leucocytes,  the  fibrin  network  and  the  red  blood- 
cdrpuscles  have  disa])peared.  A  more  advanced  condition  of  gray  hepa- 
tization is  that  known  -A'a purulent  iiiJiUralwn,  in  which  the  lung  tissue  is 
softer  and  bathed  with  a  purulent  fluid. 

The  stage  of  gray  hepatization  ai)pears  to  bo  the  first  step  in  the 
prne(  ^  of  rrsolu/ion.  The  exudate  is  softened,  the  cell  elements  are 
disintt,  ated  and  rendered  capable  of  absorption.  When  the  ])urulcnt 
infiltrati'  M  of  the  lung  tissue  rea(!hes  the  grade  sonu'times  seen  post 
iiKirtein,  it  is  pnjbable  that  resolution  couhl  not  take  place.  Small  abscess 
cavities  may  arise,  and  by  their  fusion  larger  ones.  Often  in  oiu^  lung, 
or  even  in  one  lobe,  [he  various  stages  of  the  ])rocess  may  be  seen,  and  the 
passage  of  the  engorgement  into  red  hepatization  and  of  the  latter  into 
the  gray  stage  can  be  readily  traced. 

The  general  details  of  the  morbid  anatomy  of  pneumonia  nniy  be 
Slathered  from  the  following  %3ts,  based  on  100  autopsies,  made  by  me  at 
the  (leiieral  Hospital,  Montreal:  In  51  eases  the  right  lung  was  affected; 
in  '.VI,  the  left;  in  IT,  l)oth  organs.  In  :27  cases  the  entire  lung,  with  the 
exceittion,  perhajis,  of  a  narrow  margin  at  the  a})ex  and  anterior  border, 
was  consolidated.  In  34  cases,  the  lower  lobe  alone  was  involved  ;  in  13 
cases,  tlie  upper  lobe  alone.  AVhen  double,  the  lower  lobes  Avere  usually 
atrected  together,  but  in  three  instances  the  lower  lo})e  of  one  ami  the 
upper  lobe  of  the  other  were  attacked.  In  three  cases  also,  both  upper 
lobes  were  affected.  Occasionally  the  disease  involves  the  greater  part  of 
both  lungs;  thus,  in  one  instance  the  left  organ  with  the  excc[)tion  of  the 
anterior  border  was  uniformly  hcpatized,  while  the  right  was  in  the  stage 
of  gray  hepatization,  except  a  still  smaller  portion  in  the  corresponding 
region.  In  a  third  of  the  cases,  red  and  gray  hepatization  existed 
together.  In  22  instances  there  was  gray  hepatization.  As  a  rule  the  uu- 
affectcii  portion  of  the  lung  is  congested  or  anlematous.  When  the  greater 
portion  of  a  lobe  is  attacked,  the  uniuvolvcd  part  may  be  in  a  state  of  almost 
gelatinous  anlema.     The  unaffected  lung  is  usually  congested,  particularly 


'      i 


I..  ]'   r'  'k  h\ 

}  hiv  i^      i    ti 


If ,« 


'^4 

{(     ""if 


Ml', 


TT-n' 


^i&a 


550 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


at  the  posterior  i)art.  Tliis,  it  iiuist  be  rciiu'iiihcrod,  iiiiiy  he  lurgcly  duo  to 
post-niortciii  siil)si(k!nco.  Tho  miinlluiiicd  portions  are  not  alwavs  ((m. 
gewted  and  (I'denmtons.  'I'lie  np|)er  lobe  may  be  dry  and  bloodless  whcu 
the  lower  lobe  is  uiiiforndy  eonsolidated.  The  averajjfe  weight  of  a  iinrinal 
lung  is  about  (iCO  graiuines,  while  that  of  an  intlanied  organ  mav  l»e  l.fidd 
;i,OUU,  or  even  2,oOO  grammes. 

The  bronehi  contain,  as  a  rule,  at  the  time  of  death  a  frolhy  serous 
fluid,  rarely  the  tenacious  mucus  so  characteristic  of  pneumduic  siMiium. 
The  mucous  nu'nd)ranc  is  usually  I'cddened,  rarely  swollen,  in  the  alVwted 
areas  the  smaller  bronchi  often  contain  librinous  plugs,  which  may  cxtcnil 
into  the  larger  tubes,  forming  perfect  casts.  The  broiudnal  glands  arc 
sw(dlcn  and  may  even  ])e  soft  and  pnlpy.  The  pleural  surface  of  the 
inllamcd  lung  is  invariably  involved  when  the  process  becomes  sujifrliciiil, 
Commonly,  there  is  only  a  thin  sheeting  of  exudate,  ])roduciiig  slight 
turbidity  of  the  meml>rane.  In  only  two  of  the  hundred  instances  tlii' 
pleura  was  not  involved.  In  some  eases  the  fibrinous  exudate  may  form  a 
creamy  layer  an  inch  in  thickness.  A  serous  exudation  of  variable  amount 
is  not  uncommon. 

Lesions  in  other  Organs. — The  heart  is  distended  with  lirm,  tenacious 
coagula,  wlii(di  can  be  withdrawn  from  the  vessels  as  dendritic  nioulils. 
In  no  other  acute  disease  do  we  nu'ct  with  coagida  of  such  solidity  and 
firmness,  'i'he  distention  of  the  right  chambers  of  the  heart  is  particu- 
larly marked.  The  left  chambers  ai'c  rarely  distended  to  the  sanu^  degree. 
The  spleoi  is  often  enlarged,  though  in  only  ',io  of  the  lUd  cases  was  the 
weight  above  20(i  grammes.  The  kidneys  show  parenchymatous  swelling, 
turbidity  of  the  cortex,  and,  in  a  very  considerable  proportion  of  the  cases 
— twenty-tive  per  cent — chronic  interstitial  changes. 

IVricavditis  is  not  infrequent,  and  occurs  more  particularly  with  pneu- 
monia of  the  left  side  and  with  double  ]»neumonia.  In  5  of  the  ItiOauldp- 
sies  it  Avas  present,  and  in  4  of  them  the  lappet  of  lung  overlying  the  [leri- 
cardium  with  its  pleura  was  involved.  Endocarditis  is  more  frequent  and 
occurred  in  10  of  the  100  cases.  In  5  of  these  the  endocarditis  was  of  the 
simple  character ;  in  11  the  lesions  were  ulcerative.  Fatty  degeneration 
of  the  heart  is  not  common  except  in  protracted  cases. 

Meningitis  is  not  infrequently  found,  and  in  many  cases  is  associated 
with  malignant  endocarditis.  It  was  ]iresent  in  8  of  the  100  autopsies, 
Of  twenty  cases  of  meningitis  in  ulcerative  endocarditis  fifteen  occurred 
in  pneumoiua.  The  meningeal  inllammation  in  these  ca.ses  is  usually 
cortical. 

Croupous  or  diphtheritic  inflammation  may  occur  in  other  parts,  A 
croupous  eolitis,  as  pointed  out  by  Bristowe,  is  not  very  uncommon.  It 
occurred  in  T)  of  my  100  post-mortems.  It  is  usually  a  thin,  flaky  exuda- 
tion, most  marked  on  the  tops  of  the  folds  of  the  mucous  membrane.  In 
one  case  there  was  a  patch  of  croupous  gastritis,  covering  an  area  of  I'i  by 
8  cm.,  situated  to  the  left  of  the  cardiac  orifice. 


PNKUMONIA. 


651 


'rill!  liver  sliows  piiroiifhyiuiitoiis  I'liaiigcs  and  often  extreme  eii;jjor^'e- 
iiH  III  (if  tlie  lie|)iiti(!  veins. 

Symptoms. — Al)niptly,  or  preeeded  by  a  ilay  or  two  of  iiidisposi- 
tidii,  tlie  patient  lias  a  severe  cliill,  lasting  from  ten  to  thirty  minntes.  In 
11(1  lu'uto  disease  is  an  initial  chill  so  constant  or  so  severe.  The  fever 
ri.>fs  ([luekly.  There  is  pain  in  tlie  siile,  often  of  an  agonizing  character. 
A  short,  dry,  painful  cough  soon  d  velops,  and  the  respirations  are  in- 
(■rciised  in  frequency.  When  seen  on  the  second  or  third  day  the  patient 
|ircsciits  an  appearaiuse  which  may  he  (juite  pathognomon'e.  He  lies  Hat 
ill  hed,  often  on  the  alfeeted  side  ;  the  faci'  is  Ihislied,  particularly  the 
checks ;  the  breathing  is  hurried  ;  the  ahe  nasi  dilatt;  with  each  inspira- 
tion ;  the  eyes  are  bright,  the  expression  is  anxious,  and  there  isafre(pu'nt 
shoi't  cough  which  makes  the  patient  wince  and  hold  his  side.  The  ex- 
|i(ct(>nition  is  blood-tinged  and  extremely  tenacious.  The  temperature 
rises  ra])idly  to  104°  or  10.")°.  The  pulse  is  full  and  bounding  and  the 
imlsc-respiration  ratio  much  disturbed.  Exanunation  of  the  lung  shows 
the  physical  signs  of  consolidation — blowing  lireathing  and  line  rales. 
Alter  ])ersistiiig  for  from  seven  to  ten  days  the  crisis  occurs,  and  Avith  a 
fiill  ill  the  temperature  the  patient  passes  from  a  condition  of  extreme  dis- 
tress and  anxiety  to  one  of  comparative  comfort. 

Tiie  fever  of  pneumoiua  rises  abruptly  Avith  the  chill,  during  which 
the  rectal  temperature  may  be  high.  In  children  and  in  cases  without 
chill  the  rise  is  more  gradual.  The  temperature  reaches  10J:°  or  105°  and 
is  continuous,  with  a  variation  of  a  degree  to  a  degree  and  a  half.  If 
a  two-hour  record  is  kept  the  diurnal  variations  are  seen  to  follow  the 
normal  type.  In  children  and  healthy  adults  the  fever  is  usually  higher 
thiin  in  old  persons  and  drunkards.  After  continuing  for  from  five  to 
nine  (hiys  the  temperature  falls  abruptly,  forming  what  is  known  as  the 
crisis,  so  characteristic  in  a  large  proportion  of  the  cases.  In  from  five 
to  twelve  hours,  or  even  in  an  hour  (S.  West),  the  temperature  may  fall 
six  or  eight  degrees.  The  crisis  may  occur  as  early  as  the  third  day  or  as 
lute  as  the  twelfth  or  fourteenth.  A  pseudo-c r is i)i  mny  occur  on  the  fifth 
(lay  or  earlier.  Defervescence  may  take  place  gradually  by  lysis.  In  cases 
of  delayed  resolution  the  fever  may  persist  for  weeks. 

Respiratory  Sjrmptoms. — Pain  of  an  agonizing  character  is  an  early 
anil  distressing  symptom.  It  is  usually  referred  to  the  nipple  or  axillary 
regions  of  the  affected  side.  In  exceptional  cases  it  may  be  in  the  abdo- 
men or  flank,  or  even  beneath  the  shouhler-blade.  Deep  inspiration  and 
cough  aggravate  it.  Dyspntpa  is  a  very  pronunent  feature.  The  respira- 
tions may  be  from  forty  to  sixty  in  the  minute  and  in  exceptional  cases 
innl  ill  children  may  rise  to  eighty.  To  produce  this  shortness  of  breath 
many  factors  combine — the  fever,  the  loss  of  function  in  a  considerable 
lu'ea  of  lung  tissue,  and  the  excessive  pain  in  the  side,  which  makes  it  im- 
possiMo  to  draw  a  deep  breath.  There  may  be  nervous  factors  at  work, 
as  with  the  crisis  the  number  of  respirations  may  fall  nearly  to  normal, 


!'i^,4 


1,4  -r 


ft  i   \i    X  'I  V 

'A.  ft 


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m 


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■J  '.^^.^H 


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r,52  r)ISKASF':S   OF  TIIH    liKSIMUATOllY   SYSTEM. 

wliilc  llio  coiLsolitlatioii  of  tho  luii<?  still  persists.     Tiu!  type  of  Imailiinn 
iu  puuuiuouiu  is  peculiar  uud  ulmost  distiuctivo.     Tlio  iuspimiion.,  aic 

Jnn.  in  i$  it  in  it  /,i  //i  n  it  /., 


K«tp. 


76 


70 


05 


80 


a 


SO 


20 


15 


10 


PiiUo 
IDO 


180 


170 


ISO 


100 


110 


12U 


IIU 


90 


70 


60 


SO 


to 


Tump 

lot 

108 
107 
100 
lOB 
104 
103 
102 
101 
100 


98 


00 
Temp, 

riilsc 

Reap. 
Stools 

Urine 


pay  of 


•  ?••••  ; ■■■ 


C 


10 


12 


13 


U 


BLACK,  temperature;  red,  pulse;  blue,  respiration 

Chart  XIV.— Fever,  pulse,  and  respirations  in  lobar  pneumonia. 

short  and  superficial.     Expiration  is  often  associated  with  a  short  tr'init. 
The  ratio  between  the  respirations  and  pulse  may  be  1  to  2,  or  cvin  1  to 


f 


PNKUMONIA. 


r>y.\ 


{•').    Ill  MO  other  discasi'  do  we  sec  such  iiiiiH<('(l  (listurhaiico  in  thu  ptilso- 
resiiiiiitioii  ratio,  and  this  is  soiiii'tiiiu's  an  aid  in  dia;riiiisis. 

'I'lio  ('<)ii;^h  is  also  very  cliarat'tt'ristic — ri'('(|iu'nt,  siiort,  restrained,  and 
Msseriated  with  ;;roal  ]iain  in  the  side.  It  is  at  lirst  dry,  hard,  and  with- 
(iiit  e\[iei'toi'ati()n.  In  old  jiersons  and  drnid\ards  and  in  those  di'liilitated 
Ijv  luiif,'  iUiiess  there  may  he  no  eonj,di.  Tiie  sputum  is  mucoid  at  tirst, 
but  within  twenty-four  hours  sliows  special  features.  A  hrislv  lia'mo[ttysis 
mav  lie  an  initial  sym[)t()ni.  I'ncninoni(!  sputum  is  viscid,  tenacious,  and 
bJiMMl-tiii^^'d.  The  ^'ummous  viscidity,  toj^'i-thcr  with  tlie  red  hlood-eor- 
puscles  in  various  sta^^es  of  alteration,  j^ive  pathoffuomonic  eharactcu's  to 
till'  sputa,  unknown  in  any  other  disease.  The  rusty  tin^'e  heconies  more 
marked  as  the  disease  proj^resscs,  and  so  t.'iiaeious  is  tiu'  expectoration 
that  it  has  to  be  wiped  from  the  lips  of  the  [)atient,  and  a  spit-cu[),  half 
full,  may  he  invertc(l  without  s[»illin;^.  Toward  tiie  close  it  l)ecomes 
more  li(piid  and  is  nn)re  readily  e.x|telled.  In  low  types  of  the  disease  tlio 
sputum  nuiy  bo  tluid  and  dark  brown,  reseitd)Iin;^  prune  juice.  Tho 
amount  is  very  varial)le.  In  children  and  old  iieoide  tlien^  may  he  none; 
onlinarily,  however,  there  are  from  !(•()  to  ;30(l  e.  c.  daily.  After  the  crisis 
till' i|uantity  is  varialile  ;  abundant  in  some  eases,  absent  in  others.  Micro- 
scopically, the  sputum  contains  red  blood-cor[)us(des  in  all  sta^^'s  of  de- 
goiu'riition,  alveolar  epitheliu'm,  diplococci  and  ollu'r  micro-organisms, 
ccll-iiioulds  of  the  alveoli,  and,  in  some  eases,  small  fibrinous  casts  of  tlio 
luoiii'liiiiles.     The  latter  are  sometimes  plaiidy  visible  to  the  naked  eye. 

Physical  Signs. — InK/ifcfian  may  not  at  lirst  show  any  dilferenee  be- 
tween the  two  sides,  though  usually  if  the  lower  lobe  of  a  lung  is  involved 
till'  inovi'inent  is  less  on  the  aU'eetod  side.  Later,  when  consolidation  has 
occurred,  particularly  if  it  is  massive,  this  deficient  expansion  is  very 
marked.  Mensuration  may  show  a  definite  increase  in  tli(^  volume  of  the 
side  involved.  The  intercostal  spaces  are  not  obliterated.  Palpation  in- 
dicates still  more  clearly  the  lack  of  expansion,  and  a  ])leural  friction  may 
be  1'clt.  Tactile  frenutus  is  increased.  These  signs  are  all  more  marked 
when  consolidation  is  established. 

J'l'rciissiou. — In  the  stage  of  engorgement  the  note  is  higher  pitched 
luul  iiiay  have  a  somcAvhat  tympanitic  quality,  the  so-called  Skoda's  reso- 
nance. This  can  often  be  obtained  over  the  lung  tissue  just  above  a  crn- 
solidated  area.  When  the  lung  is  hepatized,  the  jiercussion  note  is  fiat, 
the  (piality  of  the  flatness  varying  a  good  deal  from  a  note  which  ^las  in  it 
a  oortnin  tympanitic  quality  to  al)solute  dulness.  There  is  not  tiie  wooden 
tlatucss  of  elfxision  and  the  sense  of  resistance  is  not  so  great.  During 
resolution  the  tympanitic  qnality  of  the  percussion  note  may  return.  For 
v/ccks  or  months  after  convalescence  there  may  bo  a  higher-pi tcdied  note 
on  the  alTected  side. 

AnftcuUntion. — Quiet,  suppressed  breathing  in  tlio  affected,  part  is  often 
a  marked  feature  in  the  early  stage,  :  nd  is  always  suggestive.  Very  early 
there  is  heard  at  the  end  of  inspiration  the  fine  crepitant  rale,  a  series  of 


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DTSKASKS  OF  THE    IlKSPIRATOUY  SYSTEM. 


mimitc  (Tiirkliii^s  licanl  cIoho  to  the  car,  ami  [U'l'liaps  not  aiidililc  until  a 
full  Itroutli  is  ilrawii.  Wlictlicr  this  is  a  line  |ili'iiral  ci'cpitiis  ur  is  hid. 
(liiccd  in  the  air-cells  and  tliicr  hrondii  is  still  an  open  <(iit'stiiiii,  Al  iliis 
std^'c,  before  eunsolidatinii  Jms  ocenrreil,  the  hrealh-soiinds  iimv  \h\  as 
before  mentioned,  iniieli  feebler  than  in  in-alth,  bnt  on  drawiii;^^  j,  i,,,,,, 
breath  they  may  juive  a  harsh  (|uality,  to  whicdi  the  term  broiK  lio-vesicidar 
lias  bi'eii  applied.  In  the  sta^'e  of  red  hepatization  ami  when  duhiess  is 
well  deline<|,  the  res])irati(in  is  tiibniar,  similar  to  that  heard  in  lieallli  dVcr 
the  larirer  In'oiielii.  M'ith  this  blowinj,'  breathinj,'  there  may  be  nn  rak's, 
and  it  may  ])resent  an  ii't'.  nsity  nnknown  in  any  other  [)nlnionarv  iillVc- 
tion.  It  is  sini[)ly  the  prii[i;ii,'iition  of  the  larynj,'eal  and  tracheal  suuiuls 
through  tlk'  bi'diiclii  and  the  consolidated  Inn;,'  tissne.  The  p<'riii'aliilitv 
of  the  bronchi  is  essential  to  its  jH'odiiction.  Tubular  breatiiin^f  i>  absent 
in  certain  cases  of  ma.ssivo  pneumonia  in  which  the  lander  broMelii  aiv 
completely  tilleil  with  exudation.  When  resolution  be^'ins  mucous  nik'sef 
all  sizi's  can  be  heard.  At  first  tlu'y  are  small  and  iiave  been  calitil  thr 
rciln.r-crrpihiK.  The  voice-sounds  are  transmitted  tlirou<^li  the  cdiiseli- 
(lated  lun^'  Milh  ^'reat  intensity.  This  bronchophony  may  have  a  euriinis 
nasal  (piality  [n  ■which  the  term  a'po])hony  has  been  ^iveii. 

Circulatory  Symptoms.— During;  the  (.'hill  the  i)nlse  is  small,  Imt  in 
the  succecdin;^'  fever  it  be.  ..les  fnll  and  boundinj^.  In  cases  of  nioijerato 
severity  it  ranires  from  ICO  io  110.  It  is  not  often  dicrotic.  In  stronir, 
liealthy  indi'.  iduals  and  i.i  children  there  may  be  no  sij^n  of  I'ailin;;  pul-e 
throui,diont  tlie  attack.  With  extensive  consolidation  the  left  veiitrirle 
may  receive  a  very  mneh  diminished  amount  of  blood  and  the  pulse  in 
consequence  may  be  small. 

In  the  old  and  feeble  the  pulse  may  be  small  and  rapid  from  the 
outset.  Th*^  heart-sounds  are  usually  loud  and  clear.  During  the  in- 
tensity of  the  fevor,  particularly  in  children,  bruits  are  not  uncommon 
both  in  the  mitral  and  in  the  pulmonary  areas.  The  second  sound  over 
the  pulmonary  artery  is  accentuated.  Attention  to  this  sign  gives  a  vain- 
able  indication  as  to  the  condition  of  the  lesser  circulation.  With  disten- 
tion of  the  right  chambers  and  failure  of  the  right  ventricle  to  empty 
itself  completely  the  pulmonary  second  sound  becomes  much  less  distinct. 
When  the  right  heart  is  engorged  there  may  be  an  increase  in  the  didnoss 
to  the  right  of  the  sternum.  With  gradual  heart-failure  and  signs  of 
dilatation  the  long  pause  is  greatly  shortened,  the  sounds  approach  each 
other  in  tone  and  have  a  frotal  character  (embryoeardia). 

Blood. — Anaemia  is  rarely  seen.  There  is  in  most  cases  a  leueoeytosis, 
which  appears  early,  persists,  and  disappears  with  the  crisis.  The  leuco- 
cytes may  number  from  twelve  to  forty  or  fifty  thousand,  even  more,  per 
cubic  millimetre.  The  fall  in  the  leucocytes  is  often  slower  than  the  droji 
in  the  fever,  particularly  when  resolution  is  delayed.  A  point  of  consider- 
able prognostic  importance  is  that  in  malignant  pneumonia  the  leueooy- 
tosis  is  absent,  and  in  any  case  the  continuous  absence  may  be  regarded  .is 


rXKl'MOXlA. 


5^5 


(III  iiiifiivonihlo  si;.'n.  A  strikiii;,'  fcnturc  in  tlic  lilnoil-slidc  h  tlio  riduH'S!* 
aiiil  ilfiisity  (if  till'  til)riti  network.  This  {'(trri'spuiKl  \  to  tlic  yrciit  iiutrciise 
ill  till'  tihriii  I'lcniei'ts,  wliicli  Iuih  loiii;  lu'cii  known  to  iwv.uv  in  pncutnonia, 
till'  |iri(|iortion  r.ainj;  from  fonr  to  ten  piirta  pur  tlioiisainl.  Muvftii  dc- 
scrilx'S  the  hlood-phitcs  us  j,Mriitly  iniTuased.  'I'hc  diplocoeiii  can  very 
rarely  bo  detnonstruted  in  the  hlood. 

'I'lie  i/iisfrii-iti/rsfiiiiil  si/t>i/ifniiis  are  those  assoeiiited  with  an  ordinary 
stlu'iiie  fever.  Vomitinj^  is  not  fre(|iient  at  the  outset.  'I'here  is  naturally 
!n>^  of  appetite.  The  toiiifiie  is  white  and  furred,  and,  in  eawes  of  a  low 
tvue,  rapidlv  heeonies  dry.  Constipation  is  more  erimmon  than  diarrlnea, 
wliiih  does  prevail,  however,  in  some  epidi'inies.  The  spleen  is  usually 
ciiliirired,  and  the  ed<,'e  ean  he  felt  diirinj,'  a  deep  ins[)iration.  I'^xeept  i!i 
iiiM's  of  extreme  engorgement  of  the  right  heart,  the  liver  is  usually  not 
JiiiTeased  in  volume. 

Among  cit/dncmi.s  symptftins  one  of  the  most  interesting  is  the  assoeia- 
tidii  of  herpes  with  pneumonia.  Not  exeepting  malaria,  we  see  lahial 
herpes  more  fre(juently  in  this  than  in  any  other  (]i,MiaHe,  occurring,  as  it 
ildcs,  ill  from  twelve  to  forty  per  cent  of  the  eases,  ll  is  supposed  to  bo 
.'f  favonilile  prognosis,  and  ligiires  have  been  (plot.' '  in  jiroof  of  this  asser- 
tion. It  may  also  occur  on  the  nose  or  on  the  genital  .  Its  signilicunco 
and  relation  to  the  disease  are  unknown.  It  is  seareely  neeessury  to  men- 
tion t'le  U  liory  which  has  been  advanced,  that  it  is  uu  external  expression 
of  a  neui'itis  which  involves  the  pneuniogastri(!  and  induces  the  pneumo- 
niii,  At  the  height  of  the  disease  sweats  are  not  common,  hut  at  the  crisis 
they  may  be  profuse.  Uedness  of  one  cheek  is  u  phenomenon  long  ree(jg- 
iiized  in  connection  with  pneumonia,  aiul  is  usually  on  the  same  side  us 
the  disease. 

The  iiriiiP  presents  the  usual  febrile  characters  of  high  color,  high  s])e- 
I'ifu;  gravity,  high  density,  and  increased  acidity.  The  nitrogenous  ele- 
moiits,  urea  and  uric  acid,  are  notably  increased.  The  chlorides  are 
absent,  or  greatly  reduced,  during  the  heiglit  of  the  fever — due,  it  is  sup- 
posed, to  the  amount  exuded  in  the  hepatized  lung.  At  the  (crisis  there  may 
be  marked  increase  in  the  amount  of  urine,  which  is  heavily  luden  with 
unites  and  extractives.  AVhen  jaundice  occurs  there  is  bile-pigment.  A 
trace  of  albumin  is  present  in  a  large  proportion  of  the  cases.  It  is  rarely 
of  serious  significance,  and  seldom  associated  with  tube-casts. 

Cerebral  Symptoms. — As  an  initial  syTiiptom,  headache  is  common. 
Consciousness  is  usually  retained  througlioi;t,  even  in  severe  cases.  In 
children  convulsions  are  common,  and  in  at  least  one  half  the  cases  nsher 
ill  the  disease.  There  may  be  violent  maniacal  symptoms  in  the  adult.  I 
once  performed  an  autopsy  in  a  case  of  this  kind  in  which  there  was  no 
suspicion  whatever  that  the  disease  was  other  than  acute  mania.  In  drunk- 
ards the  symptoms  from  the  outset  may  be  those  of  delirium  tremens,  in 
wliicli  disease  it  should  be  an  invariable  rule,  even  if  fever  is  not  present, 
to  exiunine  the  lungs.  These  patients  are  apt  to  wander  about,  and  must 
30 


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1 4? 


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556 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


bo  carefully  watched.  The  preliminary  excitement  and  delirium  may  dvo 
place  to  hebetude,  which  deepens  to  coma.  It  is  not  possible  to  dcciile  in 
these  cases  whether  meningitis  is  i)resent  or  not,  since  it  is  iisually  (•(.rtitnl, 
and  theio  are  no  symjitoms  of  pressure  on  the  nerves.  In  only  dik-  of 
eight  instances  was  there  involvement  of  the  base,  rendering  clear  the 
diagnosis  of  meningitis.  These  cases  of  so-called  cerebral  pneuuuiiiia  arc 
frequently  associated  with  very  high  fever.  In  senile  and  alcoholic  pneu- 
monia, however,  the  temperature  may  be  low  and  yet  brain  symiitdins 
very  pronounced.  ^lental  disturbance  may  persist  during  and  after  con- 
valescence, and  insanity  develops  in  a  few  cases.  It  is  currently  statoil 
that  apex  pneumonia  is  more  often  complicated  with  severe  deliriuin,  but 
it  has  not  been  so  in  my  experience. 

Complications. — Many  of  these  seem  to  depend  directly  on  the  in- 
vasion of  the  bcdy  by  the  diplococci. 

As  already  mentioned,  jjh'iin'fy  is  an  inevftable  event  when  the  inflam- 
mation reaches  the  surface  of  the  lung,  and  thus  can  scarcely  be  tcrnieil 
a  complication.  But  there  are  cases  in  which  the  pleuritic  features  take 
the  first  place — cases  to  which  the  term  pleuro-pneumonia  is  applicable. 
The  exudation  may  be  sero-fitn'inous  with  v'opious  eifusion,  differing  from 
that  of  an  ordinary  acute  j)leurisy  in  the  greater  richness  of  the  fibrin. 
which  may  form  thick,  tenacious,  curdy  layers.  Pneunu)nia  on  one  ^iile 
Avith  extensive  pleurisy  on  the  other  is  sometimes  a  puzzling  complication 
to  diagnose  and  an  aspiiator  needle  may  be  required  to  settle  the  ques- 
tion. The  bacteriological  examiiuition  of  the  fluid  has  demonstra.ted,  in  a 
large  number  of  cases,  the  i)resence  of  the  pneumococcus.  Of  late,  siiocial 
attention  has  been  paid  to  the  frequency  with  which  empyema  conqiji- 
cates  pneumonia.  Effusion  may  not  have  been  suspected  during  tlu' 
height  of  the  disease,  but  after  the  temperature  has  been  normal  I'm'  some 
days  a  slight  rise  occurs  and  the  irregular  fever  ])ersists.  Duluess  eoii- 
tiiuies  at  the  base,  or  may  have  extended.  The  breathing  is  feel)le  i.iul 
there  are  no  rAlcs.  Such  a  condition  may  be  closely  simulated,  of  course, 
by  the  thickened  pleural  layers  which  are  so  commoidy  found  after  the 
pneumonia.  The  question  should  be  settled  at  once  by  the  introduction 
of  the  needle.  It  is  by  no  means  an  uncommon  complication,  and  nnniv 
cases  of  emi)yema  su})posed  to  be  primary  are  in  reality  secon(hiry  to  a 
slight  pneunumia. 

Pencardit !'.■>'  is  more  common  in  the  pneumonia  of  children,  particu- 
larly when  double,  and  it  is  said  with  the  pneumonia  of  the  left  side.  It 
was  present,  as  I  stated,  in  five  of  my  one  hundred  autopsies.  Tliough 
usually  plastic,  there  may  be  much  serous  effusion.  There  is  rarely  any 
difhcnlty  in  the  diagnosis,  but  when  the  pneumonia  involves  the  jiortion 
of  lung  covering  the  pericardium,  there  may  be  difficulty  in  deterininiii;:. 
by  physical  signs,  the  existence  of  fluid.  The  increase  in  the  dysimo'a, 
the  greater  feebleness  of  the  pulse,  and  the  gradual  suj)pressioii  of  the 
heart-sounds  will  give  the  most  valuable  indications.     In  some  instances 


PNEUMONIA. 


5.")" 


the  fluid  is  purulent.  Though  a  vory  serious  event,  it  is  surprising  liow 
often  rocovory  takes  pliioo  even  in  tlie  most  despenite  oases  of  pneumonia 
complicated  with  pericarditis.  I  remember  that  the  late  Dr.  Muriihison 
soiiio  years  ago  coninuuted  upon  this  feature  iu  a  case  at  St.  Thomas's 
IIos[»ital. 

Juuldcai'difis  is  still  more  frequent,  and  in  my  one  hundred  autopsies 
was  present  in  sixteen.  I  called  atteiitioniu  theGoulstonian  lectures  for 
LSS,")  to  the  great  fre([uency  of  tliis  complication.  Of  20U  case-i  of  malig- 
iiiiiit  endocarditis  collected  from  the  literature,  54  cases  occurred  in  this 
dijieaso.  Subsequent  observations  have  fully  confirmed  this  statement.  It 
may  be  said  that  with  no  acute  febrile  disease  is  endocarditis  so  fre(iuently 
rtSsoci;ited.  It  is  much  more  common  iu  t'ae  left  hcni'l  tlian  in  the  right. 
It  is  particularly  liable  to  attack  i)ersons  with  old  valvular  disease.  There 
may  ije  no  symjjtoms  indicative  of  this  complication  even  in  very  severe 
cases.  It  nuiy,  however,  be  suspe(;te(l  in  cases  (1)  in  which  the  fever  is 
priitnietcd  and  irregular;  (2)  when  signs  of  septic  mischief  arise,  sucli  as 
cliills  and  sweats  ;  {'■])  when  embolic  phenouicua  ap])ear.  The  frccjuent 
ccmplication  of  meningitis  with  the  endocarditis  of  pneumonia,  which  has 
alri'ady  been  mentioned,  gives  prominence  to  the  cerebral  .symptoms  in 
these  cases.  The  i)hysical  signs  may  be  very  deceptive.  There  are  in- 
stances in  which  no  cardiac  niuruiurs  have  been  heard.  In  others  the  de- 
velopment ii.uler  observation  of  a  loud,  rough  murmur,  particularly  if 
diastolic,  is  extremely  suggestive. 

Changes  in  the  myocardium  are  not  uncommon,  rarely  more,  however, 
than  cloudy  swelling  of  the  fibres ;  but  iu  some  instances  there  is  fatty 
change. 

Ante-mortem  heart-clots  are  rare  in  pneumonia,  even  in  tie  extreme 
grade  of  dilatation  of  the  right  chamber.  In  not  a  single  iustaiu-e  of  my 
autopsies  were  there  globular  thrombi  in  the  auricles  or  in  apices  of  the 
ventriides.  In  [)rotracted  cases  thrombi  occasionally  form  in  the  veins. 
A  rart!  complication  is  embolism  of  one  of  the  larger  arteries.  I  saw  an 
instance  in  Montreal  of  cud)olism  of  the  femoral  artery  at  the  height  of 
|ineuni(»iiia,  which  necessitated  amputation  at  the  thigh.  The  patient  re- 
(•(ivered.  Transient  aphasia  has  been  met  with  in  a  few  instances,  setting 
ill  aliniptly  with  or  witiiout  hemiplegia. 

l^y  far  the  most  important  com])lication  is  the  pneumonic  meningitis, 
whiili  vari  's  much  at  different  times  and  in  different  places.  !My  Mont- 
real experience  is  ratlier  exceptional,  as  eight  per  cent  of  the  fatal  cases  had 
this  eoinpiication.  It  usually  comes  on  at  the  height  of  tlie  fever  and  in 
the  majority  of  the  cases  is  not  recognized  unless,  as  before  mentione<l,  the 
base  is  involved,  which  is  not  common.  Meningitis  may  develop  later  iu 
the  disease  and  is  then  more  easily  diagnosed.  Associated  as  it  so  often 
is  with  ulcerative  endocarditis,  there  may  be  embolism  of  the  cerebral 
arteries,  including  hemiplegia.  Among  rare  complications  nuiy  be  men- 
tieiied  perip/irral  neuritis,  of  which  several  instances  have  been  described. 
I  saw  one  well-marked  instance,  following  pneumonia  and  inlluenxa,  in  the 


;l 


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M   '        ll'I'    '""      "  '  '"■ 


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'  t-  ^ 


558 


DISEASES  OP  THE  RESPIRATORY  SYSTEM. 


sprinfj  of  1890,  There  was  neuritis  of  the  loft  arm  with  considerable 
wasting. 

(Serious  f/asfric  complications  are  rare.  A  croupous  gasti-itis  has  iilrcailv 
been  mentioned.  Tlie  croupom  colitis  may  induce  severe  diiinii(i>a. 
Jaiuidict.'  is  one  of  the  most  interesting  complications  of  jnicunioiiia  ami 
occurs  with  curious  irregularity/  in  different  outbreaks  of  the  disease,  h 
sets  in  early,  is  rarely  very  intense,  and  has  iu)t  the  characters  of  obstruct- 
ive jaundice.  There  ai'e  cases  in  which  it  assumes  a  very  serious  form. 
The  mode  of  *iroduction  is  not  well  ascertained.  It  does  not  appear  td 
bear  any  definite  relation  to  the  degree  of  hei)atic  engorgement  and  it  Ls 
certaiidy  not  due  to  catarrh  of  the  ducts.  Possibly  it  may  be,  in  great 
part,  ha?matogen()us. 

Parotitis  occasionally  occurs,  commonly  in  association  with  endocar- 
ditis. 

A  rare  complication  of  pneumonia  is  an  arthritis  resembling  rlieiuna- 
tism,  which  may  come  on  gradually  during  the  disease  or  in  the  conva- 
lescence. 

Brif/hTs  disease  does  not  often  follow  pneumonia.  Peritonitis  is  ex- 
ceedingly rare. 

lirlapsp  in  pneumonia  is  so  uncommon  that  some  good  observers  hiive 
doul)ted  its  occurrence.  I  have  never  seen  an  instance  in  Avlii(di  1  was 
certtvin  that  there  was  a  definite  rela2)se.  There  are  cases  in  wliidi  from 
the  ninth  to  the  eleventh  day  the  fever  subsides,  and  aftor  the  teiiiponi- 
ture  has  Ix'cn  normal  for  a  day  or  two,  a  rise  occurs  and  fever  may  ])ci'sist 
for  another  ten  days  or  even  two  weeks.  Tliough  this  might  be  termed  ii 
relapse,  it  is  more  correct  to  regard  it  as  an  instance  of  an  anomalous 
course  of  delayed  resolution.  Wagner,  who  has  studied  the  subject  care- 
fully, says  that  in  his  large  experience  of  1,100  cases  he  met  with  only 
3  doubtful  cases.  When  it  does  occur,  the  attack  is  usually  abortive  and 
mild. 

Eecurrence  is  more  common  in  pneumonia  than  in  any  other  acute 
disease.  Hush  gives  an  instance  in  wliich  there  were  twenty-eiglit  attacks. 
Other  authorities  narrate  cases  of  eight,  ten,  and  even  more  attacks. 

Fornu'rly  it  was  much  disputed  whether  ordinary  lobar  })iieumoiiiii 
ever  terminated  in  pulmonary  phthisis.  These  are  really  cases  of  tnlu'r- 
culo- pneumonic  phthisis  the  onset  of  whicli  may  resemble  acute  imeii- 
n  onia. 

Clinical  Varieties. — A  number  of  different  forms  of  pneumonia  have 
been  recognized,  such  as  nnilignant,  adynamic,  bilious,  nudarial,  rheu- 
matic, and  the  like,  but  they  scarcely  require  a  full  description.  A  mala- 
rial pneumonia  is  described  and  is  thought  to  be  very  prevalent  in  soiiio 
parts  of  this  country.  Although  I  have  seen  during  the  past  seven  years 
several  hundred  cases  of  malaria  and  am  fa.miliar  Avitli  the  broncdiial  trou- 
ble so  commonly  associated  with  it,  I  have  yet  to  see  an  instance  of  pneu- 
monia which  seemed  in  any  way  connected  with  paludism.     The  so-eallou 


PNEUMONIA. 


5o9 


rhoniiiatic  pneumonia  has,  so  far  as  I  know,  no  pecnllaritios ;  nor  has 
rlu'iiiiiatism,  I  tliink,  any  special  relation  to  the  disease.  'JMie  term 
tv|ili(ii(l  pneumonia  is  commonly  used  to  designate  cases  with  adynamic 
sviiii»tonis  and  it  is  to  be  distinguished  from  those  cases  in  Avhich  typlioid 
tVvLT  l)egins  Avith  a  definite  pneumonia,  the  so-called  pncumo-t'jjthus  of 
foreign  writers. 

Epidemic  pneumonia  is,  as  a  rule,  more  fatal  and  may  display  minor 
pociiHarities  which  differ  in  different  epidemics.  In  some  the  cerebral 
cnm])li<'ations  are  marked ;  in  others,  the  cardiac.  The"e  may  be  diarrluea. 
Tlu!  pneumonia  which  occurs  with  influenza,  and  was  so  common  in  the 
last  epidemic,  presents  no  speciid  features  other  than  the  peculiarities  of 
onset.  Perhaps,  also,  it  was  more  severe  and  more  fatal.  In  diabetic; 
luitieiits  pneumonia  runs  a  rapid  and  severe  course,  ending  sonu'times  in 
abscess  or  gangrene.  In  the  subjects  of  chronic  alcoholism  the  onset  of 
piicunionia  is  insidiou:^,  the  symi)toms  may  be  masked,  the  fever  slight, 
and  the  clinical  jncture  may  be  that  of  delirium  tremens.  So  latent  is 
the  disease  in  some  of  these  cases  that  the  thermometer  alone  may  indi- 
cate the  presence  of  an  acute  disease. 

At  the  extremes  of  life  pneumonia  presents  certain  well-marked 
features.  It  is  sometimes  seen  in  the  new-born.  In  infaHis  it  very 
often  sets  in  Avith  a  convulsion.  Tiie  summit  of  the  lung  seems  more 
fivijueiitly  involved  than  in  adults  and  the  cerebral  symptoms  are  mo'o 
marked  throughout.  The  torpor  and  coma,  particularly  if  they  follcv 
I'oiivulsions,  and  the  preliminary  stage  of  excitement,  may  lead  to  the 
diagnosis  of  meningitis.  Holt  has  recently  })ublished  figures  which  indi- 
cate that  loljar  pneumonia  is  not  uncommon  in  infants  under  two  years  of 
age.     I'neumonic  sputum  is  rarely  seen  in  children. 

In  old  age  pneumonia  may  be  latent,  coming  on  without  chill ;  the 
cough  and  expectoration  are  slight,  the  physical  signs  ill-defined  and 
changeable,  and  the  constitutional  symptoms  out  of  all  proportion  to  the 
extent  of  the  local  lesion. 

When  pneumonia  is  prevailing  extensively,  particularly  in  jails  and 
garrisons,  cases  are  found  which  have  some  oi  the  initial  symi)toms  of  the 
disease — perhaps  a  slight  chill,  moderate  fever,  and  a  few  indefinite  local 
siirns.  This  is  the  so-called  larval  ]))iei(»iofiin.  Apex  pneumonia  is  said 
to  he  more  often  associated  with  adynamic  features  and  with  marked 
I'crehral  symptoms.  The  expectoration  and  cough  may  be  slight.  I  can- 
not say  that  in  my  experience  the  cerebral  symptoms  in  adults  have  been 
more  marked  in  this  form,  nor  do  I  think  it  necessarily  graver  than  if 
situ;itiMl  at  the  base. 

Tlie  en^eping  or  mujratnry  pneumonia  successively  involves  one  lobe 
after  the  other  and  is  a  peculiar  and  well-recognized  variety. 

Ihiidile  pneumonia  presents  ho  peculiarities  other  than  the  greater  dan- 
ger ((lunected  with  it.  The  term  mai^fiivc pneumonia  is  applii'd  to  the  rare 
coiulition  in  which  not  alone  the  air-cells  but  the  bronchi  of  the  entire 


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DISEASES  OF  THE   RESPIRATORY  SYSTEM. 


lobe  or  oven  of  tlio  lung  aro  filled  with  the  lil)rinoiis  exudate.  Tin-  ims- 
cultatory  signs  are  absent ;  there  is  ncntlier  fremitus  nor  tuhuJai'  bicuth- 
ing,  and  on  jjereussiou  the  lung  is  absolutely  Ihit.  It  elosely  resemliUs 
pleurisy  with  elTusion.  The  moulds  of  the  bronehi  nuiy  bo  expeeluraluii 
in  violent  iits  of  cougliing. 

Prognosis. — Tn  a  disease  Avliich  carries  oft  one  in  every  four  or  livo 
of  those  attacked  the  prognosis  in  a  large  number  of  cases  is  necfssarih' 
grave.  In  children  and  in  healtliy  adults  tiio  outlook  is  good.  In  the 
debilitated,  iii  drunkards,  and  in  the  aged  the  chanceg  are  against  recdvcrv. 
So  fatal  is  it  in  tlie  latter  class  tluit  it  has  been  ternu'd  the  natural  cml  of 
the  old  man.  ]\Iany  circumstances,  of  course,  influence  prognosis.  ],;ir- 
tieidarly  the  extent  of  the  disease,  the  height  of  the  fever,  the  preseuLT  of 
other  diseases,  anil  the  occurrence  of  complications. 

When  a  lower  lobe  on  one  side  or  the  lower  and  middle  lobes  of  tlic 
right  side  are  involved  in  a  healthy  adult,  if  there  are  no  complication!;, 
the  case  usually  proci'cds  to  satisfactory  resolution.  Meningitis  is  a  fatal 
complication.  Endocarditis  is  extrenudy  grave,  much  more  so  than  peri- 
carditis, fi-om  which  many  cases  recover.  Early  signs  of  heart-failure, 
dilatation  of  the  right  cluunbci',  gradual  cyanosis,  and  (edema  of  the  luiif,'s, 
are  symptoms  of  the  most  serious  chai'acter.  As  l)efore  stated,  the  daiiirer 
of  heart-clot  is  not  great  in  pneumonia.  The  risk  is  in  the  extreuic  dis- 
tention of  the  right  chand)er.  I  believe  the  firm  fibrinous  coagula  en- 
tangled in  the  column;\3  cavnea3  and  the  valves  are  invariably  })ro(luce(l 
during  the  death  agony.  When  there  are  symi)toms  of  abscess  of  the  luiijr 
or  of  gangrene  the  i)rognosis  is  extrc  nudy  bad  ;  yet  cases  are  on  record  of 
recovery  from  both  these  conditions.  Increasing  rapidity  of  resj)iratioii. 
Avith  difficulty  in  expectoratitm,  very  lirpud  and  dark  sputa,  a  low  iniilt.i- 
ing  delirium,  dry  tongue,  and  failing  pulse,  with  a  suffused  lividity  of  the 
fiiv!e,  are  iiulicative  of  ap})roachirg  dissolution.  Death  rarely  occurs 
from  direct  interference  with  the  function  of  res})iration,  though  it  may 
happen  in  cases  of  extensive  double  pneumonia.  In  a  majority  of  cases 
the  fatal  result  is  brought  about  by  gradual  lieart-failure,  whether  inducul 
by  the  prolonged  action  of  the  fever,  the  specific  action  of  the  poison,  or 
paralysis  due  to  overdistension  of  the  right  ventricde.  A  collateral  u'dcni;; 
of  the  uninvolved  })ortion  of  the  lung,  so  nnudi  spoken  of,  I'arely,  I  believe, 
occurs  in  pneumonia  ;  nor  is  it  likely,  if  the  ol)servations  of  Wehdi  upon 
the  i)roduction  of  this  condition  arc  correct,  that  in  the  course  of  pneu- 
monia the  left  vertricle  can  be  disproportioiuitely  weak  in  com]iaiisou 
with  the  right.     Tlie  absence  of  leucocytosis  is  an  unfavorable  sign. 

Termination. —  Ucxohition,  the  ]  process  by  which  the  lung  is  restored 
to  its  normal  state,  is  effected  ])artly  by  expectoration  and  partly  by  lii|ue- 
faction  and  absori»tion  of  the  exudate.  It  is  not  always  possible  to  esti- 
mate the  share  respectively  taken  by  these  processes.  There  aie  eases  in 
which  a  rapid  resolution  of  extensive  consolidation  takes  })lace  withmit 
any  special  increase  in  the  expectoration  ;  and,  ou  the  other  hand,  during 


PNEUMONIA. 


661 


rp-^olution  it  is  not  uncommon  to  find  in  the  expectoration  the  little  plug's 
(if  lil)rin  and  l  icocytos  wliich  have  been  loosened  from  the  air-eells  and 
exiirlled  by  eon^'hinj;.  In  a  majority  ol"  eases  botli  processes  are  probal)ly 
at  work.  A  variable  time  is  taken  in  the  restoration  of  the  luiifj.  Some- 
tinit'S  within  a  week  or  ten  days  the  dnlness  is  greatly  diminished,  the 
liiviith-sounds  become  clear,  and,  so  far  as  physicial  signs  are  any  guide, 
till'  lung  seems  perfectly  restored.  It  is  to  be  remembered  that  in  any 
fiisc  of  pneumonia  with  extensive  })leurisy  a  certain  amount  of  dnlness 
will  iHToist  fo'  months,  owing  to  thickening  of  the  pleura.  Dvlaijeil  reso- 
Iii/iuii  is  a  condition  which  causes  nuich  anxiety  to  the  physician.  It  may 
1)1'  jiostponed  until  the  fourth,  eighth,  or  even  the  tenth  week.  Usually 
the  fever  subsides,  but  the  consolidation  of  the  lung  may  persist,  with 
irreat  improvenu'ut  in  the  general  condition  of  the  ])atient.  In  ai)ex 
pneumonia  the  resolution  is  more  apt  to  be  retarded.  It  has  been  stilted 
thiit  bleeding  is  one  cause  of  delayed  resolution.  A  solid  exudation  can 
pei'sist  for  weeks  and  yet  the  integrity  of  the  lung  nuiy  be  ultimately  re- 
t^tori'd.  (irissole  describes  the  lung  from  a  ])atient  who  died  on  the  six- 
tieth day  in  which  the  atfected  part  looked  not  unlike  the  acute  disease. 

J Z».v«'.v.*(  may  result  from  purulent  infiltration  of  the  lung  tissue.  It 
occurred  in  4  of  my  100  cases.  Usually  the  lung  breaks  in  limited  areas 
ami  the  abscesses  are  not  large,  but  they  may  involve  a  considerable  por- 
tion of  a  lobe.  This  most  serious  complication  is  indicate(l  by  cavern- 
ous signs  and  the  expectoration  of  purulent  material  containing  elastic 
tissue.  The  constitutional  symptoms  are  usually  very  severe.  In  a  large 
majority  of  the  clinical  cases  in  which  abscess  of  the  lung  is  believed 
U:  follow  an  acute  pneumonia,  the  process  has  in  reality  been  rapid  tuber- 
culous consolidation  with  breaking  of  the  lung  tissue.  There  can,  how- 
ever, be  no  reasonable  doubt  that  abscess  of  the  lung  does  jtcur  as  a  rare 
se(iueuce  of  ordimiry  pneunu)nia. 

(r(i)if/rc)ie. — 'I'he  presence  of  this  com])li(>ation  is  rendered  evident  by 
the  horribly  fetid  odor  of  the  expectoration,  the  presence  of  lung  tissue, 
and  crystals  of  fatty  acids.     It  occurred  in  3  of  my  100  autopsies. 

Fibroid  Induration. — That  a  chronic  interstitial  pneumonia  may  fol- 
low the  ordinary  acute  disease  cannot  be  (|uestioned,  though  it  is  probably 
the  rarest  of  all  terminations.  It  was  present  in  one  of  my  100  autopsies. 
The  patient,  aged  fii'ty-eight,  died  on  the  thirty-second  day  after  the  initial 
chill.  The  right  lung  was  uniforndy  solid,  grayish  in  color,  firm,  and 
pi'csented  in  places  a  translucent,  smooth,  homogeiu'ous  aspect.  In  these 
areas  the  alveolar  walls  were  thickened  and  the  fibriiujus  plugs  filling  the 
air-eells  were  undergoing  transfornuition  into  a  new  growth  of  connective 
tissue. 

Mortality. — Pneumonia  is  one  of  the  most  fatal  of  acute  diseases. 
Hosjiital  statistics  show  that  the  mortality  ranges  from  twenty  to  forty 
per  lent  Of  1,012  cases  at  the  ^[ontreal  (ieneral  Hospital,  the  mortality 
was  ;.'U'4  per  cent.    It  appears  to  be  somewhat  more  fatal  iu  southern 


H. 


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562 


DISEASES  OP  THE  RESPIRATORY  SYSTEM. 


climates.  Of  3,900  ciises  treated  iit  tlie  Cliiirity  Hospital,  Xew  Oili.i„ig 
the  (leuth  rate  was  28'0l  ])er  cent.  It  has  ])eeii  iirj^ed  that  tlie  iiidiialitv 
in  this  disease  has  heeii  steadily  iiiereasiiig,  and  attenii)ts  have  heen  iniide 
to  co7inect  this  increase  with  the  expectant  plan  of  treatment  ut  jiroscnt 
in  vo{j;ue.  lint  the  careful  and  thorough  analysis  hy  C.  N.  Townsoiid  mikI 
A.  (-oolidge,  .Ir.,*  of  1,000  cases  at  the  Massachusetts  (reneral  lIo.Miital 
iiulicates  clearly  that,  when  all  cinnimstanccs  are  taken  into  considcrniiim 
this  conclusion  is  not  justified.  They  found  that  when  idl  fatal  casos 
over  fifty  years  of  ago  were  omitted,  and  those  patients  who  were  deliciiti', 
intem})erate,  or  the  subject  of  some  complication,  there  was  vei-y  little 
variation  from  decade  to  decade,  and  that,  excluding  these  cases,  the  rate 
was  but  little  over  ten  i)er  cent.  In  answer  to  the  assertion  that  tlie 
modified  treatment  is  in  part  responsible  for  the  increased  niortalitv.  those 
authors  show  clearly  that  the  rise  in  death  rate  took  place  in  the  jioriod 
prior  to  1800,  when  the  treatment  Mas  entirely  or  in  great  part  heroic. 

According  to  the  recent  anahsis  of  T08  cases  at  St.  Thomas's  Hospital 
by  Iladden,  JI.  \V.  G.  McKenzie,  and  W.  W.  Ord,  the  mortality  })r()giess- 
ively  increases  from  the  twentieth  year,  rising  from  ;{-7  i)er  cent  iiiider 
that  ago  to  22  per  cent  in  the  third  decade,  30'8  per  cent  in  the  foiu'th, 
47  per  cent  in  the  fifth,  51  per  cent  in  the  sixth,  05  })er  cent  in  the  sev- 
enth decade.  Of  223,730  cases  collected  by  Wells  from  various  sources, 
40,270  died,  a  mortality  of  18-1  per  cent. 

Diagnosis. — iSo  disea^^e  is  more  readily  recognized  in  a  large  majority 
of  the  cases.  The  extenud  characters,  the  sputa,  and  the  physical  signs 
combine  to  make  one  of  the  clearest  of  clinical  pictures.  vVfter  a  stiidv 
in  the  post-mortem  room  of  my  own  and  others'  mistakes,  I  think  that 
the  ordinary  lobar  ])neumonia  of  adults  is  rarely  overlooked.  Jiulgitii; 
from  my  autopsy  records,  I  shoidd  say  that  errors  are  i)articularly  liable 
to  occur  in  the  intercurrent  i)neumonias,  in  those  comnlicating  chnuiie 
affections,  ami  in  the  disease  as  met  with  in  children,  the  aged,  and 
drunkards.  Tul)erculo-]uieunionic  jdithisis  is  fre(pu^nt)y  confounded  with 
pneumonia.  I'leurisy  with  effusion  is,  I  believe,  not  often  mistaken  ex- 
cept in  children. 

In  diabetes,  Hright's  disease,  chronic  heart-disease,  pulmonary  phthisis, 
and  cancel*,  an  acute  pneumonia  often  ends  the  scene,  and  is  frequently 
overlooked.  In  these  cases  the  temperature  is  perhaps  the  best  index, 
and  should,  more  jiarticularly  if  cough  develops,  lead  to  a  careful  exami- 
nation of  the  lungs.  The  absence  of  expectoration  and  of  pulmonary 
symptoms  nuxy  make  the  diagnosis  very  difficult. 

In  children  there  are  two  special  sources  of  error;  the  disease  may  be 
entirely  nuisked  by  the  cerebral  symptoms  and  the  case  mistaken  for  one 
of  meningitis.  It  is  remarkable  in  these  cases  how  few  indications  there 
are  of  pulmonary  trouble.     The  other  condition  is  pleurisy  with  efTusion, 


*  Boston  Medical  and  Surgical  Journal,  1889. 


IP 

m 


PNEUMONIA. 


503 


wliiili  ill  diildivii  often  1ms  deceptive  pliysical  sifjiis.  The  breiitliiiig 
iiiiiv  l)e  intensely  tubuliir  and  tactile  freniitti.s  may  be  present.  'I'ho 
exploratory  neeiUo  is  sonietinies  reciuired  to  decide  tiie  qnestion.  In  the 
(lid  and  del)ilitate(l  a  kii()\vied<i;e  that  the  onset  of  ])neiuuonia  is  insidious, 
and  that  the  syniptoni.-  ,ire  ill-defined  and  latent,  should  place  the  [)racti- 
tidiuT  en  his  ^uard  and  make  him  very  careful  in  the  examination  of  the 
luiij:^  in  doubtful  cases.  In  chronic  alcoholism  the  cerebral  symptoms 
may  |iredominate  and  comi)letely  mask  the  local  disease.  As  mentioned, 
the  disease  may  assume  the  form  of  violent  mania,  l)ut  more  coinnionly 
the  symptoms  are  those  of  delirium  tremens.  In  any  case  rapid  pulse, 
rapid  resi>iration,  and  fever  are  symptoms  which  should  invariably  excite 
suspicion  of  inllammation  of  the  lungs. 

I'lu'iimonia  is  rarely  confounded  with  ordinary  consumption,  but  to 
diireivntiate  acute  tuberculo-pneumonic  phthisis  is  often  dillicult.  The 
ease  may  set  in  with  a  chill.  It  may  bo  impossible  to  determine  which 
condition  is  present  until  softening  occurs  and  elastic  tissue  and  tubercle 
bacilli  appear  in  the  sputum.  A  similar  mistake  is  sometimes  made  iu 
fliildrcM.  With  typhoid  fever,  ])neumonia  is  not  infre(piently  confounded. 
There  are  instances  of  i)neumonia  with  the  local  signs  well  marked  in 
which  the  i)atient  rapidly  sinks  into  what  is  known  as  the  ty})lioid  state, 
with  dry  tongue,  I'apid  pulse,  and  diarrluea.  Uidess  the  case  is  seen  from 
the  outset  it  may  be  very  dillicult  to  determine  the  true  nature  of  the 
malady.  On  the  other  hand,  there  are  cases  of  typhoid  fi'ver  which  set 
in  with  symptoms  of  lobar  pneumonia — the  so-called  pneumo-typluis.  It 
may  he  im[)ossible  to  make  a  dirt'erential  diagnosis  in  such  a  case  unless 
the  characteristic  eruption  develops. 

Treatment. — I'neumonia  is  a  self-limited  disease,  and  runs  its  course 
uuintlucnced  in  any  way  by  medicine.  It  can  neither  be  aborted  nor  cut 
short  by  any  known  means  at  our  command.  Even  undi'r  the  most  un- 
favorable circumstances  it  will  terminate  abruptly  and  naturally,  without  a 
dose  (d'  medicine  having  been  administered.  A  patient  was  admitted  into 
one  of  my  wards  at  the  riiiladelphia  Hospital  on  the  evening  of  the  seventh 
Jay  after  the  chill,  in  which  he  had  been  seen  by  one  of  my  assistants,  who 
had  ordered  him  to  go  to  hospital.  lie  remained,  however,  in  his  house 
alone,  without  assistance,  taking  nothing  but  a  little  milk  and  bread  and 
whisky,  and  was  brought  into  the  hospital  by  the  i)(dice  in  a  condition  of  act- 
ive delirium.  That  night  his  temperature  was  W'>°  and  his  pulse  above  I'-JO. 
In  his  tlelirium  he  came  near  escaping  through  the  window  of  the  ward. 
The  following  morning — the  eighth  day— the  crisis  occurred,  and  at  ward 
class  his  temperature  was  below  08".  The  entire  lower  lobe  of  the  right 
side  was  found  involved,  and  he  entered  upon  a  rapid  convalescence.  So 
also,  under  the  favoring  circumstances  of  good  nursing  and  careful  diet, 
the  experience  of  many  physicians  in  diflferent  lands  has  shown  that  pneu- 
monia runs  its  course  in  a  definite  time,  aborting  sometimes  spontaneously 
on  the  third  or  the  fifth  day,  or  continuing  until  the  tenth  or  twelfth. 


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DISKASI'IS  OF  THE   RESPIRATORY   SYSTEM. 


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Wo  have,  tlioii,no  specific  treatment  for  pnounioiiia.  Tlio  yoiiiiLj  prac- 
titioner may  bear  in  mind  tl)at  i)ati(Mit.s  arc  more  often  damaLTiil  tli;iii 
helped  Ijy  the  i)r()ini.seiious  (h'liy^iii^,  which  is  still  only  too  prevalent.  In 
cases  of  moderate  oeverity  a  purely  exi»ectant  jilan  maybe  followed- -keep- 
iiig  tlie  bowels  open,  reyulatinjf  the  diet,  and,  if  necessary,  giviii<: a  itevcr's 
])()wder  at  nie^lit  to  i)i'0('ure  sleep.  In  severer  cases  a  symi)toinatie  plan  of 
trealment  should  be  jtursued,  meeting?  the  indications  as  they  arise.  The 
first  distressing  symptom  is  nsutilly  the  j)ain  in  the  side,  which  mav  W 
relieved  by  local  de])letion — by  cupping  or  leecliing — or,  better  still,  hy  a 
hypodermic  injection  of  morjthia.  In  many  cas(!S  the  cpiestion  coiucs  nji 
at  the  outset  as  to  the  })ropriety  of  venesection.  The  reproach  (if  Vaii 
llelniont,  that  "a  bloody  Moloch  presides  in  the  chairs  of  medicine,"  eaii- 
iiot  be  brought  against  the  present  generation  of  physicians.  Diiriiiir  the 
first  five  decades  of  this  century  the  profession  bled  too  much',  but  duriiii.' 
the  last  decades  we  have  certainly  bled  too  little.  Pneumonia  is  one  of 
the  diseases  in  which  a  timely  venesection  nuiy  save  life.  'J'o  be  of  service 
it  i^hotihl  he  dona  earli/.  In  a  full-ldooded,  healthy  man  with  high  fever 
and  bounding  pulse  the  abstraction  of  from  twenty  to  thirty  ounces  of 
blood  is  in  every  way  benelicial,  relieving  the  pjiin  and  dyspnci'a,  reilneiiiL' 
the  temperature,  and  allaying  the  cerebral  symptoms,  so  violent  in  soiiie 
instances.  Unfortunately  bleeding  is  now  too  frequently  n.-',cd  at  a  lati^ 
stage  in  the  disease,  when  the  heart  is  beginning  to  ftiil,  the  riglit  ehain- 
bers  are  dilated,  the  face  is  of  a  dusky  hue,  the  respirations  are  very  rapiil. 
and  there  are  signs,  perhaps,  of  (edema  of  the  uninvolvcd  i)ortioiis  of  the 
lungs.  Though  resorted  to  rather  as  a  forlorn  ho})e,  it  is  a  rational  prac- 
tice, and,  in  em])hysema  and  in  lu'art-disease,  proves  siitisfactory  uiuler 
identical  hydraulic  indications,  but,  unfortunately,  in  a  majority  of  the 
cases  of  pneumonia  it  proves  futile.  Time  and  again,  in  such  cases,  liavi' 
I  urged  free  venesection,  but  in  twelve  hospital  patients  bled  under  tlie.^e 
circumstances  only  one  recovered.  The  indications  for  treatment  are  tu 
lower  the  temperature  and  to  support  the  heart. 

Fever  alone  is  not,  I  think,  hurtful ;  but  it  is  ditTicult  to  differentiate 
the  effects  of  fever  and  of  the  poisons  circulating  in  the  blood.  It  is  not 
impossible,  as  some  suppose,  that  the  fever  may  be  directly  benelicial: 
still,  high  and  prolonged  pyrexia  is  undoubtedly  dangerous  aiul  should  lie 
combated.  Of  eflicient  measures  cold  unquestionably  heads  the  list. 
Perhaps  the  nu)st  convenient  form  is  the  application  of  ice-bags  to  the 
affected  side — a  practice  long  followed  in  Germany  and  now  heeoinin,:: 
])revalent  in  England  and  America,  and  one  to  be  strongly  conunendcd. 
When  the  temperature  is  above  103°  or  103'5°  sponging  may  be  resorted 
to,  or  the  bath  at  70°. 

The  use  of  medicinal  antipyretics  in  pneumonia  is  of  doubtful  prn- 
priety.  Quinine  has  been  much  vaunted.  Personally  I  cannot  speak  of  any 
special  advantages  which  I  have  seen  from  its  use.  From  thirty  lo  sixty 
grains  daily  will  reduce  the  temperature,  in  a  certain  proportion  of  the 
cases,  one  or  two  degrees,  but  in  this  respect  it  is  far  below  other  antipy- 


PNEUMONIA. 


505 


ill 


rt'tica.  It  is  also  not  witliout  ill  cllVcts  in  disturbiiif,'  dij^ostion  or  own 
luusing  vomiting,  and,  according  to  some  writiTs — tliongli  this  1  have 
never  noti('t'(l — inducing  jiiarkcd  cardiac  weakness  and  depression.  Anti- 
pvrin,  antil'cl)rin,  and  plicnacctin  iiavc  liad  a  tliorongli  trial  in  imcumonia, 
iiiiil,  altliongli  tlioy  still  have  tlicir  advocates,  the  general  u])ini()n  of  clini- 
cal physicians  seems  decidedly  against  their  systematic  employment. 

The  progressive  cardiac  weakness  is,  after  all,  the  most  important 
oiieiiiv  to  light  i!i  pncnnionia  and  is  enij)hasizcd  by  the  old  axiom.  Sine 
pnlsii  )in//(i  t/irri(j)ci(t.  Doubtless  this  is  in  part  causi-d  l)y  the  fever,  but 
iiuieh  more  imi)ortant  is  the  toxic  action  of  the  po'sons  produced  in  the 
cdr.rse  of  the  disease.  To  these  must  be  a(hled  the  third  factor,  over- 
(listeiition  of  the  right  chambers  of  the  heart.  We  are  still  without  an 
agent  which  can  counteract  the  gradual  iidluence  of  the  jjoisons  which 
develop  in  the  course  of  acuto  tebrilc  diseases,  such  as  typlioid  fever, 
imeiiinonia,  and  dii)htheria,  the  chief  effect  of  which  is  exercised  upon 
the  circulation,  iiufroasing  the  rapidity  of  the  pulse  and  inducing  a  i)ro- 
jfressive  heart-failure.  To  meet  this  indication  the  general  ex[teriencc  of 
jihysieiaus  still  points  to  alcohol  as  the  most  trustworthy  ren.iedy.  Although 
seme  hold  that  alcohol  in  this  condition  is  not  indicated,  I  believe  that  it 
is  ill  many  instances  the  only  remedy  capable  of  tiding  the  patient  over 
t!ie  most  dangerous  period.  It  should  ,bo  given  when  the  i)ulsc  becomes 
small,  frequent,  and  feeble,  or  very  compressible,  and  when  the  heart- 
sounds — particularly  the  secoiul  pulmonii!  sound — begin  to  lose  their 
fnree.  The  amount  will  vary  with  the  ago  of  the  patient  and  with  his 
habits.  Beginning  with  four  to  six  ounces  of  whisky  in  ho  day  the  quan- 
tity may  be  increased,  if  necessary,  to  twelve  or  sixteen  ounces. 

Of  medicinal  agents  strychnine  is  one  of  the  most  valuable  aiul  has  come 
into  favor  as  a  useful  cardiac  tonic.  It  may  be  given  in  doses  of  from  a 
thirtieth  to  a  twentieth  of  a  grain.  Xo  certainty  has  as  yet  been  reached 
as  to  the  value  of  digitalis  in  the  failing  heart  of  fever.  TMie  practice  is 
very  general,  but  it  is  a  drug  to  be  used  with  caution.  Recently  it  has 
been  advocated  by  Petresco  as  having  almost  a  specific  action,  When 
there  are  signs  of  sudden  or  rapid  heart-failure,  hypodermic  injections  of 
ether  will  sometimes  prove  most  serviceable.  Of  other  stimulants  am- 
monia is  one  of  the  most  valuable  and  is  best  given  in  the  form  of  the 
aromatic  spirits,  which  is  quite  as  satisfactory  and  much  less  nauseous 
tlian  tlie  usiudly  administered  carbonate  of  ammonia.  Camphor  and  niysk 
luay  also  be  employed. 

Following  the  ])ractice  which  is  employed  in  spreading  erysipelas,  some 
writers  have  recommended  direct  antiseptic  injections  into  the  lung  tissue 
itself.  Lepine  has  used  with  benefit  very  dilute  bichloride  injections.  In 
cases  of  gangrene  following  pneumonia,  it  might  be  of  advantage  to  use 
iodoform  oil  or  bichloride  solutions. 

The  question  of  the  use  of  arterial  sedatives  has  not  yet  been  settled. 
Aconite  and  veratrum  viride  and  tartar  emetic  are  largely  used  and  loudly 
recommended  by  many  i)hysicians.     I  have  never  seen  such  benefit  from 


I'M: 


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DISK  ASKS  OF  THE  RESPIIIATORY  SYSTEM. 


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tlicir  curly  uso  tin  would  warrant  a  rocotnrnciKlatioii,  and  when  an  iirhriul 
si^iativc  i.s  indicati'd  in  tlio  robust,  full-blooded,  luultliy  individual,  I  inucli 
prul'or  tlio  lancet. 

Ex  pec  to  rants  are  rarely  of  any  value  in  pneumonia.  If  any  one  wlAwi 
to  bo  (!onvinced  of  the  futility  of  such  retiiedie.s,  let  liiiii  .study  tlieir  mi  tion 
on  a  series  of  cases  of  stlu'uic  |ineuiuonia,  in  v.liich  it  would  be  a  real  'saui 
to  loo.sen  the  couj,'h  and  ^Mve  to  the  sputa  a  certain  de^Mve  of  lliiidit  v.  Ndr 
in  the  st^igo  of  resolution  can  they  be  said  to  bo  of  any  special  service.  In 
cases  of  tardy  resolution  I  have  not  hesitated  to  uso  j>ilocar])ine,  as  siif;. 
gested  by  Kiess. 

For  the  distressing  cough  and  the  jjain  in  the  side,  opium  in  .^onic  fdriii 
may  be  given,  either  the  hy])o(lerniic  of  morphia  or,  for  the  cough  aloiic, 
Dover's  powder.  There  has  been  a  feeling  in  the  jjrofession  that  opium  was 
counter-indicated  in  pneumonia,  but  I  fully  agree  with  Loomis  that  it  may 
be  given  with  safety  and  with  the  greatest  comfort  to  th(^  ])atieiit.  With 
marked  cerebral  symptoms  an  ice-cap  imiy  be  used.  If  there  is  delirium,  tlio 
patient  should  bo  carefully  watched.  For  these  .symptoms  the  cold  bath  is 
by  far  the  most  etticient  remedy,  aiul  it  or  the  cold  pack  should  be  rt'sorted 
to  without  hesitation.  For  the  com])lications,  in  the  more  serious  onos, 
such  as  meningitis  and  endocarditis,  but  little  can  be  done.  I'lcurisy 
with  largo  effusion  may  re(piire  as])iration.  If  there  is  doubt  as  to  tlie  ex- 
istencc  of  fluid  the  exploratory  needle  should  be  used.  It  may  bo  tiece.s- 
sary,  in  pericanlitis  with  extensive  elfusion,  to  asi)irato  the  sac. 

Careful  feeding  f(»rms  an  essential  part  ''f  the  treatment.  The  diet 
should  be  light  and  made  up  of  articles  which,  while  nourishing,  are  not 
heavy  and  imt  apt  to  induce  flatidency.  Milk  or  milk-whey,  broths, 
beof-juice,  and  eggs  constitute  the  nuiiii  articles  of  food.  The  starchy 
articles,  as  a  rule,  should  bo  excluded,  bo(!ausc  thoy  tend  to  induce  llatii- 
lency.  If  the  milk  also  has  this  effect,  it  is  better  to  use  the  whey  ami 
egg-white  or  beef-juices.  Before  leaving  the  question  of  diet  it  may  be 
mentioned  that  the  use  of  cold  drinks,  such  as  soda  or  Apollinaris  water, 
not  only  gives  relief  to  the  distressing  thirst,  hut  also  helps  to  reduce  the 
fever,  and  may  diminish  slightly  the  viscidity  of  the  expectoration. 


I^-^^I 


III.  CHRONIC  INTERSTITIAL  PNEUMONIA 

(Cirrhosis  of  Lung — Fibroid  Phthisis.) 

This  consists  in  the  gradual  substitution  to  a  greater  or  less  extcMit  of 
connective  tissue  for  the  normal  lung.  It  is  a  fibroid  change  Avhicli  may 
have  its  starting-point  in  the  tissue  about  the  bronchi  and  blood-vessels, 
the  interlobular  septa,  the  alveolar  walls,  or  in  the  pleura.  So  diverse  are 
the  different  forms  and  so  varied  the  conditions  under  which  this  cliaiigo 
occurs  that  a  proper  classification  is  extremely  difficult.  AVe  may  recog- 
nize, however,  two  chief  forms — the  local,  which  involves  only  a  limited 


if'f  K 


CiniONIC  INTKRSTITIAL  PXKrMON'lA. 


aro!i  of  tho  lung  sulwtunco,  und  the  dilfusr,  inviuliii},'  fitluT  both  lim<»s  or 
nil  rutin'  orjraii. 

Etiology.  —  ^'"'"''  tihmid  cliiiiiijc  in  the  ]u\\<iA  is  comiiioii.  It  \f  a 
(•(in>t;iiir  m'coiii|iiiiiiiiU'iit  of  tiilu-rclc  and  in  i'Vitv  ciiso  of  phthisis  tho 
cliriinic  intiTstitiul  (•han<,'i'S  phiy  a  very  important  ni/f.  in  tumors,  al)- 
scts-:,  (,nnnmata,  hythitids,  and  i-mpliysema  it  also  occurs.  Filu-oid  pro- 
ocssi'S  arc  frc(|ucntly  met  with  at  the  apices  of  tlic  hin^r  and  may  Ik'  duo 
c'itlicr  to  a  limitiMl  heak'd  tuberculosis,  to  fibroid  iiuluration  in  consc- 
(|iu'Mcc  of  pigment,  or,  in  u  few  instances,  may  result  from  thickeniuy  of 
the  pleura. 

Diffioic  Interslitifd  Pneiimorin  is  met  with  under  t]w  following  cir- 
cumstances: 1.  Asa  sequence  of  acute  tibrinous  pneumonia.  Although 
extremely  rare,  this  is  recognized  as  a  possible  ti-rminalion.  From  un- 
known causes  resolution  fails  to  tak(*  place.  A  gradual  process  of  organ- 
ization goes  on  in  the  librinons  plugs  within  the  air-(!ells  and  the  alveolar 
Willis  become  greatly  thickened  by  a  new  growth,  first  of  nuclear  and 
sul)se(iuently  lil)rillatcd  connective  tissue.  Macroscojiically  there  is  pro- 
duced a  smooth,  grayish,  homogeneous  tissue  whicdi  has  tlie  peculiar  translu- 
eeiK  y  of  all  new-formed  connective  tissue.  This  has  been  called  gray  in- 
duration. I'he  subseipient  history  of  tliis  form  needs  more  careful  study. 
A  majority  of  the  cases  terminate  within  a  few  months,  and  instances 
wliiili  ha\e  been  followed  from  the  outset  are  very  rare. 

In  oiu^  of  Charcot's  cases,  quoted  by  liastian,  death  occurred  about 
three  months  and  a  half  after  the  onset  of  the  acute  disease  and  the  lung 
was  two  tliirds  the  nornnd  size,  grayish  in  color,  and  hard  as  cartilage.  In 
the  only  case  of  the  kind  which  has  come  under  my  observation,  the  pa- 
tient died  about  a  month  from  the  onset  of  the  chill.  The  lung  was  uni- 
feniily  solid  and  grayish  in  color.  In  certain  I'egions  the  fibrinous  moulds 
ill  the  air-cells  Avere  fatty,  while  in  others  there  were  areas  of  a  grayish 
tnuislucent  aspect,  firm,  smooth,  not  at  all  granular,  and  resembling  recent 
cdiiiieetive  tissue.  Microscopically,  these  areas  showed  advanced  tibroid 
chiiiige  and  great  thickeniiig  of  the  alveolar  walls,  while  the  fibrin  plugs 
of  die  air-cells  were  undergoing  fibroid  transformation. 

'i.  (Itronic  lironchn-PncKmonia. — The  relation  of  broncho-pneumonia 
to  eirrhosis  of  the  lung  has  been  specially  studied  by  Charcot,  who  states 
tluit  it  may  follow  the  acute  or  subacute  form  of  this  disease.  The  fibrosis 
extends  from  the  bronchi,  which  are  usually  found  dilated.  The  alveolar 
Willis  are  thickened  and  the  lobules  converted  into  firm  grayish  nnisses, 
in  which  there  is  no  trace  of  normal  lung  tissue.  This  process  may  go  on 
ami  involve  an  entire  lobe  or  even  tho  whole  lung.  Many  of  these  cases 
are  tiiherculous  from  the  outset. 

0.  Ph'urofjenous  Interstitial  Pneumonia. — Charcot  applies  this  term 
to  that  form  of  cirrhosis  of  the  lung  which  follows  invasion  from  the 
pleura.  Doubt  has  been  expressed  by  some  writers  whether  this  really 
occurs.    While  Wilson  Fox  is  probably  correct  iu  questioning  whether  aa 


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niSEASKS  OF  THE   IlESIMHATOUY  SYSTEM. 


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entire  liin;^  ciiii  iH'cornc  rirrlioHcd  l»y  the  ^ra«lii!il  inviisioii  from  t.li(  iilciira 
I  lliiiik  llirrt!  ciiii  1)0  IK)  (Iniilit  tliiit  tluTi!  arc  instances  of  priiriiiisc  dry 
j)ii;iiii.-iy,  wliicli,  us  Sir  Andrew  (Mark  Inis  pointed  out,  j^n-adiiallv  <oiii. 
presses  tiiu  lung  and  at  the  same  time  leads  to  interstitial  cirrhosis.  Tlii.^ 
iniiy  he  duo  in  part  to  the  fihroid  change  which  follows  prolongcil  cdin. 
j)ression.  In  somo  cases  there  seems  to  he  a  <li.;tinct  conn<'ction  hituccn 
the  greatly  ihickeiUMJ  pleura  and  the  dense  strands  of  lihroiis  tissue  pass- 
ing from  it  into  tho  lung  suhstancc.  Instances  occur  in  whicii  one  loljo 
or  tho  greater  part  of  it  j)resents,  on  section,  a  mottled  ai)])earaiic( ,  owinjr 
to  the  increased  thickness  of  the  interlohular  .septa — a  condition  which 
may  exist  witliout  a  trace  of  involvment  of  the  pleura.  In  miinv  other 
cu.ses,  however,  the  extension  .seems  to  he  .so  detinitely  a.ssociatccl  with  plcii- 
risy  that  there  is  no  douht  as  to  tin*  cau.sal  connection  hetween  the  two 
proces.se.s.  In  these  instances  tho  lung  is  removed  with  great  dillicuitv, 
owing  to  tho  thickness  and  close  adhesion  of  the  pleura  to  the  chest  wiill. 

4.  aitrouic  liiterslititil  J'linniKDiid,  due  to  inhalation  of  dust.  Zenker 
has  propo.sed  tho  term  jniniDKimtk-oiiidsin  for  the  group  of  diseases  due  to 
tho  irritating  etlects  oi'  dust  in  certain  occupations,  such  as  eoal-niiiiin;,', 
stone-cutting,  axe-grinding,  and  working  in  iron  dust.  It  is  essentiiilly  ii 
chronic  l)ronclio-pneumonia  leading  to  lihroid  induration,  at  first  noihijar 
and  perihronchial,  and  linally  involving  large  areas  of  the  lung  tissue, 
which  are  converted  into  dense  gniyish-hrown  or  black  nuisses.  The  sub- 
ject will  receive  sei)arate  consideraticm. 

The  term  cirrhosis  should  he  limited  strictly  to  those  cases  in  v.liifh 
a  lung  is  involved  in  the  tihroid  process,  whether  originating  in  tlio 
])arenchyma  or  in  the  pleura.  It  should  not  he  applied  to  fihroid  phthisis 
of  tuberculous  origin. 

Morbid  Anatomy. — The  disease  is  unilateral;  tho  chest  of  the 
affected  side  is  sunken,  deformed,  .ind  tlie  shoulder  much  depressed.  On 
opening  the  thorax  the  hcnirt  is  seen  drawn  far  over  to  the  alTected  side, 
The  unatfected  lung  is  emi)hysennitous  ,ind  covers  the  greater  portinii  nf 
the  mediastinum.  It  is  scarcely  credible  in  how  .omall  a  space,  close  to 
the  spim-,  the  cirrhosed  lung  may  lie.  Indeed,  it  may  be  overlooked,  as 
happened  in  the  case  of  a  physician  of  my  ac(|uaintance,  who  left  instnie- 
tions  that  his  lung  should  be  sent  to  Palmer  Howard,  of  Montreal.  It 
was  reported,  however,  that  at  the  antop.sy  no  lung  could  be  found  I  Tho 
adhesions  between  the  pleural  mo:nbranes  may  bo  extremely  dense  ami 
tbiek,  particularly  in  the  pleurogenous  cases;  but  Avhen  the  disease  ha? 
originated  in  the  lung  there  may  bo  little  thickening  of  the  pleura.  The 
organ  is  airless,  firm,  and  hard.  It  strongly  resists  cutting,  and  on  sectieii 
shows  a  grayish  fibroid  tissue  of  variable  amount,  through  which  jiass  the 
blood-vessels  and  bronchi,  ''lie  latter  may  be  cither  slightly  or  oimr- 
mously  dilated.  There  are  instances  in  which  the  entire  lung  is  converted 
into  a  .series  of  bronchiectatic  cavities  and  the  lirrhosis  is  apparent  tnih 
in  certain  areas  or  at  the  root.     The  tuberculous  cases  can  usually  be 


CHRONIC   IN'TKUSTITIAIi    PXHIMONIA. 


r.c.o 


ililT»'ivntiiittil  by  tlio  iiri'sonco  »»f  iiii  upiciil  cuvity,  not  hroiu-liicctutu',  and 
oft'ii  liirj^'c;  and  the  other  hitij,'  ahimst  invariably  siiowx  tuhrr.'nhuis 
If-iidiin.  'I'licrc  an-  cases  in  wiiicii  it  is  dillieult  to  ih'terniine  satisfactorily 
tile  true  nature.  A  iiuestio?!  <tf  some  interest  in  eunneetidn  with  eiironii! 
interstitial  |)nt'unionia  is,  Do  Hofteniiig  and  cavity  t'ornuiti(»ii  ever  occur 
a|iart  from  easeution  and  tid)erenlusis ?  'I'liat  is  to  say,  uro  there- cavities 
ill  ;i  cirrholie  Inn;;  which  may  i)e  due  to  a  simple  necrosis y  rndoulttedly, 
tliuii;;h  they  are  .'are;  I  have  seen  them  in  at  least  two  instances  of  tin- 
thraeosis,  ami  Charcot  *  refers  to  them  as  "■  iilrercs  tin  jxiinnou,'"'  U>  d'\n- 
tiii;,'aish  them  from  the  ubseoss  cavity  (»f  acuto  pneunioniii  or  a  tuberculous 
cavity.  Tho  other  Inn;,'  is  always  ^jjreatly  eidar;;ed  and  einphysetmitctus. 
The  heart  is  hy|tertropliied,  particularly  the  ri;,dit  ventricle,  and  there 
may  he  marked  atheronuitous  changes  in  tho  j)ulmonary  artery.  Au 
amyloid  condition  of  tho  visoera  is  found  in  soino  cases. 

Symptoms  and  Course. — It  is  essentially  a  chronic  disease,  ex- 
teiiiliiii,^  over  a  period  of  nuiiiy  years,  aiul  when  once  the  condition  is 
estalilished  the  health  nuiy  l)e  fairly  jf(»od.  In  a  well-marked  ease  tiio 
jiatieiit  e(mij)lains  only  of  liis  chronic  con<jh,  perhaps  of  slight  shortness 
(it  lireatli.  In  other  res|)ects  he  is  quite  well,  and  is  usually  able  to  do 
light  work.  The  cases  are  coinmoidy  regarded  as  phthisical,  though  there 
may  he  scanjely  a  symptom  of  that  alVection  except  the  cough.  There 
are  ii\stances,  however,  of  libroid  phthisis  which  cannot  he' distinguished 
from  cirrhosis  of  tho  lung  except  by  tho  ])reseiico  of  tubercle  bacilli  in 
the  expectoration.  As  tho  bronchi  are  usually  dilated,  the  symptoms  and 
physical  signs  may  be  those  of  bronchiectasis.  The  cough  is  paroxysmal 
luul  the  exiieetoration  is  generally  coi)ious  and  of  mnco-jiurnlent  or  sero- 
piiruleut  nature.  It  is  sometimes  fi'tid.  I  hemorrhage  is  by  no  means 
iiifrci|Uent,  and  occurred  in  mon^  than  one  half  of  the  cases  amdyzed  by 
Rastian.  Walking  on  the  level  and  in  the  ordinary  alTairs  of  life  the  jiatient 
may  show  no  shortness  of  breath,  but  in  the  ascent  of  stairs  and  on  exer- 
tion there  nuiy  be  dys])na'a. 

Physical  Signs. — Inspection. — Tho  alTectcd  side  is  immobile,  retracted, 
ami  shrunken,  and  contrasts  in  a  striking  way  with  tho  voluminous  sound 
siile.  The  intercostal  spaces  are  obliterateil  and  the  ribs  may  even  over- 
lap. The  shoulder  is  drawn  down  and  from  behind  it  is  seen  that  the 
spine  is  bowed.  Tbo  heart  is  greatly  displaced,  being  drawn  over  by  the 
slu'iiikago  of  tho  lung  to  the  affected  side.  AVlien  the  left  lung  is  alfected 
tliere  may  bo  a  large  area  of  visible  impulse  in  the  second,  third,  and 
f'liu'tli  intersi)aces.  ^lensuration  shows  a  great  dimiinition  in  flic  alfected 
.«iiU',  and  with  the  saddle-tape  the  oxpansion  may  be  seen  to  be  negative. 
The  prrruftsion  note  varies  with  the  condition  of  tho  bronchi.  It  may  be 
absolutely  dull,  particularly  at  tho  base  or  at  tlie  apex.  In  the  axilla 
tliore  imiy  be  a  Hat  tympany  or  even  an  amphoric  note  over  a  largo 

*  CEuvres  cotnplules  do  J.  M,  Charcot,  tomo  v,  p.  18!). 


I 


H' 


;y. 
i  '•  '■ 

i       !l        1 

i 


ti'ih*  lit    I 


;|i 


h 

i 


'HI 


'    i  ■  I        '< 
III.    '   ■'.   ^ 


-m 


H  ,  'i 


f,  V'Se^ 


570 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


:"h 


ri 


iii 


■Ml 


sacculated  bronoliiis.  On  tlie  opposite  side  tlie  percussion  zxoiv.  k  i,,-  i-iUv 
liyperrosonant.  On  auscnUafion  tlie  breath-sounds  have  either  ;i  cav- 
ernous or  anijdioric  quality  at  the  apex,  and  at  the  base  are  fochlc,  witli 
mucous,  bubbling  rales.  The  voice-souiuls  are  usually  exa<r,<]:eratiil.  Car- 
diac murmurs  are  not  uncommon,  particularly  late  in  the  disease,  wlu'n 
the  right  heart  fails.  These  are,  of  course,  the  jjliysical  t-igns  of  tin-  ilis- 
ease  when  it  is  well  established.  They  naturally  vary  consideralil  v.  ac- 
cording to  the  stage  of  the  process.  'J'he  disease  is  essentially  cliniiiic 
aiul  may  jjcrsist  for  lifteen  or  twenty  years.  Death  occurs  sometiuK-  from 
haMnorrhage,  more  commonly  from  gradual  failure  of  the  right  heart  with 
dropsy,  and  occasionally  from  amyloid  degeneration  of  the  organs. 

The  lUaynosis  is  never  dillicult.  It  nuiy  be  impossible  to  say,  without 
a  clear  history,  whether  the  origin  is  pleuritic  or  pneumonic.  IJetwcen 
cases  of  this  kind  and  libroid  ]>hthisis  it  is  not  always  easy  to  discriininutf, 
as  the  conditions  may  l)e  .dmost  identical.  When  tiU)erculosis  is  present. 
however,  even  in  long-standing  cases,  bacilli  are  usually  present  in  the 
sputa,  and  there  may  be  signs  of  disease  in  the  other  lung. 

Treatment. — It  is  oidy  for  an  intercurrent  affection  or  for  an  agirra- 
vation  of  the  cough  that  the  patient  seeks  relief.  Nothing  can  ho  (idiu' 
for  the  condition  itself.  When  possible  the  patient  should  live  in  a  mild 
climate,  and  should  avoid  expo.sure  to  cold  and  damp.  A  (li-trcssiiifr 
feature  in  some  cases  is  the  putrefaction  of  the  contetits  of  the  dilatod 
tubes,  for  which  the  same  measures  may  be  used  as  in  fetid  bronchitis. 


Wv 


■]^v  m    ;, 


'•         i: 


l\^ 


*^5 


IV.    BRONCHO-PNEUMONIA   (CapiUary  BronchUia). 

This  is  essentially  an  inflammation  of  the  terminal  bronchus  and  the 
air-vesicles  which  make  up  a  })ulmonary  lobule,  whence  the  term  l)niii<'lio- 
pneumonia.  It  is  also  known  as  h)bular,  in  contradistinction  to  lobar  iniiu- 
monia.  The  t;'rm  catarrhal  is  less  applicable.  The  process  begins  in  nil 
cases  with  an  inilainmation  of  tiie  capillary  bronchi,  which  is  a  conditio:! 
rarely  if  ever  found  without  inv(dvement  of  the  hjbidar  structures,  so  that 
it  is  now  customary  to  consider  the  att'ections  together. 

Etiology. — lironcho-pneumonia  is  as  a  rule  a  secondary  allVctidn 
met  with  under  the  following  circumstances  : 

1.  As  a  se(iuencc  of  the  infectious  fevers — measles,  diphtheria,  whoop- 
ing-cough, scarlet  fever,  and,  less  frequently,  snudl-pox,  erysipelas,  and 
typhoid  fever.  In  children  it  forms  the  most  serious  comi)licatioa  of 
these  diseases,  and  in  reality  causes  more  deaths  than  are  due  directly  to 
the  fevers.*  In  large  cities  it  ranks  next  in  fatality  to  infantile  (lianho'ii. 
Following,  as  it  does,  the  contagious  diseases  which  principally  alTcct 
children,  we  find  that  a  large  nuijority  of  cases  occur  during  esuly  life. 

•  Cyclopaedia  of  the  Diseases  of  Children,  vol.  ii. 


I3t»>^.^ 


W\ 


BRONClIO-rNEUMONIA. 


571 


secoiulurv  atTectiou 


Accordinp^  to  I^forrill's  Boston  statistics,  it  is  most  fatal  (liiriiiu;  tlio  first 
two  years  of  life.  Tlio  nuinlx'r  of  cases  in  a  coinimiiiity  increases  or  de- 
cM'cnses  with  tiic  ])rcvaleiice  of  measles,  scarU't  fever,  ami  ('.ipliUieria.  It  is 
iiidst  prevalent  in  tlie  winter  and  si)ring  months.  In  the  febrilo  aiTections 
of  iitiiilts  broncho-pneumonia  is  not  very  common.  'I'luis  in  typhoid  fever 
it  i'  not  so  frecpiont  as  lobar  pneumonia,  though  isolated  areas  of  (^onsoli- 
(liitiou  at  the  bases  arc  by  no  means  rare  in  j)rotracti'd  cases  of  tiiis  disease. 
In  old  po<i])le  it  is  an  extremely  common  alTection,  following  (h'bilitating 
causes  (if  any  sort,  and  supervening  in  the  course;  of  chronic  IJright's  dis- 
ease and  various  acaito  and  chronic  maladies. 

2.  In  the  second  division  of  this  ail'ection  are  embraced  the  cases  of 
so-cidied  aspiration  or  dcgluliliou  ])neunionia.  Whenever  the  sensitive- 
ness of  the  larynx  is  beinina])ed,  as  in  the  coma  of  apoplexy  or  unemia, 
minute  particles  of  food  or  driid<  are  allowed  to  ])ass  the  riiiid,  an<l,  reach- 
ing fhially  the  smaller  tidx's,  excite  an  intense  inilainmalidu  similar  to  the 
vagus  ])neujnonia  Avhicli  follows  tlie  section  of  tlu;  ])iu'uniogaslries  in  the 
(log.  Cases  are  very  common  after  o])erations  about  tlie  mouth  and  nose, 
after  tracheotomy,  and  in  cancer  of  tlie  larynx  and  (esophagus.  'I'he 
aspirated  ])articles  in  somo  instaiuies  induce  such  un  intense  brouoho- 
piU'Uiiionia  that  suppuration  or  even  gangrene  supervenes. 

,\u  inspiration  broncho-pneumonia  may  follow  liaMuoptysis  (which 
has  been  already  considered),  the  as])iration  of  material  from  a  bronchicc- 
tiitic  cavity,  and  occasionally  the  material  from  an  emjiyemu  whii.-h  has 
ruptured  into  tlie  lung. 

;i.  The  most;  common  and  fatal  form  of  broncho-pneumonia  is  that 
excited  by  the  tubercle  bacillus,  which  has  already  been  considered. 

Among  general  predisposing  causes  may  be  mentioned  age.  As  just 
iiiiteil.  it  is  Drone  to  attack  infants,  and  a  majority  of  cases  of  pneumonia 
ill  children  under  live  years  of  ago  are  of  this  form.  At  the  opposite 
cxtivnie  of  life  it  is  also  common,  in  association  with  various  deliilitating 
cinMiiiistances  and  with  the  clironic  diseases  incident  to  the  old.  In 
eliildren,  rickets  and  diarrluea  are  marked  jiredisposing  causes,  and  bron- 
ilio-iniounionia  is  one  of  the  most  fre(pient  post-mortem-room  lesions  in 
infants'  iiomes  and  foundling  asylums.  The  disease  prevails  most  exten- 
sively among  the  poorer  classes. 

Morbid  Anatomy. — <  )ii  the  iikniral  surfaces,  particularly  toward  the 
Itiise,  are  seen  depressed  bluish  or  blue-brown  areas  of  collapse,  between 
whicli  the  lung  tissue  is  of  a  lighter  color.  Here  and  there  are  {irojecting 
lioi'tioiis  over  which  tlie  pleura  may  be  slightly  turbid  or  granular.  The  lung 
i>  fuller  and  firmer  tiian  normal,  and,  though  in  great  jiart  (;repitant,  there 
<;ni  lie  felt  in  places  throughout  the  substance  solid,  nodular  bodies.  The 
iliuk  depressed  areas  may  be  isolated  or  a  large  section  of  one  lobe  may  be  in 
the  eoiulition  of  collapse  or  atelectasis.  (Jradual  inllation  by  a  blow-jiijie 
inserted  in  the  bronchus  will  distend  a  great  majority  of  these  (collapsed 
ureas.  On  section,  the  general  surface  luis  a  dark  reddish  color  and  usu- 
37 


.-  'If* 


I'  1 1 


',  I 


s'jSfi 


pi ;  !, 


id ' 


V   *' 


572 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


ally  (Ivips  blood.  Projecting  above  tlie  level  of  the  Reotion  are  li,f;li((r  ml 
or  reililish-gray  areas  representing  the  patches  of  broncho-pneiiiiKniia. 
These  may  be  isolated  and  separated  from  each  other  by  tracts  of  nnin- 
flamed  tissue  or  they  may  be  in  groups  or  the  greater  part  of  a  Idhr  mav 
be  involved.  Study  of  a  favorable  section  of  an  isolated  2)atch  shows:  (lA 
A  dilated  central  bronchiole  full  of  tenacious  purulent  mucus.  A  fdiiu- 
nate  section  parallel  to  the  long  axis  may  show  a,  racemose  arrangfiiu'iit— 
the  alveolar  passages  full  of  muco-pus.  [h)  Surrounding  tlic  l)r(iiKliiis 
for  from  .3  to  5  mm.  or  even  more  is  an  area  of  grayish-red  consolidation, 
usually  elevated  above  the  surface  and  firm  to  the  touch,  riilikf  tlii' 
consolidation  of  lobar  pneumonia,  it  may  present  a  perfectly  smooth  sur- 
face, though  in  some  instances  it  is  distinctly  granular.  Jn  a  late  Kta|:coi 
the  disease  small  grayish- white  points  may  be«een,  which  on  pressure  niiiv 
be  sfiueezed  out  as  purulent  droj)lcts.  A  section  in  the  axis  of  the  lohiilf 
may  present  a  somewhat  grape-like  arrangement,  the  stalk  and  stems 
representing  the  bronchioles  and  alveolar  jjassages  filled  with  a  yellowisli 
or  grayish-Avhite  pus,  while  surrounding  them  is  a  reddish-l)ro\vn  iie]iatized 
tissue,  (r)  In  the  immediate  neighborhood  of  this  peribronchial  intlam- 
mation  the  tissue  is  dark  in  .'olor,  smooth,  iiirless,  at  a  sonu'what  l((\ver 
level  than  the  hepatized  portion,  and  diJTers  distinctly  in  color  and  ap- 
pearance from  the  other  portions  of  the  lung.  This  is  the  condition  to 
Avhich  the  term  splenizatwn  has  been  given.  It  really  rei)rescuts  a  tissue 
in  the  early  stage  of  inflammation,  aiul  it  i)erhaps  would  be  as  well  to  <rive 
up  the  use  of  tiiis  term  and  also  that  of  CKrnifiratioit,  which  is  only  ii  iiu  re 
advaiu'cd  stage.  'J'ho  condition  of  collapse  probably  always  precedes  tliis, 
and  it  is  diflicult  in  some  instances  to  tell  the  difference,  as  one  shades  into 
the  other.  In  fact,  collapse,  splenization,  and  carnitication  are  but  pre- 
liminary steps  in  bronclio-iuieumonia. 

Wiiile,  in  numy  cases,  the  areas  of  broncho-pneumonia  present  a  red- 
dish-brown color  and  are  indistinctly  granular,  in  others,  particnhirly 
in  adults,  the  nodules  nuiy  resendde  more  closely  gray  hepatization  and 
the  air-cells  are  filled  with  a  grayish,  muco-purnlent  material.  Miiuite 
haMuorrhages  are  sometimes  seen  in  the  neighborhood  of  the  iutlanied 
areas  or  on  the  pleural  surfaces.  Emphysema  is  commonly  seen  iit  tiie 
anterior  borders  and  upper  portions  of  the  lung  or  in  lobules  adjaeeiit  to 
the  inflamed  ones.  In  many  cases  following  diphtheria  and  measles  the 
process  is  so  extensive  that  the  greater  part  of  a  lobe  is  involved,  and  it 
looks  like  a  case  of  lobar  he})atiz.  tion.  It  has  not,  however,  the  unil'orm- 
ity  of  this  affection,  and  collapsed  dark  strands  nuxy  be  seen  between  ex- 
tensive areas  of  he})atized  tissue. 

There  are  three  groups  of  cases:  (1)  Those  in  which  the  brnneliitis 
and  bronchiolitis  are  most  marked,  and  in  which  there  may  be  m<  deiinitc 
consolidation,  and  yet  on  microscopical  examination  many  of  the  alveolar 
passages  and  adjacent  air-cells  appear  filled  with  intlamnuitory  products. 
(2)  The  disseminated  broucho-pueumonia,  iu  which  there  are  scattered 


BRONCHO-PNEUMONIA. 


678 


aroii>  of  peribronohial  hepatization  with  patches  of  collapse,  while  a  con- 
si(li-r;iblo  proportion  of  tiio  lobe  is  still  f'rej)itant.  This  is  hy  far  the  most 
conniinu  condition,  {'.i)  Psendc-loljar  form,  in  which  tiie  greater  portion 
of  till'  lobe  is  consolidated,  but  not  nniforndy,  for  intervening  strands  of 
(lark  congested  lung  tissue  separate  the  groups  of  he})atized  Idbules. 

Microscopically,  the  centre  of  the  bronchus  is  seen  tilled  with  a  plug 
of  I'.xuilation,  consisting  of  leucocytes  and  swollen  ei)itheliuni.  Section  in 
tlio  long  axis  may  show  irregular  dilatations  of  the  tube.  The  bronchial 
wull  is  swollen  and  infiltrated  with  cells.  Under  a  low  power  it  is  readily 
swii  that  the  air-cells  next  the  bronchus  are  most  densely  filled,  while 
toward  tin  perii)hery  of  the  focus  the  alveolar  exudation  becomes  less. 
Tilt'  contents  of  the  air-cells  are  made  up  of  leucocytes  and  swollen  endo- 
thelial cells  in  varying  proportion.  Kcd  corpuscles  are  not  often  present 
ami  a  tibrin  network  is  rarely  seen,  though  it  may  be  present  in  some  alve- 
oli. In  the  swollen  walls  are  seen  distended  ca])illaries  and  numerous  leuco- 
cyte?. As  Delatield  has  pointed  out,  the  inter.stitial  inflammation  of  the 
bnniclii  and  alveolar  walls  is  the  special  feature  of  broncho-pneumonia. 

The  histological  changes  in  the  aspiration  or  deglutition  broncho- 
pneumonia differ  from  the  ordinary  post-febrile  form  in  a  more  intense 
infiltration  of  the  air-cells  with  leucocytes,  producing  su])])uration  and 
foci  of  softening,  and  even  tending  to  gangrene. 

The  organisms  most  commonly  found  in  broncho-pneumonia  are  the 
mirroroccns  lanceolafiis,  the  xtreptocorcufi  pyogenes  (either  alone  or  with  the 
tirst-named  pneumococcus),  the  .sff/pJ/i/lococcufi  aureus  et  albus,  and  Fried- 
liinder's  bacillus  jinenmonim.  The  Klebs-Loetlier  bacillus  is  not  infre- 
quently found  in  the  secondary  lesions  of  diphtheria.  Except  the  pneu- 
moeoccus  these  microbes  are  rarely  fouml  in  pure  cultures.  In  the 
lobular  type  the  streptococcus  is  the  most  constant  organism,  in  the 
pseudo-lobar  the  pneumococcus.  Mixed  infections  are  almost  the  rule  in 
broiuiho-pneumonia. 

Hrimcho-pneumonia  may  terminate  (1)  in  resolution,  vdiich  when  it 
oneo  begins  goes  on  more  rapidly  than  in  fibrinous  pneumonia.  Broncho- 
pneuiiumia  of  the  apices,  in  a  child,  persisting  for  three  or  more  weeks, 
particularly  if  it  follows  measles  or  diphtheria,  is  often  tuberculous.  In 
these  instances,  when  resolution  is  supposed  to  be  delayed,  caseation  has 
in  reality  taken  place.  {2)  In  suppuration,  which  is  rarely  seen  apart 
tioni  the  aspiration  and  deglutition  forms,  in  whit-h  it  is  extremely  com- 
mon. (:j)  In //^f»///T«(^,  which  occurs  under  the  same  conditions.  (4)  In 
fihnnil  e/nnir/es — chronic  broucho-p)ieuvion-ia — a  rare  tertnination  in  the 
simple,  a  common  sequence  of  the  tuberculous,  disease.  Formerly  it  was 
thought  that  one  of  the  most  common  changes  in  broncho-pneumonia,  par- 
tii  ularly  in  children,  was  caseation;  but  this  is  really  a  tuberculous  pro- 
''e>s.  the  natural  termination  of  an  originally  specific  broncho-pneumonia. 
It  i^  lif  course  quite  possible  that  a  broticho-pneumonia,  simple  in  its  ori- 
giii,  may  subsequently  be  the  seat  of  infection  by  the  bacillus  tuberculosis. 


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DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


Symptoms. — Much  confusion  luia  arisen  from  tho  (loscri])ti(in  (,f 
Ciipilliiry  broiicliitirf  as  a  soparato  aU'ection,  whereas  it  is  only  a  p^pt' 
thou^li  a  primary  and  important  one,  of  broneho-pneunioiiia.  At  tho 
outset  it  may  be  said  tliat  if  in  convalescence  from  measles  or  in  uhooi). 
|ing-cou^h  a  cliild  has  an  accession  of  fever  with  cougli,  rapid  i)ul.sc,  and 
rapid  breathing,  and  if,  on  anscudtation,  fine  rales  are  heard  at  the  hascs 
or  widely  spread  throughout  the  lungs,  even  though  neither  consolidation 
nor  blowing  breathing  can  be  detected,  the  diagnosis  of  bronclio-pnon- 
nioiiia  may  safely  be  made.  I  have  never  seen  in  a  fatal  case  after  diph- 
theria  or  measles  a  capillary  bronchitis  as  the  sole  lesion.  The  oiisot  is 
rarely  sudden,  or  with  a  distinct  chill ;  but  after  a  day  or  so  of  itidis- 
position  the  child  gets  feverish  and  begins  to  cough  and  to  get  siiort  of 
breath.  The  fever  is  extremely  variable;  a  range  of  from  l()'i°  to  104°  is 
common.  The  skit)  is  very  dry  and  pungent.  The  cough  is  haid.  dis- 
tressing, and  may  be  painful.  Dyspnoea  gradually  l)eeomes  a  prominent 
feature.  Expiration  may  be  jerky  and  grunting.  The  resjiiratioiis  iniiy 
rise  as  high  as  CO  or  even  80  in  the  minute.  Within  the  first  forty-oitrht 
hours  the  percussion  resonance  is  not  impaired ;  the  note,  indeed,  may  he 
very  full  at  the  anterior  borders  of  the  lungs.  On  auscultation,  nianv 
rAles  are  heard,  chiefly  the  fine  sul)cre])itant  variety,  with  sibilant  rlidnchi. 
There  may  really  be  no  signs  indicating  that  the  parenchynui of  the  lnii<:is 
involved,  and  yet  even  at  this  early  stage,  within  forty-eight  hours  of  the 
onset  of  the  j)ulmonary  symptoms,  I  have  repeatedly,  after  diphthorin, 
found  scattered  nodules  of  lobular  hepatization.  Northrup,*  in  liis  thor- 
ough article  on  the  subject,  notes  a  case  in  which  death  occurred  within 
the  first  twenty-four  hours,  and,  in  addition  to  the  extensive  involvement 
of  the  smaller  bronchi,  the  intralobidar  tissue  also  was  involved  in  plaees. 
I'he  dyspnoea  is  constant  aiul  progressive  and  soon  signs  of  deficient  aera- 
tion of  the  blood  are  noted.  The  face  becomes  a  little  suffused  and  the 
finger-tips  bluish.  1'he  child  has  an  aiixious  expressirm  and  gnidnally 
enters  ujjon  the  most  d'stressing  stage  of  asphyxia.  At  first  the  ursfoiiey 
of  the  symptoms  is  mar  ced,  but  soon  the  benumbing  influence  of  the  car- 
bon dioxide  on  the  r .  rve-centres  is  seen  aiul  the  child  no  longer  makes 
strenuous  efforts  to  breathe.  The  cough  subsides  and,  with  a  gradual 
increase  in  lividity  and  a  drowsy  restlessness,  the  right  ventricle  becomes 
more  and  more  distended,  the  bronchial  rfdes  become  more  liquid  as  tlie 
tubes  fill  with  mucus,  and  death  occurs  from  heart  paralysis.  Tliese  are 
the  symptoms  of  a  severe  case  of  broncho-pneumonia,  or  what  the  older 
writers  called  svjfornfive  cntarrh. 

The  pJn/sical  ,s('/7».s  may  at  first  be  tliose  of  oapdlary  bronchitis,  as  in- 
dicated by  the  absence  of  dulncss,  the  presence  of  fine  subcrcpitant  ami 
whistling  n'des.  In  many  cases  death  takes  place  before  any  definite  pneu- 
monic signs  are  detected.     AVhen  these  exist  they  are  nnu;h  more  fre(|ueiit 


*  Reference  Handbook  of  the  Medical  Sciences,  art.  Broncho-Pneumonia. 


BRONCnO-PNEUMONIA. 


575 


at  llic  bases,  where  there  may  be  ureas  of  impaired  resonance  or  even  of 
iKisitive  diihiess.  When  numerous  foci  involve  tlie  f^reater  part  of  a  lobo 
the  lircailiing  may  become  tubular,  l)ut  in  the  scattered  ])atclios  of  ordi- 
luu'v  l)ronoho-pneum(mia,  following  the  fevers,  the  breathing  is  more  com- 
iiioidv  harsh  than  blowing.  In  grave  cases  there  is  retraction  of  the  base 
of  the  sternum  and  of  the  lower  costal  cartilages  during  inspiration,  point- 
ing t(i  deficient  lung  expansion. 

Diagnosis. — With  lobar  pneumonia  it  may  readily  be  c<)nfounded  if 
tlic  iircas  of  consolidation  are  large  and  merged  together.  It  is  to  be  re- 
mend)ered  that  broncho-pneumonia  occurs  chielly  in  children  under  five 
veiirs  of  age,  whereas  lobar  pneumonia  in  children  is  much  nu)re  common 
between  the  ages  of  live  and  fifteen.  JS'o  writer  has  so  clearly  brought 
out  the  (litTerencc  between  pneumonia  at  these  i)eriods  as  Gerhard,*  of 
Philadelpliia,  whose  papers  on  this  subject,  though  jjiiblished  nearly  sixty 
vciu-s  ago,  have  the  freshness  and  ac'curacy  which  chai'acterize  all  the  writ- 
iiii,'s()f  that  eminent  physician.  Holt  has  recently  brought  forward  lignres 
to  siiow  tiiat  lobar  })neumonia  is  not  iiif  re(|uent  in  infants  under  two  years 
of  age.  The  mode  of  onset  is  essentially  ditferent  in  the  two  affections, 
the  one  developing  insidiously  in  the  (bourse  or  at  the  conclusion  of  an- 
other disease,  the  other  setting  in  abruptly  in  a  child  in  good  health.  lu 
Idhiir  piuiuinonia  tlu;  disease  is  ahnost  always  unilateral,  in  broncho-pnetx- 
iiioiiiii  bilateral.  The  chief  trouble  arises  in  cases  of  broncho-juieumo- 
niii,  which  by  aggregation  of  the  foci  involves  the  greater  part  of  one  lobe. 
Here  the  ditficulty  is  very  great,  atul  the  physical  signs  may  be  pi'actically 
ideiilical,  but  in  a  broncho-pneumonia  it  is  nnich  more  likely  that  a  lesion 
will  be  found  on  the  other  side.  The  course  of  the  two  affet^tions  is  very 
unlike ;  the  lobar  i)neumonia  in  children  terminates  on  the  eiglith  or 
tenth  day  with  abru})tness,  as  in  adults. 

A  still  more  ditticult  questi(m  to  decide  is  whether  an  existing  broncho- 
imeinnonia  is  simple  or  tuberculous.  In  many  instances  the  decision  can- 
not lie  made,  as  the  circumstances  uiuler  which  the  disease  occurs,  the 
mode  of  onset,  aiul  the  physical  signs  may  be  identical.  It  has  often  been 
my  experience  that  a  case  has  been  sent  down  from  the  children's  ward  to 
till'  ilfiid-house  with  the  diagnosis  of  jxist-febrile  broncho-])neumonia  in 
whiiii  there  was  no  suspicion  of  the  existence  of  tuberculosis;  but  on  sec- 
tion there  were  found  tuberculous  lironchial  glands  and  scattered  areas  of 
broncho-pneumonia,  some  of  which  were  distiiu>tly  caseous,  while  others 
■'boweil  signs  of  softening.  I  have  already  spoken  fidly  of  this  in  the 
section  on  tuberculosis,  but  it  is  well  to  emphasize  the  fact  that  there 
iire  many  cases  of  broncho-pneumonia  in  children  which  time  alone  en- 
iibles  us  to  distinguish  from  tuberculosis.  TMie  existence  of  extensive  dis- 
wiso  at  the  apices  or  central  regitms  is  a  suggestive  indication,  and  signs 
of  softening  may  be  detected.     In  the  vomited  matter,  whi.'h  is  brouglit 


'  1 J 


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*  American  Journal  of  the  Medical  Sciences,  vols,  xiv  iind  xv. 


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570 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


up  after  severe  sjk'IIs  of  coughing,  sputum  may  be  picked  out  and  clastic 
tissue  and  bacilli  detected. 

It  is  a  superfluous  relinement  to  make  a  diagnosis  between  cii|iilliiiv 
bronchitis  and  catarrhal  })neunioiua,  for  the  two  conditions  are  jian  aiul 
l)arcel  of  the  saine  disease.  In  simple  bronchitis  involving  tiie  lander 
tubes  urgent  dyspnu'a  and  puhnonary  distress  are  rarely  present  and  the 
n'des  are  coarser  and  more  sibilant.  It  must  not  be  forgotten  that,  as  in 
lobar  pneumonia,  cerebral  symptoms  may  nuisk  the  true  nature  df  the 
disease,  and  may  even  lead  to  the  diagnosis  of  meningitis.  I  recall  nunv 
than  one  instance  in  which  it  could  not  be  satisfactorily  deteriiiinnl 
whether  the  infant  had  tuberculous  meningitis  or  a  cerebral  complica- 
tion of  an  acute  pulmonary  alfection. 

Prognosis. — In  children  enfeebled  by  constitutional  disease  and  pro- 
longed fevers  broncl  o-pneumonia  is  terribly  fatal,  but  in  cases  (•(iiiiiiiir 
on  in  connection  with  whooping-cough  or  after  measles  recoverv  iiuiv 
take  place  in  the  most  desjierate  cases.  It  is  in  this  disease  that  the  tnitii 
of  the  old  nuixim  is  shown — "  >.'ever  despair  of  a  sick  child."  The  death- 
rate  in  children  under  five  has  been  variously  estimated  at  from  tliirtv 
to  fifty  per  cent.  After  dijditheria  and  nu'asles  thin,  wiry  children  seem 
to  stand  broncho-pneumonia  nu.ch  better  than  fat,  flabby  ones.  In  adults 
the  aspiration  or  tleglutition  pneumonia  is  a  very  fatal  disease. 

Prophylaxis. — Much  can  be  done  to  reduce  the  probability  of  uttiiek 
after  febrile  affections.  ^J'hua,  in  tlu"  convalescence  from  measles  and 
whooping-cough,  it  is  very  important  that  the(diild  should  iu)t  be  expused 
to  cold,  particularly  at  night,  when  the  temperature  of  the  room  natiiiidly 
falls.  In  a  nocturnal  visit  to  the  nursery — sometimes,  too,  1  am  sorry  t(i 
say,  to  a  children's  hosi)ital — how  ( f ten  one  sees  children  almost  miked, 
having  kicked  aside  the  Ijedcdothos  and  having  the  night-clothes  up  aiioiit 
the  arms!  The  use  of  light  flannel  "  conil)inations"  obviates  this  iidctiir- 
nal  ciiill,  which  is,  I  am  sure,  an  inijiortant  factor  in  the  colds  an<l  puliiKi- 
nary  affections  of  young  children,  both  in  private  houses  and  in  institu- 
tions. The  catarrhal  troubles  of  the  no:  e  aiul  throat  should  ho  cand'idly 
atteiuled  to,  and  during  fevers  the  nu)uth  should  be  washed  two  or  three 
times  a  day  Avith  an  a;itisei)tic  solution. 

Treatment.— The  frequency  and  the  seriousness  of  broncho-pneu- 
monia render  it  a  disease  which  taxes  to  the  utmost  the  resources  of  tiu^ 
practitioner.  There  is  iio  acute  ]ndniomiry  affection  over  whicli  lie  at 
times  so  greatly  despairs.  On  the  other  hand,  there  is  not  one  in  which 
he  will  be  more  gratified  in  saving  cases  which  have  seemed  past  all  siiccor. 
Tlie  general  arrangements  should  receive  special  attention.  TIic  i'"'"" 
should  be  kept  at  an  even  temperature — about  65°  to  68° — and  tlu'  uir 
should  l)e  kept  moist  with  vapor. 

At  the  outset  the  bowels  should  be  opened  by  a  mild  purge,  either 
castor  oil  or  small  doses  of  calonu'l,  one  twelfth  to  one  sixth  of  a  grain 
hourly  until  a  movement  is  obtained,  and  care  should  be  taken  thrtjughont 


BRONCHO-PNEUMONIA. 


0(  i 


the  attack  to  secure  u  diiily  ninvemont.  The  common  saliiie  fcvor  riiixturo 
of  ritruto  of  potiish,  liquor  ummonii  ucetatis,  and  aromatic  spirits  of  am- 
monia may  be  fjiven  every  two  or  three  hours.  If  tlie  disease  comes  on 
iil)ni|itly  witli  liigli  fever,  minim  or  minim  aiul  a  lialf  doses  of  tlie  tincture 
of  lU'onite  may  be  given  with  it.  The  i)ain,  tlie  distressini^  symptoms,  aiul 
till'  incessant  couifh  often  demand  opium,  which  must  of  course  be  used 
Avith  rare  and  judgment  in  tlie  case  of  young  children,  but  which  is  cer- 
tainly not  contra-indicated  and  may  be  usefully  given  in  the  form  of 
Udver's  powder,  lilisters  arc  now  rarely  if  ever  emjiloyed,  and  even  the 
jacket  jjoultice  has  gone  out  of  fashior..  For  the  latter,  however,  I  con- 
fi's;^  to  a  strong  ])rejiidicc,  and  when  lightly  nuide  and  fre(|uently  changed 
it  undoubtedly  gives  great  relief.  Much  more  commonly  we  now  see, 
l)iitli  ill  ])rivate  and  in  hospital  practice,  the  jacket  of  cotton-batting. 
Icc-poiiltices  to  the  chest  I  have  seen  used  a])j)arently  with  great  bene- 
tit,  and  they  are  warmly  recommended  by  many  (Jerman  physicians  as 
wjH  as  by  (Joodluirt  and  others  in  Enghind.  The  diet  should  consist 
of  milk,  broths,  and  egg  albumen.  Milk  often  curds  and  is  disagreeable. 
Kir^-white  is  ])articularly  suitable  aiul  very  acceptable  when  given  in  cold 
water  with  a  little  sugar.  It  forms,  indeed,  an  excellent  medium  for  the  ad- 
miiiistratio)!  of  the  stiuiulaiits.  If  the  pulse  shows  signs  of  failing,  it  is  best 
to  })egin  early  with  brandy.  As  in  all  febrile  affections  of  children,  cold 
water  sluiuld  be  constantly  at  the  bedside,  and  the  child  should  be  encour- 
aged to  drink  freely.  With  these  measures,  in  many  cases  the  disease  pro- 
gresses to  a  favorable  termination,  but  too  often  other  and  more  serious 
symptoms  arise.  Cough  becomes  more  distressing,  -dyspmea  increases, 
the  ominous  rattling  of  the  mucus  can  be  heard  in  the  tubes,  the  child's 
('<ilor  is  not  so  good,  and  there  is  greater  restlessness.  Umlcr  these  cir- 
cumstances stimulant  exiiectorants — ammonia,  squills,  and  senega. — should 
ho  given.  Together  they  make  a  very  disagree'ible  dose  for  a  young  child, 
particularly  with  the  carbonate  of  ammonia.  The  aromatic  spirits  of  am- 
niDiiia  is  somewhat  better.  If  the  carbonate  is  employed,  it  must  be  given 
in  small  doses,  not  more  than  a  grain  to  an  infant  of  eighteeri  months.  If 
the  child  has  increasing  ditficulty  in  .setting  up  the  mucus,  an  emetic 
sliouhl  be  given — either  the  wine  of  ipecac  or,  if  necessary,  tartar  emetic. 
There  is  no  necessity,  however,  to  keep  the  child  constantly  nauseated. 
Kiioiigh  should  be  given  to  cause  prompt  emesis,  and  the  benefit  results  in 
the  expulsion  of  mucus  from  the  larger  tubes.  In  this  stage,  too,  strych- 
nine is  undoubtedly  helpful  in  stimulating  the  depressed  respiratory  cen- 
tre. \\  ith  commencing  cyanosis,  inhalations  of  oxygen  may  be  employed, 
sometimes  with  great  benefit. 

\\  ith  rapid  failure  of  the  heart,  loud  mucous  rattles  in  the  throat,  and 
nicreasiiig  lividity,  every  measure  should  be  used  to  arouse  the  child  and 
excite  coughing.  Alternate  douches  of  hot  aiul  cold  water,  electricity, 
^vliirh  I  have  seen  applied  with  good  results  at  Wiederhofer's  clinic  in 
^  icnna,  and  hypodermic  injections  of  ether  may  be  tried.    For  the  roduc- 


J '- 


Mti  ''*■ 

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h  *r 

■*    '"'&3 

fi 

iii' 


DISEASKS  OP  THE  UESPIIIATORY   SYSTKM. 


,.^ 


I  -    ! 

I'-: 

i  r 


tioTi  of  t('mi)oriit;iir(',  piirticiiliirly  if  ecn.'!)!' J  sytnptoms  aro  proniiiuMit,  tlioro 
is  ii()tliiii<,'  so  siitisfartorv  as  *lie  wot  i)a('k  or  tlu;  cold  hatli.  In  ih,.  ,.■^^^. 
of  oliildrcii,  wluMi  the  latti-r  is  uwed  it  should  bo  graduated,  hegiiiiiii]i.r  wiih 
a  toniperaturc^  which  is  pleasantly  warm  and  gradually  reducing  ii  i<,  ]:,' 
or  H(»°.  KvcM  when  the  temperature  is  not  high,  the  cerebral  syiii|ii(iiiis 
are  greatly  relieveil  by  the  bath  or  the  i)ack. 


V.  EMPHYSEMA.      . 

Rupture  of  superficial  vesicles  nuiy  produce  pneumothorax.  In  the 
case  of  deep-seated  alveoli  the  air  cscajjcs  into  the  interlol)ular  coniiectivo 
tissue  aiul  causes  a  condition  comitarable  to  ordinary  subcutaneous  cinjiliv- 
senui.  It  is  Tiot  a  very  serious  condition  and  rarely  jinxhu'cs  syin|itiiiiis. 
It  usually  results  from  violent  expiratory  elVorts,  as  in  whoo))ing-((.ut:li. 
The  air-bubbles  escape  into  the  interlobular  tissue,  in  which  they  Umk 
like  little  rows  of  beads,  mid  when  extensive,  the  lobules  are  distinctly  out- 
lined by  them  (interstitial  cm])hysema).  There  may  be  large  biilLi'  W- 
neath  the  pleura.  A  very  rare  event  is  the  riijJtMre  close  to  the  root  df 
the  lung  and  the  passage  of  air  along  the  trachea  into  the  subcutaiieinis 
tissues  of  the  neck. 

The  condition  in  which  the  infundibular  passages  and  the  alveoli  are 
dilated  is  called  vrsiridar  cinp/ii/st'iiia. 

A  practical  division  may  be  made  into  compensatory,  hypertrophio, 
and  atro])liic  forms. 

I.    COMPKNSATORY    ICmI'IIYSKMA. 

Whenever  a  region  of  the  lung  does  not  expand  fully  in  ins])ir!itiitii. 
either  another  portion  of  the  lung  must  expand  or  the  chest  wall  sink  in 
order  to  occu])y  the  space.  The  former  almost  invariably  occurs.  We 
have  already  Tuentioned  that  in  broncho-pneumonia  there  is  a  vicarious 
distention  of  the  air-vesicles  in  tl«e  adj  tcent  healthy  lobules,  and  the  saui*' 
hap[)ens  in  the  neighborhood  of  tuberculous  areas  and  cicatrices.  In  I'cii- 
eral  pleural  adhesions  there  is  often  comjx'usatory  emphysema,  jiarticu- 
larly  at  the  anterior  margins  of  the  lung.  Tlu;  most  advanced  exainiilc  nf 
this  form  is  seen  in  cirrhosis,  when  the  unalfected  lung  increases  greatly 
in  size,  owing  to  distention  of  the  air-vesicles.  A  similar  though  loss 
marked  condition  is  seen  in  extensive  pleurisy  with  elfusion  and  in  piiiu- 
mothorax. 

At  first,  this  distention  of  the  air-vesicles  is  a  simple  physiological 
process  and  the  alveolar  M'alls  are  stretcheil  but  not  atrophied.  Tlti- 
mately,  however,  iji  many  cases  they  waste  and  the  contiguous  air-cills 
fuse,  producing  ti'ue  emphysema. 


EMPHYSEMA. 


oc 


II.    IlYI'KUTKOl'Iiro    E.MPnYSEMA. 

This  form,  also  known  us  Hul)stiintivo  or  idiopiithic  oniphysema,  is  a 
well  -  marked  clinical  allcction,  cliaracteri/od  by  cnlarircnicnt  of  the 
liiii.irs,  due  to  distention  of  the  air-cells  and  atrophy  ol'  their  walls,  and 
cliiiii-dly  by  inii)orfect  aeration  i  I'  the  blood  and  more  or  less  marked 
(iys|iii(i'a. 

Etiology. — Kmphysenia  is  the  result  of  persistently  high  intra- 
alvciilar  tension  actin*;;  upon  a  congenitally  weak  liinir  tissue.  If  the 
tiicciianieal  views  which  have  prevailed  so  lon<^  as  to  its  oriirin  were  true, 
(he  disease  would  certainly  be  much  more  common;  sinc(>  violent  respira- 
tory ciTorts,  believed  to  be  the  essential  factor,  are  perl'ormc(l  by  a  majority 
(if  llic  workinj^  classes.  Stroni^ly  in  favor  of  the  view  that  the  nutritive 
chaiip'  in  the  air-cells  is  the  ])rimary  factor  is  tlu'  markedly  hereditary 
cliiiracter  of  the  disease  and  the  fre(|ueiicy  with  which  it  starts  early  in 
life.  These  are  two  points  u[)on  which  scarcely  sidlicient  >tress  has  been 
laiil.  To  .lames  .Jackson,  .Jr.,  of  Boston,  we  owe  the  iirst  observations 
oil  the  hereditary  (diaracter  of  emphysema.  Workinir  under  Louis's 
"lireetions,  ho  found  that  in  18  out  of  'iS  eases  one  or  both  ])arents  were 
atlVcti'd. 

I  have  been  impressed  by  the  frerpiency  of  its  orijrin  in  cliildhood.  It 
may  Tullow  recurring  asthmatic  attacks  due  to  adenoid  vegetations.  It 
may  develoj),  too,  in  several  members  of  the  same  family.  We  are 
still  ignorant  as  to  the  nature  of  this  congenital  pulmonary  weakness. 
Colinlieiui  thinks  it  probably  due  to  a  defect  in  the  develoj)nient  of  tlie 
(la- tic-tissue  tibres — a  statement  which  is  borne  out  by  Eppinger's  obser- 
vations. 

Heightened  pressure  witiiin  the  air-cells  may  ]»e  due  to  forcible  in- 
spiratiiin  or  expiration.  ]\Iuch  discussion  has  taken  place  as  to  the  part 
played  by  these  two  acts  in  the  production  of  tiie  disease.  The  inspirat(»ry 
theory  was  advanced  by  Laennec  and  subsequently  modified  by  (lairdner, 
who  held  that  in  the  chronic  bronchitis  areas  of  collap.se  were  induced, 
and  coin])ensat()ry  distention  took  ])lace  in  the  adjacent  lo1)ules.  This 
iuu|iiesti(inably  does  occur  in  the  vicarious  or  com])ensatory  emphysema, 
hut  it  probably  is  not  a  factor  of  much  moment  in  the  form  now  uiuler 
consideration.  The  ex])iratory  theory,  which  was  supported  In'  Mendel- 
sohn and  .Jenner,  accounts  for  the  condition  in  a  much  more  satisfactory 
way.  In  all  straining  elforts  and  violent  attacks  of  coughing,  the  glottis 
is  closed  and  the  chest  walls  are  strongly  compressed  by  muscidar  efforts, 
so  that  the  strain  is  thrown  npon  those  parts  of  the  lung  least  ])rotected, 
as  tlu!  apices  and  the  anterior  margins,  in  which  we  always  find  the 
eniphysenia  most  advanced.  The  sternum  and  costal  cartilages  gradually 
yield  to  the  heightened  intrathoracic  pressure  and  are,  in  advanced 
cases,  jinshed  forward,  giving  the  characteristic  rotundity  to  the  thorax. 
As  mentioned,  the  cartilages  gradually  become  calcified.     One  theory  of 


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680 


DISRASKS  OF  THE  RESPIUATORY  SYSTEM. 


the  (liscjiso  is  tlnit  tlicro  is  ii  <;rii(liiiil  ciiliirf^oment  of  tlie  thorax  atul  tlie 
liinj^s  iiicri'usi'  in  V(»liirm(  to  lill  up  tlio  space. 

Of  oilier  c'tioloj^ncal  factors  occupation  is  tlio  most  important.  'I'lio 
disease  is  met  with  in  players  on  wind  instruments,  in  jrlass-hlowcrs  aiul 
in  occupations  neeessitatin;,'  heavy  lifting  or  straininjij.  \\  hoopinu-coujrli 
aiKJ  l)ronchitis  jiiay  an  important  rn/r,  not  so  much  in  the  clian;:e.<  wlijcli 
they  induce  in  llie  bronchi  as  in  conseipieuce  of  the  proloiij,a'd  attack.sof 
cou<i;liin^. 

Morbid  Anatomy. — The  tliorax  is  capueious,  usually  harrcl-.<li;i|Hd, 
and  the  cai'tilajj;es  are  calcilied.  On  removal  of  the  sternum,  the  aiitiridr 
mediastinum  is  found  completely  occupied  l»y  the  edi^es  of  the  luii;:.-,  and 
the  pi'ricardial  sac  may  not  be  visible.  The  or^'ans  are  very  lari^c  uiid 
have  lost  their  ela.iticity,  so  that  they  do  not  collapse  either  in  thi'  tliovii.x 
or  when  jjlaced  on  the  table.  The  ))leura  is  })ale  and  there  is  ofttn  an 
absence  of  ])iffinent,  sonuitinu's  in  patches,  termed  by  Virchow  (il/ii/n'sui  (if 
the  lun<,'.  To  the  touch  they  have  a  jieculiar,  downy,  feathery  tVcl,  and 
pit  readily  on  j)ressure.  'J'his  is  one  of  the  most  nuirked  features.  He- 
neatli  the  i)leura  greatly  enlarged  air-vesicles  may  he  readily  seen.  Tiny 
vary  in  size  from  -J  to  3  mm.,  and  irregular  bulhv,  the  size  of  a  waliuit 
or  larger,  may  ])roject  from  the  free  margins.  The  best  idea  of  tlu' 
extreme  rarefaction  of  the  tissue  is  ol)tained  from  sections  of  a  lung  dis- 
tended and  dried.  At  the  anterior  margins  the  structure  may  foriu  ai; 
irregular  series  of  air-chambers,  resemlding  the  frog's  lung.  On  canlul 
inspei'tion  with  the  hand-lens,  renuuints  of  the  interlobular  septa  or  cvfu 
of  the  alve(di  may  be  seen  on  the.se  large  emphysematous  vesicles.  Tiumgli 
general  throughout  the  organs,  the  distention  is  more  marked,  as  ii  rnlc, 
at  the  anterior  margins,  and  is  often  specially  developed  at  the  inner  mr- 
face  of  the  lobe  near  the  root,  Avhere  in  extreme  cases  air-spaces  as  laigc 
as  an  egg  may  sometimes  be  found.  !Microscoj)ically  there  is  .seen  ittr(i|i]iy 
of  the  alveidar  walls,  by  which  is  produced  the  coalescence  of  neigliltoring 
air-cells.  In  this  process  the  capillary  network  disappears  before  the 
walls  are  completely  atrojdiied.  The  loss  of  the  elastic  tissue  is  a  s|i(rial 
feature.  Tt  is  stated,  indeed,  that  in  certain  cases  there  is  a  congenital 
defe(;t  in  the  develojiment  of  this  tissue.  The  epithelium  of  the  air-ci'lls 
undergoes  a  fatty  change,  but  the  large  distended  air-spaces  retain  a  pave- 
ment layer. 

The  hronchi  in  emphysema  show  important  changes.  In  the  larfrcr 
tubes  the  mucous  mend)rane  may  be  rough  and  thickeiu-d  from  cdironic 
bronchitis;  often  the  longitudinal  lines  of  submucous  elastic  tissue  .4and 
out  prominently.  In  the  advanced  cases  many  of  the  smaller  tubis  are 
dilated,  particidarly  when,  in  addition  to  emphysema,  there  ai'e  peribron- 
chial fibroid  changes.  Bronchiectasis  is  not,  however,  an  invarinbic  ac- 
companiment of  emphysenni,  but,  as  Laennec  remarks,  it  is  ditticnlt  to 
understand  why  it  is  not  more  common.  Of  associated  morbid  clianges 
the  most  important  are  found  in  the  heart.     The  right  chamber-!  are 


EMIMIYSHMA. 


581 


ililiitcil  ami  liyportroiiliicd,  tlic  tricuspid  orilicc  is  liirirf,  ini<l  tlio  viilvo 
(i('i:iiit'iits  uiv  ol'U'U  tliicki'iiiMl  at  tlic  (mI^jcs.  In  ailvaiifcd  cases  the  cardiac! 
li\  )icrtrni)hy  is  ffciuTal.  'I'lic  ])iiliM(iiiaiT  artcrv  and  its  Itninclics  may  bo 
wiilc  and  sliow  nnirl\('(l  atiicrnmatoMs  clian;:cs. 

'i'lic  clianj,'('.s  ill  tlic  otlicr  or^^ans  arc  tliosc  commonly  associatcil  witli 
|in(l()iii;c(l  venous  coiij^iestion. 

Symptoms. — 'I'lie  disease  may  lie  tolcrahly  advanced  bel'oro  any 
s|iccial  symptoms  develop.  A  child,  for  instance,  may  he  soiiu'what  short 
of  lireath  on  jjoiiif?  up-stairs  or  may  he  uiiahle  to  run  and  jilay  as  other 
cliildrcii  without  <,M-cat  discomfort;  or,  perhaps,  has  attacks  of  sli^dit 
lividitv.  ])oiihtIcss  much  depends  upon  the  completeness  of  cardiac  com- 
])ciisati(iii.  AVlieii  this  is  perfect,  there  may  be  no  s^iecial  interru|»tion  of 
ihe  ])iilmoiiary  eirciilatiou  and,  except  in  violent  exertion,  there  is  no 
interference  with  the  aeration  of  the  blood.  In  well-developed  cases  tho 
following  are  the  most  important  synijitoms  :  Jfi/sjnio'd,  which  may  bo 
felt  only  on  sliirht  exertion,  or  may  be  jiersisteiit,  and  a.Li'^'ravated  hy  iii- 
tt'i'current  attacks  of  bronchitis.  Tho  respirations  are  often  harsh  and 
wlieezy,  and  expiration  is  distinctly  jirolonj^ed. 

Ci/diiosis  of  an  extreme  grade  is  more  common  in  emphysema  than  in 
other  all'ections  with  the  exception  of  coiiircnital  heart-disease.  So  far  as  I 
know  it  is  the  only  disease  in  which  a  ])atient  may  lie  able  to  go  about  and 
even  to  walk  into  the  hospital  or  consulting-room  with  a  livid ity  of  start-- 
JiiiL''  intensity.  The  contrast  between  the  extreme  cyanosis  and  the  t'oin- 
purative  comfort  of  the  patient  is  very  striking.  In  other  atl'cctions  of 
the  heart  and  lungs  associated  with  a  similar  degree  of  cyanosis  the  pa- 
tient is  invariably  in  bed  and  usually  in  a  state  of  ortliopmea. 

ISrnnchitis  with  associated  cough  is  a  frequent  symiitom  and  often 
the  direct  cause  of  the  pidmonary  distress.  'J'he  eonti'ast  between  eniphy- 
sciiiatoiis  patients  in  the  winter  and  summer  is  marked  in  this  respect.  In 
the  hitler  they  may  be  comfortable  and  able  to  attend  to  their  work,  but 
with  the  cold  and  changeable  Aveather  they  are  laid  uj)  with  attacks  of 
In'oncliitis.  Finally,  in  fact,  the  two  conditions  become  inseparable  and 
the  patient  has  persistently  more  or  less  cough.  The  acute  bronchitis 
may  produce  attacks  not  uiiHkj  asthma.  In  some  instances  this  is  true 
.~|  iisinodic  asthma,  Avith  which  emphysema  is  freiiuently  associati'd. 

As  age  advances  and  with  successive  attacks  of  bronchitis  the  condi- 
tion gets  slowly  worse.  In  hosjiital  practice  it  is  common  to  admit  pa- 
tiiiits  over  sixty  with  well-marked  signs  of  advanced  emphysema.  The 
iil"ection  can  generally  be  told  at  a  glance — the  rounded  shoulders,  barrel 
olifst,  tlie  thin  yet  oftentimes  muscular  form,  and  sometimes,  I  think,  a 
veiT  characteristic  facial  expression. 

There  is  another  group,  however,  of  younger  patients  from  twenty-fivo 
to  forty  years  of  age  who  winter  after  winter  have  attacks  of  intense  cya- 
nosis in  consequence  of  an  aggravated  bronchial  catarrh.  On  inquiry  we 
linil  that  these  patients  have  been  short-breathed  from  infancy,  and  they 


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582 


DISKAHKS  OK  TIIK   IlKSPIUATOHY  SYSTKM. 


liolori;,',  1  l)('li(!V(?,  Id  a  calc^'nry  in  wliicli  IIutc  Iium  Ih-cii  a  pritriiirv  di  fret 
of  stnictiirc  ill  IIk!  liin;,'  tissue. 

Physical  Signs. — I/is/irr/inii, — 'I'lic  tliomx  is  nmrki'dly  nltcrcil  in  .•li,.ii,'; 
(lio  uiituro-posU'rior  (liaiiu'tiT  is  iticrcusfil  ami  niav  lie  even  j^'rcatcr  ilmu 
lli(!  lateral,  s(i  that  tlio  flicst  is  hai'rcl-sliii|H'(l.  'I'lu'  a|i|H'araii('('  is  sdiiic- 
wliat  iis  it"  the  chest  was  in  a  jieniiaiieiit  insiiiratory  ])ositi()ii.  'i'l,,.  -ht- 
niim  and  <'()stal  cart ilaircs  are  jiroinincnt.  Tiio  lower  zone  of  the  ihniax 
looks  lar;;e  and  tlie  intercostal  spaces  are  iniieii  widened,  parliciilaiU  in 
the  hypociioiidriac  re;,dons.  'I'he  ^iternal  fossa  is  deep,  tin-  clavicK's  .-luiid 
out  with  iireiil,  proniiiience,  and  tlie  neck  looks  shortened  from  the  ele\a. 
tioii  of  tlie  tliorax  aii<l  the  steriiiiiii.  A  zone  of  dilated  venules  iiiii\  he 
Hcen  alon<^  the  line  of  attacliiiieiit  of  the  dia|>hr:if;ni.  'rhou<rli  this  ig 
coninioii  in  einphyseiiia,  it  is  hy  no  means  peculiar  to  it.  Andrew,  (jf 
liartholoinew's  Hospital,  and,  accnidin^  to  Duckworth,  liaycnck  hiive 
(•alliMJ  attention  to  it.  This  network  in  tlie  lower  tlioracic  re,i,ni>ii,  jii>t 
above  the  (Mistal  inai'f,dn  aiul  foUowiiif;  its  curves,  is  a  well-marked  feaiure 
in  many  persons,  and  is  sei'ii  not  only  in  emjihyseimi,  but  in  many  eases 
of  hepatic  troiiiih". 

IJehind,  the  curve  (d'  the  spine  is  increased  and  the  l)ack  is  remarkahly 
rounded,  so  that  the  scapula'  fcem  to  be  almost  horizontal.  Meiisiiratiou 
shows  the  rounded  form  of  the  chest  and  the  very  slight  expansion  dii 
deep  inspiration.  'I'he  respiratory  movementa,  wliieli  may  look  ciur- 
geti(!  and  forcibU^  ((xereise  little  or  no  influence.  'I'he  chest  does  nut 
ex]iand,  but  there  is  a  general  elevation.  The  inspiratory  effort  is  short 
atui  (piick  ;  the  exjiiratory  movement  is  jirolonged.  There  may  be  retriie- 
tioii  instead  of  distention  in  the  ujiper  abdominal  region  during  iii-piia- 
tion,  and  tluTc^  is  sometimes  sd'ii  a  transverse  curve  crossing  the  ahdoincii 
at  the  level  of  the  twelfth  rib.  The  ajiex  beat  of  the  lieart  is  not  visible, 
and  there  is  usually  marke<l  jailsation  in  the  ejiigastrie  region.  'J'lie  cer- 
vical veins  stand  out  jirominently  and  may  i)ul.sate. 

Puljialiun. — The  vocal  l'remitu8  is  somewhat  enfeebled  but  mil  lost. 
The  apex  beat  can  rarely  bo  felt.  There  is  a  marked  shock  in  the  lower 
sternal  region  and  very  distinct  jnilsation  in  the  epigastrium,  rvrciissiun 
gives  greatly  increased  resonance,  full  and  drum-like — what  is  sonietiiiies 
called  hyperreaonanoe.  The  mdo  is  not  often  distinctly  tymjninitic  in 
quality.  Tlie  peniussion  not^'  is  greatly  extended,  the  heart  dulness  nay 
be  obliterated,  the  U|)per  limit  if  liver  dulness  is  greatly  lowered,  and  the 
resonance  may  extend  to  the  costal  margin.  Hehind,  a  clear  jierciission 
note  extends  to  a  much  lower  level  than  normal.  I'he  level  of  sjileiiie 
dulness,  too,  may  be  lowered. 

On  ausriiUafion  the  breath-sounds  are  usually  enfeebled  and  may  be 
masked  by  bronchitic^  rAles.  The  most  characteristic;  feature  is  the  pni- 
longation  of  the  expiration,  and  the  normal  ratio  may  be  reversed — t  tn  1 
instead  of  1  to  4.  It  is  often  wheezy  and  harsh  and  associated  with  c()ar.«e 
rales  and  sibilant  rhonchi.     It  is  said  that  in  interstitial  emphysema  tlier^ 


EMIMIVSKMA. 


r.s!;^ 


iniiv  be  11  friction  sound  liciinl  imt  unlike  tiiat  of  pItMirisy.  As  aliviidy 
Hilled,  till'  ciinliiu'  inipulst'  niiiy  Itc  Imrt'ly  fi-lt  in  llio  lowvv  sU'cnal  rc^'ioii. 
Till'  licart-soiintls  art'  iisiinliy  cirar ;  Itiit  in  atlvaiifcd  cases,  when  tiicre  id 
marked  <'yanosiM,  a  tricuspid  i'c<;iir;,ntant.  niiirmur  niay  lie  heard.  Accciit- 
uiilion  of  the  piiliiioiiary  second  sound  is  present. 

The  riiiirsr  of  tiie  disease  is  si  i\v  iuit  pro;j:i'essivo,  tiie  reciirriiif^  attacks 
(if  liniiichitis  a;.'j,'i'avatiii^'  tiu'  coiiditinii.  iJcatii  iiiayoccuir  from  iiiti-rcur- 
niil  ptieiiiimiiia,  eitiier  lol)ar  or  loliular,  and  dropsy  may  supervene  from 
ciiidiac  failure.  Occasionally  death  results  from  overdisteiilion  of  tlio 
liiart,  with  extrenie  cyanosis.  I)uckworth  lias  called  uttention  to  fatal 
Imiiiorrhajio  in  oni|)liysemii.  It  certainly  is  not  common.  In  an  c'.d  ein- 
iiliv>('matous  patient  at  the  Montreal  (leiicral  Hospital  death  followed  tho 
crnsioii  of  a  main  hranch  of  the  pulmonary  artery  by  un  ulcer  near  tho 
bil'iircation  of  the  trachea. 

Treatment. —  Practically,  the  measures  mentioned  in  coTineetion 
with  bronchitis  should  be  employed.  No  remedy  is  known  which  has  any 
iiilliicnce  over  the  pro<jress  of  the  condition  itself.  Bronchitis  is  thej^nrat 
(limu'cr  of  these  iiatieiits,  ami  therefore  when  possible  they  should  live  in 
all  cijualjle  climate.  In  con-scfpience  of  the  venous  en;.for<j^eineiit  thty  aro 
liiilile  to  {gastric  and  intestinal  disturbance,  and  it  is  particularly  important 
t(i  keep  the  bowels  rejjuliitcd  and  to  avoid  the  llatuleiK^y  which  often  seri- 
(lusly  a;,f^'ravates  the  dyspiuea.  I'atieiits  who  come  into  the  hospital*  in 
a  state  of  ur<j;ont  dyspiuea  and  lividity,  with  jjfreat  encforjjement  of  the  veins, 
liaiticiilarly  if  they  are  yoiinjj:  and  vi{>-orous,  should  b(!  bhui  fro(,'ly.  On 
iiKii'c  than  one  occasion  1  liavi'  saved  the  lives  of  persons  in  this  condition 
liy  venesection.  Inhalation  of  oxygen  may  be  used  and  the  remedies 
i;iviii  already  mentioned  in  connection  with  bronchitis.  Strychnine  will 
i)e  found  specially  useful. 

III.   Atrophic  Emphysema. 

This  is  really  jv  senile  change  and  is  called  by  Sir  William  Jenner  small- 
liiiiifeil  enii)hysema.  It  is  really  a  primary  atro])liy  of  the  lung,  coming 
nil  in  advanced  life,  and  scarcely  constitutes  a  special  all'ection.  It  occurs 
in  "•  withered-looking  old  persons"  who  may  perhaiis  have  had  a  winter 
coiigli  and  shortness  of  breath  for  years.  In  striking  contrast  to  tho  essen- 
tial nr  hypertrophic  emjihysema,  the  chest  in  this  form  is  small.  The  ribs 
are  olili([uely  placed,  the  decrease  in  the  diameter  being  due  to  greatly  in- 
creased obliquity  in  the  position  of  the  rilw.  The  thoracic  muscles  aro 
usually  atrophied.  In  advanced  cases  of  this  affection  the  lung  presents  a 
I'einarkable  appearance,  being  converted  into  a  series  of  large  vesicdes,  on 
tile  walls  of  which  the  remnants  of  air-cells  may  be  seen.  It  is  u  condition 
for  which  nothing  can  be  done. 


I  i 


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584: 


DISEASES  OP  THE  IlESI'IRATOKY  SYSTEM. 


VI.  GANGRENE   OF  THE  LUNG. 


Etiology. — (JaiijfiTiu'  of  till'  Imiu  is  not  iin  iitlVt'iion  jut  sc,  hut  oc- 
curs  in  a  variety  <ii'  coiulitions  wlu'ii  lu'cmtic  aivas  uikUt^o  initivfiictinii. 
It  is  not  I'Jisy  to  say  why  sijliucohis  sliouhl  ofciir  in  oiu'  case  ami  imt  iu 
jinothor,  as  tiio  ^crnis  of  putrefaction  aiv  always  in  the  air-iiassaLTcs.  and 
yet  necrotic  territories  rarely  l)ecoine  j:an,urenous.  Total  ohstriu'tioii  nf  ;i 
pulmonary  artery,  as  a  rule,  causes  infarction,  iiiul  the  area  shut  olV  dms 
not  often,  thougn  it  may,  sphacelate.  Another  fai'tor  Mould  seem  l<i  hv 
necessary— jirobahly  a  lowered  tissue  resistance,  the  ri'sult  of  irenenil  dp 
local  t'auses.  It  is  met  with  (1)  as  a  se(]uence  of  lohar  pni'unionia.  'I'liis 
randy  occurs  in  a  previously  healthy  person — more  comniotdy  in  the  ilc- 
hilitated  or  in  the  (lial)etic  suitjcct.  (v')  (JanjjreiU'  is  very  prone  to  fulldw 
the  aspiration  |)iunnnonia,  since  the  forei<in  i)articles  rapidly  uinlii'LTo 
])utrefactive  (dianires.  Of  a  siuular  mituri'  are  the  cases  of  ijanixreiic  (hie 
to  perforation  of  cancer  of  the  (esopha,i,nis  into  the  lunj^or  into  a  liromhiis, 
(;})  The  putrid  contents  of  a  broncdiiectatic,  more  coiunnmly  of  a  tiilur- 
culous,  cavity  may  excite  uanureiu'  in  the  nei,i;hhoriii<r  tissues.  The  press- 
ure bronchiectasis  followinjjf  aneurism  or  tumor  nuiy  lead  to  exti'iisive 
sloi'uhinix.  (4)  (Jan,sirci\e  may  follow  simple  embolism  of  the  ])uhn(iiiarv 
artery.  More  commonly,  however,  the  eudtolus  is  ilerived  from  a  part 
wlrtcdi  is  mortiiied  or  conus  from  a  focus  of  hone  disease.  Lastly,  iiaii- 
jrrene  of  the  lunjj;  may  occur  in  conditions  of  ilcldlity  duriuii'  convales- 
eeiice  from  protracted  fever — occasionally,  indei'd,  without  our  heiiii:  Mo 
to  assiixn  any  i'easoiial)le  cause. 

Morbid  Anatomy. —  LaiMineo,  who  tirst  accurately  descrilied  pul- 
monary iran.iireiu',  recojiiiized  a  dilTuse  and  a  circumscribed  foi'ui.  The 
former,  though  rare,  is  sonu'times  seen  in  connection  with  pneumnnia. 
more  rarely  .ifter  obliteration  of  a  larire  bnuudi  of  the  ])nlmonary  artery. 
It  may  involve  the  greati'r  part  of  a  lolie,  and  (he  lung  tissue  is  coiiverled 
into  a  horribly  (dTensive  greenish-black  mass,  torn  aiul  ragfri'd  in  the  centre. 
In  the  circumscribed  form  there  is  well-marked  limitation  between  the 
i::an>:;renous  area  and  the  surroundiiiif  tissue.  The  focus  nuiy  be  siiii;le  or 
there  may  he  two  or  more.  The  lower  lobe  is  more  conumudy  allVeted 
than  the  upper,  ami  the  peripheral  more  than  the  central  jiortion  of  the 
lunjj;.  .\  <xan<rrenous  area  is  at  tirst  uiuforndy  {greenish  brown  in  color; 
but  softeniuij  rapidly  takes  place  with  the  forjuation  of  a  <'avity  with 
shreddy,  irreirular  walls  and  a  irreenish,  olTensive  fluid.  The  hiiii:  tis-iio 
in  the  immediate  neiuhborhoinl  shows  a  zone  of  deej)  conj::estion,  <dteii 
consolidation,  and  outside  this  an  intense  onlema.  In  the  tMuholie  eiises 
the  ])lngged  artery  can  sonu'times  be  found.  When  rapidly  extendiiiir, 
vessels  nuiy  be  opened  and  vi(dent  luvmorrhafio  ensue.  I'erforiitioii  of  the 
})leurji  is  not  uncommon.  The  irritatins;  deeomj)(tsin<j  imiterial  usually 
excites  the  most  intense  bronchitis.  Kmbolic  processes  are  not  infre(|iie!it. 
There  is  a  renuirkable  association  iu  some  cases  between  circumscribed 


GANGRKNE  OF  THE  LUNG. 


585 


('!in<'tviio  of  the  luiiij  and  iibscoss  of  i\w  brain.  T  havo  seen  two  siu'h 
tascs.  One  of  tlu'sc,  a  yoiinjj;  man,  an  Arab,  was  ])roii!j:bt  to  tbo  I'ni- 
viMsitv  IIos|iital,  almost  oxsanguini'  from  pulmonarv  lia'inorrlia,i:;i'.  lie 
liiailiiallv  ivcovcrt'd.  Tlioiv  wi'iv  very  limiti'd  siiriis  in  tiic  middli-  lobe 
iif  the  i'i<iht  lunij,  which  porsistod,  but  no  bacilli  wcri'  fuiind.  Tho'c  was 
1111  iVtnr  of  the  breath.  Weeks  afterward  he  develo[ted  sevi'iv  headache, 
ami  in  a  few  (hiys  Ix'canie  c.<malose  and  died.  Tlu're  was  a  circumscrilied 
Mica  of  healing  ganirn-ne  at  tlu  margin  of  the  lung  with  great  incri'use  of 
tilinms  tissue  about  it.  The  artery  going  to  this  somewhat  wedge-shaiied, 
ai'ca  was  obliterated.  The  contents  of  the  enca[isulated  caviiy  were  very 
I'll  ill.  There  was  a  large  limiteil  abscess  in  the  parieto-temporal  regiou 
1)11  I  he  right  side. 

Symptoms  and  Course. — I'sually  delinite  symiitoms  of  Ideal  |>ul- 
iiiiiuary  disease  precede  the  characteristic  features  of  gangrene.  'I'hcse, 
(if  ciuirse,  are  vimt  varied,  depending  on  the  nature  of  the  troiibU'.  Tho 
s|mtum  is  very  charaiit'ristic.  It  is  inti'iisely  ft  lid — usually  jirofuse — 
ami,  if  ex{)ectorated  into  a  conical  glass,  separates  into  thri-e  layers— ii 
greciii-'h-browu,  heavy  sediment;  an  intervening  thin  li(|uid,  which  soiiie- 
tiiiu's  has  a  greenish  or  a  brownish  tint;  and,  on  top,  a  thick,  frothy  layer. 
Sprcail  wii  a  glass  plate,  the  shreddy  fragments  of  lung  tissue  can  readily 
lie  picked  out.  .Microscopic'ally,  elastic  libres  are  found  in  abundance, 
witli  granular  nuitter,  pignuMit  grains,  fatty  crystals,  bacteriii,  and  Icpto- 
tlirix.  It  is  stated  that  elastic  tissue  is  sometimes  al)sent,  but  1  have  never 
iiift  with  such  an  instance.  The  jieciiliar  plugs  of  sputum  w  hich  occur 
ill  lirmichiectasy  are  not  found.  Hlood  is  often  present,  and,  as  a  ruli',  is 
iiiuili  altered.  The  sputum  has,  in  a  majority  of  the  eases,  an  inti-nsely 
fcliil  o(l(U\  which  is  couunnnicated  to  the  breath  and  may  jiermcate  tho 
ciiiire  room.  It  is  much  mmv  oil'tuisive  than  in  fi'lid  lironchilis  or  in 
alwiTss  of  the  lung.  The  fetor  is  particularly  marked  when  there  is  free 
(■oiiimunicatiiui  between  the  gangrejioes  cavities  and  the  bronchi.  On 
several  occasions  I  have  found,  post  nu)rtem,  locali/i'd  gangrene,  which 
liiiil  heen  unsuspected  during  life,  and  in  which  there  had  been  no  fetor 
(if  the  breath. 

The  physical  sig!is,  wlien  ext(>nsive  destruction  has  occurred,  are  those 
cf  cavity,  but  the  limited  circumscribed  areas  may  be  ditlicult  to  deti'ct. 
Unuichitis  is  always  present. 

Among  the  geiu'ral  symptoms  may  be  inei.tion(d  fever,  usually  of 
iiinih  rate  grade;  the  pulse  is  rapid,  and  very  often  : he  constitutional  de- 
incs-idu  is  severe.  Hut  the  only  special  fi'atures  indicative  of  gangrene 
arc  the  sjiuta  and  the  fetor  of  the  breath.  The  jtalieut  generally  sinks 
tiimi  exhaustion.  Fatal  luvmorrhago  may  etisue.  I  have  already  men- 
tiiiiiril  a  case  in  which  a  ha'inorrhage  from  a  circumscribed  gaiigreno 
ucailv  proved  fatal,  and  I  have  seen  oni'  fatal  instanci'  after  putMiinonia. 

Treatment. — 'I'he  treatuu>nt  of  gangrene  is  very  unsatisfactory.  The 
nuliialions,  of  course,  are  to  disinfect  the  gangrenous  area,  but  this  id 


\i^,t] 


1 


M  .^ilJ 


580 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


t  <i   » 


W^i^ 


N  *  ii 


;il(i 


t'l      > 


ol'tt'ii  im]K)ssible.  An  niitisoptic  spniy  of  curbolic  acid  may  bo  onipldvcd. 
A  {ifood  plan  is  for  liic  patient  to  use  over  tl>e  mouth  and  nose  au  inhaler 
which  niay  l)c  cliari^'ed  with  a  sohition  of  carbolic  acid  or  creosote  11'  the 
sij^iis  of  cavity  arc  distinct  an  attempt  should  be  nuide  to  cleanse  it  hy 
direct  injections  of  an  antiscjitic  solution.  If  the  jiatient's  conditidn  !>< 
good  and  tiie  gangrenous  region  can  be  lo(;alized,  an  uttemjit  siioiiM  l)e 
nuide  to  treat  it  surgically.  Suc-eessful  cases  have  been  re[)orte(l.  Tlio 
general  condition  of  tiie  patient  is  always  such  as  to  denumd  the  greatest 
care  in  the  matter  of  diet  and  nursing. 


VII.  ABSCESS  OF  THE  LUNG. 

Etiology. — Su])puration  occurs  in  the  lung  undc  the  folKiwiiiir 
conditions:  (i)  As  a  sequence  of  inliamnuition,  eitlua*  lobar  or  lobular. 
Apart  from  the  purulent  infiltration  this  is  un(|uestionably  rare,  and  even 
in  lobar  pneumoiua  the  aljscosses  are  of  small  size  and  usually  invuhc.  as 
Addison  remarked,  several  ])oiuts  at  the  same  time.  On  the  other  liai  d, 
abs(!ess  formation  is  extremely  frecjuent  in  the  deglutition  and  j  \n\: 
forms  of  lobular  pneumonia.  After  wounds  of  the  neck  or  (,,!•;!.-,,» 
upon  the  thi'oat,  in  su])purative  disease  of  the  nose  or  larynx,  (xu-asKnuiliy 
even  of  ilw  ear  (\'olkmann),  infective  particles  reach  the  bronchial  tiilicj; 
by  aspiration  and  excite  an  intense  iidlammatiou  which  often  ends  in 
suppurati<in.  Caiu'cr  of  the  O'sojihagus,  ])erforating  the  root  of  the  hiiijr 
or  into  the  l)roiichi,  nuiy  produce  extensive  supi)uration.  'J'he  aliscessfs 
vary  in  size  from  a  walnut  to  an  orange,  and  have  ragged  and  irrejrular 
walls,  and  ])urulent,  sometimes  necrotic,  contents. 

{'i)  Embolic,  so-called  metashdic,  abscesses,  the  result  of  infectious 
end)()li,  are  extremely  coniiiu)n  in  a  large  proportion  of  all  cases  of  pvaiiiia. 
They  may  occur  in  enormous  numbers  and  present  very  detliute  cliia'- 
acters.  As  a  rule  they  are  superficial,  beneath  the  ])leura,  and  often 
wedge-shaped.  At  first  firm,  grayish  red  in  color,  and  surrounded  ly  a 
zone  of  intense  hypera'uiia,  su])puration.  soon  follows  with  the  foriiuilinn 
of  a  definite  abscess.  Tlie  ])leura  is  usually  covered  with  greenish  lynipli, 
and  perforation  sometimes  takes  place  with  the  production  of  piieuniD- 
thorax. 

(.'})  Perforation  of  the  lung  from  without,  lodgment  of  foreign  bodies. 
and,  in  the  right  lung,  ])erforation  from  abscess  of  the  liver  or  sup[iiiralin  , 
echinococous  cyst  are  occasional  causes  of  j)ulmonary  abscess. 

(4)  Su))purative  ])rocesses  pluy  an  important  part  in  chronic  pulmonary 
tuberculosis,  many  of  the  symptoms  of  whicdi  arc  duo  to  them. 

Symptoms. — Abscess  following  pneumoiua  is  easily  recognized  by 
an  aggravation  of  the  general  sym.ptoms  and  by  the  physical  s'gnc'  of  cav- 
ity and  tlui  characters  of  the  expectoration.  Embolii;  abscesses  canno, 
often  be  recognized,  and  the  local  symptoms  are  generally  masketl  in  tlie 


.V 


PNEUMONOKONIOSIS. 


i)S. 


s 


gcnoral  pyaemic  manifestiitions.  Tlio  clmractors  of  the  sputum  arc  of  great 
inniDrtaneo  in  (leterriiiniug  tlie  ])rosL'ii('e  of  al)soess.  The  o(l(H'  is  olTousivo, 
vet  it  raroly  has  the  liorribk;  fetor  of  gaugreiio  or  of  putrid  broiu;iiitis. 
Ill  tho  ])us  fraginuiits  of  huig  tissue  eau  he  seen,  and  the  ehistie  tissue  may 
be  very  aliundant.  Tlie  presence  of  tliis  with  the  physical  signs  rarely 
leaves  any  question  as  to  the  nature  of  the  trouble.  Embolic  cases  usually 
rim  a  fatal  course.     Kecovery  occasionally  occurs  after  imetinioiiia. 

Medicinal  treatment  is  of  little  avail  in  abscess  of  the  lung.  AVhen 
well  defined  and  superficial,  an  attcnqit  sliould  always  be  made  to  open 
and  (hniin  it.  A  number  of  successful  cases  have  already  been  treated  in 
this  way. 

VIII.  PNEUMONOKONIOSIS. 


Under  this  term,  introduced  by  Zenker,  are  embraced  those  diseases  of 
the  lungs  due  to  the  inhalation  of  dusts  in  various  occupations.  They 
liav(i  received  various  names,  according  to  the  nature  of  the  inhaled 
|iarticlcs — (inthmcosis,  ov  coal-miner's  disease;  sidcrasix,  due  to  the  in- 
halation of  metallic  dusts,  particularly  iron;  chaltcoHis,  due  to  the  inhala- 
tion of  mineral  dusts,  ])roducing  the  so-called  stone-cutter's  phthisis,  or 
the  "grinder's  rot"  of  the  ShcHiehl  workers. 

'The  dust  particles  inhaled  into  the  lungs  are  dealt  with  (xtcnsively  by 
tlie  ciliated  epithelium  and  by  the  phagocytes,  which  exist  iKiriiially  in  the 
respiratory  organs.  The  ordinary  mucous  corpuscles  take  in  a  larg(  num- 
ber of  the  particles,  which  fall  upon  the  trachea  and  main  bronchi.  The 
cilia  sweep  the  mucus  out  to  a  point  from  which  it  can  be  expelled  by 
eiiiighiiig.  It  is  doubtful  if  the  particles  ever  reach  the  air-cells,  hut  the 
sudlleii  jilvcolar  cells  (in  which  they  jire  in  numbers)  probnlily  ])ick  them 
ii|i  oil  the  way.  I'lio  mucous  and  the  alveolar  cells  are  the  normal 
i'es|)iratory  scavengers.  In  dwellers  in  the  country,  in  which  the  air  is 
pure,  they  are  able  to  prevent  tho  access  of  dust  ])articlcs  to  the  lung 
tissue,  so  that  even  in  adults  these  organs  ]u-esent  a  rosy  tint,  ver\ 
tiilTereiit  from  the  dark,  carbonized  appearance  of  the  lungs  of  dwellers  in 

hies.  When  the  impurities  in  the  air  are  very  aliundant,  a  certain  pro- 
;'n!'tion  of  tile  dust  particles  escapes  these  cells  and  penetrates  the  mucosa, 
iwichiiig  tho  lymph  spaces,  wliere  they  are  attacked  at  once  by  the  cells 
<if  the  connective-tissue  stroma,  which  are  capable  of  ingesting  and  retain- 
ini,'  :i  large  quantity  In  coal-miners,  coal-heavers,  and  others  whose 
occupalidiis  necessitiitc  the  conshmt  breathing  of  a  very  dusty  atmosplicre 
even  these  forces  are  iiisuflicient.  Many  of  the  jiarticles  enter  the  lynqih 
f'treaiu  and,  as  Arnold  has  shown  in  his  beautiful  researches,  are  carrii'd 
(1)  to  tho  lymph  nodules  surrounding  the  bronchi  and  blood-vessels;  {'i) 
to  tho  interlobular  se]>ta  beneath  the  pleura,  where  they  lodge  in  and 

"Ctween  the  tissue  elements;  and  (."5)  along  the  larger  lymph  channels  to 
the  Biibsternal,  bronchial  and  tracheal  glands,  iu  which  the  stroma  cells  of 
158 


^'   1,-1     ' 


tin 


•f    I 


¥r 


588 


DISEASES  OP  THE  RESPIRATORY  SYSTEM. 


tlic  folliciiliir  cords  dispose  of  tliom  pormiinently  and  prevent  thorn  from 
enterinj^  the  general  cireuliition.  Oeeiisionally  in  untlirueosis  tlie  carhou 
grains  do  reach  the  general  circnlation,  and  the  eual  dnst  is  I'ouihI  in  the 
Hver  and  spleen.  As  Weigert  has  shown,  this  oecnrs  when  the  dnisi'ly 
pigmented  hronc-hial  glands  closely  adhere  to  the  pulmonary  veins,  tiiroiicrji 
the  walls  of  which  the  carhon  particles  pass  to  the  general  circiilatidii. 
The  lung  tissue  has  a  remarkal)le  tolerance  for  these  i)arti(;les,  prdhubly 
hccause  u  large  proportion  of  them  is  warehoused,  so  to  speak,  in  pro- 
toj)lasmie  cells.  J?y  constant  exposure  a  limit  is  reached,  and  tlicrc  is 
brought  about  a  very  detinite  ])athologieal  conditicni,  an  interstitial  sclero- 
sis. In  coal-miners  this  may  occur  in  patches,  even  before  the  lung  tissue 
is  utiiformly  infiltrated  with  the  dust.  In  others  it  ap])ears  only  aflvr  tlie 
entire  organs  have  become  so  hiden  that  they  arc  dark  in  color,  :uui  an 
ink-like  juice  tiows  from  the  cut  surface.  The  lungs  of  a  miner  may  l)e 
black  througliout  and  yet  sliow  no  local  lesions  and  be  everywhere 
crepitan*. 

As  ah  J  .'ntioned,  the  particles  are  dej)osited  in  largo  nuinhors  in 

the  folli(;ula,  ds  of  the  ti-acheal  and  bronchial  glands  and  of  the  jhti- 
bronchial  and  peri-arterial  lynii)h  luxlnles,  and  in  these  they  finally  excite 
proliferation  of  the  connective-tissue  elements.  It  is  by  no  means  un- 
common to  lind  in  persons  whose  lungs  are  oidy  moderately  carbniii/eil 
the  bronchial  glands  sclerosed  and  hard.  In  anthracosis  the  lilimiii 
changes  usually  begin  in  the  peri-bronchial  lymph  tissue,  and  in  the  early 
stage  of  the  })rocess  the  sclerosis  may  be  largely  confined  to  these  rciridus. 
A  Xova  Scotian  n)iner,  aged  thirty-six,  died  under  my  care,  at  the  Mont- 
real General  Hospital,  of  black  small-pox,  after  an  illness  of  a  few  (hiys. 
In  his  lungs  (externally  coal-black)  there  were  round  and  linear  patches 
ranging  in  size  from  a  pea  to  a  hazel-nut,  of  an  intensely  black  color,  air- 
less and  firm,  and  surrounded  by  a  crepitant  tissue,  slate-gray  in  color. 
In  the  centre  of  each  of  these  areas  was  a  small  bronchus.  Many  of  them 
were  situated  just  beneath  the  pleura-,  and  formed  typical  examiik'S  of 
limited  fibroid  broncho-pneumonia.  In  addition  there  is  usually  thicken- 
ing of  the  alveolar  walls,  particularly  in  (certain  areas.  By  the  gradual 
coalescence  of  these  fibroid  patches  large  portions  of  the  lung  iiiuy  be 
converted  into  firm  grayish-black,  in  the  case  of  the  coal-miner— steel- 
gray,  in  the  case  of  the  stone-worker — areas  of  cirrhosis.  In  the  case  of  a 
Cornish  miner,  aged  sixty-three,  who  died  under  my  care,  one  of  these 
fibroid  areas  measured  18  by  0  cm.  and  i'o  cm.  in  depth. 

A  second  important  factor  in  these  cases  is  chronic  bronchitis,  which 
is  present  in  a  large  proportion  and  really  causes  the  chief  symptoms.  A 
third  is  the  occurrence  of  emphysema,  which  is  almost  invariably  associ- 
ated with  long-standing  cases  of  pneumonokoniosis.  With  the  chaniros  >» 
fur  described,  unless  the  cirrhotic  area  is  umisnally  extensive,  the  case  may 
present  the  features  of  chroinc  bronchitis  with  emphysema,  hut  tinally 
auotlior  elemout  comes  into  play.     In  the  fibroid  areas  softening  oceur.s, 


PNEUMOXOKONIOSIS. 


589 


probably  a  process  of  necrosis  similar  to  that  by  which  softening  is  pro- 
diifod  in  fibro-myomata  of  the  utenis.  At  first  these  are  small  and  con- 
tain a  (lark  liciuid.  (Charcot  calls  tlioni,  as  already  mentioned,  nlceres  dn 
jKiiniioii.  They  rarely  attain  a  large  size  unless  a  communication  is 
formed  witli  the  bronchus,  in  wliicli  case  tliey  may  become  converted 
iiiln  suppurating  cavities.  Tlie  question  has  been  niucli  discussed  of 
late  as  to  what  part  tlie  tubercle  bacillus  plays  in  these  cases  of  pneu- 
uiouoivoniosis  witli  cavity  formatioTi.  In  some  instances  there  is  cer- 
tainly a  tuberculous  process  ingrafted,  but  that  large  excavations  may 
occur,  or  in  other  iTistaiuies  bronchiectasis  without  the  presence  of  bacillis, 
I  have  convinced  myself  by  the  examination  of  several  characteristic  spec- 
imens. 

The  sidprnsts  induced  by  the  oxide  of  iron  causes  an  interstitial  pneu- 
monia similar  to  anthracosis.  Workers  in  brass  and  in  bronze  are  liable 
to  a  similar  alTection. 

('/lalicoKis,  due  to  the  deposit  of  particles  of  silex  and  alumina,  is 
found  in  the  makers  of  mill-stones,  particularly  the  French  mill-stones, 
and  also  in  knife  and  axe  grinders  ami  stone-cutters.  Anatomically,  this 
form  is  characterized  by  the  production  of  nodules  of  various  sizes,  which 
are  cut  with  the  greatest  difficulty  and  sometimes  present  a  curious  gray- 
ish, even  glittering,  crystalloid  appearance. 

Workers  in  flax  and  in  cotton,  and  grain-shovellers  are  also  subjei^t  to 
these  chrimic  interstitial  (dianges  in  the  lungs.  In  all  the.«;e  occupations, 
ii.s  shown  by  Greenhow,  to  whose  careful  studies  we  owe  so  much  of  our 
knowledge  of  these  diseases,  the  condition  of  the  lung  may  ultimately  be 
iilmost  identical. 

The  si/inpf(»ns  do  not  come  on  until  the  ]iatient  has  worked  for  a  vari- 
iihh'  number  of  years  in  the  dusty  atmosphere.  As  a  rule  there  are  cough 
and  failing  health  for  a  prolonged  period  of  time  before  comph^te  disa- 
bility. The  coincident  emphysema  is  responsible  in  great  part  for  the 
sliortne.ss  of  breath  and  wheezy  condition  of  these  patients.  The  expec- 
toration is  usually  muco-purnlent,  often  profuse;  in  a  case  of  anthra- 
cosis, very  dark  in  color— the  so-called  "  black  spit " ;  in  a  case  of  chalicosis 
there  may  be  seen  under  the  microscope  the  bright  angular  particles  of 
silica. 

Kven  when  there  are  physical  signs  of  cavity  tubercle  bacilli  are  not 
necessarily,  and  indeed  in  my  expc^rience  thi-y  are  not  usually  jjresent.  It 
i''  ivniiirkahle  for  how  long  a  time  a  coal-miner  may  continue  to  bring 
up  sputum  laden  Avith  coal  jiarticles  even  when  there  are  only  signs 
iif  a  chronic  bronchiti.s.  Many  of  the  particles  are  contained  in  the 
cells  ol'  the  alveolar  epithelium.  In  these  instances  it  appears  that  an 
iittcmpt  is  made  by  the  leucocytes  to  rid  the  lungs  of  some  of  the  carbon 
grains. 

The  (Jiarjnofiis  of  the  condition  is  rarely  diflicult;  the  expectoration  is 
U'^ually  characteristic.     It  must  always  be  borne  in  mind  that  chronic 


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DISEASES  OF  TJIE   UESI'IRATORY   SYSTEM. 


bronchitiR  and  omjtliysoma  form  cssontial  parts  of  tlie  process  and  ilmt  in 
lato  sta.^is  tliorc!  may  ho  tuberculous  infection. 

The  IreatiDoit  of  tlie  condition  is  practically  that  of  chronic  Itronrhiii^ 
and  eniphyscnia. 


IX.  NEW  GROWTHS  IN  THE  LUNGS. 

Etiology  and  Morbid  Anatomy.— While  i)riniary  tumors  ure 
rare,  secondary  growths  arc  not  uncommon. 

'I'he  primary  growths  of  the  lung  arc  either  cncephaloid,  scirrlms  or 
epithelioma.  Kcccnt  observations  show  that  tlic  latter  is  the  most  cdiii- 
mon  form.  Sarcoma  also  is  occasionally  fouiul  as  a  primary  growth,  luul 
still  more  rarely  enchondroma. 

The  secoiulary  growths  may  be  of  various  forms.  Most  coTunnmlv 
they  follow  tumors  in  the  digestive  or  genito-urinary  organs;  not  infr,.. 
quently  also  tumors  of  the  bone.  There  may  be  cncephaloid,  scirrhus,  I'pi- 
thelioma,  colloid,  nndano-sarcoma,  enchondroma,  or  osteoma. 

Prinniry  cancer  or  sarcoma  usually  involves  only  one  lung.  Tlic  sec- 
ondary growths  are  distributed  in  both.  'I'he  jirijuary  growth  geiicrallv 
forms  a  large  mass,  which  may  occupy  the  greater  })art  of  a  lung.  Occasiun- 
ally  the  secoiulary  growths  are  solitary  and  confined  chiefly  to  the  ])l('in';i. 
as  in  a  remarkable  exam})lc  which  came  under  my  observation,  in  wliidi  tin 
disease  was  secondary  to  a  myclo-sarcoma  of  the  wrist.  The  tumur  iiiii<> 
occupied  a  large  portion  of  the  left  side  of  the  thorax.  It  grew  fnnii  tin' 
l)leura  and  extended  only  slightly  into  the  lung,  which  was  compnsst'd 
and  airless.  The  metastatic  growths_  are  nearly  always  dissemiiiiitt'il. 
Occasionally  they  occupy  a  large  portion  of  the  })uhnoimry  tissue.  In  a 
case  of  colloid  cancer  secondary  to  caiu-er  of  the  pancreas,  I  found  huth 
lungs  voluminous,  heavy,  only  slightly  crepitant,  and  occupied  by  ciroular 
translucent  masses,  varying  in  size  from  a  pea  to  a  large  walnut. 

There  are  unmerons  accessory  lesions  in  the  ])ulmonary  new  giTi\vtli>. 
There  may  be  pleurisy,  either  cancerous  or  sero-fibrinous.  The  ell'iisioii 
may  be  ha'morrhagic,  but  in  "-iOO  cases  of  cancer,  prinuiry  or  secondarv,  of 
the  lungs  aiul  pleura  analyzed  by  ^ioutard-^Nfartin,  luemorrhagic  cli'iisinii 
occurred  in  oidy  twelve  per  cent.  'I'he  tracheal  and  Ijronchial  glamls  aiv 
usually  affected,  the  cervical  glands  not  infrequently,  and  occasionally  even 
the  inguinal. 

The  disease  is  most  common  in  the  middle  period  of  life.  Thf  pri- 
mary form  atfec's  the  sexes  equally,  l)ut  secoiulary  cancer  is  much  niinv 
frequent  in  women  than  in  men.  The  conditions  wliicli  predispus;-  to  it 
are  quite  unknown.  It  is  a  remarkable  fact  that  the  workeis  in  the 
Sclineeberg  cobalt  mines  are  very  liable  to  ])rinuiry  cancer  of  tlic  liiiig>- 
It  is  stated  that  in  this  region  a  considerable  proportion  of  all  diatlis  iu 
persons  over  forty  are  due  to  this  disease. 


NEW   GROWTHS  IN   TIIK   LUNGS. 


591 


Symptoms. — Tlu-  cliniral  foaturoa  of  neoplasms  of  tlio  lim,<,'s  an-  hy 
111.  iiicans  distiiKjtivi',  particularly  in  the  ease  of  })rimary  <,n-<)\vtiis.  Tho 
iiaticiit  iiiuv,  imleed,  as  iiotrd  hy  Walshe,  present  no  symptoms  pointinj^ 
til  iiilrallioracic  iliscasr.  AiiHm;^  tht'  nmre  im|)()rtant  sym[itnms  are  pain, 
iiarliciilarly  when  the  pleura  is  involveil;  dyspiid'a,  wliidi  is  apt  to  ho 
iiarnxysmal  when  Aur.  to  pressnre  \ipon  the  traehea ;  coiii!;!!,  which  may  lie 
di'V  and  painful  and  accom|ianied  hy  the  expectoration  of  a  liark  mucoid 
sinitum.  Tliis  so-call(!(l  prune-juice  expectoration,  wluch  was  present  ten 
times  in  cii^diteoji  eases  of  primary  cancer  of  the  luii",',  was  thought  by 
Stokes  to  he  of. great  <liagnostie  value. 

In  many  instancies  then^  are  signs  of  compression  of  the  largo  veins, 
iirmhicing  liviility  of  the  face  and  upjier  extremities,  or  occasionally  of 
iiiiiv  one  arm.  ('om[)ressioii  of  the  trachea  and  hronchi  may  give  risi'  to 
wY'S'ui  dyspno-a.  The  heart  may  lie  [lUshed  over  to  the  opposite  side. 
'1"1k'  ))neumogastric  ami  recurrent  laryngeal  nerves  are  occasionally  in 
viilvfd  in  th(!  growth. 

Physical  Signs. — The  patient,  according  to  Walshe,  usually  lies  on  the 
iilTictcil  side.  On  inspection  this  side  may  he  enlarged  and  immoliile  ..  .d 
till'  intercostal  s[)a('es  arc^  ohliterated.  This  is  more  eommoidy  due  to  the 
•  ■irn>ion  than  to  the  growth  itself.  Tlie  external  lymph-glands  nniy  Ik' 
ciilargcil,  particularly  the  clavicular.  Tlie  signs,  on  percussion  and  aus- 
cuhiilioii,  are  varied,  (h'i»ending  much  upon  tlie  presence  or  ahseiice  of 
lliiiih  Signs  of  consolidation  are,  of  course,  jtresent ;  the  tactih'  fremitus 
is  absent  and  the  hreath-.scmnds  are  usually  diminished  in  intensity.  <)c- 
lusiiinally  there  is  typical  hronehial  l)reathing.  Among  otlier  symptoms 
may  he  mentioned  fever,  which  is  present  in  a  certain  number  of  eases. 
Kinaciation  is  not  necessarily  extreme.  The  duration  of  the  disease  is 
frnni  six  to  eight  months.  Occasionally  the  disease  runs  a  very  acute 
cniirse,  as  noted  by  Carswell.  Cases  are  reported  in  which  death  occurred 
in  a  month  or  six  weeks,  and  in  one  i)istanee — Jaccoud — the  patient  died 
ill  a  week  from  the  onset  of  the  symptoms. 

Diagnosis. — In  secondary  growths  this  is  not  dilhcult.  Th.e  devel- 
eiimeiit  of  jmlmonary  symptoms  with.in  a  year  or  two  after  the  removal  of 
a  ("Ulcer  of  the  breast,  or  after  the  amputation  of  a  limb  for  osteo-sarcoma, 
or  the  onset  of  similar  sym])toms  in  connection  with  cancer  of  the  liver, 
<ir  of  the  uterus,  or  of  the  rectum,  would  he  extremely  suggestive.  In 
inimary  cases  the  unilateral  involvement,  the  anomalous  character  of  the 
{thysical  signs,  the  occurrence  of  prunc-juice  expectoration,  the  progress- 
ivo  wasting,  and  the  secondary  involvement  of  the  cervical  glands  are  the 
iin})(irtant  points  iu  the  diagnosis. 

New  growths  are  occasionally  primary  in  the  pleura  (Harris,  Journal 
of  Pathology,  vol.  ii). 


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592  DISEASES  OF  THE  KKSPIllATOUY  SYSTEM. 


y.  DISEASES  OF  THE   I'LEUKA. 

I.  ACUTE   PLEURISY. 

Aniitoniiptilly,  tlic  cases  nmy  l)o  divided  into  dry  or  adhesive  pleurisy 
and  pleurisy  witli  (Elusion.  Another  classilication  is  into  j)riniiirv  oi- sec- 
ondary i'ornis.  Aecor(lin<f  to  tlie  course  of  the  disease,  a  division  niiiv  he- 
made  into  «r'/</e  and  chronic  pleurisy,  and  as  it  is  iinjjossihle,  at  })reMiit, 
to  group  the  various  i'ornis  etiologieally,  this  is  perhajis  the  most  sutisl'ac- 
tory  division.     The  following  forms  of  acute  pleurisy  may  be  considered: 

I.  FiHKiN'ors  ou  Plastic  J'lkliusy. 

In  this  the  jileural  membrane  is  covered  by  a  sheeting  of  lyin])ii  of 
variable  tbii-kness,  which  gives  it  a  turbid,  granular  appearance,  or  the 
fibrin  iiuiy  exist  in  distinct  layers.  Jt  occurs  (1)  as  an  independent  alTee- 
tion,  following  cold  or  exjjosure.  This  form  of  acute  plastic;  ])leurisv 
without  fluid  exudate  is  not  common  in  perfectly  healthy  indivi(hiids. 
Cases  are  met  with,  however,  in  which  the  disease  sets  in  with  the  usual 
symptoms  of  ])ain  in  tiie  sule  and  slight  fever,  and  there  are  the  i)hy.Mciil 
signs  of  pleurisy  as  indicated  by  the  friction.  After  persisting  for  a  few 
days,  the  friction  murmur  disai)i»ears  and  no  exudation  occurs.  Vuu>]\ 
takes  place  between  the  mend)ranes,  and  j)()ssibly  the  pleuritic  adhesions 
Avbich  are  found  in  such  a  large  iienieiitage  of  all  bodies  examined  after 
death  originate  in  these  slight  librllious  j)leurisies. 

Fibrinous  jdeurisy  occurs  (2)  as  a  secondary  process  in  acute  diseases 
of  the  lung,  such  as  pneumonia,  Avhich  is  always  accompanied  by  a  certain 
amount  of  pleurisy,  usually  of  this  form'.  CaJicer,  abscess,  and  gangrene 
also  cause  })lastic  ])leurisy  when  the  surface  of  the  lung  becomes  involved. 
This  coiulition  is  sj)ecially  associated  in  a  large  nundjer  of  cases  with 
tuberculosis.  Pleural  })ain,  stitch  in  the  side,  and  a  dry  cough,  with 
marked  fricttion  sounds  on  auscniltation  are  the  initial  phenomena  in 
many  instances  of  phthisis.  The  signs  are  usually  basic,  but  liurney  Yeo 
has  recently  called  attention  to  the  frequency  witli  which  they  occur  at 
the  apex. 

TI.  Sero-firuixou.s  Pleurisy. 

In  a  majority  of  cases  of  inflamination  of  the  pleura  there  is,  with  the 
fibrin,  a  variable  amour.t  of  fluid  exudate,  which  produces  the  condition 
known  as  pleurisy  with  ciTusion. 

Etiology. — For  generations  physicians  have  considered  caM  the 
potent  factor  in  inducing  pleurisy.  This  may  be  true  in  many  cases,  l)ut 
modern  views  of  serous  inflammations  scarcely  recognize  cold  as  anytliing 
more  than  a  predisposing  agent,  which  permits  the  action  of  various 
micro-organisms.     We  have  not  yet,  however,  brought  all  the  acute  pleu- 


ACUTK   PLEURISY. 


503 


risios  into  the  catoj^orj'  of  miorf)1)io  afToetions,  and  tlio  fact  romaiiia  that 
pleurisy  docs  follow  with  ijrcat  rapidity  a  sudden  wetting'  or  a  chill.  ( )f  late 
vears  an  attempt  lias  been  niailc.  particakirly  by  I-'rciicli  writers,  to  sliow 
tli;il  the  majority  of  a(;uto  pleurisies  are  tubcM'culous,  In  tins  coniiection 
tlic  followintf  facts  may  he  admitt(Ml  :  (I)  Iti  a  limited  number  of  oasos 
of  pleurisy  comint,'  on  abruptly  in  healthy  pi'rsons  the  disease  has  been 
shown — (fi)  by  posL-mortem,  in  cases  of  accidental  or  sudden  death,  (/;)  i)y 
the  subscfiuent  liistory — to  bo  tuberculous;  {'I)  in  a  larijer  proi)ortion  of 
tJKiso  cas(!S  which  como  on  insidiously  in  persons  who  have  boon  in  failiiifr 
health  or  who  aro  delic;ito  the  disease  is  tul)orculous  from  the  outset;  (;{) 
the  iKUito  jdourisy,  v/hich  occurs  as  a  secctndary,  oftcJi  a  terminal,  event  in 
rhrouic  alfecjtions,  such  as  cirrhosis  of  the  liver,  Brin'ht's  disease,  and 
caiieer,  is  very  fre(piently  tuberculous.  I  confess  that  the  more  carefully 
I  have  studied  tlie  question  the  larger  does  the  proportion  appear  to  be  of 
primary  jdeurisics  of  tuberculous  oriirin.  The  subsc((uent  history  of  cases 
of  acute  pleurisy  forces  us  to  conclude  that  in  at  least  two  thirds  of  the 
eases  it  is  a  cnirable  affection.  This  may  Avell  be  so,  according  to  our  })res- 
ouL  ideas  of  local  tuberculous  disease.  One  of  the  nu)st  interesting  con- 
trihiitions  to  this  question  has  been  made  from  the  records  of  irenry  I. 
Bdwditch,  of  Boston,  to  whom  we  are  indel)ted  for  so  many  im])ortant 
cctilributions  to  our  knowledge  of  ])leur'sy.*  Of  !)()  cases  of  acute  pleu- 
risy which  had  been  un<ler  observation  between  184!)  and  187!),  .'53  died 
of  or  had  phthisis — a  jiercentage  large  enough  to  indicate  what  an  impor- 
tant rolf  tuberculosis  plays  in  the  etiology  of  this  disease. 

Morbid  Anatomy. — In  sero-fd)rin()us  ])leurisy  the  serous  exudate 
is  iil)u'idant  and  the  iibrin  is  found  on  the  ])leural  surfaces  and  scat- 
tered through  the  lluid  in  the  form  of  llocculi.  The  proportion  of 
tlu'se  constituents  varies  a  great  deal.  In  some  instances  there  is  very 
little  membranous  fibrin ;  in  otliers  it  forms  thick,  creamy  kivers  and  ex- 
ists ill  the  dependent  part  of  the  lluid  as  whitish,  curd-like  masses.  The 
iluid  of  sero-fibrinous  pleurisy  is  of  a  lemon  color,  either  clear  or  slightly 
turbid,  depending  on  the  num1)er  of  formed  elements.  In  some  instances 
it  has  a  dark-brown  color.  The  microscopical  examination  of  the  fluid 
shows  leucocytes,  occasional  swollen  cells,  which  may  possibly  be  derived 
from  the  pleural  endothelium,  shreds  of  librillatcd  til)rin,  and  a  variable 
iiuinlur  of  red  blood-corpuscles.  On  boiling,  the  fluid  is  found  to  be  rich 
in  albumen.  Sometimes  it  coagulates  spontaneously.  Its  composition 
closely  resembles  that  of  lilood-sernm.  Cholesterin,  uric  acid,  and  sugar 
are  occusionally  found.  The  amount  of  the  effusion  varies  from  a  half  to 
four  litres. 

The  lung  in  acute  sero-fibrinous  pleurisy  is  more  or  less  compressed.  If 
the  exudation  is  limited  the  lower  lobe  alone  is  atelectatic  ;  but  in  an  exten- 
sive effusion  which  reaches  to  the  clavicle  the  entire  lung  will  be  found 

•Vincent  Y.  Bowditch,  in  Boston  Medical  and  Surgical  Journal,  1889. 


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DISKASKS  OF  TIIK   RKSIMRATOKY  SYSTEM. 


lyiiif?  clotio  to  till!  ppino,  durlc  and  airli'ss,  or  cvoii  bloodli-ss — i.  ,..,  cm-- 
iiiiH'(l. 

Ill  lai'iC''  I'Midatioiis  tlic  iidjacciit,  origans  arc  displaced.  In  larp'  riirlit- 
sidt'd  |ilciirisic.-i  the  liver  is  iniidi  di'iiri'sscd.  Iiatlicr  varyiiiif  stalciiiiui.; 
urc  iiiadu  with  n'rcrt-'Ucc  t(»  tlic  [»(tsiti(>ii  of  the  lu-art  and  as  to  whcllicr  up 
not  it  rotates  on  its  axis.  In  a  nunil)cr  (tf  post-ni(»rtcins  I  iiavi;  cari'f  iHv 
studied  its  position,  bnth  in  pncmnoLJiorax  and  in  lar^^c  ('(riisions,  and  can 
spualv  with  sitnic  (U'^^n'iv  of  certainly  on  the  followinj^  point-;:  (1)  Ewu  in 
tho  most  cxtensivo  left-sided  exudation  there  is  no  rotation  of  the  iiprx 
of  the  heart,  which  in  no  case  was  to  the  ri^lit  of  the  niid-stenial  Hue; 
['^)  llic  relalive  position  of  the  apex  and  base  is  usually  niaintaiiu'd  ;  in 
some  instances  the  apex  is  lifted,  in  oth(!rs  tho  wholo  lieart  lies  more  li'iiiis- 
versely ;  {'•))  the  riuht  chand)ers  of  the  heait  occupy  the  jrrciitcr  |ir,rtiiiii  nl' 
the  front,  so  that  the  dis[)lacement  is  rather  a  delinito  dislocation  of  iln- 
nu'diastinuni,  with  tho  pi-ricardiuin,  to  the  \''\'^ht,  than  any  special  twi-iiiii; 
of  the  heart  itself;  (4)  the  kink  or  twist  in  the  inferi(»r  vena  cava  deserilied 
by  Hartels  was  not  present  in  any  of  the  cases. 

Symptoms.  —  I'rodromes  are  not  utu-ommoji,  l)ut  the  disease  may  set 
in  altriiptly  with  a  chill,  followed  by  fever  and  a  severe  jtain  in  the  sidi'. 
It  is  remarkalile,  however,  with  Avhat  fre(piency  the  disease  eonies  on  in- 
sidiously, 'i'he  ])aiii  in  the  side  is  the  most  distressinjjj  symptom,  anil  i-; 
usually  referred  to  the  nip,ile  or  axilhiry  rei^dons.  It  must  be  renu'niliricil. 
liowovei,  that  |ileurii,io  pain  may  he  felt  in  tho  abdomen  or  low  dnwn  in 
tho  bac'c,  particularly  when  the  dia|)hraii:mati(;  surface  of  the  pleiii'a  i> 
iuvolvc^d.  It  i-^  lancinating,  sharp,  aiul  severe,  aiul  is  aggravated  byconiili. 
At  this  early  stage,  on  iiuscaltation,  sometimes  indeed  on  ])alpatinn.  a  iliy 
friction  rub  can  bo  deteotod.  Tlu'  fevi'r  randy  rises  so  rapidly  as  in  |inru- 
monia,  and  does  not  r.-ach  the  same  gradt".  A  temperature  of  fi'om  joi' 
to  lOo '  is  an  average  pyrexia.  It  may  droj)  to  normal  at  the  end  ef  a 
week  or  ten  days  without  tho  appearance  of  any  detinite  change  in  tln' 
physical  signs,  or  it  nuiy  persist  for  several  weeks.  Tlu  tempei-ature  nf 
the  aitootod  is  higher  than  that  of  tho  sound  side.  Cough  is  an  early 
sym[)tom  in  acaite  pleurisy,  but  is  randy  so  distressing  or  so  fre(jmMit  a<  in 
pnoKmonia.  There  are  instaiu'os  in  whicdi  it  is  absent.  Tho  expectora- 
tion is  usually  slight  in  amount,  mucoid  in  character,  and  occasionally 
streaked  with  blood. 

At  the  outset  there  may  be  dyspiuea,  duo  partly  to  the  fever  ami  ])ai'fly 
to  the  [)ain  in  tho  side.  Later  it  results  from  tho  compression  of  the  IniiLr. 
particularly  if  the  exudation  has  taken  place  rapidly.  When,  however, 
the  fluid  is  effused  slowly,  one  lung  may  be  entirely  compressed  witlinut 
inducing  shortness  of  breath,  exco])t  on  exertion,  and  the  patient  will  lir 
quietly  in  bod  witlumt  evincing  the  slightest  respiratory  distress.  Wlii'n  the 
elfusion  is  large  tho  patient  usually  prefers  to  lie  upon  the  alfecte(l  side. 

Physical  Signs. — Insjicction  shows  some  degree  of  immobility  en  the 
affected  side,  depending  upon  the  amount  of  exudation,  and  in  large  v\^.\\- 


ACUTH    PLKI'IIISV, 


595 


.eiciii.<  an  iticn^asc  in  Vdliiiiic,  wliicli  may  appear  (o  lie  inucli  inon-  (!.aii  it 
really  if*  us  (li'tcrinincil  i)y  iiu'iisiiration.  The  intercostal  spaces  are  olilil- 
eraleil.  In  rijjiit-siiied  elTnsions  tiie  apex  l)cat  may  Ito  lifted  to  tlie  i'liirtli 
inlei'spaee  or  i)e  pusiied  beyond  tiie  lelt  nipple,  or  may  even  l.e  acrw  i;i  tlie 
axilla.  When  the  exndatioii  is  on  tin  K'l'l  side  the  heart's  impulse  ma;; 
not  he  visible;  hut  ii"  the  elVusion  is  lar^^'e  it  is  seen  iu  the  third  iind 
I'diirtli  spaces  on  the  ri;,dit  side,  and  sometimes  as  far  out  as  the  nipple, 
or  even  iieyond  it. 

I'lilpiiliiiii  eiialtles  us  more  successfully  to  detei'mine  the  delieieiit 
ninscMients  on  the  atl'ected  side,  and  the  oliliteratiou  of  the  intereostiil 
spaces,  and  more  accurately  to  deline  the  ])osition  of  the  heart's  im [in Iso. 
In  simple  sero-tihi'iiions  ell'usion  there  Is  rarely  any  (edema  of  the  (diest 
walls.  It  is  searei'ly  I'ver  possible  to  oi)tain  iliictnation.  'Pactile  frt'initu;; 
is  ;;rea!ly  diininisheil  or  abolished,  if  the  elVusion  is  slij,dit  tliiMV  may  be 
only  enfeeblement.  The  absence  of  the  voice  \ibi-ations  in  etrusioiis  ol 
aiiv  size  eonslitutes  one  of  the  most  valuable  of  pliysic:d  sii,''iis.  In  children 
there  may  be  m""h  elfusion  with  retention  of  fremitus.  In  rare  cases  the 
vibrations  may  ho  communicatod  to  tliu  c:  4  walls  through  locaIi:;ed 
pleural  adhesions. 

Mnisnni/ioii. — With  the  oyrtometer,  if  the  en'ti.  ion  is  excessive,  a 
(lilTerence  of  from  half  an  inch  to  an  inch,  or  evi'ii,  in  laryc  elTusions.  an 
iiii'li  and  a  half,  may  be  found  hi-iueen  the  two  sides.  .MIowance  must 
1m  iiinile  for  the  fact  that  the  ri;;ht  side  is  naturally  larirer  than  the  left. 
U  itii  the  saddle-tapo  the  diUVrenco  in  expansion  between  the  two  sidt's 
(1111  he  conveniently  measured. 

Pt'irifssidi/. — Karly  in  the  disease,  when  tin-  ]iain  in  the  side  is  severe 
and  the  fri(ttion  murmur  evi(h'nt,  there  may  he  no  alteration,  but  witli 
tlie  LM'adual  aceumulatioii  of  (he  lluid  the  resonance  becomes  defective, 
aiul  liually  i,dves  pliice  to  absolute  dulness.  From  (hiy  to  day  the  gradual 
increase  in  height  of  the  iluid  may  be  studied.  In  a  pleuritic  ell'usion 
rising  to  the  fourth  rib  in  front,  the  percussion  signs  are  usually  very 
siigge>tive.  In  the  subclavienhir  region  the  attention  is  often  aroused  at 
"uee  i»y  ii  tymi)aniti(;  note,  the  so-called  Skoda's  resonance,  which  is 
ln'ard  perhi.ps  more  commonly  in  this  situation  with  [deunil  eil'usion 
than  in  any  other  condition.  It  sluules  insensibly  into  a  flat  note  in  the 
loui'f  inannnaryand  axillary  regions.  Skoda'n  resoiumeo  may  h(!  obtained 
i'lso  behind,  just  above  tlii^  limit  of  elfusion.  The  dnlnes.s  has  a  jiecndiarly 
I'esistant,  wooden  quality,  dilTering  from  that  of  pneumo'.ia  and  readily 
recognized  by  skilled  fingers.  It  has  long  been  known  ihat  when  the 
Jiutient  is  in  the  erect  posture  the  upper  line  of  dnliu'ss  is  not  horizontal, 
Iiiit  is  higher  behind  than  it  is  in  front,  forming  a  parabola.  Kliis  and 
•iarland,  of  Boston,  who  have  made  a  careful  study  of  this  question,  state 
tnar  the  line  of  didness  from  behind  forward  may  sometimes  be  rej)re- 
sciited  by  a  curved  line  resend)ling  the  letter  S.  The  condition  is  fully 
coujidored  in  Garland's  exhaustive  work  on  I'ueumo-dvnamics. 


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1,  :i;rr« 


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DISKASKS  OF  Till-:  UKSPIllATOUV   SVSTKM. 


On  llio  liLrht  side  tlic  (Inlncss  pii-iscH  witlwuit  cliiiTi;.'!'  into  tlmt  nf  tlip 
liver.  On  \\w  left,  sidtt  in  the  )ii|>|»lt!  line  it  ivxIcihIh  to  uml  niay  Dlilitimti.' 
'rnuil)c\s  sciiiiliiniir  spacf.  If  the  clTiisidn  is  moderate,  tlie  |ilienoiiitii,,ii 
of  iii()val)le  liiilness  may  lie  ohtaincil  hy  markiii",'  eareriilly,  in  the  .-itiiii;; 
])()Htiins  the  upper  limit  in  the  mammary  re;,'ion,  ami  then  in  the  rcrini- 
heiit  pdstnre,  iHPtiiii;  tlie  ehan^^'e  in  t!ie  lieij^ht  nf  (liiiness.  'I'hi-^  iiil'aHi!i!(' 
.sif,'ii  of  Ihiiil  caniinL  always  he  ohtained.  In  very  eopions  cxiidatinii  tln' 
didness  may  reaeh  tho  clavicle  and  even  extend  beyoml  tlio  sternal  imir- 
gin  of  the  opposite  side. 

Aiisrii/hifinii. — Karly  in  the  disease  a  friction  rnbcan  nsnally  he  lieanl, 
M'liicli  disappi^ars  as  the  llnid  accnmnlate;'.  It  is  ii  lo-and-fro  dry  ruK, 
elosc!  to  th(*  ear,  and  has  a  leathery,  creaUing  character.  There  is  anutinr 
pleural  friction  sound  which  (dosely  rcsemhles,  and  is  scarcely  to  In-  dis- 
tinguisluid  from,  the  liim  cnickling  crepitus  of  jineunionia.  This  inny  hi' 
heard  at  the  commencinnent  of  the  disease,  and  also,  as  ])oiiited  out  in 
1H44  Ijy  Machonnell,  Sr.,  of  .Montreal,  when  the  elTiision  has  receded  and 
the  pleural  liiycM's  cotno  to;^ether  again. 

With  evtiu  ii  slight  exudation  thero  is  weakened  or  distant  hreatliiiiir. 
Often  inspiration  and  expiration  are  distinctly  audilde,  though  disiiuit. 
and  hav(!  a  tidcilar  <iiudity.  Sonu'tinu's  only  a  pulling  tuhidar  cxpiratinii 
is  heard,  wiiiidi  may  have  a  nu^tallic  or  ainjthoric  (jnality.  Loud  rcsnMunt 
rales  accompanying  this  may  forcihly  suggest  a  cavity.  These  pseiide- 
oavernous  signs  are  met  with  inon^  frcfjuently  in  cdiildren,  and  often  icjnl 
to  error  in  diagnosis.  AhoV(.'  the  line  of  dulness  the  hreath-sor  arc 
usually  harsh  and  exaggerated,  and  may  have  a  tubular  (pudity. 

The  vocal  resonance  is  usually  diminished  or  ah.sent.  The  w  in.-pcrcd 
voice  is  .said  to  he  transmitted  through  a  .serous  and  not  through  i!  pnni- 
lont  exudate  (l^acci  lli'.s  sign).  There  may,  however,  he  intensilicutidii— 
bron(diophony.  The  voice  sometimes  has  a  cmuous  nasal,  s(pieaking  ( liiir- 
acter,  vvhicdi  was  termed  hy  Laiwinec  (ri/o/Jnuii/,  from  its  sni)j)osed  rescni- 
hlancc  to  tlie  bleating  of  a  goat.  In  typical  form  this  is  not  common.  Imt 
it  is  by  no  means  rare  to  hear  a  curiouh  twang-like  (juality  in  the  vciic. 
particularly  at  the  outer  angle  of  the  scapula. 

In  the  examination  of  the  heart  in  cases  of  ])lonritio  cfPu.sion  it  is  well 
to  bear  in  mind  that  when  the  apex  of  the  heart  lies  beneath  the  sternum 
there  may  be  7io  impulse.  The  determination  of  the  situation  of  the  or<ran 
may  rest  with  the  position  of  maximum  loudnes^  of  the  .sounds.  Over  tlio 
displaced  orgaJi  a  systolic  murmur  nniy  be  heard.  AVhcn  tlie  lajipet  of 
lung  over  the  jiericardium  is  involved  on  either  side  there  may  he  a  })leuro- 
pericardial  friction.     A  leucocytoais  is  usually  present. 

The  course  of  acute  sero-fibrinous  pleurisy  is  very  variable.  After  per- 
sisting for  a  week  or  ten  days  the  fever  subsides,  the  cough  and  pain  dis- 
appear, and  a  .slight  etfusion  may  be  quickly  absorbed.  In  cases  in  which 
the  effusion  reaches  as  high  as  the  fourth  rib  recovery  is  usually  slower. 
Many  instances  come  under  observation  for  the  first  time,  after  two  or 


ACUTK   I'LKrUISY, 


597 


thicf  weeks'  indisposition,  with  the  tliiid  iit  ii  level  with  tho  cliivielc.  Tho 
fi'M  r  iiiiiy  last  from  ten  to  twenty  tiays  witliont  exeiiiii;L,'  anxiety,  tlioti<,'h, 
as  a  rule,  in  onlinury  pleurisy  from  cold,  as  wo  say,  tlie  tempenitiire  in 
I'list's  of  moderate  sevi'rity  is  nornnil  within  ei^dit  or  ten  days.  Left  to 
ilscif  the  natnral  tondoncy  is  to  resorption;  hnt  this  may  take  placo  vory 
slowly.  With  tlio  alworption  of  tho  tlnid  there  is  a  redux-frietion  crep- 
itus, either  leathery  and  ereakini,'  or  craeklin;,'  and  raledike,  and  for 
iiiiiiitlis,  or  even  lon;,'er,  the  defeetive  resonance  and  feeble  hreathin;;  are 
litiird  at  tho  base.  Hare  modes  of  termination  are  perforation  and  dis- 
(hiirife  thron<;h  the  lung,  and  externally  thronj^h  the  ehesL  wall,  examples 
(pf  which  have  been  recorded  by  Sahli. 

A  sero-librinoiis  exndate  may  persist  for  months  withont  chanjje,  j)ar- 
tiiidiirly  in  tubenndous  eases,  and  will  sometimes  reaccunnilate  after  aspi- 
niti'iii  and  resist  all  treatnu'iit.  After  persistene*!  for  more  than  twelve 
iiiiiiillis.  in  sjtite  of  repeated  tapping,  a  serous  ell'nsion  was  cured  by  inei- 
.-ioii  without  deformity  of  the  chest  (S.  West).  The  change  of  the  exudate 
into  piis  will  be  spokc^n  of  in  connection  with  empyema.  Death  is  a  rare 
icriMinalion  of  sero- fibrinous  etrusion.  When  one  pleura  is  fidl  and  tho 
luart  is  greatly  dislocated  the  condition,  although  in  a  tnajority  of  cases 
piddiiciiig  remarkably  little  disturbance,  is  not  without  risk.  Snililcn  dcafh 
iiiiiy  ot'cur,  and  its  possibility  uiuler  these  circumstances  shoidd  always  bo 
cmisiilered.  1  have  seen  two  instances — one  in  light  and  the  other  in  left 
.siilod  elTusion — both  due,  apparently,  to  syncope  following  slight  exertion, 
siiili  as  getting  out  of  bed.  In  neither  case,  liowever,  was  the  amount  of 
lliiid  excessive.  Weil,  who  has  studied  carefidly  this  accident,  concludes 
as  follows:  (1)  That  it  may  be  due  to  throtnbosis  or  embolism  of  the  heart 
or  pulmonary  artery,  tedema  of  the  ojiposite  lung,  or  degeneration  of  the 
lii'iut  muscle;  (2)  such  alleged  causes  as  mechanical  impediment  to  the  cir- 
Liilution,  owing  to  dislocation  of  the  heart  or  twisting  of  the  great  vessels, 
rLMiiiiie  furtiier  investigation.  Death  may  occur  without  any  premonitory 
symptoms. 

III.  Purulent  Pleurisy  (Empt/emn). 

Etiology. — Pus  in  the  j)leura  is  met  with  under  the  following  con- 
ilitidiis:  (d)  As  a  sequence  of  acute  sero-iibrinous  pleurisy.  It  is  not 
iilwMvs  easy  to  say  why,  in  certain  cases,  the  exudate  becomes  purulent. 
It  rarely  does  so  in  the  acute  pleurisies  of  healthy  individuals.  In  chil- 
ilrtMi  many  cases  are  probably  purulent  from  the  outset.  Aspiration, 
whiih  is  said  to  favor  the  occurrence  of  empyema,  in  my  experience  does 
•SI)  wry  rarely,  (b)  Purulent  })leurisy  is  common  as  a  secondary  inflam- 
niiuion  in  various  infectious  diseases,  among  which  scarlet  fever  takes 
tliu  first  place.  It  lias  h)ng  i)een  known  that  the  pleurisy  superven- 
ing' ill  the  convalescence  of  this  disease  is  almost  always  purulent.  It 
should  be  remembered  that  it  is  latent  in  its  onset,  and  that  there  may  bo 
"0  pulmonary  symptoms.  The  pleurisy  following  typhoid  fever  is  also 
usually  purulent.    Other  infectious  diseases — measles  and  whooping-cough 


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598 


DISEASES  OF  THE   RESPIRATORY  SYSTEM. 


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111 


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■  uiv.  more  raroly  followed  by  this  ('onipliciit"on.  Of  late  years  especial 
attention  has  been  paid  to  the  connection  nf  pneumonia  witli  cMipwiim. 
and  it  has  been  shown  that  very  majiy  cases  come  on  insiduously  citlicr  in 
the  course  of  or  during  convalescence  faom  this  disease ;  and,  lastl\ ,  a  lim- 
ited  number  of  tuberculous  pleurisies  etirly  become  purulent,  (r)  llm. 
pyenui  results  from  local  causes — fraelure  of  the  rib,  pcnetratinir  Wdinids. 
malignant  disease  of  the  lung  or  u'sophagiis,  ajul,  perhaps  nuist  fre.|iuiitlv 
of  all,  the  p'u-foration  of  the  pleura  by  tuberculous  cavities. 

The  bacteriology  of  empyema  is  of  great  importance.  A  sterile  v\\\. 
date  suggests  tuberculosis.  In  numy  cases  the  pneunu)cocci  are  iiresciu, 
and  these,  as  a  rule,  run  a  very  favorable  course.  The  stre])toror'ci  are 
found  most  commonly  in  the  secoiulary  cases  in  connection  with  se])tic 
processes.     In  a  few  instances  ])sorosperms  have  been  [jresent. 

Morbid  Anatomy. — On  opening  an  empyema  i^ost  mortem,  v,o 
usually  Ihid  that  the  ert'usion  has  separated  into  a  clear,  green ish-ycllo-,\- 
serum  above  and  the  tJiick,  creain-like  pus  below.  The  (liiid  luiiy  lie 
scarcely  more  than  turbid,  with  llocculi  of  fibrin  through  it.  In  ollici'  in- 
stances it  is  uniformly  thick  and  creamy,  without  any  fibrin.  It  usually 
luis  a  heavy,  sweetish  odor,  but  in  some  instaiu'cs — particularly  those  fol- 
lowing wounds— it  is  fetid.  In  cases  of  gangrene  of  the  lung  or  ideiini 
the  pus  has  a  horribly  stinking  odor.  .Microsc()[)ically  it  has  the  cliarac- 
ters  of  ordinary  pus.  The  pleural  membranes  are  greatly  thickened,  and 
present  a  grayish-white  hiyer  from  1  to  'Z  mm.  in  thickness.  On  tin 
costal  pleura  there  may  be  erosions,  and  in  old  cases  fistulous  comiiiiinica- 
tions  are  common.  The  lung  may  be  compressed  to  a  very  small  limit. 
and  the  visceral  })leurrt  also  nuiy  show  perforations. 

Symptoms. — Purulent  pleurisy  luijy  begin  abruptly,  with  the  .-yni|i- 
toms  already  described.  More  frequently  it  comes  on  insidiously  in  the 
course  of  other  diseases  or  follows  an  ordiiuiry  sero-fibrinous  pleurisy. 
There  may  V)e  no  ])ain  in  the  chest,  very  little  cough,  and  no  (lysiin(ea. 
unless  the  s'de  is  very  full.  Symptoms  of  septic  infection  are  rarely 
wanting.  If  in  a  child,  there  is  a  gradually  developing  jiallor  and  uiak- 
ness ;  sweats  occur,  and  there  is  irregular  fever.  A  cough  is  by  no  nuau.- 
coustant.  The  leucocytes  are  usually  much  increased ;  in  one  fatal  case 
they  numbered  115,000  per  cubic  millimetre. 

Physical  Signs. — Practically  they  are  those  already  considered  in  pleu- 
risy with  effusion.  There  are,  however,  one  or  two  additional  i)oint.s  to 
be  mentioned.  In  empyema,  i)articularly  in  children,  the  disprop<irlioii 
between  the  sides  may  be  extreme,  'i'lie  intercostal  spaces  nuiy  nut  only 
be  obliterated,  but  may  bulge.  Much  more  frequently  there  is  o'dema  of 
the  chest  walls.  The  network  of  suljcutaneous  veins  may  be  very  di-iiiict. 
It  must  not  be  forgo'^en  that  in  children  the  breath-souiuls  nuiy  Ite  Imid 
and  tubular  over  a  j)urulent  effusion  of  considerable  size.  Whispered 
pectoriloquy  is  usually  not  heard  in  empyema  (liaccelli's  sign).  The  dis- 
location of  the  heart  and  the  displacement  of  tiie  liver  are  more  marked 


ACUTE  PLEURISY. 


599 


ill  empyema  than  in  8ero-fil)rinoiis  ofTusion — probably,  as  Senator  suggests, 
owing  to  the  greater  weiglit  of  the  Huid. 

A  ciirioiirf  i)lien()menon  associated  generally  with  empyema,  "nut  which 
may  occur  in  the  sero-flhrinous  exudate,  is  pidsaHu(/  2)leii  •/  ,  first  de- 
scribed by  MacDoniiell,  Sr.,  of  Montreal.  Of  •^'i  eases  31)  occurred  on 
tlie  left  side.  In  all  but  oiu;  ease  the  fluid  was  purulei>i  ''neumothorax 
iiiav  be  ])resent.  There  are  two  groups  of  eases,  the  iht.-;  ,,ieui-al  jjulsat- 
iiur  pleurisy  aiul  tbo  ruisacing  Ciiipj/oiia  iieccssifatis,  in  which  there  is  au 
external  ])nlsating  tunu)r.  No  satisfactory  explanation  has  Itecn  ollVred 
hiiw  the  heart  impulse  is  thus  forcibly  communicated  through  the  elTusiou. 

Kmpvema  is  a  chronic  affection,  which  in  a  fi'W  instances  terminates 
luilui'ally  in  recovery,  but  a  majority  of  cases,  if  left  alone,  end  in  death. 
The  following  are  some  modes  of  natui'al  cure:  {(()  Hy  absorption  of 
the  tluid.  In  small  effusions  this  nuiy  take  place  gradually.  The  chest 
Willi  sinks.  The  pleural  layers  l»ecome  greatly  thicki'iied  and  enclose  be- 
tween them  the  inspissated  ])us,  in  which  lime  salts  are  gradually  (K'i)osited. 
Such  a  condition  may  be  seen  once  or  twice  a  year  in  the  post-moi-tem 
mom  of  any  hirge  hospital.  (It)  By  perforation  of  the  lung.  Although 
ill  this  event  death  may  take  place  ]'a))idly,  by  inundation  of  the  bi-onchial 
tubes,  yet  in  many  cases  it  oc(nn"s  gradually  and  recovery  follows.  Since 
Ls;."),  when  I  saw  a  case  of  this  kind  in  Traube's  clinic,  ami  heai'd  his 
remarks  on  the  subject,  I  have  seen  a  number  of  instances  of  the  kind 
and  can  corroborate  his  statement  as  to  the  favorable  termination  of  many 
uf  lliem.  Errrpyema  may  discharge  either  by  opening  into  the  bronchus 
and  fornung  a  fistula,  or,  as  Traube  pointed  out,  by  i)roducing  necrosis  of 
the  i)ulmonary  pleura,  sutHcient  to  allow  the  soakage  of  the  pus  through 
the  spongy  lung  tissue  into  the  br'onchi.  In  the  first  way  pneumothorax 
usually,  though  not  always,  develops.  In  the  second  way  the  pus  is  dis- 
eliargeil  without  formation  of  pneumothorax.  Hveir  with  a  broiu'hial 
li-tula  recovery  is  [)ossil)le.  (r)  By  perforation  of  the  chest  wall — cuipt/cnia 
in'crssi/titi.t.  This  is  by  no  means  an  unfavorable  method,  as  many  cases 
recover.  The  perforation  may  occur  anywhere  in  the  chest  wall,  but  is, 
us  Cniveilhier  remarked,  more  ci»mmon  in  front.  It  may  l)e  anywhere 
fniiu  the  third  to  the  sixth  interspace,  usually,  according  to  Marshall,  in 
the  fifth.  It  may  perforate  in  moiv  than  one  place,  and  there  may  be  a 
listiilous  communication  which  ojieiis  into  the  pleura  at  some  distance 
fnnu  the  external  orifice.  The  tumor,  wheii  near  tlu^  heart,  nmy  pulsate. 
Tlu;  discharge  may  jx^rsist  for  year's.  In  Copcland's  Dictionary  is  men- 
tinned  an  instance  of  a  Bavarian  physician  who  bail  a  pleural  listula  for 
thirteen  years  and  enjoyed  fairly  good  health. 

An  empyema  may  perforate  the  neighboring  organs,  the  o'sophagu.s, 
l»f'ritona'um,  pericardium,  or  the  stomach.  Very  remarkable  cases  are 
tlmse  which  pass  down  the  s|)ine  and  along  the  psoas  into  the  iliac  fossa, 
iind  sinudato  a  psoas  or  lumbar  ab-scess. 


;■  ■  ! 


000 


DISEASES  OF  THE  RESPIRATORY  SYSTEM. 


IV.  TuBERcuLors  Pleurisy. 


This  1ms  already  been  considered.  Here  it  is  sufficient  to  say  Ihut  it 
occurs  as  :  (a)  An  Jicute  affection,  accompanied  by  abundant  sero-fibiinoiis 
fluid.  In  this  category  come  certainly  a  proportion  of  the  cases  repmlcd 
as  acute  ])!eurisy  from  cold.  (/>)  As  a  subacute  atfection,  latetit  in  its 
origin  and  insidious  in  its  course,  fre(|uently  jireceding  the  dcvcldpiiK.nt 
of  or  coming  on  concurrently  with  pulmonary  tuberculosis,  (r)  As  uii 
acute  pleurisy,  the  result  of  direct  extension  from  the  lung  in  cases  of 
well-tuarked  ])hthisis,  and  in  which  the  fluid  may  be  either  sero-lilii'liunis 
or  ])uru!enl.  (d)  ("hronic  adhesive  tuberculous  jjleurisy,  which  iintv  he 
unilateral  or  bilateral,  unaccomjjanied  by  exudation  and  characterized  liv 
great  thickening  of  the  pleural  membranes,  in  which  are  tubercles  and 
caseous  masses  of  varying  sizes. 

The  symptoms  and  physical  signs  of  tuberculous  pleurisy  with  cxiuiii- 
tion  do  not  re(piire  any  descri})ti()n  other  than  that  already  given  in  con- 
nection with  the  sero-fibrinous  and  purulent  forms, 

V.  Other  V.akieties  of  Pleurisy. 

Haemorrhagic  Pleurisy. — A  ))l()ody  effusion  is  met  with  under  the  fol- 
lowing conditions:  {it)  In  the  pLnirisy  of  asthenic  states,  such  as  cancer, 
IJright's  disease,  ai.d  occasionsrlly  in  the  maligniint  fevers.  It  is  inter- 
esting to  note  the  frequency  with  which  lueniorrhagic  ])leurisy  is  fdund 
in  cirrhosis  of  the  liver.  It  occurred  in  the  very  patient  in  whoui  Liiennec 
first  accurately  described  this  disease.  While  this  may  be  a  sinqile 
hix^morrhagic  pleurisy,  in  a  majority  of  the  cases  which  I  have  seen  it 
has  beeii  tuberculous.  (/>)  Tuberculous  jdeurisy,  in  which  tiic  Mdody 
effusion  niay  result  from  the  rupture  of  newly  formed  vessels  in  thi'  soft 
exudate  accompanying  the  eruption  of  miliary  tubercles,  or  it  may  come 
from  more  slowly  formed  tubercles  in  a  pleurisy  secondary  to  extensive 
pulmonary  disease,  (r)  Cancerous  ])leiirisy,  whether  ju'imary  or  second- 
ary, is  fre(piently  hiemorrhagic.  {d)  ()ccasionally  luvmorvhagic  exudation 
is  met  with  in  perfectly  healthy  individuals,  in  whom  there  is  not  the 
slightest  suspicion  of  tuberculosis  or  cancer.  Iii  one  studi  case,  a  hu-ge, 
able-bodied  man,  the  patient  was  to  my  knowledge  healthy  and  strong 
eight  years  afterward.  And,  lastly,  it  must  be  remembered  that  'iiriiig 
aspiration  the  lung  may  be  wounded  ami  blood  in  this  way  get  mixed 
with  the  sero-fibrinous  exudate.  The  condition  of  luemorrhagic  pleurisy 
is  to  be  distinguished  from  ha^mothorax,  due  to  the  ruj)ture  of  aneurism 
or  the  pressure  of  a  tunu)r  on  the  thoracic  veins. 

Diaphrag'matlc  Pleurisy.— The  inflammation  may  be  limited  partly  or 
chiefly  to  the  diaphragmatic  surface.  This  is  often  a  dry  ])leurisy.  I)ut 
there  may  be  effusion,  either  sero-fibrinous  or  purulent,  which  is  ciii  inn- 
scribed  ou  the  diaphragmatic  surface.     In  these  cases  the  pain  is  low  in 


ACUTE  PLEURISY. 


601 


the  zone  of  the  diiiplinigni  iiiid  may  siimihitc  tliat  of  acute  abdominal  dis- 
ciiso.  It  may  be  iiitensiliod  by  pressure  at  the  point  of  insertion  of  the 
(liapliragm  at  the  tenth  rib.  The  dia])hragm  is  lixed  and  the  res])iration 
is  tlioraeic  and  sliort.  Andral  noted  in  certain  cases  severe  dyspno-a  and 
attacks  siinuhiting  angina.  As  mentioned,  tlie  elfnsion  is  usually  plastic, 
not  serous.  Serous  or  pnruit  ut  cITusions  of  any  size  limited  to  the  dia- 
phragmatic surface  are  extrenu-Iy  rare.  Intense  subjective  with  trilling 
objective  features  are  always  suggestive  of  diaphragnuitic  pleurisy. 

Encysted  Pleurisy. — The  eifusion  may  be  circumscribed  by  adhesions 
or  s('[)arated  into  two  or  more  pockets  or  loculi,  which  communicate  with 
each  other.  This  is  nu)st  common  in  empyema.  In  tlicse  cases  there 
have  usually  been,  at  dilTeront  parts  of  the  pleura,  multiple  adliesions  by 
which  the  fluid  is  limited.  In  other  instances  the  recent  false  membranes 
may  encapsulate  tlie  exudation  on  the  diaphragnuitic  surface,  for  exanii)le, 
or  the  part  of  the  pleura  posterior  to  the  miil-axillary  line.  The  con- 
dition nuiy  be  very  puzzling  during  life,  and  present  special  dilliculties  in 
diagnosis.  In  some  cases  the  tactile  fremitus  is  retained  along  certuiu 
line.v  of  adhesion.     The  exploratory  needle  should  be  freely  used. 

Interlobar  Pleurisy  forms  an  interesting  and  not  uncommon  variety. 
In  nearly  every  instance  of  acute  pKsurisy  the  interlobular  serous  surfaces 
are  also  involved  and  closely  agglutinated  together,  and  s(»metimes  the 
fluiij  is  encysted  between  them.  In  a  recent  case  of  this  kind  following 
pneumonia,  there  was  between  the  lower  and  u])per  and  middle  lobes  of 
the  right  side  an  enormous  purulent  collection,  which  looketl  at  first  like 
a  large  al)scess  of  the  lung.  These  collections  nuiy  perforate  the  bronchi, 
and  the  cases  present  special  diMiculties  in  diagnosis. 

Diagnosis  of  Pleurisy.  —Acute  plastic  jileiirisy  is  readily  recog- 
nized. In  the  diagnosis  of  [deuritic  elTii  'mi  the  first  question  is,  Does  a 
thiid  exudate  exist?  the  second,  What  \u  nature?  In  large  elfusiorirt 
the  increase  in  the  size  of  the  alTected  side,  ;he  immoltility.  the  absence  of 
tactile  fremitus,  together  with  the  displacement  of  urgatis,  give  infallible 
iiiilirations  of  the  presence  of  fluid.  The  chief  diilicidt  ^  irises  in  etfiisions 
i»f  UKxlerate  extent,  whcji  the  duln(>ss,  the  presence  of  biouchophony, 
and,  perhaps,  tubular  breathing  may  <imulate  p/icnmonia.  The  cWu'' 
[Miiiits  to  1)0  borne  in  mind  are:  {(i)  DilTerences  in  the  onset  ;iiid  in  the 
general  characters  of  the  two  alTections,  more  particularly  the  initial  (hill, 
tlie  higher  fever,  nu)ro  urgent  dyspnoea,  and  the  rusty  expectoratioti.  which 
eiuiracterize  i)neumonia.  {/>)  Certain  ])hysical  signs — the  more  wouden 
eliarncter  of  the  dulness,  the  greater  resistaiu-e,  and  the  nuirktd  ''  unu- 
tidii  or  tlu^  absence  of  tactile  fremitus  in  pleurisy.  The  auscullai  i,\  signs 
may  lie  deceptive.  It  is  usually,  indeed,  the  ])ersistenco  of  tubular  breath- 
ntg.  i)articularly  the  higli-pitched,  even  amphoric  expiration,  heard  in 
siMiic  cases  of  pleurisy,  which  has  raised  the  doubt.  The  intercostal  spaces 
arc  more  eommoidy  obliterated  in  pleuritic  eifusion  than  in  pneumonia. 
As  already  mentioned,  the  displacement  of  organs  is  a  very  valuable  sign. 


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602 


DISEASKS  op  THE   RESPIRATORY  SYSTEM. 


Nowadays  with  tlii!  liypodt'rtnic  iicodlo  the  question  is  easily  settli'il.  A 
separate  small  syringe  with  a  eapaeity  of  two  (Irachins  should  be  resm'cd 
for  exploratory  purposes,  and  the  needle  should  he  lontfer  and  lii'iiicr 
than  i'l  the  onlinary  hyi)odennie  instrument.  With  eareful  ])reliiiiiiiarv 
disinfi'ction  the  instrument  ean  be  used  with  impunity,  and  in  cum'.-;  uf 
doubt  tile  exj)loratory  puncture  sliould  be  made  without  hcsiiation. 
1  have  never  sih'u  the  slifjjhtest  ill  etVects  follow  its  use.  Case.-;  arc 
re])orto(l  of  ])neumothorax  resultin<?  fi-oni  it,  but  they  are  extremclv 
rare,  'i'lie  hypodermic  needle  is  es[)ecially  usefid  in  those  cases  in  uliicji 
there  are  j)seudo-<'averiujus  sitriis  at  the  base.  In  cases,  too,  of  massive 
pneumonia,  in  which  the  bronchi  are  i)lngf,'ed  with  fibrin,  if  the  patient 
has  not  been  seen  from  the  outset,  the  diagnosis  may  be  impo.ssible  with- 
out it. 

On  the  left  side  it  may  be  difTicult  to  differentiate  a  very  largo  peri- 
cardial from  a  pleural  etfusion.  'i'he  retention  of  ivs(»nance  at  the  liase. 
the  {)re.sonco  of  Skoda's  resonance  toward  the  axilla,  the  absence  of  t\U- 
locution  of  the  heart-beat  to  the  right  of  the  sternum,  the  feebleness  df 
the  ])ulse  and  of  the  lieart-sounds,  and  the  urgency  of  the  dyspntea.  imt 
of  all  j)roportion  to  the  extent  of  the  etfusion,  are  the  chief  ])oiiits  to  be 
considered.  I'nilateral  hydrothorax,  whicdi  is  not  at  all  uncomiiiDii  in 
lieart-disease,  presents  signs  identical  with  those  of  sero-tibrinous  elfii.-inn. 
Certain  tumors  witliin  the  chest  may  sinudate  pleural  eirusion.  It  should 
bo  remembered  that  many  intrathoracic  growths  are  ac'companied  l)y  exu- 
dation. Malignant  disease  of  the  lung  and  <d'  the  pleura  and  hydatiils  of 
the  ))lcuni  produce  extensive  dulness,  with  su})pression  of  the  breath- 
sounds,  simulating  closely  effusion. 

On  the  right  side  abscess  of  the  liver  and  hydatid  cysts  may  rise 
high  into  the  pleura  and  ])roduce  dulness'and  enfeebled  breathing.  Often 
in  these  cases  there  is  a  friction  sound,  whi(di  should  excite  suspicion, 
and  the  upper  outline  of  tlu'  duliu'ss  is  sometimes  olaiidy  convex.  In  all 
these  instances  the  exploratory  puncture  shoidd  be  made. 

The  second  (ptestion,  as  to  the  nature  of  the  fluid,  is  (juick'.y  deciiled 
by  the  use  of  tlie  needle.  The  ])ersistent  fever,  the  occurrence  of  sweats, 
a  leucocytosis,  and  the  increase  in  the  pallor  suggest  the  presence  of  i>us. 
In  children  the  complexion  is  often  sallow  and  earthy.  The  unexjiecteil, 
however,  often  happens,  and  repeatedly,  in  protracted  cases,  even  in  chil- 
dren, when  the  general  symptoms  and  the  appearance  of  the  patient  has 
been  most  strongly  suggestive  of  pus,  the  syringe*  has  withdrawn  clear 
fluid.  On  the  other  hand,  effusions  of  short  duration  may  be  purulent, 
even  when  the  general  symptoms  do  not  suggest  it.  The  following  state- 
ment may  be  made  witli  reference  to  the  prognostic  import  of  the  l)aeti'- 
riological  examination  of  the  aspirated  fluid  :  The  preseiuie  of  the  pncuuio- 
coccus  is  of  favorable  significance,  as  such  cases  usually  get  well  rapidly, 
even  with  a  single  aspiration.  The  pus  oiganisms — staphylocoi'ci  and 
streptococci — are  more  common  in  empyema  of  septic  origin,  and  sueli 


w^f-) 


ACUTE   PLEURISY. 


608 


cases  are  notoriously  less  hopeful  than  others.     A  .sterile  fluid  indicates  ia 
a  niujority  of  instiinces  a  tulmnmlous  origin. 

Treatment. — At  the  onset  the  severe  pain  may  demand  leeches, 
which  usually  give  relief,  hut  a  hypodermic  of  morphia  is  nu)re  etfectiva 
'l"he  l'a(iuelin  cautery  may  he  lightly  hut  freely  applied.  It  is  well  to 
iuhiiinister  a  mercurial  or  .sdiue  purge.  I'Mxing  the  side  hy  careful  strap- 
piiitr  with  long  strips  of  adhesive  plaster,  which  should  pass  well  over  the 
iiii(hlle  line,  drawn  tightly  and  evenly,  gives  great  relief,  and  I  can  cor- 
r(il)orate  the  statement  of  F  T.  lloherts  as  to  its  etlicacy.  Cupping,  wet 
or  dry,  is  now  seldom  em})loyed.  Blisters  are  of  no  special  service  in  the 
acute  stages,  although  tliey  relieve  the  ])aiii.  The  ice-hag  nuiy  l>e  used  as 
iu  pneumonia.  The  geiuu'al  treatment  of  the  early  stage  should  he  rest 
in  hcd  arul  a  liquid  diet.  Medicines  are  rarely  retpiired.  A  Dover's 
powder  nuiy  he  given  at  night.     Mercurials  are  not  indicated. 

When  the  effusion  has  taken  i)lace,  mustard  plasters  or  iodine,  pro- 
ducing slight  counter-irritation,  api)ear  useful,  ])articuhirly  in  the  later 
stages.  The  following  rational  plan  is  suc(;essful  in  some  cases.  It  is 
l)ased  upon  the  idea  that  if  the  hlood  serum  is  depleted  (n-  if  it  is  kept 
coucentratcd,  the  liquid  will  he  ahsorhed  from  the  lymph  spaces,  of  whicdi 
the  pleura  is  one,  to  equalize  the  loss.  To  do  this  the  patient  should 
have  the  daily  amount  of  lifpiid  food  greatly  restricted.  If  there  is  no 
fever,  a  meat  diet,  M'ith  an  egg  at\d  dry  hread  and  eight  to  ten  ounces 
of  licpiid  in  the  form  of  milk  or  water,  should  he  given.  Salt  articles  of 
food  may  be  u.sed,  but  I  do  not  think  it  lU'cessary  to  give,  as  some  do, 
(losi'S  of  salt.  The  secoiul  element  in  the  treatment  is  the  active  depletion 
of  hlood  serum,  which  is  effected  in  the  way  introduced  by  Matthew  Hay. 
Every  morning,  if  tlie  patient  is  robust,  otherwise  every  second  nujrning, 
from  half  an  ounce  to  an  ounce  and  a  half  of  Epsom  salts  is  given  an  hour 
iH'forc  breakfast,  in  as  concentrated  a  form  as  is  possible.  This  i)n;duce8 
copious  li(piid  discharges.  I  have  seen  large  exudations  disaj)[)car  rai)idly 
when  this  plan  was  followed.  By  acting  upon  the  skin  and  kidney.s,  the 
same  eiul  may  be  obtained,  but  with  much  less  certainty.  The  vapor  or 
hot  hath  may  be  used  and  an  occasional  dose  of  ]nlocar])in.  Diuretics, 
.«ii('h  as  digitalis,  squills,  and  acetate  of  potash,  may  sometiuics  be  required. 
1  rarely  resort,  however,  to  iliuretics  or  diaphoretics  in  the  treatment  of 
pleurisy  with  effusion.     Iodide  of  potassium  is  of  doubtful  benefit. 

Aspiration  of  the  fluid  is  the  most  thorough  and  satisfactory  method 
;ui(|  should  be  resorted  to  whenever  the  eifusioii  becomes  large  or  if  it  re- 
sists the  ordimiry  methods  of  treatment.  The  credit  of  introducing  aspi- 
ration iu  pleuritic  effusicms  is  due  to  Morrill  Wyman,  of  Cand)ridge,  Mass., 
iind  Ih'ury  I.  Bowditch,  of  Bostcm.  Years  prior  to  Dieulafoy's  work,  as- 
piratiou  was  in  constant  use  at  the  Massachusetts  (rcneral  Hospital  and 
was  advocated  repeatedly  by  Bowditch.  As  the  question  is  one  of  some 
lustorical  interest,  1  give  the  author's  conclusions  concerning  aspiration, 
expressed  more  than  forty  years   ago,  and  wdiich   practicallv   represent 


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604 


DISEASES  OP  THE   RESPIRATORY  SVSTEM. 


the  opinion  of  to-day  :  "  (1)  The  operation  is  perfectly  simple,  but  sliirlitlv 
painful,  and  can  be  done  with  ease  upon  any  patient  in  however  ad- 
vanced a  stage  of  the  disease.  (2)  It  should  be  performed  forliiwith  in 
all  cases  in  wiiich  there  is  complete  filling  up  of  one  side  of  tiui  chest. 
(3)  He  had  determined  to  use  it  in  (tuy  case  of  even  moderate  eiTiisidn 
lasting  more  than  a  few  weeks  and  in  which  there  should  setm  to  he 
a  disposition  to  resist  ordinary  modes  of  treatment.  (4)  He  urged  this 
practice  upon  the  profession  as  a  very  important  measure  in  priulical 
medicine;  believing  that  by  this  method  death  may  frequently  be  pre- 
vented from  ensuing  either  by  siulden  attack  of  dyspno-a  or  subHcqiunt 
phthisis,  and,  finally,  from  the  gradual  wearing  out  of  the  powers  nf 
life  or  inability  to  absorb  the  fluid.  (.5)  lie  believed  that  this  oj)eration 
would  sometimes  prevent  the  occurrence  of  those  tedious  cases  of  spon- 
taneous evacuation  of  purulent  fluid  and  those  great  contractions  of  tlie 
chest  which  occur  after  long-continued  effusion  and  the  subsequent  dis- 
charge or  absorption  of  a  fluid." 

There  is  scarcely  anything  to  be  added  to-day  to  these  observations. 
When  the  fluid  reaches  to  the  clavicle  the  indication  for  aspiration  is  im- 
perative, even  though  the  patient  be  cotnfortable  and  present  tio  signs  of 
pulmonary  distress.  The  presence  of  fever  is  not  a  contra-indieation ; 
indeed,  sometimes  with  serous  exudates  the  temperature  falls  after  aspi- 
ration. 

The  operation  is  extremely  simple  aiid  is  practically  withou'^  risk. 
The  spot  selected  for  puncture  should  be  either  in  the  seventh  interspare 
in  the  mid-axilla  or  at  the  outer  angle  of  the  scapula  in  the  eighth  inter- 
space. The  arm  of  the  patient  should  be  brought  forward  with  the  hand 
on  the  opposite  shoulder,  so  as  to  widen  the  intersjjaces.  The  needle 
should  be  thrust  in  close  to  the  upper  margin  of  the  rib,  so  as  to  avoid  the 
intercostal  artery,  the  wounding  of  which,  however,  is  an  excessively  rave 
accident.  The  fluid  should  be  withdrawn  slowly.  The  amount  will  de- 
pend on  the  size  of  the  exudate.  If  the  fluid  resiches  to  the  clavicle  a 
litre  or  more  may  be  withdrawn  with  safety. 

During  aspiration  if  the  })atient  feels  faint  it  is  best  to  interrupt  the 
operation,  for  sudden  death  has  occasionally  happened  during  the  with- 
drawal. It  is,  however,  a  much  less  common  accident  than  siulden  death 
in  cases  of  full  pleura  without  operation.  Cough  is  a  symptom  whirh 
frequently  develops  toward  the  close  of  asjjiration.  Though  very  paiiifiil 
it  need  not  excite  alarm.  French  writers  have  described  cases  of  albuini- 
nous  expectoration,  associated  with  dyspnu'a,  which  may  come  on  after 
the  tapping  and  prove  rapidly  fatal.  It  must  be  an  excessively  rare  eoin- 
plication.  The  conversion  of  a  sero-fibrinous  into  a  purulent  fluid  i<  a 
danger  which  need  not  be  considered.  I  have  never  met  with  an  instaiue 
of  the  kind. 

Empyemn  is  really  a  surgical  affection,  and  I  shall  make  only  a  i"tw 
general  remarks  upon  its  treatment.     When  it  has  been  determined  hy 


CHRONIC   PLEURISY. 


605 


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cxitloratory  puncture  that  the  fluid  is  purulent,  aspiration  should  not  be 
pcit'ormed,  except  as  preliminary  to  operation  or  as  a  temporary  measure. 
I't  rhaps  it  is  better  not  to  have  an  exception  to  this  rule,  althoufjh  the 
citiiivenias  of  children  and  the  pneumonic  empyema  occasioiudly  gat  well 
rapidly  after  a  single  tapping.  It  is  sad  to  think  of  the  number  of  lives 
which  are  sacrificed  annually  by  the  failure  to  recognize  that  empyema 
.sliiiidd  be  treated  as  an  ordiiuiry  abscess,  by  free  incision.  The  oi)eration 
(lutes  from  the  time  of  Hippocrates  and  is  by  no  means  serious.  A  ma- 
jority of  the  cases  get  well,  ])r(>viding  that  free  drainage  is  obtained,  and 
it  makes  no  difference  practically  what  measures  are  followed  so  long  as 
this  indication  is  met.  The  good  results  in  an\  in-^  ;hod  depend  upon 
the  tlioroughness  with  which  the  cavity  is  draineu.  Irrigation  of  the 
cavity  is  rarely  necessary  unless  the  contents  are  fetid.  Sudden  collapse 
has  happened  during  irrigation  and  a  remarkable  accident  is  the  occur- 
rence of  convulsions.  In  the  subsequent  treatment  a  point  of  great  im- 
piirtaiice  in  facilitating  the  closure  of  the  cavity  is  the  distention  of  the 
lung  on  the  affected  side.  This  may  be  acconij)lished  by  the  method 
iulvised  by  Halstou  James,  which  has  been  practised  with  great  success  in 
the  snrgi(!al  wards  of  the  Johns  IIoi)kins  Hospital.  The  patient  daily, 
for  a  certain  length  of  time,  increasing  gradually  with  the  increase  of  his 
Htrciigth,  transfers  by  air-])ressure  water  from  one  bottle  to  another.  The 
liiittics  should  be  large,  holding  at  least  a  gallon  each,  and  by  the  arrange- 
ment of  tubes,  as  in  the  Wolff's  bottle,  an  expiratory  effort  of  the  patient 
forces  the  Avater  from  one  bottle  into  the  other.  In  this  way  expansion 
of  the  compressed  lung  is  systematically  practised.  The  abscess  cavity  is 
jrradiially  closed,  partly  by  the  falling  in  of  the  chest  Avail  and  partly  by 
the  expansion  of  the  lung.  In  some  instances  it  is  necessary  to  resect 
I'ortions  of  one  or  more  ribs. 

The  physician  is  often  asked,  in  cases  of  empyema  with  emaciation, 
hectic  and  feeble  rapid  pulse,  whether  the  patient  could  stand  the  opera- 
tion. Kven  in  the  most  desperate  cases  the  surgeon  should  never  hesitate 
to  make  a  free  incision. 


II.  CHRONIC  PLEURISY. 

This  affection  occurs  in  two  forms :  (1)  Chronic  pleurisy  with  effusion, 
ill  which  the  disease  may  set  in  insidiously  or  may  follow  an  acute  sero- 
tilirinous  pleurisy.  There  are  cases  in  Avhich  the  lif[uid  per.;ists  for  months 
without  uiulergoing  any  special  alteration  and  without  becoming  purulent. 
^uch  ca-ses  have  the  characters  which  Ave  have  described  under  ])leurisy 
\viih  effusion.  (2)  Chrome  <irji  pleurisy.  The  cases  are  met  with  (rt)  as 
a  sei|iuMice  of  ordinary  pleural  elfusion.  When  the  exudate  is  absorbed 
ami  tlie  layers  of  the  pleura  come  together  there  is  left  between  them  a 
varial)le  amount  of  fibrinous  material  which  gradually  undergoes  organi- 


hi;  i' 4' 


tit 


I   t 


f 

lii 


606 


DISEASES  OP  THE  RESPIRATOUY  SYSTEM. 


zation,  and  is  converted  into  a  layer  of  firm  conneetive  tissue.  This  pro- 
cess jfoes  on  at  tlie  l)aso,  and  is  re|)reseiited  clinically  by  a  slijflit  {.rnnlc  uf 
flatt(!iuii<j,  dclicient  e.\i)ansion,  det'cctive  resonance  on  ])ercussioii,  and  m,. 
feebled  hreathinj^.  After  recovery  from  empyema  the  ilatteniiij;  ainl  ic- 
traction  may  be  still  more  marked.  Iti  both  (iases  it  is  a  condition  which 
can  be  <freatly  benefited  l»y  jjulmonary  fjfyiimastics.  In  these  linn,  liliidiis 
memijraiies  calcilicatiou  may  o(!ciir,  particularly  after  empyema.  It  is 
not  very  uncommon  to  find  between  the  false  membranes  a  small  iKickct 
of  fluid  forming,'  a  sort  of  j)leural  cyst.  In  the  great  nuijority  of  these 
cases  the  condition  is  one  which  need  imt  cause  anxiety.  There  niav  he 
an  occasional  dra<r^nng  pain  at  the  base  of  the  lung  or  a  stitch  in  tlic  side, 
but  patients  may  remain  in  perfectly  good  health  for  years.  Tiie  most 
advanced  grade  of  this  secondary  dry  pleurisy  is  seen  in  those  cases  of  em- 
pyema which  have  been  left  to  themselves  and  have  perforated  and  iihi- 
mately  healed  by  a  gradual  absorption  or  discharge  of  the  pus,  with  retrai'- 
tion  of  the  side  of  the  chest  and  permanent  carnilication  of  the  lini<;. 
Traumatic  lesions,  such  as  gunshot  wounds,  may  be  followed  by  an  identi- 
cal conditif)n.  Post  mortem,  it  is  quite  imjiossible  to  separate  the  layers 
of  the  pleura,  which  are  greatly  thickened,  particularly  at  the  base,  and 
surrouml  a  compressed,  airless,  fibroid  lung. 

(b)  Priinitii'P,  dvy  jih'urisy.  This  condition  may  directly  follow  the 
acute  plastic  pleurisy  already  described ;  but  it  nuiy  set  in  without  any 
acute  sympt(mis  whatever,  and  the  patient's  attrition  may  be  called  to  it 
by  feeling  the  pleural  fri(!tion.  A  (Constant  effect  of  this  primitive  drv 
pleurisy  is  the  adhesion  of  the  layers.  This  is  j)robably  an  invariable  resuh, 
whether  the  pleurisy  is  primary  or  sctjondary.  The  organization  of  the  tliiii 
layer  of  exudation  in  a  pneumonia  will  unite  the  two  surfaces  by  delicate 
bands.  Pleural  adhesions  arc  extremely  common,  and  it  is  rare  to  examine 
a  body  entirely  free  from  them.  They  may  be  limited  in  extent  or  univer- 
sal. Thin  fibrous  adhesions  do  not  produce  any  alteration  in  the  percussion 
characters,  and,  if  limited,  there  is  no  special  change  heard  on  ausculta- 
tion. When,  however,  there  is  general  synechia  on  both  sides  the  exjiaii- 
sile  movement  of  the  lung  is  considerably  impaired.  We  should  naturally 
think  that  universal  adhesions  would  interfere  nuiterially  with  the  fiiiu- 
tiou  of  the  lungs,  but  practically  we  see  many  instances  in  which  there 
has  not  been  the  slightest  disturbance.  The  physical  signs  of  total  adhe- 
sion are  by  no  means  constant.  It  has  been  stated  that  there  is  a  marked 
disproportion  between  the  degree  of  expansion  of  the  chest  walls  and  the 
intensity  of  the  vesicular  nnirmur,  but  the  latter  is  a  very  variable  factor, 
and  under  perfectly  normal  conditions  the  breath-sounds,  with  very  full 
chest  expansion,  may  he  extremely  feeble. 

Is  there  a  primitive  dry  ])leurisy  which  gradually  leads  to  great  thick- 
ening of  the  membranes,  and  which  ultimately  may  invade  the  lung  and 
induce  cirrhotic  change?  Fpon  this  question  neither  pathologists  nor 
clinicians  agree.     I  think  that  Sir  Andrew  Clark,  in  his  Lumleian  lectures 


ciironk;  pleurisy. 


607 


id  tlie  IJoyiil  C()ll('}?o  of  IMiyHiciiins  (KS8r»),  1ms  iniulc  good  his  pliilm  tliut 
siirli  a  (lirtt'iiso  does  exist.  At  tlio  outset  in  these  eases  there  is  a  dry 
iilciirisy,  iisuully  at  oru!  hiise,  indicated  l)y  th(^  usual  si^nis;  and  this  per- 
sists iii  s])ite  of  all  treatment.  There  is  no  evidence  of  fluid  ;  the  ;j(!neral 
hnillli  may  not  be  much  imj)aire(l,  or  there  nuiy  he  slijjjht  fever  aiwi  dis- 
IiiiIkmI  di«^esti<m.  The  eases  {(ive  great  anxiety,  owing  to  the  miiural 
siisiiicion  that  tuhereulosis  exists.  In  time  the  evidence  of  duliu-ss  ia 
fduiid  at  the  base.  There  are  feeble  breathing  and  creaking,  leathery 
friction  sountls.  There  may  be  commencing  retraction  of  the  side.  Clini- 
cally these  eases  are  of  great  interest,  and  should,  I  think,  he  separated, 
on  the  OIU1  hand,  from  the  eoiulition  which  follows  a  healed  empyema  or 
old  pleurisy  with  elTusion,  and,  on  the  other,  from  the  rare  instances  of 
jiriniitive  cirrhosis  of  the  lung.  However,  in  all  three  states  there  may 
ultiuiately  be  an  almost  idiiiitical  clinical  picture.  Anatonncally  in  these 
pleuritic!  eases  the  pleura,  jiarticndarly  that  surrounding  the  lower  lobe, 
sometimes  the  entire  membrane,  is  thitikened,  the  two  layers  are  inti- 
malfly  united,  and  fibrinous  bands  passing  from  the  pleura  traverse  the 
liuig  tissue,  sometimes  dividing  it  in  a  remarkable  way  into  sections.  The 
bronchi  may  present  nuirked  diI:itations,  though  this  is  not  alwa3's  the 
case,  and  the  lung  tissue  is  more  or  less  sclerosed.  The  cases  belong  to 
the  group  of  chronie  pmnimonias  called  by  Charcot  plenrogeiious.  In 
many  instances  there  can  he  no  question  as  to  tlieir  non-tuberculoua 
nature.  There  are  cases,  however,  in  which,  with  chronie  ])leurogenous 
Itueumonia  in  the  lower  lobe,  there  are  cavity  formations  at  the  apex  and 
tuberculous  lesions  in  other  parts.  Such  may,  of  course,  be  tuberculous 
from  the  outset. 

Lastly,  there  is  a  primitive  dry  pleurisy  of  tuberculous  origin.  In  it 
both  parietal  ami  costal  layers  are  greatly  thickeiu'd — perhaps  from  two 
to  tiirce  millimetres  each — and  present  firm  fi])roid.  caseous  masses  <'ind 
small  tuljcreles,  while  uniting  these  two  greatly  thickened  layers  is  a 
r('(|(lish-gray  fibroid  tissue,  sometimes  infiltrated  with  serum.  This  may 
be  a  local  process  confined  to  one  pleura,  or  it  may  be  in  both.  I  have 
seen  two  typical  instances  of  it — one  in  a  young,  well-nourished  Irish  girl, 
who  (lied  of  maligmmt  scarlet  fever,  in  whom  one  pleura  was  in  the  con- 
dition al)ove  described,  and  there  were  no  other  tubercuhnis  lesions.  The 
other  was  in  a  young  num  who  died  of  typhoid  fever,  in  whom  both  ])leura3 
were  uniformly  thickened  and  tuberculous  without  any  fluid  exudate. 
'I'lu'se  eases  are  sometimes  associated  with  u  similar  condition  of  the  peri- 
oardium  and  peritonaeum. 

(Jeeasionally  remarkable  vaso-motor  phenomena  occur  in  chronic  pleu- 
risy, whether  simple  or  in  connection  with  tuberculosis  of  an  apex.  Flush- 
ing or  sweating  of  one  cheek  or  dilatation  of  the  pupil  are  the  common 
iiKiuifcstations.  They  appear  to  be  due  to  involvement  of  the  first  thoracic 
Jianirlion  at  the  top  of  the  pleural  cavity. 


im 

1  IpI 

P  3n9 

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II 11 

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* 


COS 


DISKASES  OP  THE  RESPIUATORY   SYSTEM. 


III.   HYDROTHORAX. 

Ilyilrotliorax  is  a  tmiisiuhitioii  of  Hitnple  noTi-iufluminatory  tlnid  ini,) 
the  ])k'ural  ciavities,  and  occurs  us  a  secondary  i)rocess  in  many  alTcct'ipns. 
The  thiid  is  clear,  without  any  flocculi  of  fibrin,  and  the  nienihrancs  mn 
smooth.  It  is  nu't  with  more  parti<;ularly  in  connection  witli  ;;iiiir;il 
dropsy,  eitlicr  renal,  cardiac,  or  liaMiiie.  It  nuiy,  however,  occur  aloiic,  or 
with  only  sli^dit  (cdenui  of  the  feet.  A  ciiild  was  admitted  t(»  tiu;  Mont- 
real (Jeneral  Hospital  witii  urgent  ilysi)ncea  and  cyanosis,  ami  died  tlic 
night  after  admission.  She  had  extensive  bilateral  hydrothorax,  wliirli 
had  come  on  early  in  the  nephritis  of  scarlet  fever.  In  renal  disease 
hydrothorax  is  almost  always  bilateral,  but  in  heart  .ilfectioiis  one  ))lciirii 
is  more  eommoidy  involved.  The  jdiysical  signs  are  tiioscs  of  pleural  clTii- 
sion,  but  the  exudation  is  rarely  excessive.  In  kidiu'y  ami  heart  disease, 
even  when  there  is  no  geiu'ral  dropsy,  the  occurrence  of  dyspna'a  should 
at  once  direct  attention  to  the  pleura,  since  many  patients  are  carried  (>{] 
by  a  rai)id  effusion.  Post-mortem  records  show  th(!  frcipiency  witii  which 
this  condition  is  overlooived.  The  saline  purges  will  in  nuiny  cases  rapid- 
ly reduce  the  effusion,  but,  if  necessary,  aspiration  should  re])eatediy  he 
practised. 


IV.  PNEUMOTHORAX  {Hydro- Pneumothorax  and  Pyo-Pneumothomx). 

Air  alone  in  the  pleural  cavity,  to  which  the  term  pneumothorax  is 
strictly  ap})licable,  is  an  extremely  rare  condition.  It  is  almost  nnaiiahly 
associated  with  a  serous  fluid — hydro-pjieuinothorax,  or  with  pus — pyo- 
pneumothorax. 

Etiology. — It  has  usually  been  taught  that  there  is  an  inherent 
tendency  to  pneumothorax,  which  is  induced  as  soon  as  the  jjleura  is 
opened.  The  experiments  of  S.  West  seem,  however,  to  indicate  tlie 
existence  of  a  coherent  force  between  the  j)leural  surfaces  much  in  excess 
of  the  elasticity  of  the  lung,  and  sufficient  in  certain  instances  to  main- 
tain these  organs  in  contact  with  the  thoracic  wall,  even  when  tlieic  is 
free  access  to  the  pleura;  so  that  in  reality  force  is  required  to  overcome 
the  nornud  adhesion  between  the  pleural  membranes. 

Pneumothorax  ai'ises:  (1)  In  jjcrforative  wounds  of  the  chest,  in  which 
case  it  is  sometimes  associated  with  extensive  cutaneous  emphysema.  It 
has  followed  exploratory  puncture  with  a  hypodermic  needle,  as  in  two 
cases  reported  by  Herman  Biggs.  Pneumothorax  rarely  follows  fracture 
of  the  rib,  even  though  the  lung  may  be  torn.  (2)  In  perforation  of  the 
pleura  through  the  diaphragm,  usually  by  malignant  disease  of  the 
stomach  or  colon.  The  pleura  may  also  be  perforated  in  r:'ses  of  cancer 
of  the  a'so}>hagus.  (3)  When  the  lung  is  perforated.  This  is  by  fsii'  die 
most  common  cause,  and  may  occur :  («)  In  a  normal  lung  from  rujiture 


PNKUMOTIIORAX. 


609 


(,f  I  he  air-vosirlcs  during  stniiiiiiif,'.  Sprciiil  uttontinn  liaa  lately  l>oen 
ciillfd  to  this  aci'ident  l)y  S.  West  aixl  De  H.  Hall.  TiK'  air  may  ho  ah- 
sdilii'il  ami  IK)  ill  cllVct  follows.  It  dofs  not  necessarily  excite  [)leiirisy,  us 
puinted  out  luuny  y<;urs  a^'o  by  (iairdner,  but  iiillaiiiniation  and  etTiisiou 
are  tho  usiiul  result,  {b)  From  perforation  due  to  local  disease  of  the 
liiiiU,  either  tho  softening  of  a  caseous  focus  or  the  breaking  of  a  tuber- 
culous cavity.  Acc(jrdiiig  to  S.  West,  idnety  j)er  cent  of  all  the  cases  are 
due  to  this  cause.  Less  c(;nimon  are  the  (;asi's  due  to  septic  broncho- 
piiiMimoiiia  and  to  gangrene.  A  rare  cause  is  the  breaking  of  a  ha'inor- 
rliau'ic  infarct  in  chronic  heart-disease,  of  Avhich  I  met  an  instance  a  few 
years  ago.  (f)  Perforation  of  tho  lung  from  the  pleura,  which  arises  in 
certain  cases  of  empyema  and  produces  a  pleuro-bronchial  fistula. 

I'lieumothorax  occurs  chieHy  in  adults,  though  cases  are  met  with  in 
verv  young  children.     It  is  more  frocpient  in  males  than  in  females. 

Morbid  Anatomy. — If  a  trocar  or  blow-pipe  is  inserted  between 
the  ril)s,  there  nuiy  be  a  jet  of  air  of  sutlicieiit  strength  to  l)low  oiit  a 
lighted  match.  On  oju'inng  the  thorax  the  rm-diastinum  and  pericardium 
are  seen  to  be  })ushed,  or  rather,  as  Douglas  Powell  pointed  out,  drawn 
over  to  the  opposite  side;  but,  as  before  mentioned,  tho  heart  is  not 
rotated,  and  the  relation  of  its  parts  is  nuiintaiiuMl  much  as  in  the  normal 
(•(iiidition.  A  serous  or  purulent  tlui<l  is  usually  present,  and  the  niem- 
Itraiu's  are  intlamed.  The  cause  of  the  juu'innothorax  can  usually  be 
found  without  difficulty.  In  the  great  majority  of  instances  it  is  the 
pcrrnratiun  of  a  tuberculous  cavity  or  a  breaking  of  a  superficial  caseous 
fdcus.  The  orifice  of  rupture  may  be  extremely  small.  In  chronic  cases 
tlicre  may  l)e  a  fistula  of  considerable  size  communicating  with  the  bron- 
chi.    The  lung  is  usually  compressed  and  carnified. 

Symptoms. — The  onset  is  usually  sudden  and  characterized  by 
severe  j)iiin  in  the  side,  urgent  dyspiura,  and  signs  of  general  distress, 
as  iiidicutt'd  ])y  slight  lividity  and  a  very  rapid  and  feeble  ])ulse.  There 
may.  liowever,  be  no  urgent  symptoms,  particularly  in  cases  of  long- 
standing phthisis.  On  more  than  one  occasion  I  have  found,  post  mortem, 
a  imeumothorax  which  was  unsuspected  during  life.  West  states  that 
oven  in  healthy  adults  this  latent  pneumothorax  may  occasiomilly  occur. 

Tile  phiisiral  sicjns  are  very  distinctive.  fiispcrfion  shows  marked 
enlargement  of  the  affected  side  with  immobility.  The  heart  impulse  is 
usually  much  displaced.  On  palpatinn  the  fremitus  is  greatly  diminished 
or  more  commonly  abolished.  On  perriisfiion  the  resonance  may  be  tym- 
panitic or  even  have  an  amphoric  quality.  This,  however,  is  not  always 
tile  ('ase.  It  may  be  a  flat  tympany,  reseml)ling  Skoda's  resonance.  In 
some  instances  it  may  be  a  full,  hyperresonant  note,  like  emphysema; 
while  in  others — and  this  is  very  deceptive — there  is  dnlness.  These 
extieme  valuations  depend  donbtless  npon  the  degree  of  intrajilenral  ten- 
sion. On  several  occasions  I  have  known  an  error  in  diagnosis  to  result 
from  ignorance  of  the  fact  that,  in  certain  insttinces,  the  percussion  note 


V\. 


'  .  :' 


I      I 


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II 


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■  ft, 


(no 


DISKASKS  OK  TIIK   HKSIMKATOliY   SYSTKM. 


nmy  hv  "muini'd,  tidich'ss,  almost  dtiH"  (Wulslic).  'I'licrc  is  iiMially 
(liiliicss  lit  till'  hiisc  Trodi  cITiistMl  fluid,  wliitdi  ciiii  roadily  be  iiiiidi.  t(i 
(diiiiij,'!'  the  lovtd  by  altcrini,'  tlic  jjositioii  of  tiio  piitit'tit.  Movaldi'  didncss 
cui»  be  obtained  iiiiicb  more  readily  in  piu'imiot borax  tbaii  in  a  siinujo 
pleurisy.  On  (itiscii/fu/io/i  the  breatli-soiinils  are  snppresst-d.  SonictiiiMs 
there  is  oidy  a  distant  feeble  inspiratory  niiirrniir  of  marked  aniiilimic 
(pndity.  'I'lie  contrast  between  the  loud  exa;f;,'e rated  breatli-suuiiil.-.  en 
the  normal  side  and  tiie  absence  of  the  breath-sounds  on  the  oiIht  \•^ 
very  snjr^'estive.  'I'lie  rales  havt^  u  peculiar  metallic  (puility,  ami  i.ii 
couj^liinir  oi"  <li'i'p  inspiration  there  may  i)e  what  liaenncc  termed  \\u' 
metallic  tiidvlin-j;.  'I'he  voice,  too,  has  a  curious  metallic  echo.  \\  luil  is 
sometinu'S  called  the  coin-.sound,  termed  by  'I'rousHeuu  the  //nii/  (rainn'n, 
is  very  (diaracteristie.  'i'o  obtain  it  the  auscultator  should  place  one  car 
on  the  back  of  the  <diest  wall  while  the  assistant  taps  on(^  coin  on  aMotlicr 
on  the!  front  of  the  chest.  The  metallic  ecboin;f  sound  which  is  prodiiccil 
in  this  way  is  one  of  the  most  constant  and  characteristic  si«,'ns  of  pncnnKi- 
thorax.  And,  lastly,  tin-  llippocratic  suceussion  may  be  obtaineil  when 
the  auscultator's  head  is  jilaeed  upon  tlio  patit-nt's  eluist  and  his  ImmIv 
shaken.  A  s)ilashin.<j;  sound  is  produced,  which  may  be  audible  at  a  dis- 
tance. A  patient  may  bimself  notice  it  in  makiuff  abrupt  ehaiifies  in 
posture.  Of  other  symi)toms  disjilaeement  of  orj^ans  is  most  constant. 
As  already  mentioned,  the  heart  nuiy  be  drawn  over  to  the  opjiosite  side, 
and  the  liver  jj;reatly  ilisplaced,  so  that  its  upper  surfaiu'  is  below  the  levil 
of  the  costal  marj^in,  a  dej^ree  (d'  dislocation  never  seen  in  simple  elTiisicjii. 

The  (li(i(jiiiisis  of  [tneumothorax  rarely  offers  any  ililli(uilty,  as  the  sii^iis 
are  very  ehuraetoristic.  In  ea.ses  in  which  the  percussion  note  is  dull  tlui 
condition  may  l)e  mistaken  for  effusion.  1  made  this  mistake  in  a  case  nj' 
pulsatiuiT  ])leurisy,  in  which  the  pneumothorax  followed  heavy  liftini;,  and 
it  was  not  until  several  days  later,  after  some  of  the  fluid  had  been  uiih- 
drawn,  that  a  tympaiutic  note  develo})ed.  I)iai)hragmatic  hernia  hdlou- 
ing  a  crush  or  other  acicident  may  closely  simulate  pneumothortix. 

In  cases  of  very  large  phthisical  cavities  with  tympanitic  iJenuLs-idn 
resonance  and  rules  of  an  am])horic,  metallic  (pialily  the  question  oi' 
pneumothorax  is  sometimes  raised.  In  those  rare  instances  of  total  ex- 
cavati(m  of  one  lung  the  amphoric  ami  metallie  phenomena  iiuiy  be  nio.st 
intense,  but  the  absence  of  dislocation  of  the  organs  and  of  the  suciuis- 
sion  s]dash  and  of  the  coin  sound  sufHce  to  differentiato  this  condition. 
While  this  is  true  in  the  great  majority  of  cases,  I  have  recently  luanl 
the  bruit  tVnimin  over  large  cavities  of  the  right  upper  lobe.  The  cuii- 
dition  of  pyo-pneumothorax  subphrenicus  may  simulate  closely  true  pneu- 
mothorax. 

The  pi'Of/nosis  in  cases  of  pneumothorax  depends  largely  upon  tlif 
cause.  The  phthisical  cases  usually  die  within  a  few  weeks.  J'liennio- 
thorax  developing  in  a  healthy  individual  often  ends  in  recovery.  Tliore 
are  cases  of  phthisis  in  which  the  pneumothorax,  if  occurring  early,  seouis 


AFFKCTIONS  OF  T!IK   MKDIASTIXUM. 


(Ul 


to  aiTCsi'  tlic  ])rr)^jn'SM  of  (lie  tiiltcrciilosi^.  Tliis  iippciirt'd  to  Ik-  llif  ciihc  in 
aiiiiiii  with  cliruiiic  inuMiinotlionix  wIid  was  uiiiUt  my  rare  in  l'iiilaik'l|»l  ia 
III!' Itrlwccn  tlircc  and  four  yars.  It  iiiav  In- a  clifotiii"  coiiilitioii,  as  in 
(lie  case  just  niciilioiicil,  :iihI  a  fail'  iiicasiift'  of  licaitli  iiia\  lie  i'nj<iyi'(|. 

Treat>ment. — I'mrticailv  tlicsi-  casi'S  sliouitl  It*.-  dialt  widi  as  ordinary 
plfiirisv  witli  ciriisioii.  Of  course,  wiieii  pnetunotlinrax  devi'lops  in  ad- 
vaiired  plilliisis  tlie  indication  is  to  relieve  llie  pain  and  distress  citlier  liy 
iiiorpliia  or  chloroform  ;  Itut  iii  .  ases  wiiicii  develop  early  tlic  lluid  should 
l)c  withilrawn  l»y  as|)iratioii,  or,  if  purulent,  pernnineid  draiiaijfc  should  ho 
(ilil.iineil.  Even  when  the  condition  has  seemed  to  lu-  most  desperate  I 
have  known  recovery  to  take  place  afti-r  thorough  draina<:e  of  the  sue. 
I'lMtioiis  of  rihs  may  have  to  he  exeiseil,  and  durin;,'  eon\aleseenee  it  is 
will  for  the  patient  to  practise  expansion  of  the  lun^  in  the  manner 
uhviidy  mentioned,  'riiere  are  cases  of  pneumothorax  in  phthisis  in 
which  the  ,tjeneral  I'onditioii  is  so  ifood  and  the  iiKMtnvenience  so  sli<,dit 
thai  to  let  well  enon^di  alone  seems  the  hest  course.  In  such  an  occa- 
sional aspiration  may  he  performed  if  the  11  ad  increases.  In  some  of  the 
instances  the  mere  tappinj;  of  the  chest  with  a  line  needle,  so  as  to  allow 
the  esi'ai)e  of  some  of  the  air,  seems  to  ;,dve  relief  hy  reducinir  the  inlra- 
llioracii-  pressure,  (lood  residts  are  stated  to  have  followed  the  method 
innoduceil  hy  I'otain,  of  re])laeing  the  air  and  fluid  within  the  thorax  by 
sterilized  air. 


AFFECTIONS  OF  THE   MEDIASTINUM. 

(1)  Simple  Lymphadenitis.— In  all  inthimmatory  alTeetions  of  the 
hroiiehi  and  of  the  lun<fs  the  j^^roups  of  lymph  glands  in  the  nu'diastinum 
liccome  swolhui.  In  the  hroiichitis  of  measle.i,  for  (>xample,  and  in  simple 
lii'oncho-{)neumonia  the  hroncdual  glands  are  large  and  inliltruted,  tho 
tissue  is  engorged  and  u(deniatons,  sometimes  intensely  hyjioraMnie.  Much 
.stress  has  heeii  laid  hy  some  writers  on  this  enlargement  of  the  glands  in 
till'  postin'ior  nie<liastinuin,  and  Do  Mussy  held  that  it  was  an  important 
tailor  in  inducing  i)aroxysms  of  whooping-cough.  They  may  attain  a 
size  sullicient  to  induce  dulnes-:  beneath  the  manubrium  iind  in  the  upjter 
part  of  tho  interseai)ular  regions  behind,  though  this  is  often  diilieult  to 
(irtiTinine.  In  reality  the  glands  lie  ehielly  upon  the  spine,  and  nidcss 
those  which  are  dee])  in  the  root  of  the  lung  are  large  enongh  to  indu(!C 
I'onipressioii  of  the  adjacent  lung  tissue,  I  doubt  if  the  ordinary  bronchial 
aili'iiopathy  ever  can  be  determined  by  percussion  in  the  n])])er  interscapu- 
lar region.  I  have  never  met  with  an  instance  in  which  the  compres.sion 
of  either  bronchus  seemed  to  have  resulted  from  tlu^  glands,  however  large. 
Tiilierculous  atTection  of  these  glands  has  already  been  considered. 

(■*)  Suppurative  Lymphadenitis. — Occasionally  abscess  in  the  bronchial 
or  tracheal  lymph  glands  is  found.     It  may  follow  the  simi)le  adenitis, but 


ii 


■!i. 


I  I 


Nil 


t  • 


m 


H-  I 


EC  I   ,  [ 


( 

.V  \ 

i^  ' 

^ 

?•  ' 

» 

. 

\ 

i! 

M 

^'.ll 


tii 


Si 

lilfll.  ^1- 


If 


HXi 


(512 


DISEASES  OP  THE   IlESPIRATOUY  SYSTEM. 


is  most  frequently  associiitod  with  the  presence  of  tuhercle.  The  li(|\ii(l 
])orti(>n  may  jfradually  hecoine  absorbed  and  the  inspissated  contin;-  uii- 
(h;r<fo  (^alcilieation.  Serious  accident  occasionally  occurs,  as  ])cit'Mi;(iiMn 
int(»  the  d'sojdiaj^us  or  into  a  l)ronchus. 

(:i)  Tumors;  Cancer  and  Sarc3ma.--ln  Hare's  elaborate  study  (.r  :>-n\ 
cases  of  disease  (d'  the  nicdiii^tiniMn*  there  were  I'M  cases  of  cancer,  US 
cases  of  sarcoma, '^'l  cases  of  lympiioina,  T  eases  of  libroma,  II  caso  uf 
dermoid  cysts,  H  cases  of  hydatid  cysts,  and  instances  of  liponia,  uiiinni;!, 
and  cnchondronui.  From  this  we  see  that  cancer  is  the  most  coiiiiiHin 
f(»rm  of  <,n-o\\tii.  The  tumor  occnrre(l  in  the  anterior  mi'diastiiiiiiii  almic 
in  4.S  ot'  the  cascjs  of  cancer  and  'Mi  ol'  the  <"'scs  of  sarcoma.  The  ili.'Ciiso 
may  l)e  either  prinuiry  in  the  mediastinal  tissues  and  lym]»ii  striictuiv- or 
se(M)ndary.  Sarcoma  is  more  fre(iueiitly  primary  than  cancer.  .Male-  mv 
more  frcijiicntly  aiK'cted  than  females.  The  a.ufe  of  onset  is  most  com- 
monly  between  thirty  and  forty. 

Symptoms. — The  sij^ns  of  mediastinal  tumor  are  tliose  of  intni- 
thoracic  j)ressiire.  Dt/s/iii(Ba  is  one  of  the  earliest  ami  most  coiistmit 
symptoms,  and  inay  be  due  either  to  pressure  on  the  trachea  or  on  the 
recurrent  iaryn<jjeal  nerves.  It  nuiy  indccfl  be  cardiac,  due  to  pressure 
upon  tiie  heart  or  its  vessels.  In  a  few  cases  it  results  from  the  pleiuiil 
elfusion  which  so  frecjuently  accompanies  intrathoracic  {frowiiis.  Assd- 
eiatcd  with  the  d\spn(ea  is  a  cough,  often  severe  and  jiaroxysmal  in  eliar- 
acter,  witli  the  Itrazen  (piality  of  the  so-calleil  aneurismal  conjxh  when  a 
recurri'ut  lu'rve  is  involved.  The  voice  ma.y  also  be  all'ccted  from  a  simi- 
lar cause.  Pressure  on  the  vessels  is  conp/ion.  The  superior  vciia  cava 
may  be  compressed  and  obliterated,  and  when  t'.ie  process  j;joes  on  sl(i\vl\ 
the  collateral  circulation  may  be  completely  elTected.  Less  coiuinoiily 
the  inferior  vena  cava  or  one  or  other  of  the  subcl:-.  ian  vciiis  is  einu- 
pressi'd.  'i'he  arteries  are  much  less  rarely  ol)structe(l.  It  is  remarkal)le 
how  little  the  aorta  may  be  involved,  thoujjh  entirely  surrounded  .)y  a  sar- 
comatous or  cancerous  mass.  There  nuiy  be  dyspluifria,  ilue  to  comitres- 
sion  of  the  (i'sopha,<rus.  In  rare  inshmces  there  are  ])upillary  clian,<(es, 
either  dilatation  (,r  ccatractiou,  due  to  involvenuM  t  of  the  synf[)athetie. 

Physical  Slgrns. — On  inspection  there  maybe  orthopna'a  and  ii.nkei! 
cyanosis  of  tlu'  upper  part  of  the  body.  In  siu-h  instances,  if  if  ]^<u<i 
duration,  tlicr(>  are  sifrns  of  collat^M-al  circulation  and  the  su])erlici:  1  niain- 
mary  and  epipistric  vein  are  enlarsrcd.  In  a  patient  witii  llod.irkii's  ilis- 
ease,  at  ]M-esent  '.lu'ler  observation  and  in  whom  durin>;  the  past  sixteen 
months  there  baa  been  projjtressive  compression  and  now  obliteration  "f 
the  superior  vemi  cava,  the  entire  subcutatieous  tissue  of  the  front  ot  tin' 
thora.x  seems  a  i)lexus  of  veins  and  the  cpii^astric  vessels  are  as  larirc  :is 
the  index-linger.  Such  instances  arc,  I  think,  more  common  in  lympliii'li'- 
noma  than  in  sarcoma  or  canc^er.     In  these  cases  of  ch.f  jui""  obstruetinii 


Fothergiiliaii  Trize  Essay  of  tlie  Modical  Society  of  London,  rhiliKlelpliia.  IHSO. 


AFFKCTIONS  OF  THK   MKDIASTINL'M, 


r.i3 


ilic  iiii<ior-tips  may  l)o  cliibhcd,  Tlicro  may  bo  biil^Mii;^  of  llio  sternum  or 
tlir  tumor  may  crodo  tho  bono  antl  form  a  jwominont  sulHUtaiu'ous  j^rowth. 
Till'  nipidly  growing  lym|»boi(l  tumors  moro  commonly  tliau  otbors  por- 
tbc  ohost  wall.  In  four  of  thirti'on  casos  of  llodgUiu's  ilisoasc,  of 
I  havo  notes,  tlicro  was  modiastinal  growtli,  and  in  three  instances 


tiinili' 


Willi  • 


tlir  >ternum  was  oi'ode<l  and  perforated,  'i'lie  jierfonition  may  be  ou  one 
side  of  llio  breast-bon(!.  Tho  jtrojoeting  tumor  may  pulsate  like  an  aiu'U- 
ii>iii ;  the  heart  may  bo  dislocated  and  its  impulso  miu'h  out  of  place.  Con- 
trartioii  <»f  olio  sid(?  of  the  thorax  has  been  noted  in  a  ftnv  instances.  On 
|i;il|tation  the  fremitus  is  absent  wherever  the  tumor  reaches  the  chest 
Willi.  If  pulsating,  it  rarely  has  tlu^  forcible,  heaving  impulse  of  un  aneu- 
risiiial  sac.  On  auscultation  there  is  usually  silence  over  the  dull  regicm. 
Tile  heart-sounds  arc  not  transmitted  and  tlit^  respiratory  murmur  is  fooblo 
(ir  iiiaudil)le,  rarely  broncliial.  Vocal  resonance  is,  as  a  rule,  absent.  Sig^is 
(if  pleural  elTusion  occur  in  a  great  many  instances  of  nu'diastinal  growth, 
uiiil  if  in  any  doubt  tho  aspirator  needio  should  bo  used. 

Tile  (/idi/iKisis  of  mediastinal  tumor  from  aiiciirisiu  i?   sometimes  ex- 
trciiielv  diilicult.     An  interesting  caso  reported  and  ligiireil  by  Sokolosslu, 


in 


\\i\.   Ill   of   tli(!    Doutsches  Archiv   fiir    klinische   .Med 


iclll,    111    w 


hich 


(•|ipnl/.er  diagnosed  anoiirism  and  Skoda  mediastinal  tumor,  illustrates 
Imu  ill  some  instances  tho  most  skilful  of  observers  may  be  unable  to 
airiee.  Scurcoly  a  sign  is  found  in  anonrism  Mliich  may  not  be  diiplicatod 
ill  niiiliastinal  tumor.  Tiiis  is  not  strange,  since  the  syiupintiis  in  both 
irgely  duo  to  jiressure.     The  time  clement  is  important.     If  a  case 


lire 


lia<  persisted   for  moro   than    oi^htceii    months   the  di; 


iCilSC 


pro 


tiabb 


iiii  iiri>iii.     'riiero  are,  however,  exce|)t ions  to  this. 


Ill   tl 


e  casi'  ot    coiii- 


|iiv~«iiiii  of  the  vi'iia  cava  mentioned  above,  tho  disease  has  lasted  for  moro 
than  two  years  and  the  jiatient  lias  improved  so  niarke(||y  under  tli(>  use 
iif  ar>eni(!  that  hail  ho  no  other  lymphatic  eiilargemeiits  the  diagnosis 
iiiiL'lit  be  uncertain.  By  far  the  most  valuable  sign  of  aneurism  is  the 
(lia>tiilic  shock  so  often  to  bo  felt,  and   in  a  majorilv  of  cases  to  be  lii'ard. 


ii\ii'  I'll 


wliei 

lltllCl 


•I'l 


'.     This  is  rarely,  if  ever,  present  in  mediastinal  growths,  even 

1  llii'y  perforates  tho  sternum  and  liavi'  comniunicateil  pulsation.  An- 
]ioiiit  of  iniportanco  is  that  in  a  tumor,  ailvaiiciiig  from  the  niedias- 
tiiinm,  eroding  the  sternum  and  appearing  externally,  if  aiicirisnial,  has 

ilile,  heaving,  and  distitictly  oxpansihs  pulsations.  The  radiating  pain 
ill  ilic  tiack  and  an  ^  and  neck  is  rather  in  favor  of  aiiourisni,  as  is  also 
ii  liiiiclicial  iiilluenco  on  it  of  iodide  of  iiotassium. 

riie  frequency  of  pleural  olTiisioii  in  connection  with  modiastinal 
tuiiinr  is  to  be  constantly  borne  in  mind.     It  may  give  curiously  complex 

actens  to  tho  j)liy,ical  signs — cliaract<  »s  which  are  profoundly  iiiodi- 


I'liai 


aft. 


■r  aspiration  of  tli(>  liquid. 


aiiau 


(I)  Abscess  of  tho  Mediastinum. — Hare  collected  Jl.l  cases  of  medi- 
;i:al  abscess,  in  n'  of  which  then'  were  details  sudicient   to  permit  tho 
-is.    Of  these  cuses  tho  groat  majority  occurred  in  males.     l''orty-four 


614 


DISEASKS  OF  THE  RESPIRATORY  SYSTEM. 


wore  instiinros  of  iicutc  ul)S('(;ss.  Tlio  anterior  Tiu'diii.stiiuim  is  most  cr,m- 
moJily  the  seat  of  the  siijjpuration.  Tlie  cases  arc  most  frefiiientlyassuriatal 
with  trauiiia.  Some  have  followed  erysipelas  or  occurred  in  assdciiition 
with  eruptive  fevers.  Many  cases,  particularly  the  chronic  al)s('e.ssc<,  jipl' 
•)f  tuberiHilous  ori^'in.  Of  si/iii/ifoiiis,  pai.i  behind  the  sternum  is  tin'  nuist 
(iommon.  Jt  may  bo  of  a  throl)bin,<f  characti'r,  and  in  the  aculi^  cases  is 
associated  with  fever,  sometimes  with  chills  and  sweats.  If  the  abscess  is 
]ar<f(!  there  may  bo  dys])nu>a.  The  })us  nniy  )»urr(iw  into  the  alMlnimn, 
perforate  through  an  intercostal  space,  or  it  may  erode  the  sterninn.  In- 
stances  are  on  record  in  which  the  abscess  has  discharired  into  the  trai  lieu 
or  (ivsophagus.  In  many  cases,  })articularly  of  chronic  abscess,  the  pus 
becomes  inspissated  and  produ(.'es  no  ill  elTect.  The  j)/ii/sinif  kIi/hs  may 
bo  very  indeiinite.  A  ))ulsating  and  ihictuating  tumor  may  appear  at  tlit> 
border  of  the  sternum  or  at  the  sternal  notch.  The  absence  of  /)riiif,  of 
the  diastolit'  shock,  and  of  the  expansile  pulsation  usually  enaliles  a  cor- 
re(!t  diagnosis  to  be  made.  When  in  doubt  a  line  hypodermic  needle 
may  be  inserted. 

(f))  Indurative  Mediastino-Pericarditis. — Harris  has  recently  reviewed 
the  subject.  In  one  form  there  is  adherent  pericardium  and  great  increase 
in  the  fibrous  tissues  of  the  mediastinum  ;  in  another  there  is  adlieniit  pcri- 
(lardium  witl\  union  to  surrounding  ])arls,  l)ut  very  little  nu'diastiniiis :  in 
u  third  the  pericardium  may  be  uninvolved.  The  disease  is  rare:  of 
twenty-two  cases  seventeen  were  in  males;  only  two  were  above  tliiity 
years  of  age.  The  symptoms  are  essentially  those  of  that  form  of  adiicsivc 
pericardium  which  is  associated  with  great  hypertrophy  and  dilatation  uf 
the  iieart,  and  in  wliich  the  jjatients  present  a  picture  of  cyanosis,  dys|i- 
no'a,  anasarca,  etc.  The  jjuIsus  jtaradoxicus,  descriiied  by  Kussiiuud,  i- 
not  distinctive.     Occasionally  there  is  also  a  proliferative  [leritonitis. 

(<i)  Miscellaneous  AfiFections. —  In  Hare's  moiu)grai)h  there  were  ]  in- 
stances of  fibroma,  II  cases  of  dermoid  cysts,  8  cases  of  hydatid  cysts,  am! 
cases  of  lipouui  and  gummata. 

The  ///i/iin/s  (//(Old  may  be  enlarge(l  and  produce  the  physical  signs  of 
mediastinal  tumor.  In  i-hihlren  there  are  instances  of  spasm  of  the  glottis, 
wliicii  is  believed  by  some  to  dej)end  upon  enlargement  of  the  thyiiuis. 
Jacobi,*  in  his  n.onograph,  says  that  some  instances  of  sudden  death  iimi 
also  so-called  thymic  asthma  may  occasiomilly  be  referred  to  this  cause. 
Heiu'ke  states  that  this  may  be  due  to  compression  of  the  trachea,  by  the 
eidarged  thymus  when  the  head  is  bent  back,  and  calls  attention  to  the 
danger  of  this  in  fat  and  rickety  infants.  Maligiuint  tumors  of  the  tliy- 
nins  may  attain  considerable  size  and  ])rodnce  signs  of  tinnor.  In  raiv 
cases  mediastinal  growths  develop  from  the  f/a/niid  (//(iii'f.  'I'hese  may  tn' 
substernal  in  position  and  directly  connected  with  the  gland.  Krctsciiv 
has  rep»»rte(i  a  sarcoimi  of  the  thyroid  four  and  three  quarter  incli-'s  in 


•  'I'nviisnctions  of  the  At-sooiiition  of  Amerifuii  Physicians,  vol.  iii. 


AFFECTIONS  OF   THE   MEDIASTINFM. 


615 


lt'iii:lb,  wliich  forms  ji  mediastiiiiil  tumor  piissiui;  to  tlu'  level  of  llio  niiuli 
(jinsiil  vertebni.  I  have  ri'i)orU'(l  a  sdinewiuit  ^illlila^  iusliuici',  which  dc- 
veliipod  in  the  left  lobe  of  the  tlivmid  and  foi'iiied  an  elongated  mass 
wliich  |)asscd  down  beside  the  trachea  to  the  l)ifiircation. 

(T)  Emphysema  of  the  Mediastinum.— Air  in  the  cellular  tissues  of  the 
iiiediastinuni  is  met  with  in  eases  of  lnuima„an<l  occasionallv  in  fatal  cases 
el'  ili|)litheria  and  in  whoopiiii^-couirli.  It  may  extend  to  the  subeutimcous 
tissues.  Chiimpiieys  has  called  attention  to  its  frefpieiicy  in  tracheotomy, 
ill  which  he  says  the  coiulitions  favoi'ing  the  production  aiv  division  of  the 
deep  fasci;!,  obstruction  to  the  air-passages,  and  inspiratory  ciTorts.  The 
deep  fascia,  he  says,  should  not  Itc  raised  from  the  trachea.  It  is  often 
associated  with  pneuuutthoi'ax.  The  condition  seems  by  no  means  uiu'om- 
luuii.  Angel  Money  found  it  in  KJ  of  'iS  cases  of  tracheotomy,  and  in  two 
of  these  ])ncumothorax  also  was  present. 


Ml 


:'fi 


I    I 


SECTION  Y. 


DISEASES  OF  THE  CIRCULATOEY   SYSTEM. 


I,  DISE/iSES   OF  THE  rETlICARDIUM. 
I.   PERICARDITIS. 

Pericarditis  is  tlie  result  of  iufectivo  procossos,  primary  or  .socondurv, 
or  arises  by  extension  of  inflanunatioii  from  contiguous  organs. 

etiology. — Primary,  so-called  idiopathic,  iidlammatiou  of  this  tin'in- 
brano  is  rare ;  but  cases  arc  met  with,  most  commonly  in  chilili'cu.  in 
■which  there  is  no  evidence  of  rheumatism  or  other  eoiulitions  with  which 
the  disease  is  usually  associated. 

Pericarditis  from  injury  usually  comes  under  the  care  of  the  surirfdu 
in  coniu'ction  with  the  priimiry  wound.  Interesting  cases  are  those  in 
which  the  traumatism  is  from  within,  due  to  the  passage  of  some  forciirn 
body — such  as  a  needle,  a  pin,  or  a  bone — through  the  ojsophagus  into  llio 
pericardium. 

As  a  secondary  process  pericarditis  is  met  with  in  the  following'  iilfir- 
tions :  (ii)  A  majority  of  the  cases  occur  in  connection  with  rhcuiniiti>!u. 
The  percentage  given  by  different  authors  ranges  from  tliirty  to  scNfiity. 
The  articular  troul>le  may  be  slight  or,  indeed,  the  disease  may  be  assd- 
eiated  with  acute  tonsillitis  of  rheunuitie  subjects.  Cases  are  recoidcd  in 
which  the  pericarditis  )uis  preceded  the  articular  disease.  {/>)  Siptic 
processes  rank  ju-xt  to  rheumatism.  In  the  acute  necrosis  of  bduc  and 
})uer})cnil  fever  it  is  iu)t  uiu'omnu)n.  (r)  Tultcrculosis,  in  which  I  hi  dis- 
ease may  be  ju-imary  or  part  of  a  general  involvement  of  the  serous  such 
or  associated  with  extensive  pulmonary  disease,  (rl)  Eruptive  fevers.  In 
children,  the  disease  is  not  infre((ucnt  after  scarlatina.  It  is  rarcl\  intt 
with  in  nu'ash'S,  snuillj)ox,  or  typhoid  fever.  In  other  infective  disrascs, 
sueh  as  diphtheria  and  ])neumonia,  it  is  rare.  Pericarditis  sometimes  enm- 
plicates  chorea;  it  was  present  in  10  of  7,'J  recent  autopsies  whicli  1  '(.1- 
lected ;  in  oidy  8  of  tliese  was  arthritis  present,  (c)  Dyscrasias.  Coi- 
tain  altered  conditions  of  the  system  seem  to  render  the  ]>erii';irdinni 
more  susceptible  to  infection.  Of  these  gout  takes  the  first  place  In 
chroiuc  IJright's  disease  pericarditis  is  by  no  means  rare.  The  pvnror- 
(life  i)ri(//ifii/Ki'  of  the  French  forms  one  of  the  most  important  grouiw 
of  the  disease  in  persons  over  tifty  years  of  age,  most  frequ.     ly  le  I'liii- 


PERICARDITIS. 


617 


piuiying  the  cliroTiic  interstitial  lorm.  Pericai'ditis  lias  been  met  with  also 
ill  .>rurvy  ami  diabetes. 

/V;-(Vv/;v//7/.v  hij  <:vfension  of  disease  from  contiguous  organs.  lu  i)leunt- 
piiciiiiionia  it  forms  one  of  the  most  serious  comidications,  and  was  pres- 
ent in  5  cascri  in  100  post-mortems  in  tliis  disease  wliich  I  made  at  the 
Montreal  (ieneral  Hospital.  It  is  most  often  met  witb  in  tlie  plenro- 
jiiicuinonia  of  cliildren  and  of  alcobolics.  Tbo  assoeiation  witb  simple 
])liiiri-;y  is  much  less  common.  In  ulcerative  ejidocarditis,  purulent  myo- 
canbti.'^,  and  in  aneurism  of  the  aorta  pericarditis  is  occasionally  found. 
It  iniiy  also  residt  from  extension  of  disease  from  tbe  l)roncbial  glands, 
the  ril>s,  sternum,  vertebra',  and  even  froni  the  abdominal  viscera. 

i'ei'icarditis  occurs  at  all  ages.  Cases  are  rej)orte(l  in  tbe  foetus.  In 
the  new-born  it  may  result  from  septic  infection  through  the  navel, 
Throiigliout  cbildliood  tbe  incidence  of  rheumatism  ami  scarlet  fever 
makes  it  a  frcfpient  alTection,  wiiereas  late  in  life  it  is  most  often  asso- 
ciated with  tuberenlosis,  Brigbt's  disease,  and  gout.  Males  are  somewhat 
ninro  frerpiently  attacked  than  females.  Climatic  and  seasonal  influences 
have  been  mentioned  by  some  writers.  The  so-called  ej)idemics  of  ])eri- 
carditis  have  been  outbreaks  of  pneumonia  with  this  as  a  frecpuMit  com])li- 
cutiou. 

Anatomically  as  well  as  clinically  the  disease  may  he  considered  under 
tin-  following  divisions: 

1.  Acute,  ])lastic,  or  dry  pericarditis. 

'■i.  Pericarditis  with  elTusion— scro-fibrinous,  lucmorrbagic,  or  ])urulcnt. 

;j.  chronic  adhesive  pericarditis  (adherent  pericardium). 

Acute  Plastic  Pericarditis. — This,  the  most  common  form,  occurs 
usually  as  a  sc<'ondary  jiroccss.  and  is  distinguished  by  the  small  amount 
of  lliiid  exudation,  which  docs  not,  as  in  the  next  variety,  give  special 
characters  to  the  disease.     It  is  a  benign  form  and  rarely,  if  ever,  of  itself 

I'ln'.es  f;:tal. 

Anatomically  it  may  be  partial  or  general.  In  tbe  mildest  grades  the 
senilis  nu'nd)rane  looks  lustreless  aiul  roughened.  This  is  due  to  the 
]ireseMce  of  a  thin  librinous  sheeting,  which  (.-an  be  lifted  with  the  knife, 
slmwiiig  the  nu'inbram^  beneath  to  be  injected  or  in  2'hi<'<'?^  ecchymotic. 
A-  the  fil)rinous  sheeting  increases  in  thickness  the  constant  movement 
of  the  a<ljacent  surfaces  gives  to  it  sometimes  a  ridge-likc,  at  others  a 
liiin.'yeoiiibed  a]>pearance.  With  more  almndant  librinous  exudation  the 
iiieiiiliranes  present  an  appearance  resembling  l>uttcred  surfaces  which 
tiavr  heeu  drawn  ajjart.  The  fd)rin  is  in  long  shreds,  and  tbe  heart  i)re- 
i'liiis  a  curiously  shaggy  appearance — the  so-called  hairy  heart  of  old 
writers — nir  rillosinn. 

In  mild  grades  the  subjacent  muscle  looks  lujrnud  ;  but  in  the  more 
inulniinfed  and  severe  cases  there  is  myocarditis,  and  for  )l  or  ',\  mm. 
1«  II'  alli  the  visceral  layer  the  muscle  presents  a  i)ale,  turbid  appearance. 


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618 


DISEASES  OF  THE  CIRCQIiATOllY  SYSTEM. 


■! 


if  'A 


Many  of  tlu'so  acute  cases  are  tuljrrculou.s;  covered  by  the  layers  of  l\iiii,li 
the  ffraimlations  are  easily  overlooked  in  a  sui)erlicial  examination. 

Sliji;lit  lliiid  exudation  is  iiivariaidy  present,  entangled  in  the  nii.>li(.s 
of  ilhrin,  l)ut  there  may  hv  very  thick  iii)rinou.s  layers  without  inurh 
serous  elTusion. 

Symptoms. — The  majority  of  eases  of  simple  i)lastie  pcricniliti.s, 
like  Him[)le  endocarditis,  present  no  symptoms,  and  unless  soujfiil  fur  ihere 
are  no  objective  si<;ns  indicating  its  existence.  In  the  j»ost-mortciti  ruom 
it  is  not  uncommon  to  lind  it  in  cases  in  which  its  presence  has  l)efn  im- 
susj)ected  during  life. 

Pain,  is  a  variable  syni))toin,  not  usually  intense,  and  in  this  fcinn 
rarely  excitt'd  Ity  pressure.  It  is  more  marked  in  the  early  stage,  and  inuv 
be  referred  either  to  the  pra'cordia  or  to  the  region  of  the  xiphoid  curti- 
lage. Instances  are  recorded  uf  pain  of  an  aggravated  and  most  distress- 
ing  character  resembling  angina.  Vvwv  is  usually  present,  but  it  is  not 
always  ea.sy  to  say  bow  mindi  depends  upon  the  primary  febrile  alTcctinTi, 
and  how  much  upon  the  pericarditis.  It  is  as  a  rule  ncf  high,  rarely 
exceeding  1(»".*-.")''.     In  rheumatic  cases  bypi'rpyrexia  has  been  oliservcMl. 

Physical  Signs. — limpvction  is  negative;  jHtlpnlUnt  may  reveal  the  pres- 
ence of  a  distinct  fremitus  caused  by  the  rui)l)ing  of  the  roughened  peri- 
cardial surfaces.  This  is  usually  best  marked  over  the  right  ventrii'lc.  It 
is  not  always  to  be  felt,  even  wlien  the  friction  souiul  on  auscultatidii  is 
loud  and  (dear.  Ai(snill(tti(in  :  'i'lie  friction  sound,  due  to  the  movciiR'nt 
of  the  jiericardial  surfaces  upon  ea(di  other,  is  one  of  the  most  distinctive 
of  pby.sical  signs.  It  is  donI)le,  corresponding  to  the  systole  and  diastdlc; 
but  the  syiu'bronism  with  the  heart-sounds  is  not  J'ccurate,  and  the  to-aiid- 
fro  murmur  usually  outlasts  the  time  occupiid  by  the  first  and  second 
souiul.  In  rare  instances  the  friction  is  single;  more  frcfpuMitlv  it  ap- 
pears to  be  tri]ile  in  character — a  sort  of  canter  rhythm.  'I'he  sounds  have 
a  pe(;uliar  rubbing,  grating  (piality,  characteristic  when  oiu-e  recognized. 
and  rarely  simulated  by  endocardial  murmurs.  Sometimes  instead  of 
grating  there  is  a  creaking  (piality — the  hniif  dc  ndr  nciif—ihv  iiew- 
leatlxir  murmur  of  the  Kren(  h.  The  pericardial  friction  appears  siiper- 
ticial,  very  close  to  the  ear,  and  is  usually  intensified  by  pressure  with  the 
stethoscope.  It  is  best  heard  over  the  right  ventricle,  the  part  of  the  licart 
whi(di  is  most  (dosely  in  contact  with  the  front  of  the  chest — that  is,  in  the 
fourth  and  liftli  interspaces  ai\(l  adjacent  p(»rtions  ()f  the  sternum.  There 
are  instances  in  which  the  friction  is  most  nuirked  at  the  base,  over  the 
aorta,  and  at  the  superior  reflection  of  the  pericardium.  Occasionally  it 
is  best  heard  at  the  ap(>x.  It  may  be  limited  and  heard  over  a  very  iuutoh 
area,  or  it  nuiy  be  transmitted  up  and  down  the  sternum.  There  are. 
however,  no  definite  lines  of  transmission  as  in  the  etulocardial  nnntiiiir. 
An  important  point  is  the  variability  of  sounds,  both  in  position  aiid 
(piality;  they  nuiy  be  heard  at  one  visit  and  not  at  another.  The  maxi- 
mum of  intensity  will  be  found  to  vary  with  position. 


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PERICARDITIS. 


619 


DiagnosiSfwyTlioro  is  rarely  any  (liHiculty  in  (ieterminin<]f  the  jires- 
i!ico%f"a  tlry  'jx'ricanlitis,  for  tliu  IViction  sounds  are  distinctive.  The 
liiiiihle  niurnuir  of  aortic  incoinpetcncy  may  sinuilate  closely  the  to-and- 
fro  pericardial  nib.  I  recall  one  mstaiice  at  least  iu  which  this  mistake 
was  made.  The  constant  character  of  the  aortic  niiirniur,  the  direction 
of  Iransiiiission,  the  jihenoinena  in  the  arteries,  and  the  associated  condi- 
tions of  tiie  disease  should  l)e  snllicient  to  prevent  this  error. 

I  have  never  known  an  instance  in  which  pericarditis  was  mistaken  for 
endocarditis,  though  writers  refer  to  such,  and  give  the  dilferential  diag- 
nosis in  the  two  all'ections.  The  only  possible  mistake  could  be  made  in 
those  rare  instances  of  single  soft,  systolic,  pericardial  friction. 

rieiiro-pcricardial  friction  is  very  common,  and  may  be  associated  with 
endo-pericarditis,  jiarticularly  iu  cases  of  ])leuro-i)neumonia.  It  is  fre- 
quent, too,  in  phthisis.  It  is  best  heard  over  the  left  border  of  the  heart, 
and  is  much  alVected  by  the  respiratory  movement.  Holding  the  breath 
or  taking  a  deep  inspiration  may  annihilate  it.  The  rhythm  is  not  the  sim- 
ple to-und-fro  diastolic;  and  systolic,  but  the  i'es]tiratory  rhythm  is  super- 
added, usually  intensifying  the  murmur  during  expiration  and  lessening 
it  on  inspiration.  In  ])hthisis  there  are  instances  in  which,  with  the  fric- 
tion, a  loml  systolic  click  is  heard,  due  to  the  compression  of  a  thin  layer 
of  lung  and  the  expulsion  of  a  bubble  of  air  from  a  small  softening  focus 
or  from  a  bronchus. 

('(iiirKC  and  Termination. — 8im})le  fibrinous  pericarditis  never  kills, 
but  it  occurs  so  often  in  connection  with  serious  alTections  that  we  have 
frequent  op]iortunities  to  see  all  stag<'s  of  its  progress.  In  the  majority 
of  eases  the  inllammation  subsides  and  the  thin  librinous  lamina?  gradually 
l)cconie  converted  into  connective  tissue,  whicli  unites  the  pericardial  leaves 
firmly  together.  In  other  instances  the  inllammation  ])r()gresses,  with  in- 
crease of  the  exudation,  and  the  condition  is  changed  from  a  "dry"  to  a 
"moist"  ])ericarditis,  or  the  pericarditis  with  cfTusion. 

in  a  few  instances— jirobalily  always  tuberculous — the  simple  plastic 
pericarditis  becomes  chronic,  and  great  thickening  of  both  visceral  and 
parietal  layers  is  gradually  induced. 

Pericarditis  with  Effusion.— Though  commonly  a  direct  sequence  of 
the  dry  or  jdastic  pericarditis,  of  which  it  is  sometimes  called  the  second 
stage,  this  form  presents  special  features  and  deserves  separate  consid- 
eration. It  is  found  most  frequently  in  association  with  acute  rheuma- 
tism, tuberculosis,  and  septici\3inia,  and  sets  in  usually  with  the  symptoms 
aliove  described,  namely,  prajcordial  pain,  with  slight  fever  or  a  distinct 
chill. 

Ill  children  the  disease  may,  like  pleurisy,  come  on  without  local  symp- 
toms, and,  after  a  week  or  two  of  failing  health,  slight  fever,  shortness  of 
hreath,  and  increasing  pallor,  the  physician  may  lind,  to  his  astonishment, 
si^Mis  of  most  extensive  pericardial  ellusiou.  These  latent  causes  are  often  tu- 
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620 


DISEASES  OF  THE  CIRCULATORY   SYSTEM. 


bfin-nloiis.  Tlie  ofTiision  rnny  he-  sor()-fil)rinoiis,  hifmnrrhafjif^,  or  piiiiilrnt. 
Till'  iinioimt  varifs  from  "^MiO  or  'MH)  c.  c.  to  2  litres.  In  the  cuhcs  of  scn*. 
libriiioiis  cxiidiitioji  the  iK-riciirdiiil  iiu'inbriUU'S  aro  oovercd  witli  thick, 
creamy  fibrin,  which  iiiuv  he  in  ridjjes  or  lioiioveombed,  or  may  |nvsi'iit 
loiijf,  villous  extensions.  The  parietal  layer  may  be  several  milliniciivs  ji, 
thickness  and  may  form  a  firm,  leathery  membrane.  The  lui'morriiii^^'ic 
exudation  is  usuiilly  associated  with  tuberculous,  or  with  eunceroiis  [uri- 
earditis,  or  with  the  disease  in  the  af?eil.  The  lymi»h  is  less  abundant, 
but  both  snrfaees  nro  injected  nnd  often  show  numerous  ba-morrliafjcs. 
Thick,  curdy  masses  of  lymph  are  usually  found  in  the  de|iendent  part  nf 
the  sac.  In  the  j)urulent  etVusion  (he  lluid  has  u  creamy  consistency,  par- 
ticularly in  tuberctdosis.  In  numy  cases  the  elTusion  is  really  sero-inuu- 
lent,  a  thin,  turbid  cxu(hition  containing,'  llocculi  of  fibrin. 

The  ])ericardial  layers  are  j^n'catly  thickened  and  covered  with  fdniii. 
When  the  fluid  is  ])us,  they  present  a  grayish,  rough,  granular  siirfarc. 
Sometimes  tluM-e  are  distinct  erosions  on  th(3  visiairal  mendjraiie.  'I'luj 
heart  muscle  in  these  cases  becomes  involved  to  a  gnniter  or  less  extent, 
and  on  section,  the  tissue,  for  a  distance  of  from  two  tti  three  milliuiLtres, 
is  pale  and  turbid,  and  shows  (ividence  of  fatty  and  grannlar  change.  Kn- 
docardiiis  coexists  freipiently,  hut  rarely  results  from  the  extension  uf  tin; 
inflammation  through  the  wall  of  the  heart. 

Symptoms.  —  Even  with  co|)ious  effusion  the  onset  and  course  may 
be  so  insidious  that  no  Knsi)icion  of  the  true  nature  of  the  disease  is 
aroused. 

As  in  the  simple  pericarditis,  pain  may  be  present,  either  sharp  and 
stabl>ing  or  as  a  sense  of  distress  ami  discomfort  in  the  cardiiu;  region. 
It  is  more  freqnent  with  effusion  than,  in  the  plastic  form.  Pi'cssure 
at  the  lower  end  of  the  st'M'nuTn  usually  a:jrirravatt's  it.  l)vs;t[!(i';i,  i-;  a 
common  and  important  symptom,  one  which,  perhaps,  more  than  any 
other,  excites  suspicion  of  grave  disorder  and  leads  to  careful  exauiinatimi 
of  heart  and  lungs.  The  2>atient  is  restless,  lies  u])on  the  left  side  or,  as 
the  efTusion  increases,  sits  up  in  l)ed.  .Vssociated  with  the  dys])na'a  is  in 
many  cases  a  peculiarly  dusky,  anxio.is  countcMiance.  The  pulse  is  rapid, 
small,  sometimes  regular,  ami  may  present  the  characters  known  n^^pnlsnn 
IHiradoxus,  in  which  during  each  inspiration  the  pulse-beat  becomes  very 
weak  or  is  lost.  These  symptoms  aro  due,  in  great  part,  to  the  dircet 
mechanical  effect  of  the  lluid  withii\  the  i)ericardinm  which  embarrasses 
the  heart's  action.  Other  pressure  elTects  are  distention  of  the  vi'ins  of 
the  neck,  dysphagia,  whi(di  may  be  a  marked  symptom,  and  irrit^ilive 
cough  from  compression  of  the  trachea.  Aphonia  is  not  uncommon,  duo 
to  compression  or  irritation  of  the  recurrent  laryngeal  as  it  winds  minul 
the  aorta.  Another  important  pressure  effect  is  exercised  uj)on  the  left 
lung.  In  massive  effusion  the  j)ericardial  .sac  occupies  su(di  a  large  p"i"- 
tiou  of  the  antero-lateral  region  of  the  left  side  that  the  condition  \\\\<  fi*'- 
quently  been  mistaken  for  pleurisy.     Even  in  moderate  grades  the  kft 


PEIIICAIIDITIS. 


G21 


lung  is  sojiiowhat  compressed.  This  is  an  udtlitioiial  element  in  the  pro- 
duction of  the  <lyspn(ra. 

(Jreat  restlessness,  insomnia,  and  in  the  later  stages  U)W  delirium  and 
cDina  are  symptoms  in  the  more  severe  eases.  Delirium  and  niarkt'il  cere- 
liral  symptoms  are  associated  with  the  hyperpyrexia  of  rheumatic  eases, 
hut  apart  from  the  ordinary  delirium  there  nuiy  be  peculiar  mental  symp- 
tmus.  Tiic  patient  may  heeonu!  melancholic  and  show  suicidal  teiulencies. 
In  other  cases  the  condition  resembles  clt)soly  delirium  tremens.  .Sibson, 
who  has  specially  described  this  coiulition,  states  that  the  majority  of  sucti 
cases  recover,  ('horea  may  also  occur,  as  was  pointed  out  by  Bright. 
Kjiile[»sy  is  a  rare  complication  which  has  occurred  during  paracentesis. 

Physical  Signs. — Insiwcliott. — In  children  the  pnvcordia  bulges  and 
with  copious  exudation  the  antero-lateral  region  of  the  left  chest  becomes 
enlarged.  The  interco.stal  .'(paces  are  ])rominent  and  there  may  be  marked 
ddeuia  of  the  wall.  iVri'oration  externally  through  a  space  is  very  rare. 
Owing  to  the  compression  of  the  lung,  the  ex])ansion  of  the  left  side  is 
greatly  diminished.  The  diaphragm  and  left  lobe  of  the  liver  nuiy  be 
I'lidied  down  and  may  ])roduce  a  distinct  prominence  in  the  epigastric 
region. 

Pitlpnfinn. — A  gradual  dinnnnlion  and  final  obliteration  of  the  cardiac 
shock  is  a  striking  feature  in  progressive  effusion.  The  apex  In^at  is  often 
rai~iMl  an  interspace  and  di.slocated  outward.  Alteration  in  the  position 
of  the  impulse  simultaneously  with  the  ])(>sition  of  the  patient,  a  sign 
upon  which  Oj)polzer  laid  great  stress,  cannot  often  be  tletermined,  as  the 
beat  may,  and  usually  does,  disappear  entindy.  The  pericardial  friction 
may  lessi'n  with  the  efTusion,  tliough  it  often  j)ersists  at  the  base  when 
no  longer  pal^jable  over  the  right  ventritde,  or  may  be  felt  in  the  erect 
and  not  in  the  recnmbent  i)osture.  Fluctuation  can  rarely,  if  ever,  be 
detected. 

Percussion  gives  mo.st  important  indications?.  The  gradual  distention 
of  the  pericardial  sac  pushes  aside  the  margins  of  the  lungs  so  that  a  large 
area  comes  in  contact  with  the  chest  wall  and  gives  a  greatly  iiu-rea.sed 
percussion  dulness.  The  form  of  this  dulness  is  irregularly  pear-shaped  ; 
the  base  or  broad  surface  directed  downward  and  the  stem  or  apex  directed 
upward  toward  the  manubrium.  A  valuable  sign,  to  whiuii  Ivotch  called 
utteniion,  is  the  alKsence  of  resonance  in  the  right  fifth  intercostal  s])ace. 

Aiisndlalion. — 'I'lu!  friction  sound  lieard  in  the  early  stages  may  dis- 
iipiiear  when  the  effusion  is  copious,  but  often  persists  at  the  base  or  at 
the  limited  area  of  the  apex.  It  i;  ay  bo  audible  in  the  erect  and  not  in 
till  recumbent  posture.  AVith  the  absorption  of  the  fluid  the  friction 
reiurns.  One  of  the  most  important  signs  is  the  gradual  weakening  of  the 
heart  .-rounds,  which  with  the  increase  in  the  effusion  nuiy  become  so 
11111  tiled  and  indistinct  as  to  be  scarcely  audible.  The  heart's  action  is 
iiMially  increased  ami  the  rhythm  disturbed.  Occasionally  a  systolic  endo- 
cardial murmur  is  heard.  Early  and  persistent  accentuation  of  tlie  pul- 
monary second  sound  may  be  present  (Warthin). 


rii'J 


s      I  ,  via 


vii 


hWl 


622 


DISKASKS  OF  TIIH  ClliC'ULATOllV  SYSTKM. 


WM 

K.    ■  *^W 

wM. 

i 

Tmpnrtant  accossory  sijxns  in  hwro  ofFiision  lire  iliio  to  invssiiro  on  tho 
loft,  lull},'.  'I'lif  iiiitcro-latcral  riiar<;iii  of  tlic  juwcr  lolic  is  imslicil  ii~i(l(, 
and  ill  sonio  instances  conipres.sed,  so  tliiit  percussion  in  the  iixillaiv  n- 
j^'ion,  in  and  just  l)elo\v  the  transverse  nipiile  line,  jrives  a  inodilicil  ju  r. 
(Mission  note,  usually  a  flat  tympany.  Variations  in  the  posititm  of  ihc 
patient  may  ehan<,'e  materially  this  modilied  percussion  area,  ovcm-  which 
on  auscultation  there  is  either  feclth'  or  luhiihir  hreathiiii,'. 

('oiirse. — Cases  vary  extremely  in  the  rapidity  with  which  the  elTnMdn 
tako.s  place.  In  every  instance,  when  a  pericardial  frii'tioii  iliurinui'  li:i> 
been  detected,  the  practitioner  should  innncdiatcly  outline  with  cure- 
using  the  aniline  pencil  or  nitrate  of  silver— the  mtper  and  lateral  limits 
of  cardiac  dulness,  since  he  will  in  tliis  way  have  certain  positive  guides  iu 
determining  the  rate  and  grade  of  the  effusion.  In  many  instances  tho 
exudation  is  slight  in  amount,  rea<dies  a  maximum  within  forty-ciglit 
hours,  and  tlu'ii  gradually  subsides,  in  other  instances  the  accumulation 
is  more  grailual  and  progressive,  increasing  for  .several  weeks.  Te  siirh 
ca.ses  the  term  chronic  has  been  applied.  Tlie  rajtidity  with  which  .i  sem- 
fihrinons  otTusion  nuiy  be  al)sorbe(l  is  surprising.  The  iHtssibility  ef  the 
al)sorption  of  purulent  exudate  is  shown  by  the  (nises  in  which  the  peri- 
cardium contains  semi-solid  grayish  masses  in  all  .stag(^s  of  calcilicMtiou. 
With  sero-tii)rinous  elTusion,  if  moderate  in  amount,  recovery  is  the  rule, 
with  inevitable  union,  how(^ver,  of  the  'crieardial  layers.  In  some  of  tlie 
sejjtic  cases  there  is  a  rapid  formation  of  pus  and  a  fatal  result  may  follow 
in  three  or  four  days.  More  commonly,  when  death  occurs  -with  large 
cITusion,  it  is- not  until  the  .secoiul  or  third  week  and  takes  place  h\  grad- 
ual asthcTiia.  , 

Prognosis. — In  the  sero-fil)rinous  effusions  tho  outlook  is  good,  and 
a  large  niajoi'ity  of  all  the  rheumatic!  cases  recover.  The  purulent  effn- 
sions  are,  of  course,  more  dangei'ous;  the  septic  cases  are  usually  fatal, 
and  recovery  is  rare  in  the  slow,  insidious  tuberculous  forms. 

Diagnosis. — Probably  no  serious  disease  is  so  frequently  overlooked 
by  the  practitioner.  Post-mortem  experience  shows  how  often  pericarditis 
is  not  recognized,  or  goes  on  to  residution  and  adhesion  without  attract- 
ing notice.  In  a  case  of  rheumatism,  watched  from  the  outset,  with  the 
attention  directed  daily  to  the  heart,  it  is  one  of  tlie  simplest  of  diseases 
to  diagnose;  but  when  one  is  called  to  a  ease  for  the  first  time  and  (irnls 
perha})s  an  increased  area  of  precordial  dulness,  it  is  often  very  hard  to 
determine  with  certainty  whether  or  not  elfnsion  is  present. 

The  ditliculty  usually  lies  in  distinguishing  betw'een  dilatation  of  tlio 
heart  and  pericardial  etTusion.  Although  the  ditferential  signs  arc  simple 
enough  on  paper,  it  is  notoriously  difficult  in  certain  cases,  particulaiiy  in 
stout  |)ersons,  to  say  whicdi  of  the  conditions  exists.  Tho  points  which 
deserve  attentioJi  are : 

(a)  The  character  of  impulse,  whicdi  in  dilatation,  particularly  in  thin- 
chested  people,  is  commonly  visible  and  wavy. 


rKKU'AUDlTIS. 


OjU 


{h)  The  slicnk  of  tlio  cnnliiu!  soiiiids  is  more  distinctly  piilpiibK-  in 
(iilatiition. 

((■)  The  aivii  (if  (Iiihu'SH  in  dilatiiliun  rarely  has  a  trianjridar  form; 
iKir  does  it,  except  in  eases  of  mitral  stenosis,  reach  so  hi<;h  alonj,'  the  left 
siriial  margin  or  so  low  in  the  (iftli  and  sixtli  interspaces  n'illiuiil  visihle 
1)1-  /iitl/Ki/i/r  ini/Di/si'.  An  upper  limit  of  diilnesis  shifting  with  tl:e  jjosition 
speaks  strongly  for  elTusion. 

((/)  In  dilatation  the  heart-sounds  an;  clearer,  often  siiarp,  valvular, 
(ir  f(etal  in  character;  whereas  in  elTiision  the  sounds  are  distant  and 
iiiullled. 

(r)  K'arely  in  dilatation  is  the  distention  siinicient  to  comi)ress  the 
Iuuij:  and  produce  the  tympaiutic  note  in  the  axillary  ri'i^'ion. 

The  ninnl)er  of  excellent  observers  who  have  acknowh'd<red  that  they 
have  failed  sometimes  to  discriminate  between  these  two  conditions,  atul 
wild  have  indeed  performed  paracentesis  ^vy/vZ/.v  instt-ad  of  paracentesis  y(yr/-/- 
airdii,  is  j)erhaps  the  best  comment  on  the  diillculties. 

Massive  (1^  to  '2  litre)  exudations  luive  been  confounded  with  a  jdeu- 
ral  elTusion.  On  nu)re  than  one  occasion  the  pericardium  has  been 
tapped  under  the  impression  that  the  exudate  was  pleuritic.  The  Hat 
tyiKpany  in  the  infrascapular  re<;ion,  the  absence  of  well-delincd  movable 
(luiiiess,  and  the  feeble,  mulllcd  sounds  are  indicativt-  points.  If  the  case 
has  been  followed  from  day  to  day  there  is  rarely  mm  h  dillicnlty;  hut  it 
is  dilTerent  when  a  case  presents  a  large  area  of  dulness  in  tlie  antero- 
lateral region  of  the  left  chest,  and  there  is  no  to-and-fro  pericardial 
friction  murmur.  Many  of  the  cases  have  been  regarded  as  encapsulated 
pleural  cll'usion. 

The  nature  of  the  fluid  cannot  positively  be  determined  without  aspi- 
ration; but  a  fairly  accurate  opinion  can  be  formed  by  the  nature  t)f  the 
primary  disease  and  the  general  condition  of  the  ))ati<'nt.  In  rheumatic 
ciscs  the  exudation  is  usually  sero-iibrinous;  in  septic  and  tuhercidous 
•  uses  it  is  often  ])urulent  from  the  outset;  in  senile,  nephritic,  ami  tuber- 
culous cases  the  exudation  is  scmietimes  hivmorrhagic. 

Treatment. — The  ])atient  should  have  absolute  quiet,  mentally  and 
••(•(lily,  so  as  to  reduce  to  a  nunimum  tin-  heart's  action.  Drugs  given  for 
this  purpose,  such  as  aconite  or  digitalis,  arc  of  doubtful  utility.  Local 
liliHiilK'tting  by  cu{)ping  or  leeches  is  certainly  advantageous  in  robust 
8iilij<H'ts,  particularly  in  the  cases  of  extension  in  pleuro-pneumonia.  The 
iee-hag  is  of  great  value.  It  may  bo  applied  to  the  pra'cordia  at  first  for 
uu  huiir  or  more  at  a  time,  and  then  continuously.  It  reduces  the  fre- 
(|uoncy  of  the  heart's  action  and  seems  to  retard  the  progress  of  an  eifu- 
sion.     Ulisters  are  not  indicated  in  the  early  stage. 

^Vhen  effusion  is  present,  the  following  measures  to  promote  absorp- 
tion may  be  adopted :  Hlisters  to  the  })riecordia,  a  practice  not  so  much 
ill  vogue  now  as  formerly.  It  is  surprising,  however,  in  some  instances, 
how  (juickly  au  ellusiou  will  subside  on  their  application.     If  the  patient's 


1 1 


?'!!:• 


624 


DISKASKS  OV  TFIK  CIIK'UI.ATOUY   SYSTKM. 


Wtf!     J 


strcii^rth  is  ^ond,  a  piirpfo  ov(>rv  other  iiKiniiiip:  niav  ho  p'won.  'Y\\v  di.t 
kIiouIiI  Ih'  li;;lit,  tlry,  iiml  luitritioiis.  In  casi's  in  wiiidi  Uic  imlsc  is  >ticiii;f 
1111(1  the  (•oiisfitiilioiia!  fiisturliiiiicc  not  fjrciit,  iudidi' of  |KiiiissiiMii  iiia\  Ix- 
(»f  sorvico,  and  the  actiim  <tf  the  kidnoys  may  he  itroiimti'd  hy  the  iiilH^inii 
(if  di;rifiilis  anil  acetate  of  potash. 

When  the  elfiisi((ii  is  lar^';e,  as  soon  as  sij,'ns  of  serious  ini|iairiiiiiii  (,f 
the  heart  occur,  as  indicated  hy  (iysjino'a,  small  raidd  |Mdsc,  diiskv,  iiiiximis 
countenance,  sur<.Mcal  measures  should  hv  resorted  to,  a)id  panicii^'ntesi.,  nr 
incision  of  the  pericardium,  ut  once  he  performeij.  Willi  the  sen»-liliriii- 
ous  exudate,  such  as  commonly  occurs  after  rhcuiuiilisin,  asjiiraiini;  is 
suthcient;  hut  when  the  exudate  is  purnletd  the  pericardium  shunld  ]»■ 
fri'fly  incised  and  freely  drained.  Tjie  j)unctnro  nuiy  he  made  in  tlic 
fourth  interspace,  eitlH^r  at  the  left  sternal  margin  or  'i-',  cm.  (an  indi) 
from  it.  It"  ma(h'  in  the  t[ft.h  inters^iace  it  is  well  to  ])uncture  an  iii<li 
and  a  half  from  the  left  sternal  mar{j;in.  In  large  elTusions  the  pericar- 
dium can  also  he  readily  reached  without  danger  hy  thrusting  the  incilli' 
upward  and  hackward  close  to  the  costal  nnirgin  in  the  left  costo-\i|ilMii(| 
angle.  The  results  of  paracent(\sis  of  the  pericardium  have  so  tar  imt 
heen  satisfactory.  AVith  an  earlier  operation  in  many  instances  and  a 
more  radical  one  in  others — a  t'wv  incision  and  not  aspiration  when  the 
fluid  is  jmrulent — the  percentage  of  recoveries  will  he  greatly  increased. 
yTi  Chronic  Adhesive  Pericarditis  {Atfficirnt  Pericardium).— 'VhU  con- 
dition follows  acute  pericarditis,  an<l  may  he  partial  or  nniversal.  It  is 
not  verv  uncommon  to  iiKH't  with  limited  svnechia  over  the  ri'dit  vcii- 
tricle.  In  the  mildest  grades  of  comi)lete  adhesion  the  amount  (d"  con- 
neetive  tissue  hetween  the  mendiranes  is  .slight,  and  there  is  not  niitch 
thickening.  These  are  the  instances  whiidi  f(dlow  the  fdirinous  riicii- 
matic  pericarditis.  The  most  extreme  thickening  of  the  memhraiu^  is 
met  with  in  the  (dironic  tuheivulous  form,  which  has  already  heen  de- 
scril)e(l,  and  whi(d)  is  much  more  common  than  indicated  in  the  litera- 
ture. After  the  ahsorption  of  an  extensive  purulent  or  sero-purulciit 
exudate  the  inspissated  remnants  may  undergo  calciileation.  This  inay 
he  in  (|nite  a  limited  region,  most  frecpu-ntly  over  the  auricles  or  at  the 
hase  of  the  h(>art.  In  extreme  grades  the  organ  i.s  (completely  invested 
by  a  tialcareous  membrane,  wliich  in  places  may  be  from  1  to  1-5  em.  in 
thickness. 

The  siimjrhms  of  adherent  pericardium  arc  uncertain  and  indefinite. 
A  majority  of  the  cases  are  met  with  aceidejitally  in  the  jiost-nmrti'iu 
room,  and  there  may  have  been  no  indications  whatever  during  lite  "t 
cardiac  disturbance.  Enlargement  of  the  heart  is  an  almost  constant  ac- 
companiment of  universal,  and  may  follow  even  partial,  adhesion,  aiul 
many  of  the  cases  come  under  observation  for  the  first  time  with  failure  nf 
this  hypertrophy  and  signs  of  cardiac  insufficiency. 

The  following  are  the  important  points  in  the  diagnosis : 

(1)  Lispection. — In  children,  in  whom  the   condition  is  a  not  uu- 


rKIllCAUDITlS. 


(525 


conimon  seqiiciico  of  rlit'iiiimtism,  the  liypcrtropliicd  liciirt  cniiscs  hiilir- 
iiig  of  the  chest  wall.  Tlu'  urvn  of  curdian  iiiiixilsc  is  iiicn-ascd  ami  may 
Honu'tiriit'S  be  vvm  rioiu  the  third  !<•  tlu'  sixth  iidcrHpuco  and  lu-vond  the 
iiilipii'  line.  The  strc)iij,'i'Ht  impnlsc  may  hr  to  tlii'  ri^dit  of  Iho  apfx.  TIk* 
«av}  I'lianu'ter  of  the  jitdsatioii  in  the  lliird,  fourth,  and  liflli  intfrs|)ar(s 
i-  not  )tfculiar  to  adherent  jM-ricardinm.  Not  miicii  stfcss  can  he  laid 
ii|inn  Ihf  lixt'd  |M(>ili()M  of  the  iinpidse,  wlui-h  in  j^reat  eidargcment  of  the 
liiart  is  not  imieh  inlliieneed  eitlicr  hy  jtostnic  or  respiration.  A  more 
important  jioint  is  systolic  retrartion  at  the  apc\  reyion.  ^^'hetIler  this 
(Mciirs  without  adhesion  of  the  periiardium  to  tlic  chest  wall  is  duulitful. 
It  is  often  marked,  ami  is  8(*metimt-s  ln'st  appreciated  l)_v  the  aitidication 
uf  tile  hand  over  the  iipex  re<,Mon,  wjiidi  is  felt  to  iic  drawn  in  at  the  nio- 
iiieiil  of  systole.  The  retraction  may  he  most  noticeable  in  the  lower 
sternal  regiijii  or  (!Ven  at  the  xiphoid  cartila<,'e.  FoUowin;,'  this  there  is 
MiMictinies  a  rapid  rebound  — the  diastolic  shock  -whiih  has  Itci'ii  regarded 
li\  .-(.me  as  the  most  rtdiablu  of  all  .-ii^^ns  of  pericardial  adhesion.  Asso- 
ciated with  this  diastolic  rebound  is  the  yo-ealled  Fn'n/rich'.s  ,v/V///— dias- 
tulie  collapse  of  the  cervical  veins. 

(•.')  Vcrcufiniou  ri'veals  an  increase  in  the  are.i  of  cardiac  dulness,  par- 
ticularly upward  as  high  as  the  second  interspace.  In  a  juajority  of  tl:e 
ca-cs  there  are  adhesions  as  well  betwi'cn  the  pleura  and  pericardium — in 
ten  iif  thirteen  cases  analyzed  by  Ord.  In  somt-  instances  thedidness  nuiy 
reach  as  high  as  the  lirst  inters]iaee.  A  sign  of  value  is  the  lixed  linut 
aliiive  and  to  the  left  of  cardiac  dulness,  as  jiointed  out  by  C.  J.  W.  \\\W- 
iuins.  When  the  outer  layer  of  the  pericardiuin  is  adherent  to  the  pleura 
this  is  a  sign  of  very  deihiite  value,  and  the  linut  of  dulness  varies  very 
slightly  on  deep  inspiration. 

(:!)  On  aiisciilfi/fitin  the  phenomena  vary  extremely  with  the  condition 
of  the  chambers.  There  may  bo  no  murmurs.  AVheii  extreme  dilatation 
is  present  the  gallop  or  fa'tal  rhythm  occurs.  A  loud  systolic  murmur  is 
not  uncommon  at  the  apex  region,  and  the  cases  are  frequently  mistaken 
for  old  mitral  valve  disease. 

(4)  The  p u Is H s  purajlo.rii s  in  which  during  ins})iration  the  pidso- 
wave  is  small  amTTei'hle,  is  sometimes  present,  but  it  is  not  a  diagnostic 
sii:ii  of  either  simple  pericardial  adhesion  or  of  the  cicatricial  modiastino- 
pcricanlitis. 

Adherent  pericardium  with  extreme  dilatation  of  the  heart  may  raise 
the  susi)icion  of  pericarditis  with  elTusion,  as  the  outline  of  dulness  in  both 
is  somewhat  alike.  As  a  rule,  however,  the  basic  dulness  is  broader  in  ad- 
hesion, and  has  not  the  pear-shaped  outline.  The  extent  and  wavy  char- 
acter of  the  impulse  is  never  so  marked  in  large  effusions,  and  the  heart- 
sounds  are  muffled. 

In  children,  chronic  adhesive  pericarditis  may  be  associated  with  j)ro- 
liferative  peritonitis,  perihepatitis,  and  perisplenitis,  in  which  condition 
ascites  may  recur  for  montlis,  or  even  for  years. 


h 


I'   f 


is  ,4' 


626 


DISEASES  OF  THE  CIRCULATORY  SYSTEM, 


"s^f 


I!.   OTHER  AFFECTIONS  OF  THE  PERICARDIUM. 

1.  Hyclropericardium.--Natiiriilly  there  are  in  the  ijericardinl  sac  o 
few  ('iil)ir  fH'iitiiiU'trert  of  cUnir,  eitr()n-cuh)red  Ihiid,  which  proluilily  npn;. 
sents  a  post-mortem  transudate.  In  certain  ccmditions  (hiring:  Ufc  tlicro 
may  he  hirjfe  secretions  of  serum  forminj;  what  is  known  as  (h-ojisy  nf  tlu; 
pericardiuTn.  It  occurs  usually  in  connection  with  general  drnjisy,  iiic 
to  kidney  cr  heart  disease;  more  commonly  the  former.  It  rarely  of  it- 
self proves  fatal,  though  wiicn  tiie  eifusion  is  excessive  it  adds  to  tlio 
eml)a:Tasament  of  the  heart  ar.('  the  lungs,  particularly  when  the  iiiciiral 
cavities  are  the  seiit  of  similar  exudation,  'i'here  are  rare  instances  in 
whii'h  cITusiou  i'.ito  the  pericardium  occurs  after  starlet  fever  with  few, 
if  any,  (it  her  dropsical  symptoms.  The  physical  .'•igns  are  those  aircadv 
referred  to  in  connection  with  lu'ricarditis  with  eifusion.  It  is  Irciiuciitly 
overlooked. 

In  rare  cases  the  serum  has  a  milky  character — chylop(  ricardiuiu. 

2.  HSBrao-perieardium. — This  condition,  hy  no  means  uncomnwui.  is 
1  let  with  in  aneurism  of  the  hrst  jiart  of  the  aorta,  of  the  cardiac  wall,  ^r 
of  the  corona;  ,  arteries,  and  in  rupture  and  wounds  of  the  heart.  Ucath 
usually  follows  hefore  there  is  time  for  the  jjroduction  of  sympfnuis  dtlicr 
than  tho.se  of  rapid  heart-failure  due  to  compression.  Particidarly  i^  this 
the  case  in  aiu'urism.  In  rupture  of  the  heart  the  i)aticnt  may  live  h>r 
many  hours  or  even  days  with  symptoms  of  ju'ogressive  heart-failiiiv, 
dyspno'a,  and  the  physical  signs  of  eifusion. 

As  already  nuuitioiu'd,  the  inllammatory  exudate  of  tuhercle  or  .  iuicor 
is  often  blood-stained.  The  sanu;  is  true  of  the  eifusion  in  t  le  peri- 
carditis of  Mright's  disease  and  of  old  people. 

3.  Pneumo-pericardium.— (<as  is  rareiy  found  in  the  ))ericardial  sac, 
aiul  is  due,  as  u  rule,  to  perforation  from  without,  as  in  the  case  of  stab 
wounds,  or  the  result  of  perforation  from  the  lungs,  o^sop1ia:xus,  or 
stomach.  In  those  cases,  fornu'rly  so  puzzling, in  which  the  gas  is  j)reseiit 
sliortly  after  death  (a  few  hours),  the  ga.?  hacillus  (Jt  oi'm/furK  nijisnldfys) 
will  he  found.  As  a  result  of  ])erforation,  acute  pericartlitis  is  always 
excitc(l,  and  the  eifusion  rapidly  becomes  purulent.  The  [thysical  signs 
are  remarkable.  When  the  eifusion  is  copious  the  lluid  and  gas  togetiier 
give  a  movable  area  of  percussion  duliu'ss  with  nuirked  tympany  in  the 
region  of  the  gas.  On  auscidtation,  remarkable  splashing,  churning,  iiieial- 
lic  phenomena  are  hoard  with  friction  and  jiossibly  feeble,  distant  lieart- 
sounds.  Death  follows  rapidly,  even  in  thirty-six  hours,  as  in  a  case  (the 
only  one  which  I  have  seen)  of  perforation  of  tlie  p(>ricardiuui  in  ea'ieiT 
of  the  stomach.  Kxcept  as  a  result  of  injury,  the  coiulition  is  luit  one  fur 
wlii(  h  treatment  is  available.  In  a  case  of  perforation  from  without  with 
signs  of  effusion,  to  enlarge  t'\o  wound  by  free  incision  would  i>e  jr.-ti- 
fiuble. 


ENDOCARDITIS.  C27 

II.    DISEASES  OF   THE   IIEAIIT. 

I.   ENDOCARDITIS. 

Inflammation  of  tlio  lininjf  iiK'nihriinc  of  tlic  hoart  is  usually  ronfinod 
to  tlu!  valvi's,  so  that  tlio  torni  is  practically  synonymous  with  valvular 
ciidocanlitis.  It  occurs  in  two  forms — acute,  cliMraitcri/c(i  hv  the  pres- 
ence of  vegetations  with  loss  of  continuity  or  of  sulistance  in  the  valve 
tissues;  r/initiic,  a  slow  sclerotic  ehanijrc,  resultin<f  in  thickening,  jjucker- 
iiig,  and  deformity. 

Af.'LTK    KnDOCAKDITIS. 

This  occurs  in  rare  instances  as  a  primary,  indepondent  alTection;  but 
ill  the  great  majority  of  cases  it  '.  an  accident  in  various  inft'ctivc  pro- 
cesses, so  that  in  realitv  tho  disease  does  not  constitute  an  etiulo<rical 
entity. 

For  convcnienco  of  descrijttion  we  sjieak  of  a  simple  or  heiiign,  juid  a 
malignant  or  ulcerative  endocarditis,  hctween  which,  howeviT,  there  is  no 
('s<eiitial  anatomical  dilference.  as  all  gradations  can  he  traced,  and  they 
ivprcseiit  hut  ditVerent  degrees  of  intensity  of  tiie  sanu"  process. 

Simple  Endocarditis. — This  is  characterized  hy  tiie  presence  on  tho 
valves  or  on  the  lining  mendtranc  of  the  chainl»ers  of  minute  vegetations, 
laiiging  from  1  to  4  mm.  in  size,  with  an  irregular  and  lissnrccl  surface, 
giving  to  them  a  warty  or  verrucose  appearance.  Often  tliese  little  cauli- 
tlower-like  excrescences  are  attached  by  very  narrow  pedicles.  It  is  rare 
Id  sec  any  swelling  or  inliltration  of  the  endocardium  in  the  iieighlxtrhood 
of  e\."'  the  simillest  of  the  granulations,  and  although  small  ca])illary 
vessels  (|o  exist  at  the  edges  of  the  valves,  redness,  imlu'ativc  of  the  injec- 
tion or  distention  of  the  vessels,  is  oxtreiiiely  rare.  With  time  the  vegeta- 
tions limy  increase  greatly  in  size,  Imt  in  what  may  he  called  simple 
ciidocardilis  the  sizt>  rarely' exceeds  that  mentionetl  aiiove.  '['lie  liner 
changes  in  the  process  consist  of  the  jn'oliferatioii  of  the  siilicndothetial 
coiiiicctive-tissue  elements,  resulting  in  a  small-celled  inliltration.  What 
part,  if  any,  the  endothelial  cells  play  in  this  is  not  accurately  known. 
Tlie  su])erticial  elements  iin  lergo  a  coagulation  ncerosis.  and  lihrin  is 
ilt|iosited  from  the  lilood,  often  in  layers.  I'racticaily  a  v<'grtation  is  a 
small  area  of  granulation  tissue  capped  with  fibrin.  Micro-organisms 
are  ])resent,  entangled   in   the  granular  and    tlbiillate<l    (Hii'in,  and    they 


[irohahly  constitute  an  essential  and  constant  elenu'iit  in  all 
eii-locarditis. 


cast's  o 


f 


•  imiile 


The  further  chanires  in  the  vegetation  mav  bo  either  in  the  direcliun 


•f  in 


rcased  proliferation  of  the  connect i\t  -tissue  elcnu'nts  of  the  valve 


fi 


<>riiiiiig  an  extensive  area  of  necrosis  and  tlie  pn 


(luctii 


n  of  the  condition 


WllIC 


li,  from  its  more  intense  grade,~we  speak  of  as  malignant  or  ulcerative 


eiK.oearditis;    or,  as  is  more  u.sua!,  healing  occurs.     The  vegetatio 


1 


l^r 


1 


(n.v     ,:,,,} 


1 


n   IS 


G28 


PISKASES  OF  THE  CIRCULATORY  SYSTEM. 


absorbed,  and  tliore  remains  a  small  nodular  thickening  of  the  vahc  A 
third  j)ossibility  is  the  dislocation  of  a  vegetation  with  transfercinr  as  an 
embolus  to  a  distant  part  of  ti>e  circulation.  It  is  to  be  noted,  liowi\(r, 
tliat  this  untoward  event  is  rare  in  acute  endocarditis  assoeiated  \vit!i 
fel)rile  all'ectioiis,  whereas  it  is  by  no  means  uncommon  in  the  siiiiiili' 
endocarditis  whieh  occurs  so  constantly  on  old  sclerotic  valves. 

Anatomically,  in  the  nuijority  (»f  instances  <if  acute  endocanlitis,  (!( ,i- 
trization  of  tlu(  ^n'anulation  tissue  takes  ])lace  in  tinu',  with  t)ul  liiil,. 
dama;,fe  to  the  valve  beyoiul  sliifjit  nodular  liHckeuin;;-.  The  essential 
danger  is  renuHe  and  results  from  the  slow  changes  in  the  valve  ti>su(.', 
which  are  so  apt  to  i'olhtw  an  acute  iullammation.  Why  this  slmuld  lie 
so  cannot  at  present  be  explained;  but  tim  fact  rcnuiius  that  the  simple 
endocarditis,  harndess  in  itself,  such  as  we  nu'ct  with  in  rheumatisui  or 
in  choi'ca,  lays  the  foundation  of  sub.se({iu'nt  organic  lesions,  owing  to  the 
initiation  fif  initritive  changes  leading  to  sclerosis  with  contraction  and 
deformity. 

Endocarditis  is  much  more  common  on  the  left  side  of  the  heart  and 
involves  the  valvular  endocardium  in  the  great  nuijority  of  cases.  Durin;: 
fo.'tal  life  the  right  side  of  the  heart  is  often  alTecte(l.  The  chorche  teii- 
dinea*  are  .sometimes  invohdl  with  the  valves,  rarely  alone.  The  niilial 
valves  are  nu)re  often  alTected  than  the  aortic.  On  the  mitral  segnniil 
the  vegetations  are  usually  on  the  auricular  face,  not  at  'lie  margin,  hut 
at  .1  distance  of  ■^*  or  3  nun.,  fornnng  a  row  of  beaddike  outgrowths.  Sd, 
too,  o,i  the  aortic  segnietit  they  arc  not  seen  on  the  free  margin,  but  just 
below,  on  the  ventricular  face,  following  the  margin  of  the  so-called  lunat- 
od  spaces.  In  Ixith  the  valves  this  ju'culiar  distribution  follow-,  i-  '^  '.-.m 
sugge<t-i,  the  lines  of  maximum  contact. 

Etiology.-— Simple  endocarditis  does  not  constitute  a  disease  of  it- 
self, but  is  invariably  found  with  sonu;  other  affection.  Tlw  gwieral  ex- 
perieiu'cof  the  profession  has  coiitirmed  the  original  observation  (»f  Hoiiil- 
laud  as  to  the  frcfjuency  of  association  of  simple  endocarditis  with  acute 
articular  rheumatism.  Possibly  it  is  nothing  in  the  disease  itself,  Imt 
simply  an  altered  stale  of  the  lluid  nu>dia — u  reduction  perhaps  of  the 
lethal  infhuMK'cs  whicdi  they  normally  exert — permitting  the  invasion  uf 
the  blood  by  certain  nucro-orgaiusms.  Tonsillitis,  whi(di  in  some  forms 
is  regarded  as  a  rheunuitie  alTection,  nuiy  be  complicated  with  end(Kanli- 
tis.  Of  the  specific  diseases  of  (diildhood  it  is  not  uncommon  in  scarlet 
fever,  while  it  is  rare  in  measles  and  chi(d<enpox.  In  diphtheria  simple 
endocarditis  is  rare.  It  was  not  present  in  a  single  instance  of  .'5(»  antep- 
sies  whiidi  I  made  in  this  disease  at  the  Montreal  (Jeneral  Hospital.  In 
small-]»ox  it  is  not  common.  lu  typhoid  fever  I  have  nu't  with  it  twiie  in 
80  autopsies. 

In  pneumonia  both  simple  and  malignant  endocarditis  are  common. 
In  100  autopsies  in  this  disease  made  at  the  Montreal  General  II  i-pi- 
tal  there  were  5  instances  of  the  former.     Acute  endocarditis  is  hv  no 


ENDOCARDITIS. 


G2\i 


moans  rare  in  plithlsis.  I  have  mot  with  it  in  12  cases  in  ^Jlfi  i>o«t-nior- 
tciiis. 

In  cliorca  simple  warty  vegetations  are  fonnd  on  the  valves  in  a  larye 
majority  of  all  fatal  cases,  in  Vri  of  73  eases  recently  collected  by  me.  'J'heiv 
is  no  (lisea.'Je  in  which,  post  mortem,  acnte  endocarditis  has  been  .'<o  frc- 
ijiii'iilly  fonnd.  And,  lastly,  simple  endocarditis  is  met  with  in  di.seasi'S 
assucialed  witli  loss  of  flesh  and  j)roj;ressive  debility,  as  cancer,  and  sucli 
disorders  as  gont,  diabetes,  and  Hright's  di.sease. 

A  very  coinmon  form  is  that  which  occurs  on  the  Siderotic  valves  in 
old  heart -disease — the  so-called  rcciirrin;L;  endocarditis. 

Symptoms.  —  .Neiliier  the  idinical  conrsc  nor  the  physical  si^riis  are  in 
any  respect  (diaracteristie.  The  u'reat  majority  of  the  ca.^es  are  latent  and 
thrre  is  no  indication  whatever  of  cardiac  niis(diief.  K.\[)erience  has  taiigiit 
IIS  that  endocarditis  is  freqnently  found  jxist  mortem  in  persons  in  whom 
it  was  not  suspected  dni'in:.;'  life.  Tiiere  are  certain  featnres,  however,  by 
which  its  presence  is  indicated  with  a  degree  of  pr(ilia!)ility.  'I'lie  patient, 
a-  a  nilc,  iloes  not  complain  <d"  any  i»ain  or  eai'diac  di.-tress.  In  a  ea.se  of 
ariite  rheumatism,  for  example,  the  symptoms  to  excite  sn<pii  ion  would 
he  increased  raiddity  of  the  lieai't's  action,  ])erha|>s  sliirht  irregularity,  and 
all  iiierea.se  in  the  fever  without  aggravation  of  the  j<iiiit  troiibK'.  Hows 
fit  tiny  vegetati(»ns  on  the  mitral  or  on  the  aortic  .segments  seem  a  trilling 
iiialter  to  exeite  fever  and  it  is  difhcult  in  the  endocarditis  (d'  febrile  pro- 
cesses to  say  dtdinitely  in  every  instanct'  that  an  increase  in  the  fever  de- 
pends iqion  the  endoeanlial  complication.  Hut  a  study  of  the  recurring 
endocarditis— whi(di  is  of  the  warty  variety,  consisting  (d"  minute  lieads  on 
old  selenitic  valves — shows  that  this  process  may  1m'  associated,  for  days 
or  weeks  at  a  time,  with  slight  fever  ranging  from  l(i(»"  to  Urik".  Pal- 
pitation may  be  a  marked  feature  and  is  a  symptom  upon  wliii  h  eertaiti 
aidliors  lay  great  stress. 

The  (/iiif/nn.xia  of  the  condition  rests  upon  p1i\>ical  sign-  whi(di  are 
notoriously  uncertain.  The  presence  of  a  murinnr  at  one  or  other  of  the 
eiinliiie  areas  in  a  case  of  fever  is  often  regarded  as  indicative  of  the  exist- 
ence of  endocarditis.  This  extreiiudy  i  ommon  mistake  has  arisen  from 
the  fact  that  the  /iniif  ile  s()ii[f!i.'  or  bellow-  murmur  is  common  to  endo- 
canlitis  ami  a  number  of  <dher  conditions  wdiich  have  nothing  to  do  with 
it.  .\t  first  there  may  l)e  only  a  slight  rongheiiing  of  the  tirsi  s.tund, 
which  may  gradually  develop  into  a  distinct  murmur.  Taken  alone,  it  is. 
however,  a  very  uncertain  and  fallacious  sign. 


fe,'.*!ji  s  hum 


lit  "  "-"■-■' 


jj 


I 


Malignant  Endocarditis.— Acute  endocai  'Mis  of  a  maligmint  (duira»d,er 
i>  met  witii : 

(n)  As  a  jirimary  disea.«e  of  the  lining  membraiu'  of  the  heart  or  of 
its  valves. 

(f>)  As  a  secondary  alToction  in  acute  rheiimatism.  pneumonia,  and  in 
various  specifie  fevers;  or  us  an  aasoeiated  condition  in  septic  proeesse."?. 


M  '  ■ .  .f?  i 


\^ 


630 


PISEASKS  OP  THE  CIRCULATORY   SYSTEM. 


r  y 


s 


It  is  also  known  by  the  niinios  of  ulforativo,  iufectif»iis,  or  (liplitli.  ritio 
en<l(>oiir(litis,  Vxit  the  tonii  niali<fiiiuit  sorms  most  ajipropriate  to  diarac- 
tci'izc  [hv  cssi'Mtial  clinical  fcattiri's  of  the  disoasc. 

£tiology. — 'I'Ih'  existence  of  a  priniarv  endocarditis  has  been  (Umlited; 
but  there  are  instances  in  whicii  persons  [irevioiisly  in  >r<>od  iiealili,  withdnt 
any  history  of  alTeetions  with  which  endocarditis  is  usually  associiitcd,  have 
been  attacked  with  syjuptoius  reseniblinj^  severe  typliiis  or  ty|»lii)iil.  In 
one  case  which  I  saw  death  occurred  on  the  sixth  day  and  no  h-sioiis  were 
found  other  than  those  of  inaliirnant  endocarditis. 

Rheu  latism,  with  which  simple  endoc^arditi.'-  is  frerpiently  associuterl, 
is  not  so  often  complicatcil  with  the  inali<,niant  form.  'I'hus,  in  dulv 
24  of  'iOd  eases  the  symptoms  of  severe  endocarditis  arose  in  the  p:'oi,n'ess 
of  acute  or  sid)acute  rheumatism.  In  only  'A  of  the  Montreal  casts  was 
tlu're  a  history  of  rheumatism  eithei  l)efore  or  durin;^  the  attacks. 

Maliirnant  endocuirditis  is  extremely  rare  in  chorea.  Of  all  acute  dis- 
eases complicated  with  severe  endocarditis  pneumonia  probably  lieails  tin; 
list.  This  fact,  which  had  been  referred  to  by  several  of  the  older  writers, 
was  broujrht  out  in  a  strikini;  manner  by  the  li<fure-;  on  which  my  lectures 
were  based.  In  11  of  the  '2'-i  Montreal  easi'S  the  disease  came  on  with 
lobar  pneumonia,  whik^  it  developed  willi  this  disease  in  .">  1  of  the  •Jn',) 
oases  amUy/.ed— indeed,  the  endocarditis  which  occurs  in  pneumonia  s 'eiiis 
to  be  of  an  unusually  mali^Miant  type,  as  in  K!  cases  of  my  1<HI  auti>,isies 
in  (his  disease  in  which  this  lesion  was  present,  11  were  of  this  foriu, 
M(>nin<(itis  was  as.sociated  with  endocarditis  in  "■i.")  of  the  M'd  eases,  and  in 
J")  there  was  also  pneumonia. 

The  alTection  may  complicate  erysipelas,  septicoMnia  (from  whatovor 
cause),  and  puerperal  fever  and  ixonorrlnea.  Malijiiiant  eiulocarditis  is 
very  rare  in  tul)i'rculosis,  typhoid  fever,  and  diphtheria. 

It  has  l)ccn  statecl  by  many  writers  that  endocarditis  occurs  in  atrne. 
With  the  unusual  facilities  for  the  study  of  this  disease  whi(!h  I  have  had 
in  the  past  seven  years  I  have  not  yet  nu't  with  an  instance.  UiKiuestiDU- 
ably,  in  the  majority  of  these  ea.ses,  the  int(>rmittent  pyrexia,  which  has 
been  re_i;.irde(I  as  (  haraeteristie  of  the  aujue,  has  depended  upon  the  endo- 
(uirditis.  In  dysentery  cases  have  been  ilescribed.  In  snndl-pn\  and 
scarlet  fever,  witli  whi(di  simple  endocarditis  is  not  infrequently  conipli- 
catcd.  rli(>  mali'iuaiit  form  is  extrcnudy  rare. 

Morbid  Anatomy.  'Phe  lesions  may  be  either  vej:(dative,  idceni- 
tive,  or  suppurative,  and  these  forms  may  oe-ur  alone  or  in  comhiMatien. 
Even  with  vcijetations  there  is  distinct  necrosis  ami  loss  of  the  endixardia! 
su!)s(ance.  Xfore  frerpiently  there  is  ulceration,  either  sup('rlicial,  iiivdv- 
in;j;  oidy  the  endocardium,  or  dec  p  and  distinct.  leatlinLT  to  perforatii 


)ii  t< 


a  valve,  of  a  septum,  or  even  of  the  heart  its(df.     In  the  suppurative  fc 
the  deeper  tissues  of  the  valve  apjiear  first  affecit'd  and  small  abscesses  niv 
found  at  the  bases  of  the  vegetations.     The  vegetations  may  present  a  re- 
markable greenish -gray  or  greenish-)  ellow  color,  and  when  of  long  staJid- 


ENDOCARDITIS. 


031 


ill!:,  or  even  in  o.asos  wliicli  from  tho  clinical  history  appoar  to  be  tolerably 
aiutf,  the  vegetations  may  be  cnistetl  with  lime  salts. 

A  lar2;e  vegetation  of  malignant  eiubicarditis  consists  histologically  of 
a  iiramilar  and  librillatod  librin,  colonics  of  niicni  organisms,  and  distinct 
irmmdafion  tissne  at  the  base,  while  the  subjacent  eiubx-ardial  layers 
show  intiltration  and  pndiferation.  'I'he  destruction  of  tissue  results  from 
a  L'radual  extension  of  the  necrotic  processes'.  Of  organisms  which  have 
liifii  cultivated  from  the  vegetations,  the  following  may  be  mentioned  : 
Streptococci  and  sta])hylococci — which  are  the  most  common — iiiicrdcur- 
nis  l)nirct)I(i/ns,  hufilhis  Itjphi  <iJi<hi)ni)inlis,  li(((tlht,-<  tttbcrcidosis^  the  ijono- 
rtirriis,  and  the  (xiriJIus  (i/tf/irticis. 

The  following  figures,  taken  from  my  (loulstoiiir.n  lectures  at  the  Koyal 
(iillcge  of  I'bysieians.  give  an  approximate  estimate  of  the  frequency  with 
which  in  '^(iK  cases  dilTerent  jtarts  of  the  heart  were  alTeeted  :  Ai>rtic  and 
luiiral  valves  together,  41  ;  aortic  valves  abuu',  ."t.'i ;  i  iitral  valves  alone,  ',]  ; 
tricuspid  in  1!);  the  pulnumary  valves  in  1.");  and  tiu^  heart  wall  in  ;5:j. 
Ill  !'  iustMuces  t,he  right  heart  alone  was  involved,  in  most  cases  the  auric- 
ule-ventricular  valves. 

Mural  endocarditis  is  seen  most  often  at  the  up)ier  part  of  the  septum 
of  the  left  ventricle.  Next  in  order  is  the  endocarditis  of  the  left  auricle 
on  the  postcro-external  wall.  The  ulcerative  changes  may  lead  to  pcrfiM'a- 
tinu  of  a  valv(>  segment,  erosion  of  the  chorda'  tendinea\  jierforation  of 
the  septum,  or  even  of  the  heart  itself.  A  common  result  fif  the  nN'(>ra- 
tioii  is  the  ]»rodiiction  of  valvular  aneurism.  In  three  fourths  of  the  cases 
the  iilVectiMl  valve>  ])resent  old  sclerotic  changes.  'I'he  process  may  extend 
to  the  ao/ta,  producing,  as  in  one  of  my  cases,  extensivi'  eTidarteritis  with 
nmltiiile  acute  aiuMirisms. 

The  associated  jiatludogical  changes  are  jiartly  those  of  the  primary 
disease  to  which  the  endocard'tis  is  si'condary  and  partly  those  due  to 
euilMilism.  Ill  the  endocarditis  of  .«icplic  processes  tliei'e  is  the  Incal  lesion 
— an  acute  necrosis,  a  suppiii'ativi'  wound,  or  ]nicr|icral  disease.  In  many 
cases  the  lesions  are  those  of  pneumonia,  rheiiniatism,  (.r  other  febrile  ]>ro- 
eesses.  The  changes  due  to  embolism  constitute  the  most  striking  feat- 
ures, h\it  it  is  remarkalde  that  in  some  iiistaiu'cs.  even  with  ejidocarditis 
of  a  markedly  ulcerative  (diaracter,  tluM'e  may  be  no  trace  of  embolic 
Jiroeesses. 

The  infarcts  may  be  few  in  numbcr-^only  one  or  two,  ]ierhaps,  in  .he 
spleen  or  kidney— or  they  may  exist  in  hundreds  throughout  the  various 
liart<  of  the  body.  They  may  present  tiie  ordinary  appearance  of  re  I  i.r 
wliite  infarcts  of  a  suppurative  character.  They  are  most  common  ir  tiie 
spl"en  and  kidneys,  though  they  may  be  numerous  in  the  brain.  aTid  in 
feanv  eases  are  very  abuiulant  in  the  intestines.  In  right-sided  endocar- 
diri-  there  may  be  infarcts  in  the  lungs.  In  many  of  the  ca.ses  there  aro 
imuiiiierable  miliary  abscesses.  Acute  sujipurative  meningitis  was  met 
'vith  in  ,")  of  •.>;}  of  the  Montreal  cases,  and  in  over  ten  per  cent  of  (he  '^(lO 


1; 


J 


'I    I 


ii  1 


I'  j'Ki-w' 


I 

'■IS 


}    Iff 


G32 


DISEASES  OF  THE  CIRfTLATORY  SYSTEM. 


§M 


L  -^J! 


cases  analyzed  in  tlio  literature.  Aeute  suppurative  parotitis  also  may 
occur. 

Symptoms. — It  is  dinTicult  to  n;ive  a  satisfactory  clinical  pictiii f 

tlie  disease  hccause  tlie  modes  of  onset  are  so  varied  and  tlie  syMiptoin-  so 
diverse.  .Vri.-iiii,'  in  tlic  course  of  some  otliei  disease,  tlu-i'e  may  lie  siiiiplv 
an  intensilication  of  tlie  fever  i.v  a  chan^^'e  in  its  character.  In  a  ma- 
jority of  the  cases  there  are  present  certain  j^eneral  features,  such  as  irrc;,'u- 
lar  pvrexia,  delirium,  sweatinir,  ^'radual  failure  of  streiiirth. 

J'lndxilic^  processes  may  <,dve  special  characters,  such  us  delirium,  coma 
or  paralysis  from  involvement  of  the  brain  or  its  mendn-anes,  pain  in  the 
sides  an<l  local  peritonitis  froin  infarctioii  of  the  si)leen,  bloody  urine  I'ldin 
implication  of  the  kidiu-ys,  impaired  vision  from  retiiuil  luemorrha^fc,  ami 
suppuration,  and  even  «fanj,'rene,  in  various  parts  from  the  distril)Uti<iii  of 
the  (Muboli. 

Two  special  ty[)es  of  the  diseas;-  have  been  recognized — the  septic  or 
pya-mic  and  the  typhoid.  Other  cases  closely  rescndtle  true  inteneittcut 
fever.  In  some  the  cardiac  symptoms  arc  most  prominent,  while  inolhcrs 
airain  the  main  symptoms  may  be  thosj  of  an  acute  alTcction  of  the  crre- 
bro-spimd  system. 

The  sr/)fir  hjpi'  is  met  with  usually  in  connection  with  an  external 
wound,  the  jiucrpcra!  process,  or  an  acute  necrosis.  Tlu-rc  are  rig(trs, 
.sweats,  irre^xular  fevers,  and  all  of  the  sitrns  «,>f  septic  infection.  The  heart 
symptoms  may  Ik midi-telv  masked  by  the  jjeneral  condition,  and  atten- 
tion calle(|  to  them  only  on  the  occurrence  of  embolism.  In  a  most  re- 
markable sub-<,'rfiu|)  of  this  type  the  disease  may  sinudate  a  quotidian  er  a 
tertian  a<i:ue.  The  symptoms  nuiy  develop  in  persons  with  chronic  heart- 
dist>ase  without  any  extcriuil  lesions.  These  cases  mavbe  much  priiloiiLri'd 
— fr>r  three  or  four  nninths,  or  even  hinger,  ',\<  in  a  case  of  r.ri-tnwi^. 
The  existence  in  some  of  these  instances  of  a  jn'ovious  gciuiine  malaria 
has  been  a  very  puzzling  (.'ircutnstance. 

The  tiiphoid  fijpi'  is  by  far  the  nu)st  common  and  is  characterizeil  liy 
un  irregidar  tem|terature,  early  prostr.'  ion,  delirium,  somnolenc<',  ami 
coma,  relaxed  bowels,  sweating,  which,  maybe  of  ii  nu)st  drenching  cliar- 
aeter,  ]>etechial  and  other  raslu-s,  and  occasionally  parotitis.  The  heart 
symptfuns  mav  he  completely  overlooked.  !ind  in  some  intaiices  the  tiiest 
careful  exaniination  has  failecl  to  discover  a  murmur. 

Under  tiie  ranliitc  f/roti/),  as  suggested  by  Hramwell,  may  be  eoiisiil- 
ered  those  cases  in  which  jiatients  with  chronic  valve  disease  are  attacko'l 
with  marked  fever  and  evidence  of  recent  eiulocarditis.  ^fany  such  ease-; 
present  sym]>tojns  of  the  pya^nic  and  typhoid  character  and  may  run  a 
most  ai'ute  course.  In  others  the  course  is  chronic,  lasting  for  weeks  er 
months.  I  have  reported  two  ca.ses  of  this  chronic  vegetative  eiiiiocarili- 
tis,  with  intermittent  fever,  one  of  jnore  than  Ji  year's  duration.  The  aii- 
tof)sies  showed  (;xlensiv«  vegetative  and  ulcerativo  di.seuse  of  the  mitral 
valves. 


ENDOCARDITIS, 


C33 


Thoro  arc  Piisc;^  in  which  it  is  oftoii  (liHicult  to  dooido  Avhcthor 
:iialij,'naiit  eiidocaniitis  is  itrcsciit  or  not.  'I'liiis,  a  i)ati('Mt  with  aorti(t 
valve  (liswiso  is  undiT  treatment  for  failing  oompcnsation  ami  hei^'ins  to 


liavc 


irre<nilar  fever  witli  restk'ssness  and  eardiae  di-trc<s;  emi 


XlllC 


)he- 


nninena  leay  develop — sudden  heniipletria,  j)ain  in  tln'  reixinn  of  the 
snlecii,  or  l)loody  urine,  or  ])erlia])s  ])erij)lieral  endiolism.  'I'here  may  l)e  a 
low  delirium  and  the  ease  nniy  run  a  toleralily  aeut»!  course;  but  in  other 
instances  the  fi'ver  subsi(U'S  and  recovery  occurs. 

In  wliat  may  ho  termed  the  crri'/irdl  (/roHji  of  oases  the  clinical  ])ict- 
iirc  may  simulate  a  nienin<;itis,  either  basilar  or  cercbro-s|piuid.  'i'here 
may  lie  acute  di'lirium  or,  as  in  tliree  of  the  Montreal  cases,  tlii'  jtaticnt 
may  be  brought  into  the  liospital  unconscious.  Ih'inctnan  reports  an  in- 
stance, witb  autoi)sy,  in  which  the  clinical  i>icture  was  that  of  an  acute 
cerebro-spinal  meningitis. 

Certain  special  symptoms  may  ])e  nuMitioned.  'I'bc  fever  is  not  al- 
ways of  a  remittent  tyjjc,  but  maybe  high  and  (ontinuoiis.  I'clechial 
rashes  are  very  common  and  render  the  similarity  very  strong  to  certain 
casi'S  of  t}])hoid  and  cerobro-spinal  fevers.  li\  one  case  tlie  disease  was 
tliout,dit  to  be  lui'morrhagic  small-jiox.  Erythematous  raslics  arc  not  un- 
comiuon.  The  sweating  may  be  nuist  [jrofu.se,  even  exceeding  that  which 
occurs  in  phthisis  and  ague.  Diarrluwi  is  not  necessarily  associated  with 
embolic  lesions  in  the  intestines.  Jaundice  has  been  observed  and  cases 
arc  on  record  which  were  mistaken  for  acute  yellow  atrophy. 

The  heart  symj)toms  may  be  entirely  latcn*  aiul  arc  not  found  unless  a 
careful  search  be   imidc.     Evt  n  on  "xamination  there  mav  be  no  mur- 


mur pro 


sent.     Instances  arc   recorded   ])v  cari'ful  observers,  in  which  the 


examination  of  the  heart  has  been  negative.     Cases  with  chronic  valve 
disease  usually  present  no  difficulty  in  diagnosis. 

The  course  of  the  disease  is  varied,  de]K  'iding  largely  upon  the  luituro 
trouble.     Except  in   the  disease   grafted    upon    chronic 


f   t1 


le   primary 
th 


valvulitis  the  course  is  rarely  cxtendeil  beyond  live  or  six  weeks.  As 
already  mentioned,  there  are  instances  in  which  the  disease  is  prolonged 
for  months.  Tlx  most  raiiidly  fatal  case  on  record  is  described  by 
Ehertli.  the  duration  of  which  was  scarcelv  two  davs. 


Diagnosis. — Tn  nuiny  cases  the  detection  of  the  disease  is  very  difll- 


oult 


III 


others,  M'ith  markecl  embolii^  .symptoms,  it  is  c 


isv. 


Fr 


oni  siini)l(> 


ondocarilitis  it  is  readily  distinguished,  though  confusion  ot'casionally 
oe.  uvs  in  the  transitional  stage,  when  a  sim]>le  is  developing  into  a  malig- 
nant form.  The  constitutional  sympfoms  arc  of  a  graver  type,  the  fcv(>r 
is  liiLrlier,  rigors  are  common,  and  septic  and  typhoid  symptoms  develop. 
Perhaps  a  majority  of  the  cases  not  associated  with  puer[)eral  processes  or 
hniie  disease  are  confounded  with  typhoid  fever.  A  differential  diagnosis 
may  oven  be  impossible,  -particularly  when  wr  consider  th.at  in  typhoid 
fever  iuf'irctions  and  ])arotitis  may  occur.  The  (liarrlnoa  and  abdominal 
tonderness  may  also  bo  present,  wliicdi  with  the  stupor  and  progressive 


1 1: 


•r 


If  SI 


V  • 


Vff 


\  4-ii  H 


084 


DISEASES  OP  THE  CIRCl'LATORY   SYSTEM. 


asthoniii  niiiko  ii  picture  not  to  ho  (lislitij^uishcd  from  tliis  disoaso.  Puints 
which  iiiMV  ;,'iii(h'  us  arc:  The  more  ahriipt  onset  in  eii(h)Ciir(liii>,  iIk. 
ahsenco  of  any  regularity  of  the  jiyre.xia  in  the  early  sta^'e  of  the  ilixMSf, 
and  the  canliae  ))aiu.  ()[)|)res.-iion  and  siiortne.s.s  of  hivath  may  he  ciiilv 
symptoms  in  inali,:fnant  endocardilis.  I{i;,'ors,  too,  are  not  uiicoiiininii. 
Ik'tween  pyawnia  and  malijL^nant  eiidoeai'tlilis  there  are  pi'actically  im  ilif- 
forential  features,  for  the  disease  really  constitutes  an  (irtcriid  jii/ffuiid 
(Wilks).  In  the  acute  cases  resemhliu^'  malif^nant  fevers,  the  dia^rnn.-is  is 
usually  made  of  typhus,  typlioid,  cerehro-sj)iiiaI  fever,  or  even  of  lia'iiior- 
rha^ic  small-pox.  The  intermittent  pyrexia,  occurrin«;  for  weeks  or 
nujuths,  has  led  in  some  eases  to  the  dia,t,'nosis  (tf  malaria,  hut  this  disfa,se 
could  now  lie  positively  excluded  hy  the  hlood  examiiuition. 

The  cases  usually  terminate  fatally.  'The  instances  of  rei'ovcry  luv 
those  more  >id)acute  forms,  tin?  so-called  reciirrin;;  eiidocardiiis  dcvtldji- 
inj'  on  old  sclerotic  valves  in  cases  of  chronic  hcai't-discase. 


Treatment.— W 


vuow    no    mea>ures 


I) 


wliicii    in    rlicnni;itisin. 


chorea,  or  the  eruptive  fcv(  rs  the  onset  of  endocarditis  can  he  prcvcntid. 
As  it  is  })rohal)le  that  many  <'ases  develop,  particularly  in  (duldren,in  niiM 
forms  of  these  diseases,  it  is  well  to  jruard  the  patients  a.iruinst  taUinji  ci  M 


an 


d  insist  upon  rest  and  (puet,  and  to  hcai'  in  mind  that  (d' all  coiii|il 


ica- 


tions  an  acute  endocanlitis,  tliou'di   in   its  immediate  ctl'ects  liarndcss,  i- 


This  statement  is  enforceil  l»v  tlie  ohservat 


j)erhaps  the  most  serious.  1  Ins  statement  is  eiitorceil  l»y  tlie  oliservatiuiis 
of  Sihsoii  that  on  a  system  of  absolute  rest  the  jiroportion  of  cases  cf 
rheumatism  attatd<ed  hy  endocarditis  was  less  than  of  those  who  were  not 
8(1  treated. 

It  is  (h)uhtful  whether  the  salicylates  in  rheumatism  have  an  innucneo 
in  reducing  the  liahility  to  endocarditis.  When  the  endocarditis  is  jires- 
ent  we  know  no  reniedit's  which  will  (hdinitely  influence  the  valvular 
lesions.  If  there  is  much  vascular  excitement  aconite  may  he  given  and 
an  ioc-hag  phiccd  over  the  heart. 

The  salicylates  are  strongly  advised  by  some  writers  and  the  sul|ili(i- 
oarl)olates  have  heen  rccomnieiideil  hy  Sansnm.  In  the  severer  cases  of 
malignant  eiuh)carditis  the  treatment  is  jtractically  that  of  septiea'inia. 


iP 


Chronic  ExnorAUDiTis. 

This  (M)ndition,  wlu(di  is  a  sidemsis  of  the  valve,  may  he  jirimary,  but  is 
oftener  secondary  to  acute  endocarditis,  j)arti"iilarly  tlut  rheumatic  funii. 
It  is  es.seutially  a  slow,  insidious  ju-ocess  which  leads  to  deformity  of  the 
valve  .segment  and  is  the  foundation  of  chronic  valvular  disease. 

Tertain  ])oisons  ap))ear  capable  of  initiating  the  change,  siudi  as  aleo- 
hol,  sy])hilis,  and  gout,  though  we  are  at  pre  sent  ignorant  of  the  way  iu 
which  they  act.  .\  very  important  factor,  parlicularly  in  tlie  case  (tf  tlio 
aortic  valves,  is  the  strain  of  prolonge(l  and  heavy  muscular  exertion.  In 
no  other  way  can  he  exjdaiinnl  the  occurrence  of  so  muny  cases  of  sckio- 


ENDOCAIiniTIS. 


635 


ni.-«  of  tlio  aortic  valves  in  yoim;^  luid  niidclle-iigcd  men  whoso  occupations 

lU'l'CSsitilttt   tlu^  ()V(M'I1S(!  of  llut   lllUHclt'S. 

Morbid  Anatomy. — Visjjjftulioiis  in  llio  fnrm  in  wliidi  llioy  occur 
ill  acuio  oudocunlitis  urc  not  prtvciit.  In  Itic  curly  stiiiro,  Avliicli  wo 
liiivc  frcH]U(!Tit  op|»ortiiiiili('s  of  wcijig,  tlio  cdLCc  <»f  tlic  valve  is  a  liftlo 
tliiclxciK'd  and  ))('rliai).s  presents  a  few  small  imdulur  prominences,  which 
in  some  eases  may  represent  the  henled  vej^'etations  of  Ihe  aeii to  process, 
111  the  iiortic!  valves  tlio  tissue  idiout  the  corpora  Arantii  is  first  i-lTectod, 
priMlueiufj  a  slight  thickening  with  aii  ini'rease  in  tlie  size  of  the  nodules. 
Tlie  suhshuHUf  of  tlu!  val\(^  may  lose  its  translueeney,  and  the  only  chalif^o 
notii'i'ahle  is  a  jj;rayish  opacity  and  a  sli;,dit  loss  of  its  delicate  tenuity. 
In  the  auriculo-ventricular  valves  these  .arly  clianjj;es  arc  se(>n  just  within 
the  niarj^nn  and  here  it  is  not  uneommoti  to  lind  Kwelling!!  of  a  {rrayish- 
red,  somewhat  iidiltrated  a])pearance,  almost  idcjitieal  with  the  similar 
structures  (»n  the  intinwi  of  the  aorta  in  arterio-sclerosis.  Kven  early  there 
may  he  seen  yellow  or  opaiine-white  suliintimal  fatty  areas.  As  the  sele- 
nitic cliaui^es  intToaso  the  fihron.s  tissue  contnicls  iind  produces  thickeninj:^ 
atid  deformity  f)f  the  se<j;iru'nt,  the  r{\<^vii  of  which  hecome  round,  curled, 
iind  iiicapahli^  of  that  deiieaie  apposition  nei'cssary  for  jierfcet  closure.  A 
siiruioid  valv(s  for  instance,  nuiy  he  narrowed  one  fourth  or  even  one  third 
across  its  face,  induciiif^  the  most  extreme  grade  of  insufficiency  without 
niy  special  deformity  ajul  without  any  defitute  mirrowing  of  the  arterial 
(irilice.  Ta  thi^  auriculo-ventricular  segments  a  simple  process  of  thicken- 
ing and  curling  of  the  edges  of  the  valves,  inducing  a  failun*  to  close 
without  forndng  any  ohstruction  to  the  normal  course  of  the  hlood-ilow, 
is  less  common.  Still,  wo  meet  with  instances  at  the  mitral  orilice,  par- 
ticularly in  childnMi,  in  which  the  edges  of  the  valves  are  curled  and 
thickened,  ])roducing  extreme  insulVieiency  without  any  material  narrow- 
ing of  the  orilice.  ^lore  friMpu'ntly,  as  the  disease  advaiues,  the  chordfB 
tcndinejc  hecomo  thickeiu'd,  first  at  the  valvular  ends  and  then  along 
tlirir  course.  The  edges  of  the  valves  at  their  angles  are  gradually  drawn 
tiigelher  and  there  is  a  dednite  narrowing  of  the  orifice,  leading  in  the 
aorta  to  uu>re  or  less  stenosis  ami  in  the  left  auriculo-ventricular  orifice — 
tlic  two  most  freipuMitly  invcdved — to  constriction.  Finally,  i)i  the  scle- 
rotic and  necrotic  tissues  lime  .salts  are  deposited  and  may  even  rea<'h  the 
deeper  structures  of  the  lihrous  rings,  and  the  entirt?  valve  becomes  a 
dense  calcareous  mass  Avilh  .scarcely  a  remnant  of  normal  tissue.  The 
eliorda'  tendinea^  may  gradually  heeotne  shortened,  greatly  thickened,  and 
ill  I'Xtreme  <'ases  the  papillary  muscdes  are  implantid  directly  uiK)n  the 
sileroficr  aial  deformed  valve.     The  apices  of  the  partillarv  muscles  u,*^ 


isually 


t^h"\v  marked  fihroid  (diange. 

In  all  stages  of  the  ])rocesa  the  vegetations  of  simple  endocarditis  may 
li('  foiiiul,and  upon  sclerotic  valves  we  find  lh(>  severer,  ulcerative  form  of 
the  disease. 

Chronic  mural  endocarditis  produces  eicatricial-liko  patches  of  a  gray- 
41 


1 J 


■i'.! 


-?' 


f^4 


i  11 1' 
li'j  ■ 


If. 


'i 


1  - ) 


(536 


DIHKASrOS  OF  TIIK  CIIlCUIiATORY  SVSTKM. 


I 


N  % 


Ir 


>4     .     « 


'S 


V  ! 


ish-wliito  appciirimoo  wliidi  arc  soiMctiiiK-s  seen  cm  tlic  iiiiisciilai-  (r;tlii'(  u. 
Ill'  of  tlic  vciitricli-  or  i'l  tlic  iuirifli's.  It  ol'lcii  «ici'iir.s  in  ussucialiou  willi 
inyoi'urditis. 

'l'li(!  IVciiiiciicy  with  \vlii(  h  cliroiiic  ('iidocanliti.-;  is  iiict  wii.li  tiia\  Im 
^atlu'ivtl  i'roiii  till!  I'ollowiiiLr  li^^qirt's  :  In  tiu-  statistics,  aiiioiiiiliii;i  In  Irmii 
l^',(lt)(»  to  14,(100  autopsies,  reported  I'roiii  Ihvsdeii,  Wurzlmr;^, and  I'lairiio 
tiie  pereeiituj^e  ruiijied  rmiu  foiii'  to  nine.  'I'lie  relativi-  lri((iienev  of  ia- 
volveinent  ol'  the  various  valves  is  thus  j,Nven  in  the  eolleeted  sUilisties  of 
I'arrot :  The  mitral  oriliee  was  involved  in  O".'!,  tin-  aortic  in  ;>,S(i,  the  tri- 
cuspid in  -Ifl,  and  tiic  [•ulnionai)  in  11.  'I'liis  j^ives  ol  instaiieos  in  the 
right  to  1,001  in  the  left  lu'art. 

The  endocarditis  of  the  fietus  is  usually  of  the  sclerotic  form  and  in- 
volves the  valves  of  the  right  more  fri'<|uenily  than  those  I'f  the  left  side. 


'I'ho  elVeets  of   sclerotic  endocarditis  are   |iraelically  liiose  of  elm 


luc 


valvular  diseascj  and  the  general  inlluencc  on  the  work  of  the  heart  luay 
he  hrielly  slatccl  as  follows  :  The  si-lerosis  induces  insullicieney  or  ste- 
nosis, which  may  e.\ist  .separately  or  in  coudiination.  'l"hc  narnnving  re- 
tards in  a  measure  the  normal  outllow  and   the  insutliciency  periniu  tlio 


hlood  current  to  take  an  alinormal  cour; 


in  both  inUances  the  elVi'rt 


dilatation  of  a  elaunher.  The  result  in  the  former  ca.s»!  i.s  an  increase 
in  the  ililUculty  which  the  chandter  has  in  expelling  it.«.  contents  through 
the  narrow  oriliee;  in  the  other,  the  ovi'riilling  of  a  chandu'r  hy  hliuid 
flowing  into  it  from  an  improper  source,  as,  for  instance,  in  iidtral  insiif- 
liciency,  when  the  lid't  auricle  receives  hh)od  both  Irom  the  pulnujuary 
veins  ami  from  the  left  ventricle. 

The  cardiac  ini'(;hanism  is  fully  preparcil  to  nuvd.  ordinarv  grades  nf 
dilatation  which  constantly  occur  during  sudden  exertion.  .\  man,  fur 
instance,  at  the  end  of  a  hundred-yard  race  has  his  riglit  chanilKTs 
greatly  dilated  and  his  reserve  cardiac;  power  worked  to  its  fidl  capacity. 
The  slow  progress  of  the  sclerotic!  changes  hrings  about  a  gradual,  not  ini 
abrupt,  insullicieney,  and  the  moderate  dilatation  which  follows  is  at  lirst 
overcome  by  the  exercise  of  the  (U'dinary  reserve  strength  of  the  heart 
muw'les.  (Ji'adually  a  new  faitor  is  introduced.  The  res(M-ve  power  wliirh 
is  capable  of  meeting  sudden  enu-rgcincies  in  su<'h  a  remarkable  manner  is 
unable  to  cope  long  with  a  pernuinent  and  j)crhaps  increasing  (Hiatal ion. 
More  work  has  to  be  done  and,  in  accordance  v\itli  dednite  physiological 
laws,  more  power  is  given  by  increase  of  the  muscdes.  The  lu-art  hyper- 
trophies and  the  eU'ect  of  the  valve  lesion  becomes,  as  we  say,  amtptii- 
sated.     The  equilibrium  of  tiie  oirciilation  is  in  this  way  niaintuined. 


ii ; 


CllltONIC   VALVUF.AIl   DISKASK.  637 

II.  CHRONIC  VALVULAR   DISEASE. 

AoHTK!    IncoMI'KTKNCY. 

Inrniiipctcnfy  of  tlio  iiortic  viilvcs  arises  fitlicr  IVnni  iiiiil)ility  nf  tlio 
viilvc  s(';,Mii('iits  to  dose  tin  al)iuiniiiilly  lar^o  orilicc  or  more  (•(•iiiiiionly 
from  discast'  of  tlic  scginciits  tlicmsi'lvcs.  'I'liis  licsl-drliiicl  and  most 
easily  rt'cofxiii/ctl  of  valvular  Ii'sioiis  was  lirst  ('ari'fully  stiulictl  Iiy  Corii^'aii, 
uliox'  name  it  sonictiiiifs  hears. 

Etiology  and  Morbid  Anatomy.—  It  is  more  freijuent  in  males 
tliaii  ill  females,  alTeetiiijr  eliielly  able-lmdied,  vi;^for<iiis  men  at  the  midi'll" 
[leriod  of  life.  'I'lie  ratio  wliiidi  it,  hears  to  other  valve  diseast'S  lias  heen 
variously  <j;iv('ii  from  thirty  to  fifty  per  eei:t. 

Amoii;^  the  important  factors  in  prcdnein^'  this  eonditiun  arc:  {(i) 
('(in;,'enital  malformation,  particularly  fusion  of  two  se;,'ments — most 
conimonly  tlioso  hehind  which  the  coronary  arteries  are  i:i\en  oil'.  It  is 
proliahle  that  an  aortic  orilicc  nuiy  he  competent  with  this  hicu.-pid  state 
of  the  valves,  l)ut  a  great  danger  is  the  liahility  of  thc.-i'  nudformed  segments 
to  sclerotic  endocarditis.  Of  .seventeen  cases  which  I  ha\i'  reported  all 
presented  .selenttic  changes,  and  the  majority  of  them  had,  during  life,  tho 
clinical  features  of  chronic  liourt-(lisea.sc. 

(/»)  Acute  endocarditis.  'I'his  docs  not  ])roihice  aortic  incompetency 
unless  the  process  passes  on  to  ulceration  and  dcsti'uctioii,  nmler  which 
circiinistaui'es  it  is  often  found,  and  nuiy  cause  a  rapidly  fatal  issue.  Sim- 
ple endocarditis  a.ssociated  witii  the  sjtccitic  fevers  is  not  nearly  so  com- 
mon on  the  aortic  as  on  the  mitral  segnu'nts;  so  also  with  rhcnmalism, 
which  plays  a  less  important  rolr  here  than  in  mitral  valve  di.sea.se. 

('•)  By  far  the  most  frcfptcnt  cause  of  insnfliciency  is  the  js^low,  j»ro- 
gressive  sclerosis  of  the  segment,  resulting  in  a  curling  of  the  edge, 
which  lessens  the  working  surface  of  tlie  valve.  This  may,  of  course,  fol- 
low acute  eiulocarditis,  but  it  is  so  often  met  with  in  strong,  ahh'-lio(lled 
men  among  the  working  clas.ses,  without  any  history  of  rheumatism  or 
special  fehrile  di.seases  with  which  endocarditis  is  commonly  associated, 
that  otiier  conditions  must  he  sought  for  to  cxjilain  its  frcipu'ucy.  Of 
these,  un»|ucsti()nably  strain  is  tlie  most  important— iu>t  a  sudden,  foicihle 
strain,  liut  a  persistent  incretuse  of  the  normal  ti'usion  to  which  the 
sciriiieuts  are  sid)ject  duriu''  th(>  diastole  of  the  ventricle.  Of  cin-um- 
stiuices  increasing  this  tension,  heavy  and  e.\ce<>ive  use  of  the  muscles  is 
I"  rliaps  the  most  important.  80  often  is  this  form  of  h"art-disi'ase  I'ouml 
ill  persons  devoted  to  athletics  that  it  is  sometimes  called  the  "athlete's 
heart."  Alcohol  is  a  second  imjuirtant  factor,  and  is  state(l  to  raise  con- 
sidcri'iily  till- tension  in  the  aortic  .system.  A  conihination  of  these  two 
ciuiso,*  is  extremely  common.  A  third  element  in  inducing  chronic  sde- 
tdtic  ci.angej  in  these  valves  is  syphilis.  Cases  are  rarely  seen  in  which 
Dtlier  faciors  must  not  be  taken~riito  account,  but  the  association  is  too 


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DISEASES  OF  THE  CIRCULATORY  SYSTEM, 


frequent  to  be  accidental.  Tliat  syphilis  is  capable  of  inducing  art(>rial 
sclerosis  is,  I  think,  acknowledged,  although  the  way  in  which  it  is  done  is 
not  yet  clear.  It  is  interesting  to  note  Avith  what  frequency  this  form  of 
valve  disease  occurs  in  soldiers.  1  was  strucik  with  this  fact  in  the  IMiila- 
deli)hia  Hospital,  to  ^vhich  so  many  veterans  of  the  civil  war  are  admitted. 
I  was  in  the  habit  of  enforcing  upon  my  students  the  etiological  lesson  by 
a  mythological  reference  to  IJacchus  and  Vulcan,  at  whose  shrines  a  ma- 
jority of  the  cases  of  aortic  insufficiency  have  worshipped,  and  not  a  few 
at  that  of  Venus. 

The  condition  of  the  valves  is  such  as  has  already  been  descrilied  in 
chronic  endocarditis.  It  may  be  noted,  however,  how  slight  a  gra(h'  of 
curling  may  produce  serious  incomi)etency.  Associated  with  the  valve 
disease  is,  in  a  majority  of  the  cases,  a  more  or  less  advanced  arterio-scle- 
rosis  of  the  arch  of  the  aorta,  one  serious  effect  of  which  nuiy  be  a  narrow- 
ing of  the  orifices  of  the  coronary  arteries.  The  sclerotic  changes  are 
often  combined  with  atheroma,  either  in  the  fatty  or  calcareous  stage. 
This  may  exist  at  the  attached  margin  of  the  valves  without  inducing  in- 
sufficiency. In  other  instances  insufficiency  may  result  from  a  calcified 
spike  projecting  from  the  aortic  attachment  into  the  body  of  the  valve, 
and  so  preventing  its  proper  closure.  8ome  writers  (Peter)  have  laid 
great  stress  upon  the  extension  of  the  endarteritis  to  the  valve,  and  would 
sei)arate  the  instances  of  this  kind  from  those  of  simple  valvular  endocui'- 
ditis.  I  must  say  that  I  have  not  been  able  to  recognize  clinical  dilTcr- 
ences  between  these  two  conditions,  though  anat;omically  we  may  separate 
the  cases  into  two  groups — those  with  and  those  without  arterio-sclerosis. 

{■()  And,  lastly,  insufficien(!y  may  be  induced  by  rupture  of  a  segment 
— a  very  rare  event  in  healthy  valves, .but  not  uncommon  in  disease, 
either  from  excessive  strain  during  heavy  lifting  or  from  the  ordinary 
endarterial  strain  in  a  valve  eroded  and  weakened  by  ulcerative  endo- 
carditis. 

Relative  imnffieiency  of  the  sigmoid  valves,  due  to  dilatation  of  tlio 
aortic  ring,  is  a  rare  condition.  It  is  said  to  occur  in  extensive  arterial 
sclerosis  of  tlie  ascending  portion  of  the  arch  with  great  dilatation  just 
above  the  valves.  I  have  myself  never  met  with  a  pure  instance  of  tlio 
kind,  for  in  su(di  cases  I  have  always  found  the  valve  vsegments  involved 
with  the  arteiial  coats.  In  aneurism  just  above  the  aortic  ring,  relative 
insufficiency  of  the  valve  may  be  present. 

It  would  ajjpear  from  the  careful  measurements  of  Bencke  that  the 
aortic  orifice,  which  at  birth  is  20  mm.,  increases  gradually  witli  flio 
growth  of  the  heart  until  at  one  and  twenty  it  is  about  GO  mm.  Af  this 
it  remains  until  the  age  of  forty,  beyond  which  date  there  is  a  graduiil 
increase  in  tlu;  size  up  to  the  age  of  eighty,  when  it  may  reach  from  <i8 
to  70  mm.  There  is  thus  at  the  very  period  of  life  in  which  sclerosis  of^ 
the  valve  is  most  common  a  ])hysiological  tendency  toward  the  production 
of  a  state  of  relative  iusufficiency. 


artcriiil 
1  (lone  is 

form  (if 
V  IMiila- 
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ossoii  by 

OS  il  lllll- 

(jt  a  I'cw 

:ribc'(l  in 
grade  of 
:hc'  valve 
;eri()-scl('- 
i  narrow- 
iiigcs  are 
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uoing  in- 
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the  valve, 
have  laid 
ind  would 
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segment 
disease, 
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ive  eiido- 

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with   the 

At  this 

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irodnotion 


CHRONIC  VALVULAR  DISEASE. 


G39 


The  insufficiency  may  be  combined  with  various  grades  of  narrowing, 
but  the  majority  of  tlio  cases  of  aortic  insufficiency  ])rese!it  no  signs  of 
stenosis.  On  the  other  hand,  cases  of  aortic  stenosis  almost  Avithout 
exception  are  associated  with  some  grade,  however  slight,  of  regurgitation. 

The  direct  effect  of  aortic  insutHciency  is  the  regurgitation  of  blood 
from  the  artery  into  the  ventricle,  causing  an  ovci'distention  of  the  cavity 
and  a  reduction  of  the  blood  column ;  that  is,  a  relative  ana-niia  in  the 
arterial  tree.     As  an  immediate  effect  of  the  donble  b]o:)(l-llow  into  the 
lift  ventritde  dilatation  of  the  chamber  occurs,  and  linally  hyjK'rtrophy. 
In  this  way  the  valve  defect  is  compensated  and  as  with  eacdi  ventricular 
systole  a  larger  amount  of  blood  is  propelled  into  the  arterial  system,  the 
regurgitation  of  a  certain  amount  during  diast(dc  does  not,  for  a  time  at 
least,  seriously  impair  the  nutrition  of  the  peri[)lieral  j)arts.     In  this  valve 
lesion  dilatation  and  hypertrophy  reach  their  most  extreme  limit.     The 
heaviest  hearts  on  record  arc  described  in  connection  with  this  affection. 
The  so-called  bovine  heart,  cor  boviiiu?)},  may  weigh  3")  or  40  ounces,  or 
even,  as  in  a  case  of  Dulles's,  48  ounces.     'I'he  dilatation   is  usually  ex- 
treme, and  is  in  marked  contrast  to  the  condition  of  the  chandter  in  cases 
of  pure  aortic  stenosis.     The  papillary  muscles  may  be  greatly  flattened. 
The  mitral  valves  are  usually  not  seriously  affected,  though  the  edges 
may  present  slight  sclerosis,  and  there  is  often   relative  incompetency, 
owing  to  distention  of  the  mitral  ring.     Dilatation  and   hypertro])hy  of 
the  left  auricle  are  common,  and  secondary  cidargcment  of  the  right  heart 
occurs  in  all  cases  of  long  standing.     The  myocardium  usually  presents 
changers,  fibroid  or  fatty ;  more  commonly  the  former  in  a.   ociation  with 
disease  of  tlie  coronary   arteries.      The  arch  of  the  aorta  may  i)resent 
extensive  arterio-scler  )sis  and  dilatation.     In  rare  instances,  usually  the 
rheumatic  cases,  the  intlma  is  perfectly  smooth,  and  the  arch  with  its 
main  branches  not  dilated.     This  (iondition  nuiy  be  found  post  mortem 
even  when  during  life  there  have  been  the  most  characteristic  signs  of 
enlargement  of  the  arch  and  of  ddatation  of  tlu!  innominate  and  right 
carotid.     I  have  even  known  the  condition  of  aneurism  to  be  diagnosed 
when  post  mortem  no  trace  of  dilatation  or  sclerosis  was  found,  only  an 
extreme  grade  of  insuflRciency  with  enormous  dilatation  and  hypertrophy. 
The  coronary  arteries  are  usually  involved   in   the  sclerosis,  and  their 
orifices  may  be  much  narrowed^     Although  these  vessels  have  been  shown 
hy  Martin  and  Sedgwick  to  be  filled  during  the  ventricular  systole,  the 
circulation  in  them  must  be  embarrassed  in  aortic,  incompeteiuty.     They 
must  miss  the  effect  of  the  blood-pressure  in  the  sinuses  of  Valsalva  dur- 
ing the  elastic  recoil  of  the  arteries,  which  surely  aids  in  keeping  the 
coronary  vessels  full.     The  arteries  of  the  body  usually  picsent  more  or 
less  sclerosis  consequent  upon  the  strain  which  they  undergo  during  the 
forcible  ventricular  systole. 

Symptoms. — The  condition  is  often  discovered  accidentally  in  per- 
sons who  have  not  presented  any  features  of  cardiac  disease. 


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G40 


DISEASES  OP  THE  CIRCULATORY  SYSTEM. 


Physical  Signs. — Inspection  shows  a  wide  and  forcible  area  of  cardiac 
impulse  with  tlic  a])(.'X  beat  in  the  sixth  or  seventh  interspace,  and  p(  r- 
iiaps  as  far  out  as  the  anterior  axillary  liiu;.  In  young  subjects  the 
pra'cordia  may  bulge.  On  pal])ation  a  thrill,  diastolic  in  time,  is  occa- 
sionally felt,  but  is  not  comnum.  The  impulse  is  usually  strong  mul 
heaving,  unless  in  conditions  of  extreme  dilatation,  when  it  is  wavy  and 
indefinite.  Percussion  shows  a  greater  iiu;reaso  in  the  area  of  heart  dal- 
nessthan  is  found  in  any  other  valvular  lesion.  It  extends  chielly  dnwii- 
ward  arul  to  the  left. 

On  auscultation  there  is  heard  a  murmur  during  diastole  in  the  second 
right  interspace,  which  is  ])ro])agated  with  intensity  toward  the  en.iforin 
cartilage  or  down  the  left  margin  of  the  stenuun  toward  the  apex.  In 
the  majority  of  cases  it  is  a  soft,  long-drawn  Ijruit,  and  is  of  all  cardiac 
murmurs  the  most  reliable.  It  occurs  during  the  time  of,  and  is  produced 
by,  the  reflux  of  blood  from  the  aorta  into  the  ventricle.  In  a  large  pro- 
portion of  the  cases  there  is  also  a  systolic  murmur  heard  !it  the  aortic 
region,  iisually  shorter,  often  rougher  in  quality,  and  which  may  he  propa- 
gated upward  into  the  neck.  A  common  mistake  is  to  regard  tliis  as 
indicating  stenosis,  whereas  in  the  great  majority  of  instances  of  aortic 
insuflficiency  there  is  no  material  nan-owing,  and  the  murnmr  is  pnxhuted 
by  roughening  of  the  segments  or  of  the  intima  of  the  arch.  The  second 
souiul  is  usually  obliterated,  though  in  some  instances  both  the  nnirinur 
and  the  valvular  sound  may  be  distinctly  heard.  At  the  apex  murmurs 
are  also  heard,  either  transmitted  from  the  aortic  orifice  or  produccil  at 
the  mitral.  In  the  majority  of  cases  with  aorti(!  incompetency  of  high 
grade,  the  mitral  orifice  is  dilated,  ami  tiiere  is  relative  insufTiciency  of  the 
valves.  It  can  frequently  be  determined -that  the  systolic  munmir  at  the 
apex  differs  in  quality  from  that  at  the  base.  A  second  murmur  id  the 
apex,  probably  produced  at  the  mitral  orifice,  is  not  uncommon.  Atten- 
tion was  called  to  this  by  the  late  Austin  Flint,  aTul  the  murmur  usually 
goes  by  his  name.  It  has  a  distinctly  rumbling  quality,  is  limited  in  area, 
and  is  sometimes,  though  not  always,  exactly  presystolic  in  time.  The 
explanation  of  its  occurrence,  as  given  by  Flint,  is  that  in  the  extreme 
dilatation  of  the  ventricle  the  mitral  segments  cannot  during  diastole  ho 
forced  back  against  the  wall,  and  therefore,  remaiiung  in  the  blood  cur- 
rent, they  ])roduce  a  sort  of  relative  narrowing,  and  in  consequence  a 
vibratory  murmur  not  uidike  in  quality  the  presystolic  murmur  of  niitr;  i 
stenosis.  This  apex  diastolic  murmur  of  aortic  insufliciency  occurs  i!i  a 
considerable  ])roportion  of  all  cases.  It  is  variable,  and  may  disai)pear  as 
the  dilatation  of  the  ventricle  diminishes.  There  is  never  the  loud  sy-s- 
tolic  shock  which  follows  the  murmur  of  mitral  stenosis. 

The  exainimvtion  of  the  arteries  in  aortic  insutRcienoy  is  of  great  value. 
Visible  pulsation  is  more  commoidy  seen  in  the  perijjheral  vessels  in  this 
than  in  any  other  condition.  The  carotids  may  be  .seen  to  throb  forcilily, 
the  temporals  to  dilate,  and  the  brachials  and  radials  to  expand  with  ojich 


CHRONIC   VALVULAR  DISEASE. 


641 


hoart-bcat.  With  tlio  oplithiilmoscope  the  rotiiial  artorii's  aro  seen  to 
]iiilsatc.  Not  only  is  the  pulsation  evident,  but  tlie  characteristio  jerking 
(|iiality  is  aj)[iare;it.     Iti  tlie  tliroat  the  t]irobl)ing  carotids  may  Iciad  to  the 

the 


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diagnosis  ot"  aneurism.  In  many  (;ases  the  ()ulsation  eaii  be  seen 
suprasternal  iKjtcdi,  and  j)rominent,  fonubly-throbbing  vessels  beneath  the 
right  slerno-mastoid  muscle.  The  abdominal  aorta  may  lift  the  epigastrium 
with  each  systole.  To  be  nu'ntioncd  with  this  is  the  capillary  pulse,  met 
very  often  in  aortic  insufliciency,  and  best  seen  in  the  finger-nails  or  by 
drawing  a  li;  'i  u]nin  the  forehead^  when  the  margin  of  hypera'mia  on  either 
side  alternatcdy  bhislies  and  pales.  In  extreme  grades  the  face  or  the 
hand  may  blush  visibly  at  each  systole.  It  is  met  with  also  in  profound 
nniemia,  occasionally  in  ""ura>thenia,  and  in  health  in  conditions  of  great 
relaxation  of  the  peripiicral  arteries.  Pulsation  may  also  l)e  present  in 
the  j)eripheral  veins.  On  palpation  the  characteristic  water-hammer  or 
Corrigan  pulse  is  felt.  Iiitbe  majority  of  instances  the  pulse  wave  strikes 
the  finger  forciTTTy  wfth  a  quick  jerking  impulse,  arid  immediately  recedes 
or  collapses.  'IMie  characters  of  this  are  sometimes  best  appreciated  by 
grasping  the  arm  abovt;  the  wrist  and  holding  it  uj).  On  auscultation 
a  double  murmur  may  Ije  beard  in  the  carotids  and  subclavians  when  it 
is  present  at  the  aortic  orifice.  Occasionally  in  the  carotid  the  second 
sound  is  distinctly  audible  when  absent  at  the  aortic  cartilage.  In  the 
femoral  artery  a  double  murmur  also  may  be  heard  sometimes,  as  pointed 
out  l)y  Duroziez. 

Aortic;  insuiliciency  may  for  years  b(>  fully  compensated.  Persons  do 
not  necessarily  suiTer  any  inconvenience,  and  the  condition  is  often  found 
accidentally.  So  long  as  the  hypertrophy  just  ccpuilizes  the  valvular 
defect  there  may  be  no  symptoms  and  the  individual  nuiy  even  take 
moderately  heavy  exercise  without  experiencing  sensations  of  distress 
about  the  heart.  The  cases  wbicdi  last  the  longest  are  those  in  wdiich  the 
insufficiency  follows  endocarditis  and  is  not  a  part  of  a  general  arterio- 
sclerosis. Coexistent  lesions  of  the  mitral  valves  tend  early  to  disturb  the 
compensation.  It  has  scarcely  been  sufficiently  recognized  by  the  profes- 
sion at  large  that  pure  aortic  insufliciency  is  consistent  with  years  of  aver- 
age health  and  with  a  tol(;rably  active  life.  I  know  several  physicians  with 
aortic  insufTiciency  whf»  have  been  able  to  carry  (mi  for  years  large  and 
somewhat  onerous  practices.  One  of  them  since  the  establishment  of  insuf- 
lii'iency  has  passed  .successfully  through  two  attacks  of  acute  rheumatism. 
Ill  large  hospital  ])ractice,  scarcely  a  month  ])asses  without  the  discovery 
of  a  case  of  aortic  insufl'^-icncy  in  cionneetion  with  some  other  affection. 

With  the  onset  of  myocardial  changes,  with  increasing  degeneration  of 
the  arteries,  particularly  with  a  progressive  sclerosis  of  the  arch  and  in- 
volvement of  the  orifices  of  the  coronary  arteries,  the  compensation  be- 
comes disturbed.  In  advanced  cases  the  changes  about  the  aortic  ring 
niay  bo  associated  with  alterationr.  in  the  cardiac  nerves  and  ganglia,  and 
BO  introduce  an  important  factor. 


I  i 


n,  I 


'  V  -. 


642 


DISEASES  OF   HIE  CIRCULATORY  SYSTEM. 


Ilcaduclie,  dizziness,  flaslies  of  light,  and  a  feeling  of  faintness  oti  ris- 
ing  quickly  are  among  the  earliest  symptoms.  Palpitation  and  eiirdiae 
distress  on  slight  exertion  are  common.  Long  before  any  signs  of  fiulinif 
compensation  pain  may  become  a  marked  ami  troublesome  feature.  It  is 
extremely  varialjle  in  its  manifestations.  It  may  bo  of  a  dull,  aching  chiir- 
acter  conlliied  to  the  pnecordia.  .More  fre(|uontly,  however,  it  is  sliarp 
and  radiating,  and  is  transmitted  up  the  neck  and  down  the  arms,  par- 
ticularly the  left.  Attacks  of  true  angina  pectoris  are  more  frecjuent  in 
this  than  in  any  other  valvular  disease.  Aruemia  is  also  common,  much 
more  so  than  in  aortic  stenosis  or  in  mitral  aH'cctions. 

More  serious  symptoms,  as  compensation  fails,  arc  shortness  of  breath 
and  u'dcnia  of  the  fetit.  The  attacks  of  dyspna'a  are  liable  to  come  (in  at 
night  and  tlie  jtatient  has  to  sleep  with  the  head  high  or  even  in  a  chair. 
Of  respiratory  sympt(Mns  cough  may  develop,  due  to  the  congestiuii  df 
the  lungs  or  o'dema.  I  hemoptysis  is  less  frequent  than  in  mitral  disease. 
I  have  reported  a  case  in  which  it  was  profuse  and  believed  to  be  due  to 
tuberculosis  of  the  lungs,  inasmuch  as  the  patient  was  admitted  in  a  state 
of  emaciation  and  profound  exhaustion.  (Jieneral  dropsy  is  not  common, 
but  anlenui  of  the  feet  may  occur  early  and  is  sometimes  due  to  the  anas- 
mia,  at  others  to  the  venous  stasis,  at  times  to  both.  IJidess  there  is  co- 
existing disease  of  the  mitral  valve,  it  is  rare  in  pure  aortic  inctonipe- 
ten(!y  for  the  patient  to  die  with  general  amisarca.  Sudden  death  is  fre- 
quent ;  more  so  in  this  than  in  other  valvular  diseases.  As  compensation 
fails  the  patient  takes  to  bed  and  slight  irregular  fever,  associated  usually 
with  a  recurring  end(jcarditis,  is  m)t  uncommon  toward  the  ((lose.  Kiii- 
bolic  symi)toms  are  not  infrequent — pain  in  the  splenic  rcgitm  witii  en- 
largement of  the  organ,  hoiinaturia,  an(j  in  some  cases  paralysis.  Dis- 
tressing dreams  and  disturbed  sleep  arc  more  common  iu  this  than  in  other 
forms  of  valvular  disease. 

Here  may  apjiropriately  be  mentioned  the  connection  between  n.cntal 
symptoms  and  cardiac  disease,  as  they  arc  oftenest  seen  with  this  lesion. 
An  admirable  account  of  the  relations  between  insanity  and  disease  of 
the  heart  is  to  be  found  in  Mickle's  Goulstonian  lectures  for  ISSS.  In 
general  medical  practice  we  seldom  find  marked  mental  symptoms,  except 
toward  the  close  of  the  disease,  when  there  may  be  delirium,  hallucinations, 
and  morbid  impulses.  It  is  to  be  remembered  that  in  many  heart  cases 
this  terminal  delirium  is  urajinic.  The  irritability  and  peevishness  sonie- 
timcs  found  in  persons  the  subject  of  organic  heart-disease  cannot,  I  think, 
be  associated  with  it  in  any  special  manner.  We  do  meet  insanity,  break- 
ing out  in  i)atients  with  aortic  and  mitral  disease,  in  the  stage  of  com})eii- 
sation,  which  appears  to  be  related  definitely  to  the  cardiac  lesion.  It  is 
important  to  bear  this  in  mind,  for  cases  occasionally  display  suicidal 
tendencies.  I  have  twice  had  patients  throw  themselves  from  a  window 
of  the  ward. 


CHRONIC  VALVULAR  DISEASE. 


AoiiTic  Stknosis. 


64.3 


XaiTOwing  or  stricture  of  the  aortic  orifice  is  not  nearly  so  coramon  as 
insulHcieiicy. .\  The  two  (conditions,  us  lUreudy  stated,  may  occur  togetlier, 
however,  and  probahly  in  ahnost  every  ease  of  stenosis  there  is  some  lealvage. 

Etiology  and  Morbid  Anatomy. — In  the  mihh'r  grades  tliere  Is 
adlu'sion  between  tlie  segtnents,  whicli  are  so  stitl'eneil  that  during  systole 
they  canaot  be  })ressed  back  against  the  aortic  -wall.  ^I'he  ])rocess  of  co- 
hesion between  the  segments  nuiy  go  on  without  great  tliickening,  and 
j)r().luce  a  condition  in  whicli  the  orilice  is  guarded  by  a  comparatively 
thin  membrane,  on  tlie  aortic  face  of  which  may  be  seen  the  primitive 
raphes  sc])aratiug  the  sinuses  of  V^alsalva.  In  some  instances  this  mem- 
l)raiie  is  so  thin  and  i>resents  so  few  traces  of  atheromatous  or  scksrotic 
clianges  that  the  condition  looks  as  if  it  had  originated  during  fcetal  life- 
.More  comnujnly  the  valve  segments  are  thickened  and  rigid,  and  have  a 
(•artilaginous  hardness.  In  advanced  cases  they  may  be  represenUid  by 
stilT,  calcilied  masses  obstructing  the  oriiice,  througli  which  a  circular  or 
slit-Hke  passage  can  be  seen.  The  older  the  patient  the  more  likely  it  is 
that    'le  valves  will  be  rigid  and  calcified. 

W .  may  speak  of  a  relative  stenosis  of  the  aortic  orifice  when  with 
normal  alves  and  ring  the  aorta  immediately  beyond  is  greatly  dilated, 
A  stenosis  due  to  involvement  of  the  aortic  ring  in  sclerotic  and  calcareous 
changes  without  lesion  of  the  valves  is  referred  to  by  some  authors.  I  have 
never  met  witli  an  instance  of  this  kiml.  A  subvalvular  stenosis,  the  result 
of  endocarditis  in  the  mitro-sigmoidean  sinus,  usually  o^'curs  as  the  re- 
sult of  a  fo'tal  endocarditis.  In  comparison  with  aortic  insutliciency,  ste- 
nosis is  a  rare  disease.  It  is  usually  met  with  at  a  more  advanced  period 
of  life  than  insuflicicncy,  ar.d  the  most  typical  cases  of  it  are  found  asso- 
inated  with  extensive  calcareous  changes  in  the  arterial  system  in  old  men. 

When  gradually  produced  and  when  there  is  not  much  insuiliciency 
the  dilatation  of  the  left  ventricle  may  be  slight,  though  I  think  that 
in  all  cases  it  does  occur.  The  walls  of  the  ventricle  become  hypertro- 
pliied,  and  we  see  in  this  condition  the  most  typical  instances  of  what  is 
called  concentric  hypertrojihy,  in  which,  without  much,  if  any,  enlarge- 
ment of  the  cavity,  the  walls  are  greatly  thickened,  in  contradistinction 
t')  the  so-called  eccentric  hypertrophy,  in  which  the  chamber  is  greatly 
dilated  as  well  as  hypertrophied.  There  may  be  no  changes  in  the  other 
cardiac  cavities  if  compensation  is  well  maintained  ;  but  with  its  failure 
come  dilatation,  impeded  auricular  discdiarge,  pulmonary  congestion,  and 
increased  work  for  the  right  heart.  The  arterial  changes  are,  as  a  rule, 
not  so  nuirked  as  in  aortic  insufficiency,  for  the  walls  have  not  to  with- 
stand the  impulse  of  a  greatly  increased  blood-wave  with  each  systole.  On 
the  contrary,  the  amount  of  blood  propelled  through  the  narrow  orifice 
may  be  smaller  than  normal,  though  when  compensation  is  fully  estab- 
lished the  pulse-wave  may  be  of  medium  volume. 


A, 


%'i   > 


^''^     'M.fl 


--Hi 


m 


I 


GU 


DISEASES  OF  THE   CIUCULATORY   SYSTEM. 


Symptoms.  Physical  S\siiS.-~fnsj)criion  may  fiiil  to  rovonl  .niv 
area  of  canli  u;  impulse.  Particularly  is  tliis  tlic  case  in  old  iiicii  with 
rijfid  oli(.'st  walls  and  lari^c  crnpliysi'idatous  liiiiiis.  I'lidcr  these  ciiviiin- 
staiices  there  may  be  a  hi^di  <frade  of  hypertrophy  without  any  visible  im- 
pulso.  Even  when  the  apex  beat  is  visible  it  may  be,  as  'rraiibc  pointiil 
out,  feeble  and  indefinite.  In  many  cases  the  u])cx  is  soon  displaeeil  down- 
ward and  outward,  and  the  impidse  looks  stroiit,'  and  forcible. 

J'(iJj)ii/ion  I'eveals  iii  many  ca.ses  a  thrill  at  the  base  of  the  heart  of 
maximum  force  in  the  aortic  rc<^ion.  With  no  other  condition  do  wc 
meet  with  thrills  of  greater  intensity.  ^Phe  apex  beat  may  not  be  palpable 
under  the  conditions  above  mentioned,  or  there  may  be  a  slow,  lieavinir, 
forcible  impulse. 

Pi'missioH  never  gives  the  same  wide-  area  of  dulness  as  in  aortic  iti- 
suflicioncy.  The  extent  of  it  depends  largely  on  the  state  of  the  lungs, 
whether  emjihysematous  or  not. 

AusntUalioii. — A  systolic-  murmur  of  maximum  intensity  at  the  aortic 
cartilage,  and  propagated  into  the  great  vessels,  is  })re.sent  in  aortic  ste- 
nosis, but  is  by  no  means  pathognomonic.  One  of  the  last  lessons  learned 
by  the  student  of  jthysical  diagnosis  is  to  recognize  the  fact  that  this  sys- 
tolic murmur  is  oidy  in  comparatively  rare  cases  produced  by  decided 
narrowing  of  the  aortic  oritico.  Roughening  of  the  valves,  or  the  intimii 
of  the  aorta,  and  Int'inie  states  arc  much  more  frequent  causes.  In  aortic 
stenosis  the  murmur  often  has  a  much  harsher  quality,  is  louder,  and  is 
more  frequently  musical  than  In  the  conditions  just  mentioned.  When 
com])ensation  fails  and  the  ventricle  is  dilated  and  feeble  the  murnuu' 
may  bo  soft  and  distjiiit.  The  sccoiul  sound  is  rarely  heard  at  the  aortic 
cartilage,  owing  to  the  thickening  and  stilfness  of  the  valve.  A  diastolic 
murmur  is  not  uncommon,  but  in  many  cases  it  cannot  be  hoard.  The 
pulse  in  pure  aortic  stenosis  is  small,  usually  of  good  tension,  regular, 
and  perhaps  slower  than  normal. 

The  condition  may  be  latent  for  an  indefinite  period,  as  long  as  the 
hypertrophy  is  maintained.  Early  symptoms  are  those  duo  to  defective 
blood-supply  to  the  brain,  dizziness,  and  fainting.  Palpitation.  ])ain 
about  the  heart,  and  anginal  symptoms  arc  not  so  marked  as  in  insulli- 
cicncy.  With  degeneration  of  the  heart-muscle  and  dilatation  relative 
insufliciency  of  the  mitral  valve  is  established,  and  the  ]iatioj»t  may  present 
all  the  features  of  engorgement  in  the  lesser  and  systemic  circulations, 
Avith  dyspmca,  cough,  rusty  expectoration,  and  the  signs  of  anasarca  in  the 
lower  part  of  the  body.  ^lany  of  the  cases  in  old  people,  without  ])resent- 
ing  any  dropsy,  have  symptoms  pointing  rather  to  general  arterial  disease. 
Clieyne-Stokes  breathing  is  not  uncommon  with  or  without  signs  of 
ura?mia. 

Diagnosis. — With  an  intensely  rough  or  musical  murmur  of  maxinnim 
intensity  at  the  aortic  region  and  signs  of  hjqiertrophy  of  the  loft  venti'icio, 
a  thrill,  and  a  hard,  slow  pulse  of  moderate  volume  and  faiidy  good  tension, 


CHRONIC  VALVULAR   DISEASR. 


645 


a  diagnosis  of  aortic  stenosis  can  bo  made  witli  sonio  dcirrco  of  prol lability, 
partioulaHy  if  tbo  sulijot't  is  an  old  man.  Mistakes  arc  common,  how- 
I'Vcr,  and  a  ron<,dicn('d  or  calciticd  valve  sc;riiiciit,  or,  in  somi'  instances, 
a  very  roii.s^bened  and  prominent  caleilied  jilate  in  tlie  aorta,  and 
liyiiertrophy  associated  with   renal  disease,  may  produce   similar   symp- 

toMlS. 

Let  ni(!  repeat  that  a  murnnir  of  jnaxinnim  intensity  at  tbe  aortic 
ciirtilaj^e  is  of  no  iinportanci^  in  itself  as  a  diairiiostic  sis^ii  of  stenosis. 
lloii<,dienin<^  of  the  valve,  sclerosis  of  the  intima  of  the  arcli,  and  antemia 
arc  conditions  more  frequently  a.ssociated  with  a  .systolic  murmur  in  this 
rcirion.  Seldom  is  there  ditliculty  in  distinjjfuishing  the  niurmur  due  to 
ana'inia,  since  it  is  rarely  so  intense  and  is  not  associated  with  thrill  or 
with  marked  liyj)ertroj)hy  of  the  left  ventricle.  In  aortic  insnfliciency  a 
systolic  murmur  is  usually  jire.sent,  but  has  lu'ither  the  intetisity  iu)r  the 
musical  quality,  nor  is  it  accomjianied  Avith  a  thrill.  With  rou_i,diening 
and  dilatation  of  the  ascending  aorta  the  murmur  nui\  be  very  harsh  or 
nuisical ;  but  the  existence  of  a  second  sound,  accentuated  and  ringing  in 
(|uality,  is  usually  sutticient  to  differentiate  this  condition. 

Mitral  Ixoompetkxcy. 

Etiology. — Insufficiency  of  the  mitral  valve  results  from:  {a) 
Changes  In  the  segments  whereby  they  are  contracted  and  shortened, 
usually  combined  with  changes  in  the  chordai  tendinea\jir  with  nu)re  or 
less  narrowing  of  the  orifice,  {b)  As  a  result  of  changes  in  the  muscular 
walls  of  the  ventricle,  either  dilatation,  so  that  the  valve  se<jfnu>nts  fail  to 
close  an  eidarged  orifice,  or  changes  in  the  muscular  substance,  so  that 
the  segments  arc  imperfectly  coapted  during  the  systole — muscular  in- 
enm})etency.  The  common  lesions  producing  insutliciency  result  from 
endocarditis,  which  causes  a  gradual  thi(d<ening  at  the  edges  of  the  valves, 
contraction  of  the  chordiB  tendine;x%  and  union  of  the  edges  of  the  seg- 
ments, so  that  in  a  majority  of  the  instances  there  is  not  only  insufli- 
ciency,  but  some  grade  of  narroAving  as  well.  Except  in  children,  we 
rarely  see  the  mitral  leaflets  curled  and  puekei'cd  without  narrowing  of 
the  orifice.  Calcareous  plates  at  the  base  of  the  valve  may  jn-event  per- 
fect closure  of  one  of  the  segments.  In  long-standing  cases  the  entire 
mitral  structures  are  converted  into  a  firm  Cidcareous  ring.  From  this 
valvular  insulTiciency  the  .other  condition  of  muscular  in(!ompetency  must 
1)0  carefully  distinguished.  It  is  met  with  in  all  conditions  of  extreme 
dilatation  of  the  left  ventricle,  and  also  in  weakening  of  the  muscles  in 
prolonged  fevers  and  in  anaemia. 

Morbid  Anatomy. — The  effects  of  incompetency  of  the  mitral 
segment  upon  the  heai't  and  circulation  are  as  follows  :  (a)  The  imperfect 
elosiire  alloAvs  a  certain  amount  of  blood  to  regurgitate  from  the  ventricle 
iuto  the  auricle,  so  that  at  the  end  of  auricular  diastole  this  chamber  con- 


«;              H'f  ■-.::;    > 

i-                !t'-:''    :':   i 

i   r! 


640 


DISKASES  OP  THE  CIRCULATORY  SYSTPLM. 


:'  ;f'*i 


Ik 


tains  not  only  tlio  blood  \vl>i<']i  il  has  rocioivcd  from  the  Imifjs,  Inil  :\\»< 
that  wliich  has  iv^'ur<fitatc'(i  from  the  k'ft  vcntrich-.  'I'liis  tu'ccs>iiiii(.s 
tlilatalioii,  aii<i,  as  iiicri-asi'd  work  is  tlimwu  upon  it  in  oxiu'llin-^r  Hi,.  ii„^r. 
nuintfd  contents,  liyj)crtrojthy  as  well. 

(//)  With  each  systolo  of  tlu'  left  auricle  a  larj,'cr  vohimc  of  I)|(i(m|  is 
forced  into  thi!  leitventriele,  whicii  also  dilates  and  siil)se(jiiciill_v  licet, mcs 
hyiuirh'o])hii'd. 

Jc)  Durinj^  the  iliastole  of  tlu-  K'ft  auritdt-,  as  blood  is  re;,Mir<,dtiilc(l 
into  it  from  the  left  ventricle,  the  pulmonary  veins  are  less  readily  ciii)iiiiM|. 
In  couseriuenci^  the  rifxht  ventricle  expels  its  contents  less  freely,  ai.d  in 
turn  becomes  dilated  and  hypertrophicd. 

{(l)  Finally,  the  right  auricle  also  is  involved,  its  ehambor  is  eiUar^icd, 
.and  its  walls  are  increased  in  thickness. 

{(•)  'riio  effect  upon  the  [lulmonary  vessels  is  to  produce  dilatation 
both  of  the  arteries  and  veins — ofti'ii  in  long-stand in,<,^  (lascs  atheroiiiatdus 
changes;  the  cai)illaries  are  disti'uded,  and  ultimately  the  condition  of 
brown  induration  is  produced.  Perfect  compensation  may  be  etfccted, 
chiefly  through  the  hypertrophy  of  both  ventricles,  and  the  eilc^ct  upon 
the  peripheral  circulation  may  not  be  manifested  for  years,  as  a  normal 
volume  of  blood  is  discharged  from  the  left  heart  at  each  systole.  Tlic 
time  comes,  however,  when,  owing  either  to  increase  in  the  grade  of  the 
incompetency  or  to  failure  of  the  compensation,  the  left  ventricle  is 
unable  to  send  out  its  nornud  volume  into  the  aorta.  Then  there  is  ovcr- 
filli'-  ■'"  *lie  left  auricle,  engorgement  in  the  lesser  circulation,  endiarrassed 
acti(  die  right  heart,  and  congestion  in  the  systemic  veins.     For  years 

thiij  SO)  .cwhat  congested  condition  may  be  limited  to  the  lessor  circulation, 
but  finally  the  right  auricle  becomes  dilated,  the  tricuspid  valves  incom- 
petent, and  the  systemic  veins  are  engorged^  This  gradually  leads  to  the 
condition  of  cyanotic  induration  in  the  viscera  and,  when  extreme,  to 
dropsical  effusion. 

Muscular  incompetency,  due  to  impaired  nutrition  of  the  mitral  and 
papillary  muscles,  is  rarely  followed  by  such  perfect  com])ensation.  There 
may  be  in  acute  destruction  of  the  aortic  segments  an  acute  dilatation  of 
the  left  ventricle  with  relative  incompetency  of  the  mitral  segments,  great 
dilatation  of  the  left  auricle,  .ind  intense  engorgement  of  the  lungs,  under 
which  circumstances  profuse  haemorrhage  may  result.  In  these  cases 
there  is  little  chance  for  the  establishment  of  compensation.  In  cases 
of  hypertrophy  and  dilatation  of  the  heart,  Avithont  valvular  lesions.  ])iit 
associated  with  heavy  work  and  alcohol,  the  insufficiency  of  the  mitral 
valve  may  be  extreme  and  lead  to  great  pulmonary  congestion,  engorge- 
ment of  the  systemic  veins,  and  a  condition  of  cardiac  dropsy,  wlu^h 
cannot  be  distinguished  by  any  feature  from  that  of  mitral  incomiieteiiey 
due  to  lesion  of  the  valve  itself.  In  chronic  IJright's  disease  tius  hyper- 
trophy of  the  left  ventricle  may  gradually  fail,  leading,  in  the  later  stages, 
to  relative  insufficiency  of  the  mitral  valve,  and  the  production  of  a  con- 


rriuoNK;  valvular  diskase. 


647 


(litiim  of  piilinoMiiry  and  systemic  coti^^'cslioi),  siiiiiliir  to  tliat  iiidiiccd  by 
ihc  most  cxtrciiu'  <,M'ad('  of  Ifsioii  of  tlio  valve  itself. 

Symptoms.  —  l)iiriii<,'  tlie  (levelopniciit  of  tlie  ie^ioii,  unless  the  iii- 
(•oiii|ieteii('y  eonies  on  acutely  in  eonsc(|Uence  of  rupture  of  the  valve 
sei,nnent  or  of  ulceration,  the  eotupensatory  clian/;es  ^,^0  hand  in  hand 
with  the  defect,  and  there  ari'  no  siihjeidive  symptoms.  So,  also,  in  the 
st;i;;('  ot  perfect  coinpciisatioii,  thci'c  may  be  the  most  extreme  grade  of 
mitral  insuHiciency  with  enormous  hvpertruphv  of  the  heart,  vet  the 
patient  may  m)t  be  uwiire  of  the  existence  of  heart  trouble,  and  may 
siilTcr  no  inconvenience  oxeopt  perhaps  a  little  shortness  of  breath  on 
exertion  or  on  going  ni)-8tairs.  It  is  oidy  when  from  any  cause  tln^  com- 
pensation has  Jiot  been  ])erfectly  t  ITectcd,  or  having  been  so  is  broken 
aiiniiitly  or  gradnally,  that  the  jtatients  begin  to  be  troubled.  The  symp- 
toms may  ho  divided  into  two  groups  : 

[11)  The  minor  manifestations  while  eompensation  is  still  good.  ]*a- 
tient-*  with  extreme  incompetency  often  have  a  congested  appearance  of 
the  face,  the  lips  and  ears  have  a  bluish  tint,  and  the  venules  on  the 
elu'olvs  nuiy  bo  cidarged,  which  in  many  cases  is  very  suggestive.  h\ 
long-standing  eases,  purtieularly  in  children,  the  fingers  may  be  clubljod, 
and  there  is  shortness  of  breath  on  exertion.  This  is  one  of  the  most 
constant  features  in  mitral  insutliciency,  and  may  exist  for  years,  even 
when  the  comj)ensation  is  perfect.  Owing  to  the  somewhat  congested 
condition  of  the  lungs  these  patients  have  a  tendency  t;)  attacks  of 
bronchitis  or  Invmoptysis.  There  may  also  be  palpitation  of  the 
heart.  As  a  rule,  however,  in  well-balanced  lesions  in  adults,  this 
period  of  full  compensation  or  latent  stage  is  not  associated  with  symp- 
toms which  call  the  attention  to  an  affection  of  the  heart. 

[h)  Sooner  or  later  conies  a  period  of  disturbed  or  broken  compensa- 
tion, ill  which  the  most  intense  symptoms  are  those  of  venous  engorgement. 
There  are  palpitation,  weak,  irregular  action  of  the  heart,  and  signs  of 
dilatation.  ])yspna\a  is  an  especial  feature,  and  there  may  be  coiijjh.  A 
distressing  symptom  is  the  cardiac  "sleep-start,"  in  which,  just  as  the  pa- 
tient falls  asleep,  he  wakes  gasping  and  feeling  as  if  the  heart  was  stop- 
l>ing.  There  is  usually  a  slight  cyanosis,  and  even  a  jaundiced  tint  to  tho 
skill.  Tho  most  marked  symptoms,  however,  are  those  of  venous  stasis. 
The  overfilling  of  the  pulmonary  vess(ds  accounts  in  part  for  the  dysp- 
no'a.  There  is  cough,  often  with  bloody  or  watery  expectoration,  and  the 
alveolar  epithelium  containing  brown  pigment-grains  is  abundant.  Drop- 
sical elTnsion  usually  sets  in,  beginning  in  the  feet  and  extending  to  the 
body  and  the  serous  sacs.  Tho  liver  is  enlarged,  and  there  are  signs  of 
portal  congestion,  gastric  irritation,  and  catarrh  of  the  stomach  and  in- 
testines. The  urine  is  usually  scanty  and  albuminous,  and  contains  tube- 
casts  and  sometimes  blood-corpuscle;..  With  judicious  treatment  the  com- 
pensation may  be  restored  and  all  the  serious  symptoms  may  pass  away. 
Patients  usually  have  recurring  attacks  of  this  kind,  and  die  of  a  general 


''  l\ 


iill! 


II 


1 1 


II  ! 


i  1  ' 

'If. 
.11' 

I'    i 


M 


048 


DISKASKS  OF  TllH  CIIiCULATOIlY   SVSTKM. 


ml 


drop.sy  or  tlicrc  is  ])r()^n'ssiv('  (lilalatioii  of  the  liciirt,  jind  dcatli  fium 
usywtolc.     Smhlcii  (Icalli  in  tlicsc  ca'^cs  \n  rare. 

Physical  Signs.—  /nyrr/ii)//. —  In  cliiltlrcn  tlir  pra'conlia  may  hiil^ro 
untl  IlitTu  nniy  bo  u  largo  aivii  of  visihlc  jmlsatioii.  Tlui  apex  Ix'at  is  to 
llic  left  of  lli((  ni|i|il(',  in  sonic  cases  in  tlic  sixth  interspace,  in  tlic  aiilrii,,r 
axillary  line,  'i'licre  may  he  a  wavy  impulse  iu  lliu  cervical  veins  which 
are  often  full,  j)articnlarly  when  the  patient  is  recnmheut. 

I'(i//)(i/iou. — A  thrill  is  rare;  wIumi  present  it  is  felt  at  tlic  apex, 
often  in  a  limited  area.  The  f-irce  of  the  ini[)ulse  may  (U'pend  larirelv 
u|)on  th(f  shii;('  in  which  the  case  is  examined.  In  full  compensatinn  it  is 
forcihle  and  heaving;  when  the  compensation  is  disturbed,  usually  wavy 
and  f(!eble. 

rernissto)!. — The  dulnes.s  is  l.icreasod,  i)articuhirly  in  a  lateral  dint •- 
tioii.  There  is  no  disease  of  thi'  valves  which  produces,  in  long-stainiii!;,' 
cases,  a  more  extensive  transverse  area  of  heart  dulness.  It  does  not  ex- 
tend so  much  upward  along  the  left  margin  of  the  sternum  as  beyond  the 
right  margin  and  to  the  left  of  thi^  niitple  line. 

Aiisnil/iifioii. — At  the  apex  there  is  a  svstolic  murmnr  which  wliollv 
or  partly  obliterates  the  first  soiiml.  It  is  loudest  here,  and  has  a  bluw- 
ing,  sometimes  nnisicid  (diaractc.  particularly  toward  the  latter  part.  The 
murmur  is  transmitted  t;*  tlu'  axilhi  iind  may  be  heard  at  the  1  a<k,  in 
some  instances  ovctr  the  entire  (best.  There  are  cases  iu  which,  as  pointed 
out  by  Naiinyn,  the  mnrmur  is  heard  best  along  the  left  border  of  tlie 
stermim.  Usually  in  diastole  at  the  a|)ex  the  loudly  transmitted  seeoiid 
sound  may  be  heard.  Occasionally  there  is  aLso  a  soft,  sonu'tinies  a 
rough  or  rumbling  presystolic  murmur.  As  a  rule,  in  cases  of  extreme 
mitral  insuihcitMu  v  from  valvular  lesion  with  great  hypertr()[)hy  of  both 
ventricles,  there  is  heard  only  a  loud  blowing  murnuir  during  systole. 
A  murmur  of  mitral  insufru'iency  may  vary  a  great  deal  according  to  the 
position  of  the  patient.  It  may  he  present  in  the  recumbent  and  ab- 
sent in  the  erect  posture.  In  cases  of  dilatation,  particularly  when  dr(i[isy 
is  ])resent,  there  may  he  heard  at  the  ensiform  cartilage-  and  in  the  lower 
sternal  region  a  soft  systolic  nuirnmr  duo  to  tricuspid  regurgitation.  An 
important  sign  on  auscultation  is  the  accentuated  pulmonary  second  sound. 
This  is  hoard  to  the  left  of  the  sternum  in  the  secoiul  interspace,  or  over 
the  third  left  costal  cartilage. 

The  pulse  in  mitral  insutlicioncy,  during  the  period  of  fvdl  c()m]ieiisa- 
tion,  may  he  full  and  regular,  often  of  low  tension.  Usually  with  the  tu'st 
onset  of  the  symptoms  tho  pulse  becomes  irregular,  a  feature  which  then 
domiiuites  the  case  throughout.  There  may  be  no  two  beats  of  eijual 
force  or  volume.  Often  after  tho  disappearance  of  the  symptoms  of  fail- 
ure of  compensation  the  irregularity  of  the  pulse  persists. 

The  three  important  i)hysical  signs  thou  of  mitral  regurgitation  are; 
(a)  systolic  murmur  of  maximum  intensity  at  the  apex,  which  is  })r(ipa- 
gated  to  the  axilla  and  heard  at  the  angle  of  the  scapula ;  (b)  acccutuution 


1 


CllliOXIC    VAliVUIiAU    DISKASH. 


♦;4i> 


uf  llu!  jdilmoiiiiry  socoiid  sound  ;  (r)  cn  idcncc  of  I'lilarj^i'iiiont  of  the  lioart, 
]i;irtiniliirl.v  tlio  'Mcn'usc  in  tlic  triiiisvcrsc  (liiiiiictt'r,  due  to  livpcrlropliy 
of  l)(itli  ri^'lit  !i.i(l  left  vi'iilriclcs. 

Diagnosis. — 'I'licn-  is  mrdy  liny  dilliculty  in  tlic  dia^-nosis  of  niitr.,1 
insiillicicncy.  Tiit*  |iliysiral  si;,Mis  just  rcftTfi'd  to  arc  (iiiitr  idiaraclcrislii' 
and  distinctivo.  Two  [loiiits  arc  to  l)c  i)ornc  in  mind.  First,  u  murmur, 
systolic^  in  cliaructci-,  and  of  maximum  intensity  at  the  apex,  and  piMpa- 
iratcii  even  to  tlic  axilla,  does  not  necessarily  indicate  incomitctencv  of  the 
mitral  valve.  There  is  heard  in  this  I'eijiou  a  lar^.-'c  ;rrou|)  of  what  ari' 
termeil  accidental  murmurs,  the  precise  iialuiv  of  which  is  still  douhtful. 
They  are  proliahly  foi-mcd,  however,  in  the  ventricle,  and  aiv  not  a.-soci;:ted 
with  liyi)ertro[)liy,  or  accentuation  of  pidnionary  second  sound. 

Second,  it  is  not  always  jiossihU!  to  say  whether  tiie  insiillicicncy  is 
due  to  lesion  of  the  \alve  segment  or  {■>  dilatation  of  tlu'  mitral  riin,"-  and 
relative  incompetency,  lien?  lu'ither  tin-  (diiiiMctcr  of  the  niurmiir,  tlcj 
propiiijation,  tlie  accentuation  of  the  |)ulmonary  :  coiid  sound,  nor  tlio 
liyperlrophy  assists  in  the  dilfercntiiiti(tn.  'I"he  his!  )ry  is  sometimes  of 
fjroater  vaUie  in  this  matter  than  the  physical  i  amination.  Tlie  cases 
most  likely  to  load  to  error  are  those  of  the  so-called  idioi)athic  dilatation 
and  liypertropliy  of  the  heart  (in  which  the  syst(»lic  murmur  may  I»e  of 
the  ;:n  iii'st  intensity),  and  the  instance^  of  arterio-schn'osis  with  dilated 
heart. 

MiTUAi.  Stknosfs. 


(    i 


i   !. 


I 


Etiology. — Xarrowinif  <d'  the  mitral  orilice  is  nsually  the  result  of 
viilviilar  endocarditis  occurrin^jj  in  the  earlier  years  of  life;  very  r'lrely  it 
is  congenital.  It  is  very  much  more  common  i*.  women  than  in  i.'.en— in 
(!3  of  H'J  eases  noted  hy  J)uek\vorth.  This  is  not  easy  to  explain,  but  there 
are  at  least  two  factors  to  ho  considered.  Khcumatism  prevails  more  in 
girls  tliiui  in  boys  and,  as  is  wi'U  known,  endocarditis  (jf  the  mitral  valve 
is  more  common  in  rlunimati.-uu.  Chorea,  also,  as  suggested  by  liarlow, 
has  an  important  inllnonce,  occurring  more  fre(piently  in  girls  and  often 
associated  with  endocarditis  Of  IW  cases  of  chorea  which  I  examined  at 
a  period  more  than  two  years  subseipient  to  the  attack,  T-i  eases  had  signs 
of  organic  heart-disease,  among  which  were  '^4  instances  with  the  jihysical 
signs  of  mitral  stenosis.  Amemia  and  chlorosis,  which  are  prevalent  in 
girls,  have  been  regarded  as  possible  factors.  In  a  ininibcr  of  cases,  how- 
ever, no  recognizable  etiological  factor  can  be  discovered.  This  has  been 
regarded  by  some  writers  as  favoring  the  view  that  many  of  the  eases  are 
of  congenital  origin;  but  it  is  not  improbable  that  with  any  of  the  febrile 
allections  of  childhood  endocarditis  may  be  associated.  Whooping-cough, 
too,  with  its  terrible  strain  on  the  heart-valves,  may  be  accountable  for 
certain  cases.  Congenital  affections  of  the  mitral  valve  are  notoriously 
rare.  While  met  with  at  all  iiges,  stenosis  is  certainly  more  frequent  in 
young  persons. 


iv 


650 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


Morbid  Anatomy.— In  a  majority  of  instances  with  the  stenosis 
there  is  some  incomiietenoy.  The  narrowing  results  from  thickening  aiid 
contraction  of  the  tissues  of  tlie  ring,  of  the  valve  segments,  und  nf  ihc 
chorda!  tcndinciB.  Tlic  condition  varies  a  good  deal  according  to  tho 
amount  of  atheromatous  change.  In  many  cases  the  curtains  mr  so 
welded  together  and  the  whole  valvular  region  so  thickened  that  tJK' 
orifice  is  reduced  to  a  mere  chink — Corrigan's  button-hole  contraction. 
In  other  cases  the  curtains  jire  not  much  thickened,  but  narrowing  lias 
resulted  from  gradual  a'Hiesion  at  the  edges,  and  thickening  of  the  cliordiE 
tendinea},  so  that  from  the  auricle  it  looks  cone-like — the  so-called  fumicl- 
shai)ed  variety  of  stenosis.  The  instances  in  which  the  valve  seguu'iits 
are  very  slightly  deformed  but  in  which  the  orifice  is  consideral)ly  nar- 
rowed, are  regarded  by  sonu^  as  possibly  of  congenital  origin.  Oocu- 
sionally  the  curtains  are  in  great  part  free  from  disease,  but  the  nar- 
rowing results  from  large  calcareous  masses,  which  project  into  thom 
from  the  ring.  The  involvement  of  the  chordaj  tendineie  is  usually  ex- 
treme, ami  the  papillary  muscles  may  bo  inserted  directly  ui)on  the 
valve.  In  moderate  grades  of  constriction  the  orifice  will  admit  the  tip 
of  the  index-finger;  in  more  extreme  forms,  the  tip  of  the  little  linger; 
and  occasionally  one  meets  with  a  specimen  in  which  the  oi'ifice  seems 
almost  obliterated,  as  in  a  case  which  came  under  my  notice,  which  only 
admitted  a  medium-sized  Bowman's  probe. 

The  heart  in  jnitral  stenosis  is  not  greatly  enlarged,  rarely  weighing 
more  than  14  or  I.')  ounces.  Occasionally,  in  an  elderly  person,  it  may 
seem  slightly  if  at  all  enhirged,  and  again  there  are  instances  in  which 
the  weight  may  reach  as  much  as  20  ounces.  The  left  ventriide  is  usually 
small,  and  may  look  very  small  in  comparison  with  the  right  ventricle, 
which  forms  the  greater  portion  of  the  aj)ex.  In  cases  in  which  Mith  the 
narrowing  there  is  very  considerable  incompetency  the  left  ventricle  nuiy 
be  moderately  dilated  and  hyjiertropliied. 

These  changes  gradually  induced  are  associated  with  secondary  alten,- 
tions  of  great  importance  in  the  heart.  The  left  auricle  discharges  its 
blood  with  greater  difficulty  and  in  consequence  dilates,  and  its  wails; . 
reach  three  or  four  times  their  normal  thickness.  Although  the  auricle  ii^ 
by  structure  unfitted  to  compensate  an  extreme  lesion,  the  i)robal)ility  is 
tiiat  for  some  time  during  the  gradual  production  of  stenosis,  the  increas- 
ing muscular  power  (»f  the  walls  is  sufficient  to  counterbalance  the  defect. 
Eventually  the  tension  is  increased  in  the  pulmonary  circulation,  owiiijr 
to  impeded  outflow  from  the  veins.  'I'o  overcome  this  the  right  ventricle 
undergoes  dilatation  and  hypertrophy,  and  upon  this  chamber  fulls  the 
work  of  equalizing  the  circulation.  Relative  incompetency  of  the  tricuspid 
and  congestion  of  systemic  veins  at  last  supervene. 

It  is  not  uncommon  at  the  examination  to  find  white  thrombi  in  the 
ajjpendix  of  the  left  auricle.  Occasionally  a  large  part  of  the  anriclc  is 
occupied  by  an  ante-mortem  thrombus.     Still  more  rarely  the  renuukuble 


CHRONIC   VALVULAR   DISEASE. 


651 


iiall  thrombus  is  found,  in  wliieh  a  globular  concretion,  varying  in  size 
jioin  a  walinit  to  a  small  egg,  lies  free  in  the  auricle,  two  examples  of 
which  have  come  under  my  observation. 

Symptoms.— Physical  Signs. —  /tisprrfion. — In  children  the  lower 
sicrnum  and  the  tilth  and  sixth  left  costal  cartilages  are  often  prominent, 
owing  to  hypertrophy  of  the  right  ventricle.  The  apex  beat  n)ay  be  ill- 
licrmod.  Usually,  it  is  not  dislocated  far  beyond  the  nipplo  line,  and  the 
cliit'f  in.pulse  is  over  the  lower  sternum  and  adjacent  costal  cartilages. 
Often  in  thin-chested  persons  there  is  pulsation  in  the  third  and  fourth 
Id't  interspaces  close  to  the  sternum.  \Vhen  compensation  fails,  the  prai- 
cordial  impulse  is  much  feebler,  and  in  the  vein<  of  the  neck  there  may 
1)0  marked  systolic  regurgitation. 

Paljmtion  reveals  in  a  majority  of  the  cases  a  characteristic,  well- 
(Ictined  fremitus  or  thrill,  which  is  best  felt,  as  a  rule,  in  the  fourth  or 
til'tii  interspace  within  the  nipple  line.  It  is  of  a  rough,  grating  quality, 
often  peculiarly  limited  in  area,  most  nuirked  during  expiration,  and  can 
lie  felt  to  terminate  in  a  sharp,  sudden  shock,  synchronous  with  the  im- 
j)itise.  This  most  characteristic  of  physical  signs  is  pathognomonic  of 
imrrowing  of  the  mitral  orifice,  and  is  perhaps  the  only  instance  in  which 
tlic  diagnosis  of  a  valvular  lesion  can  be  made  by  palpation  alone.  The 
ciinliac  i'npulse  is  felt  most  forcibly  in  the  lower  sternu  n  and  in  the 
fourth  and  fifth  left  interspaces.  The  impulse  is  felt  very  high  in  the  third 
iiiul  fourth  interspaces,  or  in  rare  cases  even  in  the  second,  and  it  has 
boon  thought  that  in  the  latter  interspace  the  impulse  is  due  to  pulsa- 
tion of  the  auricle.  It  is  always  the  impulse  of  the  right  ventricle  ;  even 
ill  the  most  extreme  grades  of  mitral  stenosis,  there  is  never  such  tilting 
forward  of  the  auricle  or  its  appendix  as  would  ciuible  it  to  produce  an 
iiii|)ression  on  the  chest  wall. 

Percussion  gives  an  increase  in  the  cardiac  dulness  to  the  right  of  the 
sternum  nnd  along  the  left  margin ;  not  usiudly  a  great  in(!rease  beyond 
tlic  nipjile  line,  except  in  extreme  cases,  when  the  ti-ansverse  dulness  may 
ivach  from  .5  cm.  beyond  the  right  margin  of  the  sternum  to  10  cm. 
beyond  the  nipple  line. 

Auscultntion. — In  the  mitral  area,  usu  '\  to  the  inner  side  of  the 
ajH'x  beat  and  often  in  a  very  limited  region,  is  heard  a  rough,  vi])ratory 
or  purring  murmur,  which  terminates  abruptly  in  the  first  sound.  By 
(dinliiniiig  palpation  and  auscultation  the  purring  murmur  is  found  to  be 
syiiihronons  with  the  thrill  and  the  loud  shock  with  the  firet  sound.  This 
is  the  presystolic  murmur,  about  the  time  and  mode  of  production  of  which 
so  iiiiu'h  discussion  has  occurred.  I  hold  with  those  who  regard  it  as  oc- 
<'iiriing  during  the  auricular  systole.  In  whatever  way  produced,  it  re- 
iiianis  one  of  the  most  distinctive  and  characteristic  of  murmurs  and  its 
picsiMioe  is  positively  indicative  of  narrowing  of  the  mitral  orifice.  The 
soli'  cxcejition  to  this  statement  is  the  Flint  murmur  already  referred  to 
Hi  aortic  incompetency.  Once^  in  a  case  of  enormous  cidargement  of  the 
42 


P 


■51 


I'  I'iE"  'u 


t  '< 


'^fn 


052 


DISEASES  OF  THE  CIllCULATOIlV  SYSTEM. 


spleen,  willi  dropsy,  in  wliicli  the  heiirt  wus  greatly  pnslied  up,  T  licaiii  ;i 
jire.sy.stolie  niiinntir  of  rough  rpiality,  and  the  mitral  valves  were  I'oiiinl 
post  mortem  to  be  normal.  The  presystolic  murmur  may  ofcnjiv  \\w 
entire  ))eri()d  of  the  diastole,  or  the  middle  or  only  the  latter  liail",  c.ir- 
res])oiiding  to  the  auricular  systole.  The  dilTerenec  may  sometiims  bo 
noted  between  the  first  and  second  portions  of  the  murtnur,  when  it  (hcu- 
pi(!S  the  entire  time.  Often  there  is  a  peculiar  rumbling  or  echoing  (|iial- 
ity,  which  in  some  instances  is  very  limited  and  may  be  heard  only  over  a 
single  bell-spaee  of  the  stethoscope.  A  systolic  murmur  may  be  heard 
at  the  apex  or  along  tlitj  left  sternal  border,  often  of  extreme  softness  and 
audible  only  when  the  breath  is  held.  Sometimes  the  systolic  niuriiiu:'  is 
loud  and  distinct  and  is  transmitted  to  the  axilla.  The  second  sound  in 
the  second  left  interspace  is  loudly  accentuated,  sometimes  reduj)licat(M|. 
It  may  be  transmitted  far  to  the  left  and  be  heard  witli  great  clearness 
beyond  the  apex.  In  uncomplicated  cases  of  mitral  stenosis  there  are 
usually  no  murmurs  audible  at  the  aortic  regicm,  at  which  spot  the  hi^idiid 
sound  is  less  intense  than  at  the  pulmonary  area.  In  the  lower  stenuun 
and  to  the  right  a  tricuspid  murmur  is  sometimes  heard  in  advanced  cases. 
Other  points  to  be  noted  are  the  following ;  The  unusually  sharp,  clear 
first  sound  which  follows  the  presystolic  murmur,  the  cause  of  which  is 
by  lu)  means  easy  to  ex|)lain.  It  can  scarcely  be  a  valvular  sound  pro- 
duced chieily  at  the  nutral  orilice,  since  it  may  be  heard  with  great  inten- 
sity in  cases  in  which  the  valves  are  rigid  and  calcified.  It  has  been  snjj- 
gested  by  W.  8.  Fenwick  and  Overeud  that  it  is  a  loud  "sua])"  of  the 
tricuspid  valves  caused  by  the  powerful  contraction  of  the  greatly  liyiu  i- 
trophied  right  ventricle. 

Those  physical  signs,  it  is  to  be  borne  in  mind,  are  characteristic  only 
of  the  stage  in  which  com])ensation  is  maintained.  Finally  there  comes  a 
period  in  which,  with  rn])ture  of  compensation,  the  presystolic  nuirninr 
disai)pears  and  there  is  heard  in  the  apex  region  a  sharp  first  sound,  or 
sometimes  a  gallop  rhythm.  The  marked  systolic  shock  may  be  present 
after  the  disappearance  of  the  thrill  and  the  characteristic  murmur.  I'n- 
der  treatment,  with  gradual  recovery  of  compensation,  probably  with  in- 
creasing vigor  of  cotitraction  of  the  right  ventricle  and  left  auricle,  the 
presystolic^  murmur  reai)pears.  In  cases  seen  at  this  stage  of  the  disease 
the  nature  of  the  valve  lesion  may  be  entirely  overlooked. 

Steiiosis  of  the  mitral  valve  may  for  years  be  efficiently  compensate.! 
by  the  hypertroj)hy  of  the  right  ventricle.  Many  persons  with  the  char- 
acteristic physical  signs  of  this  lesion.  ])resent  no  symptoms.  They  may 
for  years  j)erhaps  be  short  of  breath  on  going  up-stairs,  but  are  al)le  to  [niss 
through  the  ordimiry  duties  of  life  without  discomfort.  The  pulse  is 
smaller  in  volume  than  normal,  but  may  be  perfectly  regular.  A  speciiil 
danger  of  this  stage  is  the  recurring  endocarditis.  A'c^getations  may  he 
whipped  otf  into  the  circulation  and,  blocking  a  cerebral  vessel,  may  vdmo 
hemiplegia  or  aphasia,  or  both.    This,  unfortunately,  is  not  an  uneoinnion 


CnnONIC  VALVULAR  DISEASE. 


653 


poquence  in  wotnon.  Puticnts  witli  mitral  stenosis  may  survive  this  acci- 
dent for  an  indeliuite  period.  A  woman,  above  .seventy  years  of  age,  died 
ill  one  of  my  wards  at  the  Philadelphia  Hospital,  wiio  liad  luvn  in  the 
iilinsli(Piise,  heniiplegic,  for  more  than  tiiirty  years.  TIk!  heart  ])resi'iited 
nil  extreme  grade  of  mitral  stenosis  which  had  probably  existed  at  the  time 
of  the  hemiplegic  attack. 

i'ailnre  of  compen.sation  brings  in  its  train  the  group  of  symptoms 
which  have  been  discussed  under  mitral  insuniciency.  Bi'iclly  enumerated 
tlicy  are:  liapid  and  irregubir  action  of  the  heart,  shortness  of  breath, 
cdugli,  signs  of  pulmonary  engorgement,  and  very  frequently  lia'mo])tysis. 
Attacks  of  this  kind  may  recur  for  years.  Bronchitis  or  a  febrile  attack 
in.iy  cause  shortness  of  breath  or  slight  bluencss.  Inllammatory  affections 
(if  tiie  lungs  or  pleura  seriously  disturb  the  right  heart,  and  these  patients 
.^liiiul  pneumonia  very  badly.  Many,  perhaps  a  majority  of  cases  of  mitral 
stenosis,  do  not  have  dropsy.  TTie  liver  may  be  greatly  enlarged,  and  in 
tlic  late  stages  siscTtesTs  not  uncommon,  particularly  in  children.  (Jen- 
eral  anasarca  is  most  frerpiently  met  with  in  those  cases  in  Avhieh  tiiere 
is  secondary  narrowing  of  the  tricuspid  orilice  (Hroadbent). 


••^KKO'I- 


i  M: 


Tuicrspin-VALVi"  Diskask. 


(a)  Tricuspid  Regurgitation.— Occasionally  this  results  from  acute 
or  chronic  endocarditis  with  puckering;  more  commonly  the  condition  is 
one  of  relative  insufficiency,  and  is  secondary  to  lesions  of  the  valves  on 
the  left  side,  particularly  of  the  mitral.  It  is  met  with  also  in  all  condi- 
tions of  the  lungs  which  cause  obstruction  to  the  circulation,  such  as  cir- 
rhosis and  emjiliysenm,  particularly  in  condtination  with  chnniic  bron- 
oliitis.  The  syinjito2ns_ave  those  of  obstruction  in  the  lesser  circulation 
with  venous  congestion  in  the  svstemic  veins,  such  us  has  alreadv  been 
descrrbectiTI  connection  with  mitral  insufliciency.  The  signs  of  this  con- 
dition are : 

(1)  Systolic  regurgitation  of  the  blood  into  the  right  auricle  and  the 
transniission  of  the  pulse-wave  into  the  veins  of  the  neck.  If  the  regurgi- 
tation is  slight  or  the  contraction  of  the  ventricle  is  feeble  there  may  be 
no  venous  pulsation,  but  in  other  cases  there  is  nuirked  systolic  ))ulsation 
in  the  cervical  veins,  'i'hat  in  the  right  jugular  is  more  forcible  than 
that  in  the  left.  It  may  be  seen  both  in  the  internal  and  the  extcrind, 
|iiirticularly  in  the  latter.  Marked  ])ulsation  in  these  veins  occurs  only 
when  the  valves  guarding  them  become  incom]>etent.  Slight  oscillations 
are  by  no  means  uncommon,  even  when  the  valves  are  intact.  The  dis- 
tciition  of  the  veins  is  sometimes  enormous,  parti<'ularly  in  tlu'  act  of 
•'fiiighing,  when  the  right  jugular  at  the  root  of  the  lu'ck  may  stand  out, 
f'lrining  an  extraordinarily  prominent  ovoid  nuiss.  Occasionally  the  re- 
gurgitant pulse-wave  may  be  widely  transmitted  and  be  seen  in  the  sub- 
fliiviau  and  axillary  veins,  and  even  in  the  subcutaneous  veins  over  the 


^1  [f;- 


1 1,  J 


"vS- 


It 


v'i 


'Mi   '   Jtf 
"•ml.  /•  "4^*iw 


.r- 


G54 


DISEASES  OP  THE  CIRCULATOUV  SYSTEM. 


sbouldor,  or,  as  in  a  case  recently  nntler  observation,  in  the  suporfiiiiil 
mammary  veins. 

Keffur^Mtant  jmlsation  through  the  tricnsjnd  orifice  maybe  transiiiiih  il 
to  the  inferior  cava,  and  so  to  the  liepatic  veins,  causing  a  systolic  disten- 
tion of  the  liver.  Tliis  is  best  appreciated  by  bimanual  palpation,  j)lufiii;r 
one  hand  over  the  fifth  and  sixth  costal  cartilages  and  the  otlicr  in  the 
lateral  region  of  the  liver  in  the  mid-axillary  line.  The  rhythmical  ex- 
pansile pulsation  may  be  readily  distinguished,  as  a  rub;,  from  the  systolic 
depression  of  the  liver  due  to  communicated  pulsation  from  the  lel'l  ven- 
tricle. 

(3)  The  second  important  sym})tom  of  tricuspid  regurgitation  is  tlie 
occurrence  of  a  systolic  murmur  of  maximum  intensity  in  the  lower  ster- 
num. It  is  usually  a  soft,  low  murmur,  often  to  be  distinguished  from  a 
coexisting  mitral  murmur  by  differences  in  quality  and  pitch,  and  may  he 
heard  to  the  right  as  far  as  the  axilla.  Sometimes  it  is  very  limited  in  its 
distribution. 

Together  these  Uvo  signs  positively  indicate  tricuspid  regurgitutii)ii. 
In  addition,  the  percussion  usually  shows  increase  in  the  area  of  duliie?;s 
to  the  right  of  the  sternum,  and  the  impulse  in  the  lower  sternal  region  is 
forcible.  In  the  great  majority  of  cases  the  symptoms  are  those  of  tlie 
associated  lesions.  In  cirrhosis  of  the  lung  and  in  chronic  emphysema  tlie 
failure  of  compensation  of  the  right  ventricle  with  insuf!iciency  of  the  tii- 
cuspid  not  infrequently  leads  either  to  acute  asystole  or  to  gradual  faihu'o 
with  cardiac  dropsy. 

(b)  Tricuspid  Stenosis. — This  interesting  condition  may  be  either  (>()n- 
genital  of 'acquired.  The  congenital  cases  are  not  uncommon,  and  aie 
associated  usually  with  other  valvular  defects  which  cause  early  death. 
The  acquired  form  is  not  very  infrequent.  Bedford  Fenwick  collected  4<! 
observations,  of  which  41  were  in  women.  Leudet*  has  analyzed  117 
cases.  Of  101  of  these  in  which  the  ages  Avere  mentioned,  80  were  in 
women  and  21  in  men.  A  great  majority  of  the  cases  were  in  adults,  only 
eight  being  between  the  ages  of  ten  and  twenty.  Its  rarity  as  an  isolated 
condition  may  be  gathered  from  the  fact  that  of  114  autopsies,  in  11  only 
was  the  lesion  confined  to  this  valve.  In  '21  the  tricuspid,  mitral,  and 
aortic  segments  were  involved,  and  in  78  the  tricuspid  and  mitral.  Pi-ac- 
tically  the  condition  is  almost  always  secondary  to  lesions  of  the  left  heart. 

The  physical  signs  are  sometimes  characteristic.  For  instance,  a  ]  ire- 
systolic  thrill  has  been  noted  by  several  observers.  The  percussion  shows 
dulness  to  be  increased,  particularly  to  the  right  of  the  stermim.  On  iuis- 
cultation  a  presystolic  murmur  has  been  determined  in  certain  eases,  iiml 
is  heard  best  at  the  root  of  the  ensiform  cartilage,  or  a  little  to  the  i-iiiht 
of  i  Of  general  symptoms,  cyanosis  of  the  face  and  lips  is  very  coninKui, 
and  in  the  late  stages,  when  drop.sy  supervenes,  it  is  a])t  to  be  intense. 


*  Paris  Thesis,  1888. 


CIIIIOXIC  VALVULAR  DISEASE.  G55 

'I'lie  lesior  is  interesting  chiefly  because  it  forms  one  of  the  most  serious 
(■omi)lications  of  mitral  stenosis. 

1*1  LMOXAUY  Valve  Disease. 

Tliis  is  extremely  rare. 

{(i)  Sfcuosix  is  almost  invaria])ly  a  congenital  anomaly.  It  constitutes 
one  of  the  most  important  of  the  congenital  cardiac  affections.  The  valve 
segments  are  usually  united,  leaving  a  small,  luirrow  orifice.  In  the  adult 
cases  occasionally  occur.  In  Case  (i()8  of  my  post-mortem  records  there 
was  extreme  stenosis  in  a  girl  of  eighteen,  owing  to  great  thickening  and 
adhesion  of  the  segments,  and  there  were  also  numerous  vegetations.  'Y\n\ 
orifice  was  only  two  millimetres  in  diameter.  The  congenital  lesion  is 
cuiiinu)nly  associated  with  j)atency  of  the  ductus  Hotalii  and  imperfection 
of  the  ventricular  sei)tum.     There  may  also  be  tricuspid  stenosis. 

The  physical  signs  are  extremely  uncertain.  There  may  be  a  systoli(! 
murmur  with  a  thrill  heard  best  to  the  left  of  the  sternum  iji  the  second 
intercostal  space.  This  murmur  may  be  very  like  a  murmur  of  aortic 
stenosis,  but  is  not  transmitted  into  the  vessels.  Xaturally  the  puhnonary 
soe(md  sound  is  weak  or  obliterated,  or  may  be  replaced  by  a  diastolic  m'ur- 
iiuir.     Usually  there  is  hypertro])hy  of  the  right  heart. 

{h)  Piihnouftri/  Iiisi/JJiriciiri/. — This  rare  affection  is  occasionally  due 
to  congenital  mairormation,  ]iarticularly  fusion  of  two  of  the  segments. 
It  is  sometimes  present,  as  Hramwell  has  shown,  in  cases  of  malignant 
emlocarditis.     Harie  has  collected  fifty-eight  cases. 

Tiu^  physical  signs  are  those  of  regurgitation  into  the  right  ventricle, 
but,  iis  a  rule,  it  is  diflicult  to  difTerentiate  the  murmur  _iom  that  of  aortic 
insuniciency,  though  the  maximum  intensity  may  be  in  the  imlmoiuiry 
area.  'IMie  absence  of  the  vascular  features  of  aorti('  insufficiency  is  sug- 
gestive. Both  (libson  and  (Jraham  Hteell  have  called  attention  to  the 
jxissibility  of  leakage  through  these  valves  in  cases  of  great  increase  of 
pressure  in  thi;  ])ulmonary  artery,  and  to  a  soft  diastolic  murmur  heard 
uiuler  these  circumstances,  which  Steell  calls  "  the  murmur  of  high  pres- 
sure in  the  puluionary  artery." 

CoMMiVKi)  Valvilah  Lksioxs. 

These  are  extrenu-ly  common.  The  mitral  and  aortic  segments  may 
be  .ilTected  together ;  iu!,\t  in  frefpiency  comes  the  combination  of  mitral 
.•111(1  tricuspid  lesions ;  aJid  then  of  aortic,  mitral,  and  tricuspid.  7\ortic 
insnlliciency  or  aortic  stenosis  is  more  frequently  combined  with  mitral 
iiieoinpetency  than  aortic  stenosis  with  mitral  stenosis,  or  mitral  stenosis 
with  aortic  insufliciency.  In  children  the  most  common  combiiuition  is 
'.entic  and  mitral  insuflicieiun'.  In  adults,  mitral  insufliciency  with  thick- 
eiiiiig  of  the  aortic  valves  and  slight  narrowing  is  i)erhaps  the  most 
cimiiuon. 


4 


g' 


I       t  .'  i 

V   id 


656 


DISKASKS  OF  THK  CIRCULATORY   SYSTEM. 


Tlie  (liiif^nosis  rests  upon  tlie  cliaructor  of  the  murmurs  and  the  stjitc 
of  tlie  cliaiiilu'iN  as  re^'anls  liypertroitliy  and  dilatation. 

Prognosis  in  Valvular  Disease.— The  (luestion  is  entirely  imc 

of  ((IVicieiit  eonipensation.  Sd  loiif^  as  tiiis  is  maintained  the  patient  may 
siilTer  no  inconvenience,  and  even  with  the  most  serious  forms  of  valve 
lesion  the  fuiicti(ni  of  the  heart  may  he  little,  if  at  all,  disturhed. 

Practitioners  who  are  not  adej)ts  in  anseultatioo  and  feel  unahle  to 
estimate  the  value  of  the  various  heart  murmurs  should  remember  that 
the  best  judj^ment  of  the  conditions  may  he  gathered  from  inspecti((n 
and  palpation.  With  an  apex  he-at  in  the  normal  situation  and  regular  in 
rhythm  the  auscultatory  ])henomena  may  he  practically  disregarded. 

As  Sir  Andrew  ("lark  states,  a  murmur  ^>»t'r  sc  is  of  little  or  no  mouicnt 
in  determining  the  prognosis  in  any  given  ease,  'i'liere  is  a  large  group 
of  patients  who  pivsent  no  other  symptoms  than  a  systolic  murmur  heard 
over  the  body  of  the  heart,  or  ov(!r  the  apex,  in  whom  the  left  ventricle  is 
not  hypertrophied,  the  heart  rhythm  is  i\ormal,  and  who  may  not  have 
had  rheumatism.  Indeed,  the  condition  is  accidentally  discovered,  often 
durinir  examination  for  life  insurance.  I  know  cases  of  this  kind  which 
have  persisted  unchanged  for  more  than  tifte(>n  years  Among  the  condi- 
tions inlhiencing  ))rognosis  are : 

{(i)  A(jc — Cliildrcn  under  ten  are  bad  subjects.  Com]iensation  is  well 
elfected,  and  tlicy  are  free  from  many  of  the  inftuenees  which  distiirli 
eom])ensation  in  adults.  The  coronary  arteries  also  are  healthy,  and 
nutrition  of  the  heart-muscle  can  be  readily  nudntaincd.  Yet,  in  spite 
of  this,  the  outlook  in  cardiac  lesions  developing  in  very  young  childirti 
is  usually  bad.  One  reasrm  is  that  the  valve  lesion  itself  is  apt  to  l)e 
rapidly  progressive,  aiul  the  limit  of  cardiac  reserve  force  is  in  such  cases 
early  i-eached.  There  .secnis  to  be  i)roportionately  a  greater  degree  of 
hypertroi)hy  and  dilatation.  Anmng  other  causes  of  the  risks  of  this 
})eriod  are  to  be  mentioned  insulhcient  food  in  the  poorer  classes,  the 
recurrence  of  rheunuitic  attack.s,  ami  the  existence  of  i)ericardial  adhesions 
The  outlook  in  a  child  who  can  be  carefully  supervised  and  prevented 
from  damaging  himself  by  overexertion  is  naturally  better  than  in  one 
who  is  constantly  overtasking  his  nniscles.  The  valvular  lesions  which 
develop  at,  or  sul)se(pu'nt  to,  the  period  of  pul)crty  are  more  likely  to  he 
l)ermanently  and  erticicntly  compensated.  Sudden  death  from  heart- 
disease  is  very  rare  in  children. 

(/y)  Si'X. — Women  bear  valve  lesions,  as  a  rule,  better  than  men,  owing 
partly  to  the  fact  that  they  live  (piieter  lives,  partly  to  the  less  coniinoii 
mvolvemeut  of  the  coronary  arteries,  and  to  the  greater  frequency  of  mit- 
ral lesions.  Pregnancy  and  parturition  are  disturbing  factors,  but  are,  I 
think,  less  serious  than  some  writers  would  have  us  believe. 

{c)  Voire  <iffi>rl('<J. — The  relative  prognosis  of  the  different  valve  lesions 
is  very  dilHcult  to  estimate.  Each  case  must,  therefore,  be  judged  on  its 
own  merits.     Aortic  insuHiLieucy  is  unquestionably  the  most  serious;  yet 


CHRONIC   VALVULAR  DISEASE. 


657 


for  years  it  may  be  i^erfectly  0()Tn})OJisak'd.  Favoniblo  circunistances  in 
any  case  are  the  moderaic  grade  of  liyportroijliy  and  dilatation,  the  absence 
(if  all  syinptonis  of  cardiac  distress,  and  the  absence  of  extensive  arti'rio- 
t^cicrosis  and  of  aiiLnna.  1'he  prognosis  rests  in  reality  with  the  condition 
(if  the  coronary  arteries.  Kheninatic  lesions  of  tlie  valves,  inducing  insuf- 
liciency,  are  less  apt  to  l^e  associated  with  endarteritis  at  the  root  of  the 
iiorta;  and  in  such  cases  the  coronary  arteries  nuiy  esca^ie  for  years.  I 
know  a  pliysician,  now  about  thirty -nine  years  of  age,  who,  wlu-n  sixteen, 
iiad  his  lirst  attack  of  rheumatism,  which  involved  the  aortic  segments. 
lie  has  had  two  sul)sequent  attacks  of  rheumatism,  but  with  care  has  been 
able  to  live  a  comfortable  and  fairly  active  life.  On  the  other  hand,  when 
the  aortic  insufficiency  is  oidy  a  i)art  of  an  extensive  aricrio-sclerosis  at  the 
rout  of  the  aorta,  the  coronary  arteries  are  almost  invarial)ly  involved,  and 
the  outlook  in  such  cases  is  nuich  nu)re  serious.  Sudden  death  is  not  un- 
conmion,  either  from  acute  dilatation  during  some  exertion,  or,  more  fri>- 
(juently,  from  blocking  of  one  of  the  branches  of  the  coronary  arteries. 
The  liability  of  this  form  to  be  associated  with  angina  ])ectoris  also  adds 
to  its  severity.  Aortic  stenosis  is  a  rare  lesion,  most  commoidy  met  with  in 
middle-aged  or  elderly  men,  and  is,  as  a  rule,  well  compensated.  In  many 
eases  it  does  not  appear  to  limit  the  duration  of  life. 

Tn  mitral  lesions  the  outlook  on  the  whole  is  much  more  favorabh< 
than  in  aortic  insufficiency.  3Iitral  insufficiency,  when  well  comptMisated. 
carries  Avith  it,  perhaj)s,  a  better  prognosis  than  mitral  stenosis;  i)ut  it 
must  be  borne  in  mind  tliat  the  cases  which  last  the  longest  are  those  in 
M'liich  the  valve  orifice  is  more  or  less  narrowed,  as  well  as  incompetent. 
There  is,  in  reality,  no  valve  lesion  so  rajjidly  fatal  and  so  poorly  oom- 
]iensated  as  that  in  which  the  mitral  segments  are  gradually  curled  aiid 
))U('kered  until  they  form  a  narrow  strip  around  a  wide  mitral  I'ing — a  con- 
dition specially  seen  in  children.  There  are  many  cases  of  mitral  insuffi- 
ciency in  which  the  defect  is  thoroughly  balanced  for  thirty  or  even  forty 
years,  without  distress  or  inconvenience.  Eveii  with  gi'cat  hy])ertrophy 
and  the  apex  beat  almost  in  the  mid-axillary  line,  there  may  be  little  or  no 
distress,  and  the  compeiisatioii  may  be  most  effective.  Wonien  may  ])ass 
safely  through  re])eate(l  ]iregnancies,  thongh  here  they  are  liable  to  acci- 
<lents  associated  with  the  severe  strain.  I  have  had  under  my  care  for 
)nany  years  a  patient  who  had  her  first  attack  of  rheumatism  at  the  age  of 
llfteen,  when  she  already  had  a  well-mark((l  mitral  nuirmur.  When  she 
first  came  nnder  my  observation,  eighteen  years  ago,  she  had  signs  of 
liypcrtroj)hy  of  the  left  ventricle  with  a  loud  systolic  murmur.  She  has 
had  no  cardiac  distur])ance  whatever.  She  has  lived  a  very  active  life,  has 
1h'(M\  unusually  vigorous,  has  borne  eleven  children,  and  has  i)assed  through 
three  sid)sequent  attacks  of  rheunnitisni. 

In  mitral  stenosis  the  prognosis  is  usually  regarded  as  less  favorable. 
My  own  experience  has  led  me,  however,  to  place  this  lesion  almost  on  a 
level,  particularly  in  women,  with  the  mitral  insufficiency.     It  is  found 


!  ! 


>h 


C58 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


m 


very  often  in  persons  in  perfect  health,  wlio  have  had  neither  palpitiitiiii 
nor  sit,Mis  of  heart-faihire,  and  wlio  have  lived  laborious  lives.  The  fi^'iins 
iriven,  too,  1)V  Jiroadbent  indicate  tiiat  the  date  of  death  in  niitrul  stenosis 
is  comparatively  advanced.  These  patients,  too,  ]iass  throiif^di  repealed 
])r.><ijnancies  witii  safety.  There  are  of  course  those  too  common  accident -, 
the  result  of  cerebral  embolism,  which  tire  nu)ro  liable  to  occur  in  this 
than  in  other  forms. 

Hard  and  fast  lines  cannot  be  drawn  in  the  question  of  pro<,nu)sis  in 
valvular  disease.  Every  case  must  be  judi.'ed  separately,  and  all  the  lii- 
cunistances  carefully  balanced.  There  is  no  question  which  re(|uiris 
greater  experience  and  more  mature  judgment,  aiul  even  the  most  ex- 
j)erieneed  are  sometimes  at  fault. 

The  following  brief  suinnuiry  of  the  conditicms  which  justify  a  favorn- 
ble  j)roguosis  endiodies  the  hirge  aiul  varied  clinical  experieiu.-e  of  Sir 
Andrew  Clark:  (iood  geiu'ral  health;  just  habits  of  living;  no  excep- 
tional liability  to  rheumatic  or  catarrhal  affections;  origin  of  the  valvulin- 
lesion  iiulependently  of  degeneration  ;  existence  of  tlie  valvular  lesion 
without  change  for  over  three  years;  souml  ventricles,  of  nuHlerate  fre- 
quency and  general  regularity  of  action;  sound  arteries,  with  a  normal 
amount  of  blood  and  tension  in  the  snudler  vessels ;  free  course  of  l)l()()(l 
through  the  cervical  veins ;  and,  lastly,  freedom  from  pulmonary,  hepatic, 
and  renal  congestion. 

Treatment  of  Valvular  Lesions.— For  this  purpose  the  valvu- 
lar lesion  may  be  divitled  into  the  period  of  i)rogressive  development,  with 
estidjlishnient  and  maintenance  of  hyjiertrophy,  aiul  the  pei'iod  of  ilis- 
turlied  comi)ensatiou. 

{(i)  Stage  of  Compensation. — ^Fedicinal  treatment  at  this])erio(l  is  ui>\ 
necessary  aiul  is  often  hurtful.  A  very  common  error  is  to  administer 
cardiac  drugs,  such  a.s  digitalis,  on  the  discovery  of  a  murmur  or  of  hyper- 
trophy. If  the  lesion  has  been  found  accidentally,  it  may  be  best  not  to 
tell  the  i)atient,  l)ut  rather  an  intimate  friend.  Often  it  is  necchsarv. 
however,  to  be  jierfectly  frank  in  order  that  the  patient  may  take  certain 
preventive  measures.  He  should  lead  a  quiet,  regulated,  orderly  life,  free 
from  excitement  and  worry.  An  ordinary  wholesome  diet  should  he 
taken,  tobacco  should  be  interdicted,  and  stimulants  not  allowed.  Exer- 
cise should  be  regulated  entirely  by  the  feelings  of  the  patient.  So  long 
a.s  no  cardia(^  distress  or  palpitation  follows,  moderate  exercise  will  ])ri>ve 
very  b(!neficial.  The  skin  should  be  kept  active  by  a  daily  bath.  Hot 
baths  should  be  avoided  and  the  Turkish  bath  should  be  interdicted.  In 
the  case  of  full-blooded,  somewhat  cori)ulent  individuals  an  occasional 
.saline  purge  should  be  taken.  Patients  with  valvular  lesions  shonld  lel 
go  int<»  very  high  altitudes.  The  act  of  coition  has  serious  risks,  particu- 
larly in  aortic  insufficiency.  Knowing  that  the  causes  which  most  surely 
and  powerfully  disturb  the  compensation  are  overexertion,  mental  wnii\, 
and  malnutrition,  the  physician  should  give  suitable  instructions  in  ca'  li 


CIIKONIC  VALVULAH   DISEASK.  659 

;is('.  As  it  is  ulwiiys  bi'ttcr  to  Imvc  the  co-opiTiition  of  jui  intolligont 
|.iitient,  ho  slioukl,  as  a  rule,  hu  told  of  the  condition,  but  in  this  matter 
ih('  physician  must  he  guided  by  circunistauces,  ami  tlierc  are  cases  in 
uliich  reticence  is  the  wiser  policy. 

(/y)  Stage  of  Broken  Compensation.— T lie  break  may  l)e  immediate  and 
liiiiil,  as  when  sudden  death  results  from  acute  dilatation  or  from  bloekinir 
(if  a  branch  of  the  eoroiuiry  artery.  Among  the  first  indications  are  short- 
ii.iss  of  breath  on  exertion  or  attacks  of  nocturnal  dyspnu'a.  I'hese  are 
often  asso(,'iated  with  impaired  nutrition,  i)articid,irly  with  amemia,  and  a 
course  of  iron  or  change  of  air  may  suttice  to  relievo  the  symptoms. 

Irregularity  of  the  action  of  the  heart  cannot  always  be  termed  an  in- 
dication of  failing  compensation,  particularly  in  instances  of  mitral  disease. 
Ii.  has  greater  signiticance  in  aortic  lesions.  Serious  failure  of  compensa- 
tion is  indicated  by  signs  of  dilatation  of  the  heart,  the  gallop  rhythm,  or 
various  forms  of  arrhythmia,  with  or  witlumt  the  existence  of  dropsy. 
I'lider  these  circumstances  the  following  measures  are  to  be  carried  out : 

(1)  Rest. — Disturbed  compensation  may  be  completely  restored  by  rest 
(if  the  body.  Hoth  in  Montreal  and  in  IMiiladelphia  it  was  a  favorite  dem- 
onstration in  practical  therajieutics  to  show  the  intlueiice  of  complete  rest 
and  (puet  on  the  cardiac  dilatation.  In  many  cases  with  onlema  of  the 
ankles,  moderate  dilatation  of  the  heart,  and  irregularity  of  the  pulse,  the 
rest  in  bed,  a  few  doses  of  the  compouiul  tincture  of  cardamoms,  and  a 
saline  ])urge  suHice,  Avithin  a  week  or  ten  days,  tt)  restore  the  compensa- 
tion. One  patient,  in  Ward  11  of  the  Montreal  (iem  lal  Hospital,  with 
aortic  insutliciency  recovered  from  four  successive  attacks  of  failing  com- 
prnsation  by  these  measures  alone. 

("i)  The  relief  of  the  end)arrassed  circulaticm. 

(<i)  liji  Voii'xectinn. — In  cases  of  dilatation,  from  whatever  cause, 
whet  her  in  mitral  or  aortic  lesions  or  distention  of  the  right  ventricle  in 
emphysema,  when  sigTis  of  venons  engorgement  are  marked  ajid  when 
tliore  is  ortho])nn^a  with  cyanosis,  the  abstraction  of  from  twenty  to  thirty 
ounces  of  blood  is  iiidicated.  This  is  the  occasion  in  which  timely  vene- 
section may  save  the  patient's  life.  It  is  a  condition  in  which  I  have  had 
most  satisfactory  results  from  venesection.  It  is  done  much  better  early 
than  late.  I  have  on  several  occasions  regretted  its  posti)onement,  par- 
ticularly in  instances  of  acute  dilatation  and  cyanosis  in  connection  with 
('ni|iliysema.* 

(It)  By  Depletion  thro}i(jh  the  Bmveh. — This  is  ])articidarly  valuable 
wlieu  dropsy  is  ]n'esent.  Of  the  various  purges  the  salines  are  to  be  pre- 
tVntd,  and  may  be  given  by  Matthew  Hay's  method.  Half  an  hour  to 
lu  hour  before  breakfast  from  half  an  ounce  to  an  ounce  and  a  half  of 
KpsoMi  salts  may  be  given  in  a  concentrated  form.     This  usually  produces 

*  I'or  illustrative  cases  from  my  wards  see  paper  bj'  II.  A,  Lafleur,  Medical  News, 
Inlv.  18!)1. 


<   Jl 


HI 


'1 '  -y 


.tv 


'irt 


660 


DISKASKS  OF  TIIH  ClKCUF-A'nUlY   SVSTMM. 


m^ 


ft' 74 

"•If     /- 


from  tliroc  to  iiw  li(|ui(l  oviu'imtions.  'I'lic  conipoutid  jalap  powd.  i  m 
linll'-draclmi  doses,  or  clatfriimi,  may  Ik-  ciiiploytMl  for  the  same  piiipuM'. 
Evi'ii  wlicM  the  pidsc  is  very  I'cchk'  tlH'sc  liydni;;o<,nu'  cat  hart  ics  uic  udl 
borne,  and  tliey  deplete  the  portal  system  rapidly  and  etlieiently. 

{>')  The  I'sc  of  JivnU'dicx  irliirit  stinnihth'  llir  llna-Ts  Ai/imi.  (if 
tliose,  by  far  the  most  important  is  di^dtalis,  whieh  was  introduced  miu 
practice  liy  Witlierin;;.  The  indication  For  its  use  is  dilatation;  iln' 
contru-indieation  is  a  perfectly  balanced  compensatory  hypertrophy,  sihh 
us  we  see  in  all  forms  of  valvular  disease.  Broken  compensation,  no  tnat- 
ter  what  the  valve  li'sion  may  be,  is  the  si<^nal  for  its  use.  It  acts  ii|iiiii 
the  heart,  slowing  and  at  the  same  time  increasiiijf  the  force  of  the  pulsa- 
tions. It  acts  on  the  periphi-ral  arteries,  raisinjf  their  tension,  so  thai  a 
steady  and  o(piablo  flow  of  blood  is  maintaiiu'd  in  the  capillaries,  which, 
after  all,  is  the  prime  aim  and  object  of  the  circulation.  The  bcncliiial 
eflfects  are  best  seen  in  eases  of  mitral  disease  with  small,  irrejrular  pulse 
and  cardiac  dropsy.  Its  effects  are  not  le.ss  strikinj;  in  the  dilatation  nf 
the  left  ventri(;le,  in  the  failinj?  compensation  of  aortic  insullicieiicy  or 
of  arterio-sderosis.  On  theoretical  {^rounds  it  has  been  urged  that  its  use 
is  not  so  advantageous  in  aortic  insutliciency,  since  it  ])rolong8  the  diastole 
and  leads  to  greater  distention.  This  need  not  be  considered,  and  diiri- 
talis  is  just  as  serviceable  in  this  as  in  any  other  condition  associated  with 
progressive  dilatation ;  larger  doses  are  often  re(piired.  It  may  he  given 
as  tiie  tincture  or  the  infusion.  In  cases  of  cardiac  dropsy,  from  whatevt  r 
cause,  fifteen  minims  of  the  tincture  or  luilf  an  ounce  of  the  iidusion 
may  be  given  every  three  hours  for  two  days,  after  which  the  dose  may 
be  reduced.  Some  prefer  the  tincture,  others  the  infusion  ;  it  is  a  matter 
of  indilTerence  if  the  drug  is  good.  1'he  urine  of  a  i)aLient  taking  digi- 
talis should  be  carefully  estinnited  each  day.  As  a  rule,  when  its  act  ion 
is  beneficial,  there  is  within  twenty-four  hours  an  increase  in  the  ainoutit; 
often  the  How  is  very  great.  Under  its  use  the  dyspiuT'a  is  reliuveil,  tlic 
dropsy  gradually  disapjiears,  the  })ulse  becomes  lirmer,  fuller  in  vuliinie, 
and  sometimes,  if  it  has  been  very  intermittent,  regular. 

Ill  effects  sometimes  follow  digitalis.  There  is  no  such  thing  as  a 
cunndative  action  of  the  drug  manifested  hy  sudden  symi)toms.  Toxic 
effects  are  seen  in  the  i)roduction  of  nausea  and  vomiting.  The  pulse  lie- 
comes  irregular  and  small,  and  there  may  be  two  l)eats  of  the  heart  to  one 
of  the  pulse,  which,  as  pointed  out  by  Broa(ll)ent,  is  found  })articularly  in 
cases  of  mitral  stenosis  when  they  are  under  the  influence  of  this  drug. 
The  urine  is  reduced  in  amount.  These  sym])toms  subside  on  the  with- 
drawal of  the  digitalis,  and  are  rarely  serious.  There  are  jiatieiits  who 
take  digitalis  uninterruptedly  for  years,  and  feel  palj)itation  and  distress  if 
the  drug  is  omitted.  In  mitral  disease,  even  when  it  does  good  it  does  not; 
always  steady  the  })ulse.  There  are  many  cases  in  which  the  irreguhnity 
is  not  affected  by  the  digitalis.  When  the  compensation  has  been  re- 
established the  drug  may  be  omitted.     When  there  is  dyspnani  on  >  xer- 


CIIUOXIC   VALVl'LAU   DlSKASK. 


(w;  I 


tion  aiid  ciinliao  distress,  from  fivo  to  ten  iiiiiiiins  tlirce  times  u  day  may 
lie  udvaiitu;^eoiisly  "fiveii  for  proloiij^'etl  periods,  hut  tlio  elTects  should  ho 
(•iirefidly  wutclit'd.  In  cardiao  dntpsy  dij^italFs  slioiild  ho  used  at  tlie  out- 
sit  witli  a  free  haiul.  Small  doses  should  not  he  ^iven,  but  from  tlu^  first 
half-ounce  doses  of  the  infusion  every  three  hours,  or  from  tlfteen  to 
twenty  minims  of  the  tineture.     'I'heri'  are  no  substitutes  for  di;^MtaIiH. 

of  other  remedies  strophanthus  alone  is  of  service,  (iiven  in  doses 
(pf  from  live  to  eif^ht  minims  of  the  tincture,  it  acts  like  digitalis,  it  cer- 
tainly will  sometimes  steady  the  intermittent  heart  of  mitral  valve  disease 
when  dif,Mtalis  fails  to  do  so,  but  it  is  not  to  bo  compared  with  this  drug 
when  dro[)sy  is  present.  Convallaria,  citrate  of  (^alfeine,  and  at/onis  vt'r- 
jiiills  and  x/uirtciitc  are  warmly  recommended  as  substitutes  for  digitalis, 
liiit  their  inferiority  is  so  manifest  that  their  use  is  rarely  indicated. 

There  are  two  valuable  adjuncts  in  the  treatment  of  valvular  disease — 
iron  and  strychiua.  When  ana'inia  is  a  marked  feature  iron  should  be 
<rivcn  in  full  doses.  In  some  instances  of  failing  compensation  iron  is  tlie 
(imIv  medicine  needed  to  restore  the  loalanee.  Arsenic  is  occasiomilly  an 
excellent  substitute,  and  one  or  other  of  them  sliould  I)e  administered  in 
all  instances  of  heart-trouble  when  ])allor  is  present.  Strychnia  is  a  heart 
tdiiic  of  very  great  value.  It  may  be  given  in  combination  with  the  digi- 
talis in  one  or  two  droj)  doses  of  the  one  per  cent  solution. 

Treatment  of  Special  Symptoms,    (a)  lh-tmsi^.—'V\w  increased 

arterial  tension  and  activity  of  the  ca])illary  circulation  under  the  influ- 
ence of  dj^alij^  hastens  the  interstitial  lymph  How  and  favors  resorption 
ofthetluid.  The  hydragogue  cathartics,  by  rapidly  depleting  the  blood, 
|iiiiiiiote  the  absorption  of  the  iluid  from  the  lym])h  spaces  and  the  lymph 
sacs.  These  two  measures  usually  sutHce  to  rid  the  ])atient  of  the  dr()])sy. 
Ill  some  cases,  however,  it  cannot  be  relieved,  and  then  Soiithey's  tulies 
may  lie  used  or  the  legs  jmnctnred.  If  done  with  care,  after  a  thorough 
washing  of  the  parts,  and  if  antiseptic  precautions  are  taken,  scarification 
is  a  very  serviceable  nieasnre,  and  should  be  resorted  to  more  frequently 
than  it  is.  Canton-Hannel  bandages  may  be  ajiplied  on  the  o'deniatous 
legs. 

{!))  /)j/spnfe(i. — The  patients  are  nsually  unalile  to  lie  d(<wn.  A  com- 
fortable bed^^est  should  therefore  be  provided — if  possible,  one  with  lateral 
imijectious,  so  that  in  sleeping  the  head  can  be  sniijiorted  as  it  falls  over. 
Tlie  shortness  of  breath  is  asso(Mated  with  dilatation,  chronic  bronchitis, 
"1'  livdrothorax.  The  chest  should  be  carefully  examined  in  all  these 
cases,  as  liydrothorax  of  one  side  or  of  both  is  a  common  cause  of  short- 
ness of  breath.  There  are  cases  of  mitral  regurgitation  with  recurring 
livilrothorax  as  the  sole  dropsical  symptom,  which  is  relieved,  week  by 
Week  or  month  by  month,  by  tap))ing.  For  the  nocturnal  dyspmea,  par- 
ticularly when  combined  with  restlessness,  morphia  is  invaluable  and  may 
'>i'  iriveu  without  hesitation.  The  value  of  the  calming  influence  of  opium 
ill  III!  conditions  of  cardiac  insutticiency  is  not  enough  recognized.     There 


\t 


IH' 


1,1;  r 


^1  III 


602 


DlSliASKS  OF  TUK  ClUCUIiATOKY  SYyTKM. 


lire  iiistiiTiros  of  ciinliiic  (lvs|)(i(i'ii  uimssdciiilcd  witli  dropsy,  purticiiliiih  in 
mitnil-vidvf  discnsc,  in  wliidi  iiitroj.dy('<'i'iii  is  (tf  jfrciit  service,  if  <.'iv(ii  |>, 
liie  one  per  cent  solntioi;  in  iiwreasin^  doses.  It  is  esiH'eially  serviceable 
ill  tlie  eases  in  wineli  the  pulsn  teiisioji  is  iii^di. 

(r)  I*(il/)i/titi(in  find  Ciin/iifr  /h'sfirss. —  In  instances  of  jjreat  livpir- 
tropliy  and  in  the  throhhinj;  winch  is  so  distressing;  in  some  easi  >  i,f 
aortic  insullicieiicy,  aconite  is  of  service  in  (h)ses  of  from  one  to  three 
miidms  every  tvo  or  threes  honrs.  An  ice-ha<r  over  the  heart  or  liciicr's 
coil  is  also  of  service  in  allayin;jf  tht!  rapid  action  and  the  throl)hin<r.  I  nr 
the  pains,  winch  are  often  so  niari<e(l  in  aorti<'  h-sions,  iodide  of  potas.-iiim 
in  ten  j^rain  (h»ses,  three  times  a  <hiy,  or  tiie  lutro^dyeerin  may  he  tried. 
Small  blisters  are  .sometimes  ad vanta^i'ons.  It  must  he  remend)ered  that 
an  important  cause  (d'  palpitation  and  cardiac  distress  is  flatulent  disicn- 
tion  of  the  colon,  ajjaiiist  whi(di  suital)k'  measures  must  ho  directed. 

((f)  (liixtrir  Si/ni/>fi)tns. — The  ca.ses  of  cardiac  insnlticiency  which  iju 
l)adly  and  fail  to  respond  to  di<j;italis  arc  nu)st  often  tho.se  in  which  luiiiscu 
anti  vonutin<f  are  prominent  features.  The  liver  is  often  greatly  enlarL'cd 
in  the.se  cases;  there  is  more  or  less  stasis  in  tlie  hepatic  vessels,  ami  Init, 
little  can  he  expected  of  druf,'s  until  the  venous  en^'orjijement  is  relieved. 
If  the  vomitinji;  persists,  it  is  best  to  stop  the  food  and  <,nve  small  hits  ef 
ice,  small  qiuintities  of  milk  and  lime  water,  and  cll'ervescinji  drinks,  such 
as  Apollinaris  water  and  champagne,  ('rcosotc,  hydrocyanic  acid,  and  the 
oxalate  of  cerium  are  sonietiines  u.seful;  hut,  as  a  rule,  the  condition  is 
obstinate  and  always  serious. 

(r)  ('(iii;/h  (Hill  I/(t'i)i(i/i/i/sis. — The  former  is  almost  a  necessarv  ceii- 
comitant  of  cardiac-  insutticiency,  owinfj  to  enj^orjfemeut  of  tin-  vessels 
and  more  or  less  bronchitis.  It  is  allayi'd  by  measures  directed  rather  to 
the  heart  than  to  the  lunjjs.  ILvmoptysis  in  chronic  valvular  disease  is 
sometimes  a  .salutary  symptom.  An  army  surgeon,  who  was  invaliiled 
during  the  late  civil  war  on  account  of  Inemoptysis,  sup])ose(l  to  he  due 
to  tuberculosis,  has  since  that  time  had,  in  association  with  mitral  insidli- 
ciency  and  eidarged  heart,  many  attacks  of  luptnoptysis.  He  assures  me 
that  his  condition  is  invariably  better  after  the  attack.  It  is  rarely  fatal, 
except  in  soine  cases  of  acute  dilatation,  and  seldom  calls  for  sjiecial  treat- 
ment. 

(_/■)  S/ei'pIes.'iues.s. — One  of  the  most  distressing  features  of  valvular 
lesions,  even  in  the  stage  of  com]iensiition,  is  disturbed  sleep.  Patients 
may  wake  suddeidy  with  throbbing  of  the  heart,  often  in  an  attack  of 
nightmare.  Subsetjuently,  when  the  compensation  has  failed,  it  is  aUn  ii 
worrying  symptom.  The  sleep  is  broken,  restless,  and  frequently  dis- 
turbed by  frightful  dreams.  Sometimes  a  dose  of  the  spirits  of  clilnro 
form  or  of  ether,  with  half  a  drachm  of  spirits  of  camphor,  given  in  n 
little  hot  whisky,  will  give  a  quiet  night.  The  compound  .spirits  of  el  her, 
llotfman's  anodyne,  though  very  unpleasant  to  take,  is  frequently  a  trivat 
boon  in  the  intermediate  period  when  compensation  has  partially  failed 


CIIIIONIC  VAIiVu'LAU   DISKASE. 


003 


■sscls 
cr  til 

ISC    i^ 

)V  due 

islltVl- 

vs  me 

liitiil, 

trciit- 


ilv\ilar 

itii'iits 

tiick  "f 

ly  .lis- 
chliin'- 
n  ill  ii 
t'  ctliri'i 
;i  Lnvat 
~1v  failed 


iiml  tlu'  piitit'iitrt  HiilTtT  from  reHtloss  uikI  sleepless  iiij,'lits.  Piiruldeliyde 
iiMil  aiiiyleiie  liydnite  are  sometimes  servieeiilde.  I  retluui,  siil|ilioiial, 
iiiiil  cliloralamiile  are  rarely  etrieaeious,  and  it  is  best,  after  a  few  trials, 
liartirularly  it  the  paraldehyde  dues  iiul  answer,  to  {j;ive  morphia.  It  may 
Ih'  fiivon  in  pond)ination  with  atropine. 

(//)  licuul  Si/inji/iinis. — With  raptured  compensation  and  lowerijifi  of 
llic  tension  in  ;he  aorta,  the  urinary  secretion  is  trreatly  diminished,  and 
the  amount  may  sink  to  li\e  or  six  ounces  in  the  ^ny.  l)i<,Mtalis,  and 
siniplianthus  when  ellicieiit,  usually  increase  the  How.  A  brisk  purf,'(^ 
may  be  followed  by  aufjuieiited  secretion.  The  combiiaition  in  pill  form 
ol'  ili^ntalis,  sr|nill,  and  the  bhick  oxide  of  mercury,  will  sometimes  prove 
cllVi'tive  when  the  infusion  or  tincture  of  di<;italis  alone  has  failed.  Calo- 
nicl  acts  well  in  somu  cases,  <;iven  in  ^n-s.  iij  every  si.v  hours  for  three  or 
four  days. 

TIr!  ///'/  in  chronic  valve  diseases  is  often  very  dinicult  to  regulate. 
W  illi  the  dilatation  and  venous  en<jorj;ement  come  nausea  and  often  a 
<l]Vi\{  tlistaste  for  food.  'I'he  amount  of  li(piid  shoidd  i>e  restricted,  and 
milk,  beef-juice,  or  e<;<;  albunu-n  ;^iven  every  three  hours.  When  the 
serious  .symptoms  have  pas.sed,  o^fjs,  scraped  meat,  lisli,  and  fowl  nuiy  be 
allowed,  Starchv  foods,  and  all  articles  likely  to  cause  flatulencv,  should 
be  forbidden.     Stimulants  are  usually  necessary,  cither  whisky  or  brandy. 


III.  HYPERTROPHY  AND  DILATATION. 

Hypertrophy  is  an  enlar<»ement  of  the  heart  due  to  an  increased  thick- 
ness, total  or  j)artial,  in  the  muscular  walls.  Dilatation  is  an  increa.se  in 
size  of  one  or  more  of  the  cliandjer.s  with  w  without  thickeiiinfj  of  the 
walls.  The  conditions  usually  coexi.st,  and  could  be  more  correctly  de- 
scrilu'd  tofjether  under  the  term  enlarfj^ement  of  the  lieart.  Simple  hyju'r- 
tropliy,  iu  which  the  cavities  remain  of  a  normal  size  and  the  walls  are 
increased,  occurs,  but  simple  dilatation,  in  which  the  cavities  are  increased 
anil  tlie  walls  remain  of  a  normal  diameter,  jirobably  docs  not,  as  it  is 
always  associated  with  thinninj;  or  with  thickeninj^  of  the  coats.  Com- 
inoiily  we  have  the  forms  of  simph,  hypertrophy,  hypertroidiy  with  dilata- 
tion, and  dilatation  with  thinning  of  the  coats. 

Hypf.iituophy  ov  tiik  IIkaiit. 

There  are  two  forms — the  simple  hypertrophy,  in  which  the  cavity  or 
cavities  are  of  normal  size;  and  hypertrophy  with  dilatation  (eccentric 
liypi  rtro])hy),  in  whicli  the  cavities  are  enlarged  and  the  Avails  increased 
ill  thickness.  The  condition  formerly  spoken  of  as  concentric  hyjjer- 
iii'pliy,  in  which  there  is  diminution  in  the  size  of  the  cavity  with  thick- 
en ing  of  the  walls,  is,  as  u  rule,  a  post-mortem  change. 


^\b^ 


ih!'  -iii 


it  f 


flO-t 


DISKASKS  OF  TlIK  CIllCULATORY  SYSTEM. 


Tlio  oiiliir^otnont  may  alTcct  tho  ontirc  organ,  o!ie  siilo,  or  onlv  oiio 
clianibor.  >iutiirally,  as  the  loft  ventriclo  does  the  chief  work  in  foivimf 
the  bh)od  tlirough  tlie  systemic  arteries,  the  cliaiige  is  most  fri'(|iu mly 
found  in  it. 

Etiology.  —  Ilyportropliy  of  tho  heart  follows  the  law  poveniinn: 
mnscics,  tiiat  within  certain  limits,  if  the  nutrition  is  kept  up,  incrcixil 
work  is  followed  by  increased  size — i.  o.,  hypertrophy.  Hypertrojiliv  of 
the  left  ventricle  alone,  or  with  general  enlargement  of  tlie  heart,  is 
brought  about  by — 

Cotulitions  atfecting  tile  heart  itself:  (1)  Disease  of  tlu'  aortic  valve; 
(2)  mitral  insulliciency ;  (3)  i)ericardial  adhesions ;  (4)  sclerotic  uivo- 
earditis ;  (5)  disturbed  innervation,  with  overactiou,  as  in  exophthahuic 
goitre,  in  long-continued  nervous  paljjitation,  and  as  a  result  of  the  iictidu 
of  certain  articles,  such  as  tea,  alcohol,  and.  tobacco.  In  all  of  these 
conditions  the  work  of  the  heart  is  increased.  In  the  case  of  the  vidve 
lesions  the  increase  is  due  to  the  increased  intraventricular  pressure ;  in 
the  case  of  the  adherent  pericardium  and  myocarditis,  to  direct  interference 
with  the  symmetrical  and  orderly  contraction  of  the  chambers. 

Conditions  acting  upon  the  blood-vessels  :  (1)  (Jenoral  arterio-sclornsis. 
with  or  without  renal  disease;  (2)  all  states  of  increased  arterial  teiisidii 
induced  by  the  contraction  of  the  smaller  arteries  under  the  influence  of 
certain  toxic  substances,  which  act,  as  Bright  suggested,  by  affecting  •  ihe 
minute  capillary  circulation,  render  greater  action  necessary  to  send  the 
blood  through  the  distant  subdivisions  of  the  vascular  system  " ;  (;ij  pm- 
longed  muscular  exertion,  which  enormously  increases  the  blood-l)r('^slil•o 
in  the  arteries;  (4)  narrowing  of  the  aorta,  as  in  the  congenital  stencsis. 

Hypertrophy  of  tho  right  ventricle  is  met  with  under  the  fnlhiwiiig 
conditions —  • 

(1)  Lesions  of  the  mitral  valve,  either  incompetence  or  stenosis,  wliieli 
act  by  increasing  the  resistance  in  the  pulnionary  vessels.  (3)  Pulnioiiary 
lesions,  obliteration  of  any  number  of  bhjod-vessels  within  the  lungs,  siu  h 
as  occurs  in  emphysema  or  cirrhosis,  is  followed  by  hypertrophy  of  tiie 
right  ventricle.  {'.])  Valvular  lesions  on  the  right  side  occasionally  cause 
hypertrophy  in  the  adult,  not  infrorpiently  in  the  fa^tns.  (4)  Chmiiii" 
valvular  disease  of  the  left  heart  and  pericardial  adhesions  are  sooner  nr 
later  associated  with  hy])ertrophy  of  the  right  ventricle. 

In  the  auricles  sim})le  hyperi.-ophy  is  never  seen ;  it  is  always  dilata- 
tion with  hyiiertrophy.  In  the  left  auricle  the  condition  develops  in  lesions 
at  the  mitral  oritlce,  particularly  stenosis.  The  right  auricle  hyiiertropliics 
when  there  is  greatly  increased  blood-pressure  in  the  lesser  circulatidii. 
whether  due  to  mitral  stenosis  or  pulmonary  lesions.  Narrowing  of  the 
tricuspid  orifice  is  a  less  frequent  cause. 

Morbid  Anatomy. — The  heart  of  an  average-sized  man  weighs 
about  nine  ounces  ("280  grammes);  that  of  a  woman,  about  eight  ounces 
(250  grammes).     In  eases  of  general  hypertrophy  the  heart  may  A\(igli 


IlYPHllTROI'IIY  AND   DUiATATlOX. 


665 


fiuin  sixteen  to  twenty  ounces.  AVoights  above  twenty-five  ounces  are  rare. 
So  fiii'  as  I  know,  the  heaviest  lieart  on  reconl  is  one  (U'scrihcd  hy  Beverly 
I.'ohiiison,  weighing  tit'ty-three  ounces.  J)unes  lias  reported  one  weighing 
forty-eight  ounces.  The  nieasurenient  of  the  thickness  of  the  walls  is, 
iii'Vt  U)  weighing,  the  best  means  of  determining  the  hy[)ertrophy.  In 
I  xticme  dilatation  the  walls,  though  actually  thickened,  may  look  thin. 
When  rii/<ir  nidiiis  is  ])resent,  the  cavity  may  Re  small  and  the  walls  may 
ai'pear  greatly  thickened.  The  measurements  should  not  be  made  until 
the  heart  has  been  soaked  in  water  and  thoroughly  relaxed.  Jn  the  left 
voiitricle  a  thickness  of  ten  lines,  or  from  twenty  to  twenty-th  e  millimetres, 
iiulicates  hypertrophy.  The  right  ventricle  is  thiniu'r  than  the  left,  and 
lias  an  average  diameter  of  from  four  to  seven  millimetres.  In  hyi)er- 
trophy  it  may  measure  from  thirteen  to  twenty  millimetres.  The  left 
auricle  has  a  nornud  thickness  of  about  three  millimetres,  which  may  be 
(Iduhled  in  hypertrophy.  'J'he  wall  of  the  right  auricle  is  thinner  than 
that  of  the  left,  rarely  exceeding  two  millimetres  in  diameter.  The  appen- 
dices of  the  auricles  often  present  marked  increase  in  thickness  and  tlio 
musculi  pectinati  are  greatly  developed. 

The  shape  of  the  heart  is  altered  in  hypertrophy ;  with  great  enlarge- 
ment of  the  ventricles,  the  apex  is  broadened,  and  the  conical  slia])e  is  lost. 
In  the  enormous  enlargement  of  aortic  insiithciency  this  rotundity  of  the 
a[)ex  is  Aery  marked.  When  the  right  ventricle  is  chiefiy  all'ected  it  occu- 
pies the  largest  share  of  the  apex.  In  mitral  stenosis  the  contrast  is  very 
striking  lietween  the  large,  broad  right  ventricle,  reaching  to  the  apex, 
and  the  small  left  clunnber. 

The  hy[)ertrophied  muscle  has  a  deep  red  color,  is  firm,  and  is  cut  with 
ini'ivusing  resistance.  The  right  ventricle,  as  Kokitansky  noted,  may  have 
a  in'cnliar  hard,  leathery  consistence.  In  simple  hypertrophy  of  the  left 
ventricle  the  paj)iUary  muscles  and  the  columme  canuvc  may  be  enlarged, 
hut  the  former  are  often  much  flattened  in  dilated  hypi'rti'ophy.  The 
Miusculur  tnibeculae  are  more  developed,  as  a  rule,  in  the  right  ventricle 
than  in  the  left. 

The  increase  in  size  of  the  lieart  is  ])robably  due  to  a  definite  numerical 
iiinvase,  resulting  from  dcvelojuneiit  of  new  fibres. 

Symptoms. — irypertro])liy  is  a  conservative  process,  secoiuhiry  to 
some  valvular  or  arterial  lesion,  and  is  not  necessarily  accompanied  by 
syinj)toms.  So  admirable  is  the  adjusting  jiower  of  the  heart  that,  for 
oxaiiiplc,  an  advancing  stenosis  of  aortic  or  mitral  orifice  may  for  years  bo 
perfectly  c(pialized  by  a  iirogressive  liyjiertrophy,  and  the  subject  of  the 
affection  be  happily  unconscious  of  the  existence  of  heart-troulde.  llyper- 
t 'ophy  is  ill  almost  sill  cases  an  unmixed  good;  the  symptoms  which  arise 
are  usually  to  bo  attributed  to  its  failure,  or,  as  we  say,  to  disturbance  of 
eoin[)eiisa.tion. 

Among  the  most  common  symptoms  are  unpleasant  feelings  about  the 
heart — a  sense  of  fulness  and  discomfort,  rarely  amounting  to  pain.    This 


\h\i\ia 

1  J.  A'i\ 


Hj     ^'i 


fiOO 


DISHASKS   (»!•'   TIIK  ClIlCiri.ATOUY   SVSTKM. 


limy  lu'  very  ii()tic('ul)lo  when  llic  palit'iit  is  rcciimlii'ni  on  llu- Icl't  side. 
A<'(iiiil  pain  is  rare,  i-xci^pt  in  the  irrilaMc  heart  I'ntni  toliacco  nr  in  ikui 
astlienics.  I'nlpitalion  may  not  occur,  n(»r  (h)  patients  always  have  sen- 
sations from  tile  violent  shocks  ol'  a}.!:really  hypertropiiied  orj^aii.  Thciv 
are  instances  in  whicli  very  nneasy  I'eelinifs  arise  rroin  a  moderately  e\:ii:- 
fjerated  j)ulsation.  'IMi(>  ^'t;neral  condition  has  nnicii  to  do  with  this.  In 
health  we  are  not  conscious  of  the  heart's  pulsations,  hut  ouv  of  the  liisi 
indications  of  exliaustion  from  excesses  or  overstiidy  is  the  consciousness 
of  the  heart's  action,  not  necessarily  with  pjilpilation.  II(>adaches,  tliisli- 
inj:;s  of  tlu^  face,  noises  in  the  ears,  and  Hashes  of  li«j;ht  may  lu^  present. 

Certain  untoward  elTects  of  lon<i;-continned  hypertrophy  of  the  left 
ventricle  must  he  nu'iitioni'd,  chief  amonj,'  which  is  the  production  of 
artt'rio-sclerosis.  I'articularly  is  this  the  case  when  the  hypertrophy  rc- 
sidts  from  increased  j)eripheral  resistanci'.  Thi'  hei^htene(l  hlood-pi-essnrc 
(expressed  hy  the  word  strain)  in  the  arteries  j^'radnally  induces  an  eiidiir- 
teritis  and  a  stilT,  iiu'histie  state  of  those  ves.sels  most  exposal  |,o  it — viz., 
the  iiorta  and  its  prinuiry  divisions.  In  overconunj^  the  peripheral  nh- 
struction  the  hypertrophy  "  rui.is  the  arteries  as  a  secpiential  resnll" 
(l''(4.her!;ill).  J'rol()n<.;:ed  nuiscul.ir  exertion  also  nets  injuriously  in  llii.s 
way. 

Another  danjjer  is  rupture  of  the  bh)od -vessels,  particularly  those  of  the 
brain.  In  j^eiieral  arterial  dej^eneration  associated  with  c(nitracted  kidnevs 
and  hyjiertrophied  left  iu-art  apoplexy  is  common.  Indeed,  in  the  majority 
of  cast's  of  (H'rebrul  IniMuorrhafie  there  is  sclerosis  of  the  smaller  vessels, 
often  with  the  development  of  miliary  anourisnis,  and  the  rupture  may  ho 
eau.sed  hy  the  forcible  action  of  the  heart. 

Physical  SigllS. —  iHsjHrtioii  may  show  hulijinjj  of  the  pnvcordia,  pro- 
ducinjr  in  children  marked  asyminetryof  the  clu'st.  It  may  0(H'ur  willi- 
out  jH'rieardial  adhesions,  which  Sehroetter  thinks  are  invariably  associated 
with  this  coiulition.  The  intercostal  sjtaees  are  widened,  ami  .the  area  of 
visilile  impulse  is  much  increased.  On  paljxitioii  the  impidse  is  fonilile 
and  lii-aviuiT,  and  with  each  systole  the  hand  or  the  ear  applied  over  the 
heart  may  be  visibly  raised.  A  slow,  heaving  impulse  is  one  of  the  lust 
sijxns  of  simple  hypertro|)hy.  With  lari^e  dilated  hypertrojdiy  the  fopihio 
impulse  is  often  more  sudden  and  abrupt.  A  second,  weaker  impulse  can 
sometimes  be  felt,  due  perhaps  to  a  rebound  from  the  aortic  valves  ((iowcrs). 
The  beat  may  be  felt  in  the  sixth,  seventh,  or  eij^hth  interspace  from  unc 
to  three  inches  outside  the  nipple.  This  downward  dislocation  of  tlio 
apex  is  an  important  sign  in  hypertrophy  of  the  left  ventricle.  In  niodei- 
ate  grades,  such  as  are  seen  in  chronic  Hright's  disease,  the  impulse  ma\  ito 
in  the  sixth  intersjmce  in  the  nipple  line,  or  a  little  outside  of  it. 

Pt'irnstd'on  reveals  increased  dulness,  which  in  the  parasternal  lino 
may  begin  at  the  third  rib  or  in  the  second  interspace,  and  transvei  ->  ly 
may  extend  from  half  an  inch  to  two  inches  beyond  the  nipple  line  ;!iiil 
an  equal  distance  beyond  the  middle  line  of  the  sternum.     The  dull  :"'.'» 


llYrKllTUOIMIY   AND   DIIiATATloN. 


607 


is  mom  ovdiil  tliim  in  lifaltli.  Wlmii  curtifiilly  (Icliiiiitcd  tlio  c.oloHHal 
liv|uirln>i)liy  ol"  jiorLic  vulvti  discdisu  iiiii)  givi:  an  arcii  of  «liiliu!ss  Irotii  suviiii 
III  v\'^\\i.  inrlics  ill  ti'iui.svrrsn  cxtotit.  In  moderate  ^^'radcs  a  Iransvorsc 
(lidniiss  ol'  roiir  ini^lies  is  not-  imooininon. 

On  (iiisniUtilion  tlie  Honnds,  when  liie  valves  are  lieiiltiiy,  may  present 
no  special  changes,  bnt  I  lie  lirst  sound  is  often  |ii'oion;,fe(l  and  dnil. 
When  tluu'O  is  liilatation  as  well,  it  may  be  vtiry  clear  and  sharp.  IJedn- 
plieation  is  common  ii;  the  liyj)ertropliy  ol"  renal  disease.  A  peculiar  clink 
-  llie  liiilciiit'iit  iiir/<i//i(/ifi'  ol  I'ouillaiid — may  he  heard  jnst  to  the  ri^^lit 
ol'  \\\{'  apex  heut.  'IMic  second  sound  is  clear  and  loud,  sometiirnvs  I'in^atif^ 
in  cliaractei'  or  re(hiplicatc(|.  Willi  valvular  lesion.s,  the  sounds,  ol"  eoui'se, 
are  much  allereil,  and  are  I'eplai'ed  or  ai'companieij  hy  murmurs. 

In  simple  h\  pertropliy  not  dcpeudeiit  on  valvular  k!>ions,  the  puls<( 
is  usually  rei^nlar,  full,  stronj,',  and  of  lii;,di  tension.  It  may  he  in- 
ereaseil  in  rapi<lity,  hut  is  often  normal.  In  eccentric  hypertrophy  the 
pulse  is  full,  hilt  softer,  and  usually  more  rapid.  One  of  the  earliest  signs 
of  failure  aiul  dilatation  is  irre;,ndarity  and  iiitcrmitti-iice  of  the  pulse. 

Ilvjicrl'-ophy  of  the  /•//////  rnilriric,  in  tlu;  uchilt  very  rarely  follows 
valvular  disease  on  the  ri^^lit,  side,  hut  results  from  incn^ased  resistance  in 
the  pulmonary  eireulation,  as  in  cirrhosis  of  the  Iiin;.f  and  emphysema,  or 
in  stenosis  of  tlu'  mitral  orilice.  With  perfect  compensation,  wdiidi  fully 
maintains  the  (Mpiilibriiim  of  tlu^  circulation,  there,  an;  no  .syiniitonis. 
Kxtra  exertion,  as  the  a.S(!ent  of  stairs  or  running,  rmiy  cuiise  shortru^ss  of 
breath,  but  in  many  w^ays  hypertrophy  of  tint  right  vtMitricIc  is  the  most 
enduring  and  salutary  form  in  the  whole  cycle  of  cardiac  airtjctions.  l''oi' 
long  periods  of  years  [\w  elVectsof  mitral  stenosis  may  be  counterbalanced, 
and  only  sudden  death  by  acciilent  or  an  acute  disease;  reveal  the  existence 
of  an  unsuspected  lesion.  In  the  hypertrophy  secondary  to  cmphysctrna 
or  cirrhosis  of  ihe  lungs,  then;  may  be  sensitions  of  distress  in  the  cardiac 
region,  with  cough  and  shortness  of  breath  ;  but  as  long  as  the  dilatation 
is  moderate;  tlu;  syni[itoni.s  art;  not  marke(|.  Willi  great  dilatation  and 
triciisjiid  leakage  como  venous  eiig(»rgei'(;iit,  (edema,  and  pulmonary 
troubles.  The  increasod  [jHssure  in  the  lesser  circulation  lea<ls  to  schjrosis 
of  the  juihnoiiary  arteries  and  tlu;  constant  engorgenu;nt  of  the  (;apillaries 
leads  ultimately  to  a  deposition  of  pigme'iit  and  incre;ise  in  tlu;  fibrous 
elements  in  the  lung — the  brown  induration.  Ivxti'eme  pulmonary  con- 
gestion and  apo[)Iexy  are  more  often  associated  with  dilatation.  Iliumop- 
tysis  may  result  from  ruptur(>  of  vessels  during  sudden  exertion. 

Phjisiml  Si(/ns. — liulging  of  the  lower  part  of  the  sternuin  and  left 
cartilages  ()(;curs.  The  apex  beat  is  forceel  to  tlu;  left,  but  is  not  so  often 
displaced  downward.  The  most  marked  inipiils;'  may  be  in  the  angle 
between  the  ensiforin  cartilage  and  the  seventh  rib  or  beneath  the  carti- 
lages of  the  sixth  and  seventli  ribs.  The  pulsation  is  rather  diffuse, 
not  ]ninctuate,  particularly  if  there  is  much  dilatition.  In  thin-walled 
chests  tlioro  may  be  pulsation  in  the  third  and  fourth  right  interspaces. 
4;i 


iji*. 


;:< 


I 


Ml'/ 


(•» 


;<r 


4.' 


3, 


668 


DISEASES  OF  THE  CIRCULATORY   SYSTEM. 


The  cardiac  dulness  is  increased  transversely  und  toward  tlie  riglil  •  it 
may  extend  an  incli  or  more  beyond  the  border  of  the  stornuui.  On 
auscultation  the  first  sound  at  the  lower  part  of  the  sterimm  is  louder  and 
fuller  than  normal,  but  the  differences  are  not  very  marked  uidess  thcro 
is  much  dilatation,  when  the  sound  is  clearer  and  sharper.  Aecontuatiuu 
and  reduplication  of  the  second  souiul  are  heard  in  the  ])ulmonary  artery 
on  account  of  the  increased  tension.  The  pulse  at  the  wrist  is  usually  small. 
Pulsation  occurs  in  the  jugulars  when  there  is  tricuspid  iiieompetencc. 

Hypertrophy  of  the  aurides  always  occurs  with  dilatation.  It  is  uiDst 
common  in  the  left  chamber,  which  hypertrophies  in  mitral  stenosis  and 
incompetency  and  naturally  assists  in  restoring  the  balance  of  the  circu- 
lation. There  are  no  distinctive  physical  signs,  and  we  usually  can  infer 
its  presence  only  l)y  the  existence  of  mitral  stenosis  and  a  presystolic  nuir- 
mur.  Iiu'reased  dulness  may  be  determined  to  the  left  of  the  stornuin, 
and  there  may  be  a  presystolic  wave  in  the  secoiul  left  interspace. 

Hypertrophy  and  dilatation  of  the  right  auricle  are  met  with  (associ- 
ated with  a  similar  condition  in  the  right  ventricle  and  incompetency 
of  the  tricuspid)  in  emphysema,  cirrhosis  of  the  lung,  chronic  bronchitis, 
and  mitral  disease.  In  coiujiarison  with  the  left  auricle  the  greater  de- 
velopment and  hyitertrophy  of  the  ap])endix  and  its  musculi  pectinati  is 
very  striking.  The  latter  may  be  distributed  over  the  anterior  wall  of 
the  sinus  to  a  greater  extent  tlian  in  health.  There  are  increased  dulness 
in  the  third  and  fourth  interspaces,  j)ulsation  sometimes  presystolic  in 
rhythm,  signs  of  venous  engorgement,  jugular  pulsation,  and  other  evi- 
dences of  dilatation  of  the  right  heart. 

Diagnosis.  —  Among  conditions  to  be  distinguished  are  : 

(1)  Neurotic  palpitation,  from  whatever  cause,  even  when  very  forci- 
ble, has  not  the  heaving  impulse  of  genuine  hypertrophy.  Enlargement 
of  the  organ  may,  however,  follow  prolonged  overaotion,  as  in  the  smoker's 
heart,  the  irritable  heart  of  neurasthenics,  and  in  exophthalmic  goitre,  but 
it  is  usually  slight. 

(2)  The  increased  area  of  dulness  may  be  due  to  a  variety  of  causes, 
some  of  which  may  closely  ..iinulate  hypertrophy,  such  as  pericardial  effu- 
sion, aneurism,  mediastinal  growths,  or  displacement  of  the  heart  from 
pressure,  or  the  existence  of  malformation  of  the  chest.  With  the  exer- 
cise of  ordinary  care,  however,  the  diagnosis  can  usually  be  made.  There 
are  two  opposite  conditions  which  frecpicntly  give  trouble.  With  the  left 
lung  contracted  from  2)leurisy,  phthisis,  or  cirrhosis,  a  large  surface  of  the 
heart  is  exposed  ;  the  pulsation  may  be  extensive  and  forcible,  and  may  at 
first  sight  resemble  hypertrophy.  In  this  condition  there  is  dislocation 
upward  and  to  the  left.  The  existence  of  pulmonary  or  pleuritic  disease 
and  the  fixation  of  the  lung  on  deep  inspiration  will  suffice  to  prevent 
mistakes.  A  less  extensive  exposure  of  the  heart  may  occur  Avithout  any 
disease  in  very  narrow-chested  persons  with  ill-developed  lungs;  here, 
though  the  area  of  dulness  may  be  much  increased,  the  normal  position 


IIYPERTROPny  AND   DILATATION. 


669 


of  the  apex,  the  absence  of  forcible,  heaving  impulse,  and  of  any  obvious 
oauso  of  hypertropliy  will  afford  satisfactory  criteria  for  a  diagnosis,  'I'ho 
reverse  condition  exists  in  some  cases  in  which  emphysema  masks  moder- 
ate cardiac  hypertrophy.  The  area  of  dulness  may  be  normal,  or  even 
(liininished,  and  the  pulse  and  character  of  the  sounds  will  help  in  the 
(liairnosis;  but  it  is  sometimes  a  difTicult  matter. 

Prognosis. — I'he  course  of  any  case  of  cardiac  hypertrophy  may  be 
divided  into  tliree  stages: 

(rt)  The  period  of  development,  which  varies  with  the  nature  of  the 
primary  lesion.  For  examph;,  in  rupture  of  an  aortic  valve,  during  a  sud- 
den exertion,  it  may  re([uire  months  before  the  hyiiertrophy  l)ecomes  fully 
developed  ;  or,  iude(!d,  it  may  never  do  so,  and  death  may  follow  from  an 
uncompensated  dilatation.  On  the  other  haiul,  in  sclerotic  affections  of 
the  valves,  with  stenosis  or  incompetency,  the  hypertrophy  develops  step 
by  stej)  with  the  h-sion,  and  may  continue  to  counterbalance  the  progress- 
ive and  increasing  impairment  of  the  valve. 

{/))  The  period  of  full  compensation — the  latent  stage — during  Avliich 
the  heart's  vigor  meets  the  requirements  of  the  circulation.  This  period 
may  last  an  indefinite  time,  and  a  patient  nuiy  never  be  made  aware  by 
any  symptoms  that  he  has  a  valvular  lesion. 

(r)  The  period  of  broken  compensation,  which  may  come  on  suddenly 
during  very  severe  exertion.  Death  niay  result  from  acute  dilatation ; 
l)ut  more  commojdy  it  takes  place  slowly  and  results  from  degeneration 
and  weakening  of  the  heart-muscle. 

The  breaking  or  rupture  of  cardiac  compensation  may  be  induced  by 
many  causes,  among  which  the  most  important  are:  (1)  Failure  of  the 
general  nutrition.  In  many  instances  of  heart-disease,  exposure,  poor 
food,  and  alcohol  combine  to  bring  about  disturbance  of  a  well-balanced 
heart  lesion.  Acute  illiu'sses,  ])articularly  the  fevers,  may  induce  general 
debility  and  with  it  weakening  of  the  heart-muscle,  {'i)  Disturbance  of 
tlie  local  nutrition  of  the  heart,  owing  to  gradual  sclerosis  of  the  coronary 
arteries,  is  a  common  cause.  (.3)  Yi^ry  severe  muscular  exertion,  which  may 
disturb  a  compensation,  perfect  for  years,  and  induce  death  in  a  few  days 
(Traul)e).  (4)  Mental  emotions.  Severe  grief  or  fright  may  bring  on 
failure  of  compensation. 

The  prognosis  is  largely,  as  already  stated,  a  matter  of  maintained 
compensation.  Once  established,  the  hypertro])hy  rarely,  if  ever,  disap- 
])ears,  inasmuch  as  the  cause  usually  persists.  Occasionally,  perhaps,  the 
liypcrtrophy  associated  with  neurotic  palpitation  from  tobacco,  or  other 
causes,  or  the  hypertrophy  following  muscular  over-exertion,  may  dis- 
appear. 


m 


1  -' 


1 


670 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


Dilatation  of  the  Heart. 

Two  variotii'S  an;  recojjfuizcd,  dilatation  with  thickening  and  dilatu- 
tion  witli  tliiHMiiii(.  'I'lic  former  is  the  most  common,  and  coi'responds  lu 
the  (lihited  or  oeeciitric  hyiiertropliy. 

Etiology. — Two  important  causes  comhine  to  produce  dihitution— 
increased  pressure  within  the  cavities  and  imi)air_od_resistance,  due  to 
weakening  of  tiie  muscular  wall — wliicli  nuiy  act  singly,  hut  are  ofU'ti 
comhiiied.  A  weakened  wall  may  yield  to  a  normal  distending  fonc,  or 
a  normal  wall  may  yield  under  a  heightened  hlood-pressure. 

(1)  Heightened  endocardiac  pressure  results  either  from  an  increased 
(luantity  of  blood  to  he  nu)V(Kl  or  an  obstacle  to  be  ovei'come,  and  ir:  the 
most  frcfpient  cause.  It  docs  not  necessarily  bring  about  dilatation  ;  sim- 
ple hypertrophy  may  follow,  as  in  the  early  period  of  aortic  stenosis,  and 
in  the  hypcrtnjphy  of  the  left  ventricle  in  liright's  disease. 

A  majority  of  the  important  causes  of  increased  endocardiac  pressure 
have  already  been  discussed  under  hypertrophy.  One  or  two  may  be  con- 
sidered more  in  detail. 

'I'he  size  of  the  cardial-  chanibcr.s  varies  in  health.  "With  slow  actimi 
of  tiie  heart  the  dilatati'Ui  is  complete  and  fuller  than  it  is  with  rapiil 
action.  Physiologically,  the  limits  of  dilatation  are  reached  when  the 
chand)er  does  not  empty  itself  during  the  systole.  This  nuiy  occur  as  an 
acute,  transient  condition  in  severe  exertion — during,  for  example,  tlie 
ascent  of  a  mountain.  'Inhere  may  be  great  dilatation  of  the  right  heart, 
as  shown  by  the  increased  e])igastri(!  ])ulsation,  and  even  increase  in  the 
cardiac  dulness.  The  safety-valve  action  of  the  tricuspid  valves  may  here 
come  into  play,  relieving  the  lungs  by  permitting  regurgitatiim  into 
the  auricle.  With  rest  the  condition  is  removed,  but  if  it  has  been  ex- 
treme, the  heart  may  suffer  a  strain  from  which  it  may  recover  slowly,  or, 
indeed,  the  individual  may  never  1)0  aI)lo  again  to  undertake  severe  exer- 
tion. In  the  process  of  training,  the  getting  wiiul,  as  it  is  called,  is 
largely  a  gradual  increase  in  the  ca])ability  of  the  heart,  particularly  of 
the  right  chand)ers.  A  degree  of  exertion  can  be  safely  nmintained  in 
full  training  which  would  be  quite  impossible  under  other  circunistancos, 
because,  by  a  gradual  process  of  what  wc  may  call  physical  education,  the 
heart  has  strengthened  its  reserve  force — ■widened  enormously  its  limits  of 
physiological  work.  Endurance  in  prohmged  contests  is  measured  by  tlie 
capabilities  of  the  heart,  and  its  essence  consists  in  being  able  to  meet  the 
continuous  tendency  to  overstep  the  limits  of  dilatation. 

We  have  no  positive  knowledge  of  the  nature  of  the  changes  in  the 
heart  whicdi  occiur  in  this  process,  l)ut  it  must  be  in  the  direction  of 
increased  muscular  and  nervous  energy. ,  The  large  heart  of  athletes  may 
be  due  to  the  prolonged  use  of  their  muscles,  but  no  man  becomes  a 
great  runner  or  oarsman  who  has  not  naturally  a  capable  if  not  a  large 
heart,      blaster   McGrath,   the   celebrated   greyhound,   and   Eclipse,  the 


TKM. 


keniiig  and  dilutu- 
uiul  corre8p()n(ls  lo 

roduco  diliitatioii — 
^rt'sistiince,  ilm^  to 
ii<rlv,  l)iit  iuv  ofieii 
distt'uding  fonc,  dv 
ssuro. 

from  iin  inorciiscd 
veiTomi',  and  i^  llic 
out  dilatation  ;  siin- 

aortic  stenosis,  and 
^casf. 

"udoeardiae  pri'ssnrc 
1  or  two  may  bo  cuu- 

1,     AVitli  slow  action 
lian  it  is  with  rapiil 
V  reached  when  the 
his  may  oi-eur  as  an 
ijr,  f(n-  example,  the 
n  of  the  right  heart, 
even  increase  in  the 
spid  valves  may  here 
r  regurgitation   into 
it  if  it  has  been  ex- 
iiy  recover  slowly,  or, 
dertake  severe  exer- 
d,  as  it  is  called,  is 
heart,  particularly  of 
-ai'ely  maintained  in 
other  circumstances, 
ysical  education,  the 
)rmously  its  limits  of 
,s  is  measured  l)y  tin; 
ling  able  to  meet  the 
on. 
the  changes  in  the 
in  the  direction  of 
leart  of  athletes  may 
no  man  becomes  u 
ipable  if  not  a  largo 
d,  and  Eclipse,  tlif 


IlYPKRTROPnY  AND  DILATATIOX. 

race-horse,  both  famous  for  endurance  rather  tlian  speed,  had  very  largo 
hearts. 

Excessive  dilatation  during  severe  muscular  effort  results  in  heart- 
strain.  A  man,  perhaps  in  poor  condition,  calls  upon  his  heart  for  extra 
work  during  the  ascent  of  a  high  mountain,  and  is  at  once  seized  with 
pain  about  the  heart  and  a  sense  of  distress  in  the  epigastrium.  Ho 
hreathes  rapidly  for  some  time,  is  "puffed,"  as  we  say,  but  the  symptoms 
pass  off  after  a  night's  quiet.  An  attempt  to  repeat  the  rxercise  is  fol- 
idwed  by  another  attack,  or,  indeed,  an  attack  of  cardiac  dyspnn'a  may 
eonie  on  while  he  is  at  rest.  For  jnonths  such  a  man  may  be  unfitted  for 
severe  exertion,  or  he  may  be  permanently  incapacitated.  In  somi-  way  Im 
has  overstrained  his  heart  and  become  "  broken-winded."  Exactly  what 
has  taken  place  in  these  hearts  we  cannot  say,  but  their  reserve  force  is 
lost,  and  witii  it  the  power  of  meeting  the  demands  exacted  in  maintain- 
ing the  circulation  during  severe  exertion.  The  "  heart-shock  "  of  Ijathani 
includes  cases  of  this  nature — sudden  cardiac  breakdown  during  exertion, 
not  due  to  rupture  of  a  valve.  It  seems  probable  that  sudden  death  in 
men  during  long-continued  efforts,  as  in  a  race,  is  sometimes  due  to  over- 
distention  and  ])aralysis  of  the  lieart. 

Examples  of  dilatation  occur  in  all  forms  of  valve  lesions.  In  aortic 
iiieom]iitency  blood  enters  the  left  ventricle  during  diastole  from  the 
unguarded  aorta  and  from  the  left  auricle,  and  the  quantity  of  l)loo(l  at 
the  termination  of  diastole  subjects  the  walls  to  an  extreme  degree  of 
]irossure,  under  which  they  inevitably  yield.  In  time  they  augment  in 
tliickness,  and  present  the  tyi)ical  eccentric  hypertrophy  of  this  condition. 

In  mitral  insuthciency  blood  which  should  have  been  driven  into  the 
aorta  is  forced  into  and  dilates  the  auricde  from  which  it  canu',  and  then 
ill  the  diastole  of  the  ventricle  a  large  amount  is  returiKvl  from  the  auri- 
cle, and  with  increased  force.  In  mitral  stenosis  the  left  auricle  is  the 
seat  of  greatly  increased  tension  during  diastole,  and  dilates  as  well  as 
hyjiertrophies ;  the  distention,  too,  may  be  enormous.  Dilatation  of  the 
riglit  ventricle  is  produced  by  a  number  of  conditions,  which  were  con- 
sidered uiuler  hypertrophy.  All  circumstances,  such  as  mitral  stenosis, 
emphysema,  etc.,  which  permanently  increase  the  tension  of  the  blood  in 
tlie  pulmonary  vessels,  cause  its  dilatation. 

{'i)  Impaired  nutrition  of  the  heart-walls  may  lead  to  a  diminution  of 
the  resisting  power  so  that  dilatation  readily  occurs. 

The  loss  of  tone  due  to  parenchymatous  degeneration  or  myocarditis 
in  fevers  may  lead  to  a  fatal  condition  of  acute  dilatation.  It  is  a  recog- 
nized cause  of  death  in  scarlatinal  dropsy  (Goodhart),  and  may  occur  in 
rheumatic  fever,  tj'plms,  typhoid,  erysipelas,  etc.  The  changes  in  the 
hoart-nmscle  which  accompany  acute  endocarditis  or  pericarditis  may  lead 
to  dilatation,  especially  in  the  latter  disease.  In  anaemia,  leukaemia,  and 
chlorosis  the  dilatation  may  be  considerable.  In  sclerosis  of  the  walls,  the 
yielding  is  always  where  this  process  is  most  advanced,  as  at  the  left  apex. 


S?'a 


C72 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


Under  any  of  these  circumstances  the  walls  may  yield  with  normal  blood- 
pressure. 

IJoricardial  adhesions  are  a  cause  of  dilatation,  and  wo  p;enerally  flml 
in  cases  with  extensive  and  linn  union  considerable  hy|)ertroj)hy  and  dila- 
tation. There  is  usually  here  some  impairment  as  well  of  tlie  sujjerficiul 
layers  of  muscle. 

Morbid  Anatomy.— The  cojulition  usually  exists  with  hypertropliy 
in  two  or  nu)re  chand)ers.  It  is  more  common  on  the  rij^ht  than  on  tlio 
left  side.  The  most  extreme  dilatation  is  in  (uises  of  aortic  incomjjeteiiov, 
in  which  all  the  caviti(!s  may  be  enormously  distended.  In  mitral  stenosis 
the  left  auricle  is  often  trebled  in  capacity,  and  the  riji^ht  chambers  also  arc 
very  capacious.  The  auricles  may  (;ontain  from  eighteen  to  twenty  ounces 
of  blood.  In  chronic  lesions  of  the  lungs  the  right  chambers  are  chiellv 
involved.  In  great  distention  of  one  ventricle  the  septum  may  bulge 
toward  the  other  side.  The  auri(nilo-ventricular  rings  are  often  dilated, 
and  there  nuiy  be  an  increase  in  the  cinuimferenee  of  an  inch  and  a  half 
or  even  two  inches.  Thus,  the  tricus})id  orifice,  the  circumference  of 
which  is  about  four  and  a  half  in(;hes,  may  freely  admit  a  graduated  heart- 
cone  of  above  six  inches ;  and  the  mitral  orifice,  which  normally  is  about 
three  and  a  half  inches,  may  admit  the  cone  to  five  and  a  half  inches  or 
even  more.  Great  dilatation  is  always  accompanied  with  relative  incom- 
petency of  the  valves,  so  that  free  regurgitation  into  the  auricles  is  ])er- 
mitted.  The  orifices  of  the  vente  cavae  and  of  the  pulmonary  veins  may 
be  greatly  dilated. 

The  endocardium  is  often  opaque,  particularly  that  of  the  auricles. 
The  nuiscle  substance  varies  according  to  the  ])resence  or  absences  of  de- 
generations. The  microscope  may  show  marked  fatty  or  parenchynuitous 
change,  but  in  sonie  instances  no  special  alteration  may  be  noticeable. 
There  is  mn(di  truth  in  Xiemeyer's  assertion  "  that  it  is  not  possible  hy 
means  of  the  microsco])e  to  recognize  all  the  alterations  of  the  muscular 
fibrilla)  which  diminish  the  functional  power  of  the  heart."  Of  the 
changes  in  the  ganglia  of  the  heart  we  know  very  little.  As  centres  of 
control  they  probably  have  more  to  do  with  cardiac  atony  and  breakdown 
than  we  generally  admit.  Degeneration  of  them  has  been  noted  by  Put- 
jakin,  Ott,  and  otiiers. 

Symptoms  and  Physical  Signs. — Dilatation  causes  weakness  of 
the  cardiac  walls,  diminishes  the  vigor  of  their  contractions,  and  is  there- 
fore the  reverse  of  hypertrophy.  So  long  as  compensation  is  maintained 
the  enlargement  of  a  cavity  may  be  considerable.  The  limit  is  reached 
when  the  hypertrophied  Avails  in  the  systole  can  no  longer  expel  all  tlio 
contents,  part  of  which  remain,  so  that  at  each  diastole  the  chamber  is 
abnormally  full.  Thus,  in  aortic  incompetency  blood  enters  the  left  ven- 
tricle from  the  aorta  as  well  as  the  auricle ;  dilatation  ensues,  and  also 
hypertrophy  as  a  direct  effect  of  the  increased  pressure  and  increascnl 
amount  of  blood  to  be  moved.     But  if  from  any  cause  the  hypertro2)hy 


IIYPEUTROIMIY  AND  DILATATION. 


673 


weakens  and  the  ventricle  (lufin<,'  systole  fails  to  empty  itst'lf  completely, 
a  still  larger  amount  is  in  it  at  the  end  of  each  diastole,  and  the  dilatation 
becomes  greater.  The  amount  reinaiiung  after  systole  prevents  the  blood 
from  entering  freely  from  the  auricile.  Incomi)eteney  of  the  aurienlo- 
veiitricular  valves  follows,  willi  dilatation  of  the  aurich?  and  impeded 
lilood-flow  in  the  i)ulinonary  veins.  Dilatation  and  hypertrophy  of  the 
right  heart  may  compensate  for  a  time,  hut  when  this  fails  the  venous 
svstcm  becomes  engorged  and  dro])sy  may  result.  The  consideration  of 
the  symptoms  of  chronic  valvular  lesions  is  largely  that  of  dilatation  aiul 
its  cll'ects.  Acute  dilatation,  such  as  we  see  in  fevers  or  in  sudden  failure 
of  a  hypertrophied  heart,  is  ai!(U)mpanied  l)y  three  chief  symptoms — weak, 
usually  rapid,  impulse,  dyspnoea,  aixl  signs  of  obstructed  venous  circula- 
tion.    Cardiac  {)ain  may  be  preiX'ut,  but  is  often  absent. 

The  p/ii/sic(il  sif/ns  of  dilatation  are  those  of  a  weak  aiul  eidarged 
organ.  The  impulse  is  diifuse,  often  undulatory,  and  is  felt  over  a  wide 
area,  and  an  apex  beat  or  a  point  of  maximujii  intensity  may  not  exist. 
When  it  does  exist,  it  may  be  visible  and  yc^t  caniu)t  be  felt — a  valuable 
observation  nuide  by  Walshe.  An  extensive  area  of  im])ulse  with  a  (piiiik, 
weak  maximum  apex  beat  may  be  })resent.  When  the  right  heart  is 
cluelly  dilated  the  left  may  be  pushed  over  so  as  to  occujjy  a  much  less  ex- 
tensive area  in  front  of  the  heart,  and  the  true  ai)ex  beat  cannot  be  felt ; 
but  the  chief  impulse  is  just  below,  or  to  the  right  of,  the  xiphoid  carti- 
lage, and  there  is  a  wavy  i)ulsation  in  the  fourtii,  fifth,  and  sixth  inter- 
spaces to  the  left  of  the  sterimm.  In  extreme  dilatation  of  the  right 
auricle  a  pulsation  may  sometimes  be  seen  in  the  third  right  interspace 
close  to  the  sternum,  and  with  free  tricuspid  regurgitation  this  may  be 
systolic  in  character.  Whether  the  pulsation  frerpiently  seen  in  the  sec- 
ond left  interspace  is  ever  due  to  a  dilated  left  auricle  has  not  been  deter- 
mined. I  have  sometimes  thought  it  was  presystolic  in  rhythm,  though 
it  may  be  distinctly  systolic.  Post  mr)rtcm,  it  is  rare  in  the  most  extreme 
distention  to  see  the  auricular  appendix  so  far  forward  as  to  warrant  the 
belief  that  it  could  beat  Jigainst  the  second  interspace.  The  area  of  dul- 
ness  is  increased,  but  an  emphysematous  lung  or  the  fully  distended  organ 
in  a  state  of  brown  induration  may  cover  over  the  heart  aiul  greatly  limit 
the  extent.  The  directions  of  increase  were  considered  in  connection  with 
hypertrophy. 

The  first  sound  is  shorter,  sharper,  more  valvular  in  character,  and 
more  like  the  second.  As  the  dilatation  becomes  excessive  it  gets  weaker. 
Reduplication  is  not  common,  but  occasionally  diirerences  may  be  heard 
in  the  first  sound  over  the  right  and  left  hearts.  The  sounds  are  fre- 
<|ueutly  obscured  by  murmurs,  which  are  produced  by  incompetency  of 
tilt,  valves  due  to  the  great  dilatation,  or  are  associated  with  the  chronic 
valve  disease  on  wliich  the  condition  depends.  The  aortic  second  sound 
is  replaced  by  a  murmur  in  aortic  regurgitation.  The  pulmonary  sound 
is  accentuated  in  mitral  regurgitation  and  pulmonary  congestion,  but 


4 


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I.' 


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GU 


DlSHASliS  OP  THE  CIRCULATORY  SYSTEM. 


witli  extreme  (liliitiitioii  it  iiiiiy  be  nmcli  weukciicd.  Tlie  lieart's  aetioii 
is  irrojfuiiir  aiul  intermittent,  and  the  j)ulse  is  small,  Aveai<,  and  iniiek. 

On  aiiscidtation  l)oth  tiit^  sounds  may  be  free  from  tnnrmur.  Often 
tiiere  is  tiie  conditioti  known  as  emUrvoeardia  or  fo'tal  licart-rliytliin,  in 
wliicli  the  first  and  second  sounds  are  very  alike,  and  the  h)njf  pause  is 
KJiorteiU'd.  In  other  instances  there  is  the  typical  and  characteristic 
gallop  rhythm,  rarely  I'oniul  apart  from  conditions  of  dilatation.  With 
the  various  valvular  lesions  the  corres|ioiulin]i,'  niurnuirs  may  l)e  heard. 
Murmurs,  however,  M'hich  have  been  [)resent  may  disappear,  as  in  the  case 
of  mitral  stenosis.  In  other  instances  a  loud  systolic  murmur  may  l)e 
heard  at  tin;  apex,  and  Avhen  the  case  iirst  comes  under  obHcrvation  it 
muy  he  impossible  to  say  whether  this  is  due  to  organic  mitral  lesion. 
Tlie  nuirmur  may  be  confined  to  the  apex  rofjion,  or  propai^atcd  well  to 
the  back.  It  is  extremely  common  in  the  dilatation  which  follows  the 
hy[)ertr()i»hy  of  the  left  ventricle  in  arterio-sclerosis.  Under  treatment, 
with  the  ffradual  disa})i)earance  of  the  dilatation,  a  murnuir  of  this  kind, 
even  though  most  intensi-,  nniy  completely  disai)pear,  showing  that  it  has 
been  due  to  a  relative  insufficiency,  not  to  a  v'd\ular  lesion.  All  varieties 
of  arrhytluuia  may  occur  in  dilatation  of  the  heart.  The  pulse,  as  a  rule, 
is  small,  weak,  (piick,  and  often  irregular. 

Dilatation  and  Hypertrophy  due  to  Overexertion  and  Alcohol.— Thercf 

is  a  grouj)  of  cases  of  dilatation  and  hy[)ertrophy  dependent  upon  pro- 
longed overexertion,  which  rarely  comes  under  observation  until  compen- 
sation has  failed,  and  which  then  may  be  very  ditlieult  to  distinguish  from 
tlie  similar  conditions  produced  by  valvular  disease.  The  patients  are 
able-])odied  men  at  the  middle  period  of  life,  and  complain  iirst  of  pal- 
pitation or  irregularity  of  the  action  of  the  lieart,  shortness  of  breath,  and 
subsequently  the  usual  symi)tonis  of  cardiac  insufficiency  develop.  On 
in([uiring  into  tlie  history  of  these  patients  none  of  the  usual  etiological 
factors  causing  valve  disease  are  present,  but  they  liave  always  been  en- 
gaged in  laborious  occupations  and  have  usually  been  in  the  habit  of 
taking  stimulants  freely.  This  is  the  affection  which  has  been  specially 
studied  by  ^IcLean,  Cliiford  Albutt,  8eitz,  and  others,  and  in  its  earlier 
condition  by  Da  Costa,  in  what  he  termed  the  irritable  heart  It  is  met 
with  very  frequently  in  soldiers.  These  cases  may  return  to  hospital 
three  or  four  times  with  cardiac  insufficiency,  sometimes  with  slight  ana- 
sarca, htvmoptysis,  and  signs  of  jiulmonary  engorgement.  The  condition 
is  by  no  means  infrequent.  Bollinger  has  called  attention  to  the  common 
occurrence  of  dilatation  and  hypertrophy  in  benr-drinkers,  particularly  in 
the  workers  in  the  German  breweries,  who  drink  twenty  or  more  litres  in 
the  day.  Htrlimpell,  at  his  Erlangen  clinic,  told  me  that  this  condition 
was  very  common  in  the  draymen  and  workers  in  the  breweries  of  that 
town,  very  few  of  whom  pass  the  forty-fifth  year  Avithout  indications  of 
hypertrophy  and  dilatation  of  the  heart.  On  post-mortem  examination  the 
valves  may  be  quite  healthy,  the  aortji  smooth,  and  no  extensive  arterio- 


AFFECTIONS  OF  TIIK   MYGCARDILTM, 


G75 


sclerosis  or  roiiiil  (Hsoaso.  'IMu'  heart  \V('i<f|is  from  (M;;l»teon  to  twcnty-fivo 
ounces;  the  chtiiiiher.s  are  dihited.  'I'he  condition  lias  heeii  met  with  also 
in  animals,  and  ilonghton  states  that  the  heart  ol"  the  celcl)ratcd  grey- 
hound Master  Mel! rath  weighed  U-^u  ounces,  jnst  throefohl  in  excess  of 
ihc  normal  proportion  of  heart-weight  to  hody-wcight. 

Idiopathic  Dilatation. — And,  lastly,  thei-e  are  other  cases  in  which 
tlilatatioji  of  the  heart  occurs  without  discoverahle  cause.  In  some  in- 
stances tlicre  has  hoeu  ii  history  of  sudden  exercise  or  of  mental  enudion, 
but  in  other  cases  the  condition  seems  to  have  c(»me  on  spontaneously. 
In  some  the  condition  is  acute  and  the  patirnt  has  dys|in(ca,  slight  cyano- 
sis, cough,  and  great  cardiac  distress.  Death  juay  occur  in  a  few  days,  or 
dropsy  iiuiy  su[)ervenc  and  the  case  may  heconu'  chronic.  Delalield  has 
reported  an  interesting  series  of  cases  of  this  groU(). 

Treatment. — The  treatnu'ut  of  iiypertrophy  and  dilatation  has  al- 
ready hceu  considered  under  the  section  on  valvular  lesions.  I  would 
only  here  emphasize  the  fact  that  with  signs  of  dilatation,  as  indicated  hy 
gallop  rhythm,  urgent  dyspno\i,  and  slight  livid ity,  venesection  is  in 
many  cases  the  only  means  by  which  the  life  of  the  patient  may  be  sjivcd, 
and  from  twenty-five  to  thirty  ounces  of  bh)od  should  be  abstracted  with- 
out delay.  Subseqiu'utly  stimulants,  such  as  ammonia  and  digitalis,  may 
he  administered,  but  they  are  accessories  only  to  the  l)leeding  in  the  criti- 
cal condition  of  acute  dilatation,  Avhich  is  so  frequently  met  with  in 
cardiac  lesions. 


I . 


{ 


1  «Aii 

ft" 


A- 


ri 


IV.    AFFECTIONS  OF  THE   MYOCARDIUM. 

1.  Lesions  due  to  Disease  of  the  Coronary  Arteries.— A  knowledge  of  the 
changes  i)roduced  in  the  myocardium  by  disease  of  the  coronary  vessels 
gives  a  key  to  the  understanding  of  many  j)roblems  in  cardiac  luithol- 
ogy.  The  terminal  branches  of  the  coronary  vessels  are  end  arteries. 
The  blocking  of  one  of  these  vessels  by  a  thrombus  or  an  embolus  leads  to 
ii  condition  which  is  known  as — 

(a)  Aiucmic  necrosis,  or  white  infarct.  This  is  most  commonly  seen 
ill  the  left  ventricle  and  in  the  septum,  in  the  territory  of  distribution 
of  the  anterior  coronary  artery.  The  affected  area  has  a  yellowish- 
white  color,  sometimes  a  turbid,  parboiled  aspect,  at  others  a  grayish- 
red  tint.  It  may  be  somewhat  wedge-shaped,  more  often  it  is  irregular 
ill  contour  and  projects  above  the  surface.  Microscopically  the  changes 
are  very  characteristic.  The  nuclei  disappear  from  th:-  muscle  fibres, 
the  condition  of  fragmentation  is  present,  and  the  fibres  present  a  ho- 
niogcneous,  hyaline  appearance.  In  some  instances  there  is  com})lcte 
transformation,  and  even  to  the  naked  eye  a  firm  white  patch  of  hyaline 
liegeneration  may  appear  in  the  centre  of  the  area.  Sudden  death  not 
infrecpiently  follows  the  blocking  of  one  of  the  branches  of  the  coronary 


t'i 


070 


DISEASES  OK  TIIR  CIHCirFiATOUY  SYSTEM. 


artery  and  tlic  production  of  this  iinii'inic  iiooroHis.  ///  mcdicd-htjaJ 
caneH  it  u  a  point  of  priinary  im/iortnnrr  /o  inncni/jir  llml  t/n'.s  is  mic 
of  the  coiimioii.  niiiscs  (f  sittlilcH  drntli.  'I'liis  condilioii  sliould  lie  cjirc- 
fullv  soti^dit  Tor,  iiiasiiuich  us  it  niiiy  Ik;  tlic  soK;  lesion,  except  n  geiiernl, 
soiiictinies  sli^dit  arterio-sclerosis.  Uupturu  ol'  tlio  lieari  may  bo  -uhc 
c'hitod  with  aiiii'niic  necrosis, 

(/y)  Tho  st'cond  important  cITect  of  coronury-urtery  disease  n|.()n  the 
myocardium  is  seen  in  the  production  oi  fihninx  nii/(inin/i/i.s.  This  luav 
result  from  tlie  jfnidual  transformation  of  areas  of  ana-mic;  nec!'o.si>. 
More  commoidy  it  is  caused  by  the  narrowing  of  a  coronary  l)rancli  in 
a  process  of  ol)literativft  endarteritis.  'I'lie  sclerosis  is  most  freipientlv 
seen  at  the  apex  of  the  left  ventricle  and  in  the  sej)tum,  hut  it  iiiav 
occur  in  any  portion.  In  tho  septum  and  walls  tliore  arc  often  streaks 
and  patches  which  are  oidy  seen  in  carefully  nnide  systematic  sections. 
Ilypertropliy  of  the  heart  is  commonly  associated  with  this  degeneration. 
It  is  the  invariable  precursor  of  aneurism  of  the  heart. 

Complete  obliteration  of  one  coronary  iirtery,  if  jjroduced  suddenly,  is 
usually  fatal.  When  induced  slowly,  either  by  arterio-sclerosis  at  tlm  ori- 
fice of  the  artery  at  the  root  of  the  aorta  or  by  an  obliterating  endarteritis 
in  the  course  of  the  vessel,  the  circulation  may  be  carried  on  through  the 
other  vessel.  Sudden  death  is  not  uncommon,  owing  to  thrombosis  of  u 
vessel  which  has  become  narrowed  by  sclerosis.  In  the  most  extreme 
grade  one  coronary  artery  may  be  entirely  blocked,  with  the  production 
of  extensive  fibroid  disease,  and  a  main  branch  of  the  other  also  may  be 
occluded.  A  large,  powerfully  built  iml)ecile,  aged  thirty-five,  at  the 
Elwyn  Institution,  Pennsylvania,  who  had  for  years  enjoyed  doing  the 
heavy  work  about  tlie  place,  died  suddenly,  without  any  preliminary 
symptoms.  The  heart,  which  is  in  my  'collection,  weighed  over  twenty 
ounces;  the  anterior  coronary  artery  was  practically  occluded  by  oblit- 
erating endarteritis,  and  of  the  posterior  artery  one  main  branch  was 
occluded. 

(c)  Septic  Infarcts. — In  pyaemia  the  smaller  branches  of  the  coronary 
arteries  may  be  blocked  with  septic  emboli  and  cause  infarcts  in  the  myo- 
cardium in  the  form  of  abscesses,  \  uying  in  size  from  a  pea  to  a  pin's 
head.  I'hese  may  not  cause  any  disturbance,  but  when  large  they  may 
perforate  into  the  ventricle  or  inti*  the  pericardium,  forming  what  has 
been  called  acute  ulcer  of  the  heart. 

2.  Acute  Interstitial  Myocarditis. — In  the  fevers  and  in  pericarditis 
the  intermuscular  connective  tissue  is  swollen  and  infiltrated  with  roiuui 
cells  and  nuclei,  the  vessels  are  dilated,  there  are  minute  extravasations. 
and  the  muscle  fibres  may  be  granular  or  fatty,  with  indistinct  striic  and 
nuclei.  These  instances  have  been  met  with  in  typhoid  fever,  small- 
pox, and  diphtheria.  The  muscle  substance  is  pale,  soft,  and  easily  torn, 
and  the  condition  has  been  described  either  as  inflammatory  or  degener- 
ative. 


akkk(;ti()Ns  of  tiik  myocardium. 


677 


'.).  Parenchymatous  Degeneration.— 'IMi is  is  uMimlly  met  with  in  fovora, 
<ir  in  (Mtniifctioii  with  fiKldcnnlitis  or  pcricuniitiH.  It  is  cluiriictcri/cd 
liv  11  piilt',  tiirltiil  slate  ol'  the  canliac  imisclc,  which  is  general,  not  local- 
i/,c(l.  Turbidity  and  softness  are  the  special  features.  It  is  the  soft- 
eiii'(l  lieart  of  riU(*nnec  an«l  l.nuis.  Stokes  speaks  of  an  instance  in  which 
"so  great  was  the  softening  of  tiic  organ  that  wlu'ii  tiie  heart  was  gras[)e(l 
liy  the  great  vessels  and  hclil  with  the  aiu-x  pointing  upward,  it  fell  down 
over  the  iiand,  covering  it  like  a  cap  of  a  large  mushroom." 

Histologically,  there  i.-i  a  degeneration  of  the  muscle  lihrt^,  which  aro 
inliitraled  to  a  various  extent  with  grannies  which  resist  the  action  of 
ether.  Sometimes  this  granular  change  in  the  lihres  is  extreme,  and  no 
truce  of  the  striiB  can  bo  detected.  It  u  jjrohahly  the  cITect  of  a  toxio 
iigcut,  and  is  seen  in  its  most  ox<[uisit;(  form  in  the  lumbar  mustdes  in 
eases  of  toxic  luemoglohiiuiria  in  the  horse.  It  is  met  with  in  cases  of 
typhoid,  typhus,  small-pox,  and  other  infectious  diseases,  particularly  when 
the  course  is  protracted.  'J'here  is  no  dellnito  relation  between  it  and  tho 
liigh  temperature. 

A  form  of  myocarditis  has  been  described,  characterized  by  fragmonta- 
tiiin  of  the  tibres  owing  to  softening  of  the  cement  sul)stanee.  Ac(;ording 
to  von  IJecklinghausen  this  is  a  ])ost-mortem  change. 

4.  Fatty  Heart. — Umler  this  term  are  cndjraced  fatty  degeneration 
and  fatty  overgrowth. 

{ii)  Ftitfi/  t/rijt'in'rafin/i  is  a  very  common  condition,  and  mild  gi-ades 
are  met  with  in  many  diseases.  It  is  found  in  the  failing  nutrition  of 
old  age,  of  wasting  diseases,  ami  of  cachectic  states;  in  prolonged  infec- 
tious fevers,  in  which  it  may  follow  or  accompany  the  parenchymatous 
change  ;  associated  with  acute  and  chronic  .iiiitmias.  Certain  jioisons,  such 
asi)h()sphorus,  ])roduce  an  intense  fatty  degeneration.  Local  causes:  Peri- 
carditis is  usually  associated  with  fatty  or  ])arenchynuitous  changes  in  the 
su))erficial  layers  of  tho  myocardium.  Disease  of  the  coronary  arteries  is 
a  common  and  important  cause.  Lastly,  in  the  hypertrophied  ventricular 
wall  in  chronic  heart-disoaso  fatty  change  is  hy  no  means  infrequent. 
This  degeneration  may  be  limited  to  the  heart  or  it  may  be  more  or  less 
general  in  the  solid  viscera.  Tho  diai)hragm  may  also  bo  involved,  even 
when  tho  other  muscles  show  no  special  changes.  There  appears  to  be 
a  special  i)roneness  to  fatty  degeneration  in  the  heart-muscle,  which  may 
perhaps  be  connected  with  its  incessant  activity.  So  great  is  its  need  of 
an  abundant  oxygen  supply  that  it  feels  at  once  any  deficiency,  and  is  in 
consequence  the  first  muscle  to  show  nutritional  changes. 

Anatomically  the  condition  may  bo  local  or  general.  The  left  ven- 
tricle is  most  frequently  affected.  If  the  process  is  advanced  and  general 
the  heart  looks  large  and  is  flabby  and  relaxed.  It  has  a  light  yellowish- 
browu  tint,  or,  as  it  is  called,  a  faded-leaf  color.  Its  consistence  is  re- 
duced and  the  substance  tears  easily.  In  the  left  ventricle  the  papillary 
columns  and  the  muscle  beneath  the  endocardium  show  a  streaked  or 


;;  lU 


I   '  ! 


Ml   h 


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f  I' 


l^  I  • 


678 


DISEASES  OF  THE  CIHCULATORY  SYSTEM. 


patcliy  appearance.  Mioroscopically,  the  fibres  are  seen  to  be  oeeupui]  l.v 
niimito  jylobules  distributed  in  rows  along  tbc  line  of  llie  primitive  IIIjits 
(Welcli).  In  advanced  grades  the  fibres  seem  completely  occupied  by  tluj 
minute  glo])uleH. 

{/>)  Fdtlji  Ot'cr growth. — This  is  u.sually  a  simple  excess  of  the  normal 
subpcricardial  fat,  to  Avliich  the  term  cor  ndiposnm  was  given  bv  tiic 
older  writers.  In  other  instances  the  fat  infiltrates  the  muscular  suh- 
.stance  and,  separating  the  strands,  may  reacli  even  to  the  endoeardiiiiu. 
In  corpulent  j)ersons  there  is  always  much  pericardial  fat.  It  forms  pmt 
of  the  general  obesity,  and  occasionally  leads  to  dimgerous  or  even  fatal 
impairment  of  tl;e  contractile  power  of  the  heart.  Of  122  cases  analyzed 
by  Forehbeimer  there  were  88  males  and  ;3-t  females.  Over  eighty  per 
cent  occurred  betwei^n  the  fortieth  and  seventieth  years. 

The  entire  heart  may  be  envelo])ed  in  a  thick  sheeting  of  fat  through 
which  not  a  trace  of  muscle  substance  can  be  seen.  On  section,  i\w  fat 
infiltrates  the  muscle,  separating  the  fibres,  and  in  extreme  cases — particu- 
larly in  the  right  ventrirle — reaches  the  endocardium.  In  sonu'  places  there 
may  be  even  complete  substitution  of  fat  f(U'  the  muscle  substance.  In 
rare  instances  the  fat  may  be  in  the  papillary  muscles.  The  heart  is  usual- 
ly much  relaxed  and  the  chambers  are  dilated.  Microscopically  the  unis- 
cle  fibres  may  show,  in  addition  to  the  atrophy,  marked  fatty  degeneratiiMi. 

0.  Other  Degenerations  of  the  Myocardium.  (^0  /'''"""'"  Alr<ipli)i.~ 
This  is  a  common  change  in  the  heart-muscle,  particularly  in  chniiiic 
valvular  lesions  and  in  the  senile  heart.  When  advanced,  the  color  of  the 
muscles  is  a  dark  red-brown,  and  the  consistence  is  usually  iiuMvased. 
The  fibres  present  an  accumulation  of  yellow-brown  pigment  cliiclly 
about  the  nuclei.  The  cement  substance  is  often  unusutdly  distinct,  but 
seems  more  fragile  than  in  healthy  muscle. 

(/>)  Amyloid  degeneration  of  the  heart  is  occasionally  seen.  It  occurs 
in  the  intermuscular  connective  tissue  and  in  the  blood-vessels,  not  in 
the  fibres. 

{(')  The  hyaline  transformation  of  Zenker  is  sometimes  met  with  in 
prolonged  fevers.  The  affected  fibres  are  swollen,  homogeneous,  trans- 
lucent, and  the  strine  are  very  faint  or  entirely  absent. 

{(1)  Calcareous  degeneration  may  occur  in  the  myocardium,  and  the 
muscle  fibres  may  be  infiltrated  aiul  yet  retain  their  appearance  as  ligiu'cd 
and  described  by  Coats  in  his  Text-book  of  Pathology. 

Symptoms  of  Myocardial  Disea'se. —These  are  notoriously  un- 
certain, A  num  with  advanced  fibroid  myocarditis  may  drop  dead  sud- 
deidy,  Avhile  doing  heavy  work,  without  having  complained  of  cardiac  dis- 
tress. On  the  other  hand,  a  patient  may  present  enfeel)le(l,  irregular  action 
and  signs  of  dilatation;  he  may  have  shortness  of  breath,  onlema,  and  the 
general  symptoms  believed  to  be  characteristic  of  cases  of  filn'oid  and  fatty 
heart,  and  the  post-mortem  show  little  or  no  change  in  the  myocardium. 

Cardio-sclerosis  or  fibroid  heart  is  in  some  cases  characterized  by  a 
feeble,  irregular,  slow  pulse,  with  dyspncjoa  on  exertion  and  occasional  at- 


AFFECTIONS  OF  THE   MYOCARDIUM. 


679 


tacks  of  angina.  Irroguliirity  is  present  in  many,  bnt  not  in  all  oases. 
Tho  piii.so  may  bo  very  slow,  even  ;J0  or  40  per  minute.  Ultimately  the 
cases  come  under  observation  with  the  symptoms  of  cardiac  insuflicieney. 
The  arrhythmia,  which  may  have  been  present,  becomes  aggravated  and, 
according  to  Kiegel,  may  not  only  precede,  but  also  persist  after  the  car- 
diac insuflicieney  has  passed  away. 

Fatty  degeneration  of  tlie  heart  presents  the  same  ditticulties.  Extreme 
fatty  changes,  as  in  perniciou.<  ana-mia,  may  be  consistent  with  full,  regu- 
lar jndse  and  a  regularly  acting  heart.  In  some  of  these  cases  the  fat  does 
not  appear  to  interfere  seriously  with  the  function  of  the  organ.  The  truth 
is  it  nuiy  exist  in  an  extreme  grade  without  producing  symjjtoms,  so  long  as 
great  dilatation  of  the  chambers  does  not  occur.  The  cardiac  irregularity, 
tlie  (lyspna>a,  palpitation,  and  small  i)ulse  are  in  reality  not  symjjtoms  of 
the  fatty  degeneration,  but  of  dilatation  which  has  supervened.  The  fatty 
(irriis  senilis  is  of  no  moment  in  the  diagnosis  of  fatty  heart.  The  heart- 
sounds  may  be  weak  and  the  action  irregular.  When  dilatation  occuir.s, 
tliere  is  often  the  gallop  rhythm,  shortening  of  the  long  pause,  aiul  a  sys- 
tolic murmur  at  the  apex.  Shortness  of  breath  on  exertion  is  an  early 
featur'"  in  many  cases,  and  anginal  attacks  may  occur.  There  is  some- 
times a  tendency  to  syncope,  atul  in  both  fibroid  and  fiuty  heart  there  are 
attacks  in  which  the  patient  feels  cold  and  depressed  and  the  pulse  sinks 
to  40  or  :50,  or  even,  as  in  one  case  which  I  saw,  to  *^(i.  Tlie  ])atient  nuiy 
wake  from  sleep  in  the  early  morning  with  an  attack  of  severe  cardiac 
ustluna.  These  "  s})ells  "  may  be  associated  with  nausea  and  may  alter- 
nate Avith  others  in  which  there  are  anginal  symptoms.  These  are  the 
cases,  too,  in  which  for  weeks  tlu're  may  be  nu'iital  sym|)toms.  The  })a- 
tieiit  has  delusions  and  may  even  become  numiacul.  Toward  the  close, 
the  type  of  breathing  known  as  Cheyne-Stokes  may  occur.  It  was  de- 
scribed in  tiie  following  terms  by  John  Cheyne,  s})eaking  of  a  case  of 
fatty  heart  (Dublin  Hospital  Reports,  vol.  ii,  p.  '2'21,  1818)  :  "  For  several 
(lays  his  breathing  was  irregular ;  it  would  entirely  cease  for  a  quarter  of 
a  minute,  then  it  would  become  perceptible,  though  very  low,  then  by 
degrees  it  became  heaving  and  quick,  and  then  it  would  gradually  iH'ase 
again:  this  revolution  in  the  state  of  his  breathing  lasted  about  a  minute, 
ilaring  which  there  were  about  thirty  acts  of  resi)iratioii."  It  is  seen  much 
more  frequently  in  arterio-sclerosis  and  ura'mic  states  than  in  fatty  heart. 

Fatty  overgrowth  of  the  heart  is  a  condition  certain  to  exist  in  very 
tibese  persons.  It  produces  no  symptor.is  until  the  muscular  libre  is  so 
Weakened  that  dilatation  occurs.  These  patients  may  for  years  present  a 
feeble  but  regular  pulse;  the  heart-sounds  are  weak  aiid  mullled,  and  a 
Minrniur  may  be  heard  at  the  apex.  Attacks  of  cardiac  asthma  are  not 
uncommon,  ami  the  patient  may  suffer  from  bronchitis.  Dizziiu'ss  and 
l)seudo-apoplectic  seizures  nuiy  occur.  Sudden  death  un\y  result  from 
syncope  or  from  rupture  of  the  heart.  The  physical  examimition  is  ot  ^n 
diflicult  because  of  the  great  increase  in  the  fat,  and  it  may  be  impossible 
to  define  the  area  of  dulness. 


H  1 


r  , 


680 


DISEASES  OP  THE  CIRCULATORY  SYSTEM. 


For  practical  purposes  we  may  group  the  cases  of  myocardial  c^isoase 
as  follows : 

(1)  Those  in  which  sudden  death  occurs  with  or  without  previous 
indications  of  heart-trouble.  Sclerosis  of  the  coronary  arteries  exists 
— ill  some  instances  witli  recent  thrombus  and  white  infarcts;  in  others, 
extensive  fiI)roi(l  disease ;  in  others  again,  fatty  degeneration.  Muiiy 
patients  never  complain  of  cardiac  distress,  but,  as  in  the  case  of  Clial- 
mers,  the  celebrated  Scottish  divine,  enjoy  unusual  vigor  of  mind  and 
body. 

(2)  Ciises  in  which  there  are  cardiac  arrhythmia,  shortness  of  broatli 
on  exertion,  attacks  of  cardiac  asthma,  sometimes  anginal  attacks,  collapse 
symptoms  with  sweats  and  extremely  slow  pulse,  and  occasionally  marked 
mental  symptoms.  These  are  the  cases  in  which  the  condition  may  he 
strongly  suspected  and,  in  some  instances,  diagnosed.  It  is  rarely  possible 
to  make  a  distinction  between  the  fatty  and  fibroid  heart. 

(3)  Cases  in  which  there  are  cardiac  insutficiency  and  symptoms  of  dila- 
tation of  the  heart.     Dropsy  is  often  present,  and  with  a  loud  murmm-  it 
the  apex  it  may  be  dithcult,  unless  the  case  has  been  seen  from  th''  i.ntse; 
to  determine  whether  or  not  a  A'alvular  lesion  is  present. 

Frog'nosis. — T'he  outlook  in  affections  of  the  myocardium  is  ex- 
tremely grave.  Patients  recover,  however,  in  a  surprising  way  from  the 
most  serious  attacks,  particularly  those  of  the  second  group. 

Treatment. — Many  cases  never  come  under  treatment ;  the  first  are 
the  final  symptoms. 

Cases  with  signs  of  well-marked  cardiac  insufficiency,  as  manifested  by 
dyspncca,  weak,  irregular,  rapid  heart,  and  tt^dcma,  may  be  treated  on  the 
plan  laid  down  for  the  treatment  of  broken  compensation  in  valvular  dis- 
ease. Digitalis  may  be  given  even  if  fatty  degeneration  is  suspected,  and 
is  often  very  beneficial. 

Much  more  difficult  is  the  management  of  those  cases  in  which  there 
is  nuirked  cardiac  arrhythmia,  with  a  feeble,  irregular,  very  slow  pulse, 
and  syncope  or  angina.  Dropsy  is  not,  as  a  rule,  present;  the  heart- 
sounds  may  be  perfectly  clear,  and  there  are  no  signs  of  dilatation.  Di- 
gitalis, uiuler  these  circumstances,  is  not  advisable,  particularly  when  the 
pulse  is  infrequent.  Complete  rest  in  bed,  a  carefully  regulnted  diet,  and 
the  use  of  the  aromatic  spirits  of  ammonia,  sulphuric  ether,  and  stinnUaiits 
are  itulicated.  For  the  restlessness  and  distressing  fcelitigs  of  anxiety  ni'ir- 
phia  is  invaluable.  From  an  eightieth  to  a  sixtieth  of  a  grain  of  strydiiiia 
may  be  given  three  times  a  day.  If,  as  is  sometimes  the  case,  the  i)ulse  is 
hard  and  firm,  nitroglycerin  may  be  cautiously  administered,  begiiuiiuL^ 
with  one  minim  of  the  one  per  cent  solution  three  times  a  day  and  in- 
creased gradually. 

In  certain  cases  of  weak  heart,  particularly  when  it  is  due  to  fatty  over- 
growth, the  plans  recommended  by  Oertel  and  by  Schott  are  advanta- 
geous.    They  are  invaluable  methods  in  those  forms  of  he  ut-wci.'iiess 


3?. 


AFFECTIONS  OF  THE  MYOCARDIUM. 


681 


W; 


duo  to  intcmperaiico  in  eating  and  drinking  and  defective  bodily  exer- 
cise. The  Oertel  plan  consists  of  tlireo  })arts :  I'irst,  tlie  rednetion  in  the 
amount  of  liquid.  This  is  an  important  factor  in  reducing  tlie  fat  in 
those  patients.  It  also  slightly  increases  the  density  of  the  blood.  Oertel 
allows  daily  about  thirty-six  ounces  of  lifpiid,  which  includes  the  amount 
taken  with  the  solid  food.  Free  perspiration  is  j)r(»niotod  l)y  bathing  (if 
advisable,  the  Turkish  bath),  or  even  by  the  use  of  ])ilocarpine. 

The  second  important  point  in  his  treatment  is  the  diet,  which  should 
consist  largely  of  proteids. 

Morning. — Cup  of  coffee  or  tea,  with  a  little  milk,  about  six  ounces 
altogether,     l^ead,  three  ounces. 

Xoon. — Three  to  four  ounces  of  soup,  seven  to  eight  ounces  of  roast 
beef,  veal,  game,  or  poultry,  salad  or  a  light  vegetable,  a  little  fish ;  one 
ounce  of  bread  or  farinaceous  pudding;  three  to  six  ounces  of  fruit  for 
dessert.  No  liquids  at  this  meal,  as  a  rule,  but  in  hot  weather  six  ounces 
of  light  wine  may  be  taken. 

Afternoon. — Six  ounces  of  coffee  or  tea,  witii  as  much  wat-jr.  As  au 
indulgence  an  ounce  of  bread. 

Evening. — One  or  two  soft-boiled  eggs,  an  ounce  of  bread,  perhaps  a 
small  slice  of  cheese,  salad,  and  fruit ;  six  to  eight  ounces  of  wine  with  four 
or  live  ounces  of  water  (Veo). 

The  most  important  element  of  all  is  graduated  exercise,  not  on  the 
level,  but  up  hills  of  various  grades.  The  distance  walked  each  day  is 
mtirkod  off  and  is  gradually  lengtheiu'd.  In  this  way  the  heart  is  sys- 
tematically exercised  and  strengthened. 

At  the  Bad  Nauheim,  under  Schott,  good  results  are  obtained  by  a 
combination  of  stimulating  COg  batlis  and  a  system  of  "  resistance  gym- 
nastics" in  which  the  patient  makes  certain  dellnih;  movements  of  each 
liml)  In  succession,  winch  are  resisted  by  the  attendant.  Cases  of  fatty 
(ivorgrowth  of  the  heart  are  those  most  suitable.  'I'lu!  plan  of  treatment 
reduces  the  obesity,  ami  the  patients  are,  for  a  time  at  least,  nuich  more 
comfortable  and  are  able  to  go  about  and  do  their  work  without  cardiac 
distress  or  great  shortness  of  breath. 


•  Vim 


i; 


h  =1 1  n 


*  MP'i 


■A  M"\ 

V  f '  * 

.  i  I 

•  Mi    t 

ll  >  >  I 


■'li-p 


li. 


AXEI^'iasM    OF   THK    HlCAllT. 


y^. 


(<')  Aneurism  of  a  Valve  results  from  acute  endocarditis,  which  pro- 
du.  softening  or  erosion  and  may  lead  eitiier  to  perforation  of  the  seg- 
ment or  to  gradual  dilatation  of  a  limited  area  under  the  inlliience  of  the 
bleed-pressure.  The  aneurisms  are  usually  spheroidal  and  project  from 
the  ventricular  face  of  a  sigmoid  valve.  They  are  nuieh  less  common  on 
the  mitral  segments.  They  frecpicntly  rupture  and  produce  extensive 
dcstniction  and  incompetency  of  the  valves. 

{/')  Aneurism  of  the  Walls. — 'i'his  comparatively  rare  condition  results 
from  the  weakening  of  the  walls  by  chronic  njyocarditis,  oi  occasionally 


682 


DISEASES  OP  THE  CIRCULATORY  SYSTEM. 


it  follows  mural  endociinlitis,  wliieh  more  commonly,  howovor,  leads  to 
perforation.  Aneurism  has  followed  a  stab-wound  of  tlie  heart.  The 
left  veuiriele  near  the  apex  is  usually  the  seat,  at  the  situation  in 
which  tlie  fibrous  degeneration  is  most  common.  Fifty-nine  of  the  90 
cases  collected  by  Legg  were  situated  here.  In  the  early  stages  tlie  ante- 
rior wall  of  the  ventricle,  near  the  septum,  sometimes  involving  the  septini; 
itself,  is  slightly  dilated,  the  endocardium  opa(|ue,  and  the  muscular  tissiui 
sclerotic.  In  a  more  advanced  stage  the  dilatation  is  j'l'onounced  and 
layers  of  thrombi  occu})y  the  sac.  Ultimately  a  large  rounded  tumor  may 
project  from  the  ventricle  and  may  attain  a  size  equal  to  that  of  the  heart 
Occasionally  the  aneurism  is  sacculated  and  commuiucates  with  the  ven- 
tricle through  a  very  small  orilice.  The  sac  nuiy  be  double,  as  in  a  case 
reported  by  Janeway.  In  the  museum  of  Cuy's  Hospital  there  is  a  .•;])eci 
men  showing  the  wall  of  the  ventricle  covered  with  aneurisiual  bulgiugs. 
llu])tui-e  occurred  in  7  of  the  90  cases  collected  by  Legg. 

The  ,s7/)«/"i,»v  produced  by  aneurism  of  the  heart  are  indefinite.  Oc- 
casionally the.  I.  irked  bulgiiig  in  the  apex  region  and  the  tumor  niav 
perforate  the  cic  vvall.  AVhen  the  sac  is  large  and  produces  pressure 
upon  the  heart  itself,  there  nuiy  be  a  inarked  disproportion  l)ctwi'eii  tlio 
strong  cardiac  impulse  and  the  feeble  pulsatioTi  in  the  peripheral  'irtcrics. 

RUPTIKE    OF   TlIK    IIkAUT. 

This  rare  event  is  usually  associated  with  fatty  infiltration  or  degenera- 
tion of  the  heart-muscles.  In  some  instances,  acute  softening  in  conse- 
quence of  emliolism  of  a  branch  of  the  coronary  artery,  suppurative  myo- 
carditis, or  a  gummatous  growth  has  been  the  cause.  Of  100  cases  col- 
lected by  Quail.,  fatty  degeneration  wa^  noted  in  77.  Two  thirds  of  the 
patients  were  over  sixty  years  of  age. 

The  rent  may  occur  in  any  of  the  chambers,  })ut  is  found  most  fre- 
quently in  the  left  ventricle  on  the  anterior  wall,  not  far  from  the  septum. 
The  accident  usually  takes  place  during  exertion.  There  may  ])e  no  jire- 
liminary  symptoms,  but  Avithoiit  any  warning  tlie  patient  may  fall  and  die 
in  a  few  moments.  Sudden  death  occurred  in  seventy-one  jicr  ci'iit  of 
Quain's  cases.  In  other  instances  there  may  be  in  the  cardiiic  ri'gidii  ji 
sense  of  anguish  and  suffocation,  and  life  may  be  prolonged  for  sevenil 
hours.  In  a  Montreal  case  which  I  examined  the  patient  walked  up  a 
steep  hill  after  the  onset  of  the  symptoms,  and  lived  for  thirteen  hours. 
A  case  is  on  record  in  which  the  patient  lived  for  eleven  days. 


New  Growths  axd  Pauasitks. 

Tubercle  and  syphilis  have  already  been  considered.  Primary  cancer 
or  sarcoma  is  extremely  rare.  Secondary  tumors  may  be  singU;  or  niiil- 
tiple,  and  are  usually  unattended  M'ith  . symptoms,  even  when  the  disi'use 


AFFECTIONS  OP  THE  MYOCARDIUM. 


CS3 


is  most  extensive.  In  one  case  I  fouiul  iu  the  wall  of  the  right  ventricle 
a  mass  which  involved  the  anterior  segment  of  the  tricuspid  valve  and 
partly  blocked  the  orilice.  The  surface  was  eroded  and  there  were  nu- 
merous cancerous  emboli  in  tlie  pulmonary  artery.  In  anotlier  instance 
tlic  heart  was  greatly  eidargcd,  owing  to  the  })rescnce  of  innumerable 
masses  of  colloid  (  ancer  the  size  of  cherries.  The  mediastinal  sarcoma 
may  penetrate  the  heart,  though  it  is  remarkable  how  extensive  the  dis- 
ease of  the  mediastinal  glands  may  be  without  involvement  of  the  heart 
or  vessels. 

Cysts  in  the  heart  are  rare.  They  are  found  in  different  parts,  and 
are  filled  either  with  u  brownish  or  a  clear  fluid.  Blood-cysts  occasionally 
occur. 

The  parasites  will  be  discussed  under  the  appropriate  section,  but  it 
may  be  mentioned  here  that  ])oth  the  cyst  ice  re  us  celluloscB  and  the  echino- 
coccus  cysts  occur  occasionally  in  the  heart. 


'irtcru'; 


ir\  cancer 
|(>  or  mul- 
lic  disi'iiso 


Wounds  akd  FonEicx  Bodies. 

Wounds  of  the  heart  are  usually  fatal,  although  there  are  many  in- 
stances in  which  recovery  has  taken  })lace.  Bullets  have  been  found  en- 
cysted inside  the  ventricle.  A  majority  of  the  cases  of  gunshot  wounds, 
however,  are  necessarily  fatal.  I'uncture  of  the  heart  by  a  sharp-point- 
ed body,  such  as  a  needle  or  a  stiletto,  does  not  always  ju'ove  fatal. 
Poab(jdy  has  re{)orted  a  case  in  wliicdi  a  })in  was  found  embedded  in  the 
left  ventricle.  Suicide  has  been  attempted,  by  })assing  a  needle  or  pin 
into  the  heart.  It  is  net,  however,  necessarily  fatal.  Moxon  mentioned  a 
case,  at  the  Clinical  Society  of  London,  in  which  a  medical  student,  while 
on  a  spree,  })asscd  a  pin  into  his  heart.  The  pericardium  was  opened,  and 
the  head  of  the  pin  was  found  outside  of  the  right  ventricle.  It  was 
gras])ed  and  an  attem])t  nuide  to  remove  it,  but  it  was  withdrawn  into  the 
heart  and,  it  is  said,  caused  the  ])atient  lu)  further  trouble.  Hysterical 
girls  sometimes  swallow  jiiiis  and  needles,  which,  passing  through  the 
o'so])hagus  and  stomach,  are  found  in  various  parts  of  the  body.  A  re- 
markable case  is  reported  l)y  Allen  .1.  Smith  of  a  girl  from  whom  vfeveral 
dozen  needles  and  j)ins  were  removed,  usually  from  subcutaneous  abscesses. 
Several  years  later  she  developed  sym])toms  of  chronic  heart-disease.  At 
tlie  post-mortem  needles  were  found  in  the  tissues  of  the  adherent  peri- 
eaniinm,  and  between  thirty  and  forty  were  embedded  in  the  thickened 
pleural  membranes  of  the  left  side. 

Puncture  of  the  lieart  has  been  recommended  as  a  therapeutic  pro- 
cedure to  stimulate  it  to  action,  as  in  chloroform  narcosis,  ami  experi- 
mental evidence  has  been  brought  forward  by  B.  A.  Watson  in  favor  of 
the  operation.  He  advises  abstrai:tion  of  blood  in  combination  with  the 
puncture — cardioeentesis.  The  proceeding  is  not  without  risk.  Ilajmor- 
rhage  may  take  ])lace  from  the  puncture,  though  it  is  not  often  extensive. 
44 


i   t 


684 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


Sloan  lias  reoontly  iii-nfod  its  use  in  all  cases  of  asphyxia  and  in  siifTo- 
cation  by  dn.w  iiiiif^  and  from  coal-gas.  The  successful  case  which  he  re- 
ports illustrates  forcibly  its  stimulating  action. 


V.  NEUROSES  OF  THE   HEART. 


Palpitation. 

In  health  wo  aro  unconsciona  of  the  action  of  the  heart.  In  some  peo- 
ple one  of  the  first  indications  of  debility  or  overwork  is  the  consciousiu'ss 
of  the  oardiiic  ])uls;itiniis,  which  mny,  however,  be  i)erfectly  rofjular  tnid 
orderly.  This  is  not  palpitation.  The  term  is  properly  limited  to  irregu- 
lar or  forcible  action  of  the  heart  perceptible  to  the  individual. 

Stiology. — The  expression  " percei)til)lo  to  the  individual"  covers 
the  essential  element  in  ]»!dpitation  of  the  heart.  The  most  extreme  dis- 
turbance of  rhythm,  a  conditinn  even  of  what  is  termed  delirium  ronlis, 
may  bo  unattended  wiMi  subjective  sensations  of  distress,  and  there  mav 
be  no  consciousness  of  disturbed  action.  On  the  other  hand,  there  are 
cases  in  which  complaint  is  made  of  tiie  most  distressing  palpitation  ;mil 
sonsiitions  of  throbbing,  in  which  the  physical  examination  reveals  a  regu- 
larly acting  heart,  the  sensations  tteing  entirely  subjective.  We  meet  with 
this  symptom  in  a  large  group  of  cases  in  which  there  is  increased  excita- 
bility of  the  nervous  .system.  Palpitation  may  be  a  marked  feature  at  the 
time  of  puV)erty,  at  the  climacteric,  and  occasionally  during  menstruation. 
It  is  a  very  common  sym])tom  in  hysteria  and  neurasthenia,  particularly  in 
the  form  of  the  );'Hcr  whicli  is  asyociate(l  Avith  d^^spepsia.  Eniotiims, 
such  as  fright,  are  common  causes  of  palpitation.  It  may  occur  as  a 
sequence  of  the  acute  fevers.  Females  are  more  liable  to  the  atfection  tluui 
males. 

In  a  second  group  the  palpitation  results  from  the  action  upon  the 
heart  of  certain  sul)staiice>,  such  as  tobacco,  coffee,  tea,  and  alcohol.  And, 
lastly,  pal|)itation  lUiiy  be  associated  with  organic  disease  of  the  heart, 
either  of  the  myoc^ardium  or  of  the  valves.  As  a  rule,  however,  it  is  a 
purely  nervous  ))hcnomeno!i — seldom  associated  witb  orgaitic  disease — in 
which  the  most  violent  action  and  the  most  extreme  irregularity  may  exist 
without  that  subjective  element  of  consciousness  of  the  disturbance  which 
constitutes  the  essential  feature  of  palpitation. 

The  irritable  heart  described  by  Da  Costa,  which  was  so  common  among 
the  young  soldiers  during  the  civil  war,  is  a  neurosis  of  this  kind.  Tiie 
chief  symptoms  were  [)a1pitation  with  great  frequency  of  the  pulse  on  ex- 
ertion, a  variabht  amount  of  cardiac  j)ain,  sind  dyspnoea.  The  factors  at 
work  in  producing  this  condition  appeared  to  be  the  mental  excitement, 
the  unwonted  muscular  exertion  associated  with  the  drill,  and  diarrh«a. 


NEUROSES  OF  THE  HEART. 


685 


The  ooiulitiou  is  i>ot  infrequent  in  civil  life  among  young  men,  and  it  leads 
ill  .some  cases  to  hypertrophy  of  the  heart. 

Symptoms. — In  the  mildest  form,  such  as  occurs  during  a  dys- 
peptic attack,  there  is  slight  Huttering  of  the  heart  and  a  sense  of  what 
]);iti(;nt3  sometimes  call  "goneness."  In  more  severe  att'icks  the  heart 
kats  violently,  its  i)ulsations  against  the  chest  wall  are  visible,  the  rapidity 
of  the  action  is  much  increased,  the  arteries  throb  forcibly,  and  there  is  a 
sense  of  great  distress.  In  some  instances  the  heart's  action  is  not  at  all 
cpiickened.  The  most  striking  cases  are  in  neurasthenic  women,  in  whom 
the  mere  entrance  of  a  jjerson  into  the  room  will  cause  the  most  violent 
action  of  the  heart  and  throbbing  of  the  peripheral  arteries.  The  ])ulse 
may  be  rapidly  increased  until  it  reaches  150  or  IGO.  A  dilfuse  Hushing 
of  the  skin  may  appear  at  the  same  time.  After  such  attacks,  there  may 
111'  the  passage  of  a  large  quantity  of  j)ale  urine.  In  nuiny  cases  of  pali)i- 
tiition,  particularly  in  young  men,  the  condition  is  at  once  relieved  by 
exertion.  A  ])atient  with  extreme  irregularity  of  the  heart  may,  after 
walking  quickly  one  hundred  yards  or  running  up-stairs,  return  with  the 
jiulse  perfectly  regular.  This  is  not  infrequently  seen,  too,  in  the  iriegu- 
lar  action  of  the  heart  in  mitral -valve  disease. 

The  physical  examination  of  the  heart  is  usually  negative.  The  sounds, 
the  shock  of  which  may  be  very  palpal)le,  are  on  auscultation  cleai',  ringing, 
iiiid  iiu'tallie,  but  iu)t  associated  with  murmurs.  The  second  sound  at  the 
b;ise  may  be  greatly  accentuated.  A  murnuir  may  sometimes  be  heard 
over  the  pulmonary  artery  or  even  at  the  ai)ex  in  cases  of  ra])id  action  in 
neurasthenia  or  in  severe  anaemia.  The  attacks  may  be  transient,  lasting 
only  for  a  few  minutes,  or  may  persist  for  an  hour  or  more.  In  some  in- 
stances any  attempt  at  exertion  renews  the  attack. 

The  proijno.^is  is  usually  good,  tliough  it  may  be  extremely  difficult  to 
remove  the  conditions  underlying  the  palpitation. 


.r 


'  ^tii' 


Aruiiythmia. 

An  intermission  occurs  when  one  or  more  beats  of  the  heart  are 
dropped.  Irregularity  is  the  condition  wlien  the  beats  are  unequal  in  vol- 
ume and  force,  or  follow  each  other  at  unerpuil  distances.  Allorrhythmia 
is  a  term  which  is  also  used  to  express  deviations  from  the  nornud  lieart 
rhythm. 

The  following  varieties  of  arrhythmical  action  may  be  recognized  : 

(1)  The  paradoxical  pulse  of  Kussmaul,  in  which  the  beats  during 
inspiration  are  more  frequent  but  less  full  than  during  exi)iration.  Tiiis 
is  found  in  weak  heart,  in  chronic  pericarditis,  and  when  fibrous  bands 
encircle  the  root  of  the  aorta  ;  but  it  may  also  occur  lujrnudly  from  the 
iiiiluence  of  the  respirations  upon  the  heart.  It  is  sometimes  to  be  felt  iu 
slwjang  children. 

(2)  Intcrmittence,  in  which  there  is  simply  au  intermission  or  drop- 


680 


DISEASES  OP  THE  CIRCULATORY  SYSTEM. 


ping  of  a  cardiac  beat.  Tlio  term  ilejicience  is  more  correctly  applied  to 
tlioso  instances  in  which  the  absence  of  the  heart-sound  proves  that  the 
systole  is  really  omitted.  The  systole  may  be  so  weak  as  not  to  prodiici'  a 
pulsation,  and  yet  at  the  same  time  a  feeble  first  sound  may  be  heard. 

(3)  The  alternate  heart-beat,  in  which  strong  and  weak  pulsations 
alteriuite  regularly  ami  which  is  expressed  in  the  peripheral  arteries  liy 
alternate  fidl  and  feeble  pulse-beats. 

(4)  The  bigeminal  and  trigemiind  pulsations  occur  when  two  or  three 
beats  follow  each  other  in  ra])id  succession,  each  group  being  separated 
from  the  following  by  a  longer  interval.  This  is  not  very  uncommon  in 
mitral  disease  and  as  an  effect  of  digitalis.  In  the  bigeminal  pulse  the 
first  beat  of  the  pair  is  usually  the  stronger.  Indeed,  in  the  condition 
known  as  heart  bigeminism  the  second  systole  is  so  feeble  that  the  pulse 
wave  does  not  reach  the  peri})lieral  arteries  and  the  two  systoles  are  re])re- 
sented  by  only  a  single  pulse-beat  at  the  wrist. 

(5)  Delirium  cordis,  in  which  those  various  factors  are  combined  and 
the  heart's  action  is  wholly  irregular. 

(0)  Fcjotal  heart  rhythm — embryocardia — described  by  Stokes,  is  a 
very  common  condition  in  which  the  long  panse  is  shortened  and  the 
characters  of  the  sounds  are '.'almost  completely  identical."  The  resem- 
blance to  the  fcetal  heart-l)eat  is  very  striking.  In  the  later  stages  of 
fevers  and  in  extreme  dilatation  this  form  of  heart  rhythm  is  very  fre- 
quently heard. 

(T)  (iallop  rhythm,  in  which  the  sounds  resemble  the  ff)otfall  of  a 
horse  at  canter,  usually  results  from  the  reduplication  of  the  second 
sound  in  a  ra])idly  acting  heart.  It  is  expressed  by  the  words  "  rat- 
ta-tat."  Sometimes  it  seems  as  if  the  first  sound  was  split;  more  com- 
monly it  is  the  second.  It  is  most  frequently  heard  in  interstitial  ne- 
phritis and  arterio-sclerosis,  but  it  is  said  to  be  met  with  also  in  healthy 
persons. 

The  causes  of  these  various  disturbances  of  rhythm  arc  thus  classified 
by  Vx.  Baumgarten  :  * 

(1)  Those  due  to  central — cerebral — causes,  either  organic  disease,  as 
in  luvmorrhiige,  or  concussion  ;  more  commonly  ])sychical  influences. 

(■•2)  Keflex  influences,  such  as  produce  the  cardiac  irregularity  in  dys- 
pepsia and  diseases  of  the  liver,  lungs,  and  kidneys. 

(.'?)  Toxic  influences.  Tobacco,  coffee,  and  tea  are  common  causes  of 
arrhythmia.  Various  drugs,  such  as  digitalis,  belladonna,  and  aconite, 
may  also  induce  it. 

(4)  Changes  in  the  heart  itself,  {a)  In  the  cardiac  ganglia.  Fatty, 
pigmentary,  and  sclerotic  changes  have  been  described  in  cases  of  this 
sort  and  may  have  an  important  influence  in  producing  disturbances  in 
the  rhythm ;  but  as  yet  we  do  not  know  their  exact  significance.     They 


*  Transactions  of  the  Association  of  American  Physicians,  vol.  ill. 


NEUROSES  OF  THE   HEART. 


687 


may  be  present  in  cases  wliieli  have  not  presented  arrliythrnia.  (h)  Mural 
c'liiinges  are  common  in  conditions  of  this  kind.  Siiiiph'  dilatalion,  i'atty 
(lt';,'oiieration,  and  scderosis  arc  most  connnouly  ])n'Sfiii,  tlie  two  latter 
usually  associated  with  sclerosis  of  tlu;  coronary  arteries. 

The  significance  of  arrhythmia  is  not  always  easy  to  determine.  Sim- 
ple irregular  action  of  the  heart  may  })ersist  for  years.  The  late  Chan- 
cellor Ferrier,  of  Mc(iill  University,  a  man  of  unusual  hodily  and  mental 
vigor,  who  died  at  the  age  of  eighty-seven,  had  an  extremely  irregular 
])ulse  for  ahnost  fifty  years  of  liis  life.  One  or  two  otlier  instances  have 
come  under  my  notice  of  persons  in  good  liealth,  without  arterial  or  car- 
diac disease,  in  whom  the  heart's  action  was  })ersistently  irregular.  Tlio 
l)igeminal  and  trigeminal  pulsations  are  found  more  fre(ptently  in  mitral 
than  ill  other  conditions.  I'he  delirium  cordis  is  met  with  in  the  dilata- 
tion associated  with  valvular  lesions,  particularly  toward  the  latter  stages. 
Fietal  heart  rhythm  is  rarely  found  apart  from  dilatation. 

Rapid  ITeaut— Tachycardia. 

The  rapid  action  may  be  perfectly  natural.  There  are  individuals 
whose  normal  heart  action  is  at  100  or  even  more  per  minute.  It  may 
he  caused  by  the  various  conditions  wliicli  iiuluce  palpitatictn ;  J)ut  the 
two  are  not  necessarily  associated.  iMuotioiial  causes,  violent  exercise,  and 
fevers  all  produce  great  increase  in  the  rajiidity  of  the  heart's  action. 
The  extremely  rapid  action  which  follows  fright  nniy  persist  for  days,  or 
eveu  weeks.  Tranbe  reports  an  instance  in  which,  after  violent  exercise, 
t'le  rapid  action  of  the  heart  continued.  Cases  are  not  uncommon  at  the 
menopause. 

There  are  cases  again  in  which  the  condition  can  hardly  be  termed  a 
neurosis,  since  it  depends  upon  definite  changes  in  the  pneumogastrics 
or  ill  the  medulla.  Cases  have  been  reported  in  Avliich  tumor  or  clot  in 
or  about  the  medulla  or  pressure  u})on  the  vagi  has  been  associated  with 
lieart  hurry.  Some  of  the  cases  of  frerpient  action  of  the  heart  in  women 
havvT  been  thought  to  be  due  to  reflex  irritation  from  ovarian  or  uterine 
disea.ie. 

Paroxysmal  tachycardia  is  a  remarkable  alfection,  characterized  by 
spells  of  heart  hurry,  during  which  the  action  is  greatly  increased,  the 
pulse  reacliing  200  and  over.  The  cases  are  not  common.  Tlie  condition 
1ms  been  thoroughly  studied  by  Xothnagel.  The  attack  may  be  (juite 
short  and  persist  only  for  an  hour  or  so.  A  ])atient  at  tlie  Philadelpliia 
lulirniary  for  Xervous  Diseases  was  attacked  every  wx'ck  or  two;  the  pulse 
would  rise  to  220  or  230,  and  there  were  such  feelings  of  distress  and  un- 
easiness that  the  patient  always  had  to  lie  down.  There  may  be,  however, 
no  sul)jective  disturbance,  and  in  another  case  the  patient  was  able  to 
walk  about  during  the  paroxysm  and  had  no  dyspnoea.  One  of  the  most 
remarkable  cases  is  reported  by  H.  C.  Wood.     A  physician  iu  his  eighty- 


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(588 


DISEASES  OP  TOE  CinCULATORV   SYSTEM. 


seventh  year  has  had  attucks  at  intervals  since  his  tliirty-sevoiitii  year. 
Tlie  onset  is  abrupt  uiul  the  pulse  rapidly  rises  to  200  a  niiiiuto.  For  more 
than  twenty  years  the  taking,'  ol'  ice-water  or  strong'  colTee  would  arrest  the 
attaiks.  lioiiveret  has  analyzed  a  lunnher  of  cases  of  this  essential  er 
idio|)atliic  form  ;  he  finds  that  a  i)erniaiicnt  cure  is  rare,  and  that  the  pu 
tients  suffer  for  ten  or  more  years.  Four  instances  termiiuited  fatally  from 
heart-failure.  Wood  suggests  that  these  cardiac  paroxysms  are  caused 
by  discharging  lesions  affecting  the  centres  of  the  accelerator  nerves. 
Fran(;ois  Franck  has  shown  that  the  acceleration  of  tlu;  heart's  action  is 
due  to  the  siiortening  of  the  diastole,  and  during  the  systole  so  little  lijuml 
is  expelled  from  the  lieart  that  the  average  amount  in  tlui  minute  is  in.t 
increased.  Moreover,  the  accelerators  appear  to  have  no  trophic  relatiini 
to  the  heart,  and  stimulation  of  them  is  not  accomjjanicd  either  by  in- 
creased arterial  pressure  or  by  augmentation  of  the  work  done  by  the 
heart. 

S  LOW  II EA  UT — Jiu  AC  II Y  c  A  K  I)  I A   ( h'nuli/cdrdia). 

Slow  action  of  the  heart  is  sometimes  normal  and  may  he  a  family 
peculiarity.    Na})o]eon  is  stated  to  have  had  a  ])ulsc  of  only  -lO  per  minute. 

In  any  ease  of  slow  pulse  it  is  imijortant  first  to  make  sure  that  the 
mimber  of  heart.and  artorial  beats  correspond,;  In  many  instances  this  is 
not  the  case,  and  with  ,i  radial  pulse  at  40  the  cardia(!  imlsations  may  he 
80,  half  tin  beats  Jiot  reaching  the  wrist.  The  heart  conti'aetions,  not  the 
})ulsc  wave,  s!i"uld  be  taken  into  account.  A  most  exhaustive  study  of 
this  condition  lias  been  made  recently  by  IJiegel,  whoso  division  is  hero 
f  llowed: 

(a)  Physiological  bro.'hycardia.  Iiv  the  puerperal  state  the  ])ulse  mny 
beat  from  44  to  (JO  per  minute,  or  may  even  be  as  low  as  oi.  It  is  seen  in 
premature  labor  as  well  as  at  term.  The  ex])lanation  of  its  occurrence  at 
this  period  is  not  clear.  Slowness  of  the  i)ulse  is  associateu  with  hunger. 
Brachycardia  depending  on  individual  peculiarity  is  extremely  rare. 

{/>)  Pathological  brachycardia,  wliiidi  is  met  with  under  the  following 
conditions:  (1)  In  convalescence  from  acute  fevers.  This  is  extrenu'ly 
common,  particularly  after  pneumonia,  typhoid  fever,  acute  rheumatism, 
and  diphtheria.  It  is  most  frequently  seen  in  young  persons  and  in  cases 
■which  have  run  a  normal  course.  Traubc's  explanation  that  it  is  duo  to 
exhaustion  is  probably  the  correct  one.  (2)  In  diseases  of  the  digestive 
system,  such  as  chronic  dyspe})sia,  nicer  or  cancer  of  the  stonnich,  and 
jaundice.  The  largest  number  of  Eiegel's  cases  were  of  this  group,  ('i) 
In  diseases  of  the  respiratory  system.  Here  it  is  by  no  means  so  common, 
but  is  seen  not  infrequently  in  emphysema.  (4)  In  diseases  of  the  circu- 
latory system.  Excluding  all  cases  of  irregularity  of  the  heart,  brachy- 
cardia is  not  common  in  diseases  of  the  valves.  It  is  most  frequently  seen 
in  fatty  and  fibroid  changes  in  the  heart,  but  is  not  constant  in  them.  (">) 
In  diseases  of  the  urinary  organs.     It  occurs  occasionally  in  nephritis  iinil 


NEUIIOSKS  OF  THE   HEART. 


C89 


iniiv  l>o  ii  feature  of  unvinia.  (t!)  I-'rom  tlu;  iU'tioii  of  toxic  nponts.  It 
ot'ciii's  ill  urit'iniii,  poisoning  In  k'lul,  alt'oii(.)l,  and  follows  the  u.su  of  to- 
Idtcc'o,  coiToo,  uiul  (ligituliri.  (7)  In  constitutional  disordoi's,  such  as  iinav 
niiii,  chlorosis,  and  diabetes.  (S)  In  diseases  of  the  nervous  system. 
Apoplexy,  e[)ilepsy,  the  cerebral  tumors,  aU'ections  of  tim  medulla,  and 
(lis('a.ses  and  injuries  of  the  cervical  cord  may  be  associated  with  very  slow 
pulse.  In  general  paresis,  mania,  and  melancholiu  it  is  not  iid'reiiuent. 
(!))  It  occurs  occasionally  in  aU'ections  of  the  skin  and  sexual  organs,  ami 
ill  sun.stroke,  or  in  j)rolonged  exliaustion  from  any  cause. 

It  is  seen  most  fre(iuently  in  the  convalescence  from  acute  fevers,  thou 
in  disorders  of  the  digestive  system.  The  sigiulieance  of  this  symptom  is 
viiriablo.  It  is  oidy  in  diseases  of  the  heart  or  liraiu  that  it  is  onnnous. 
It  nuiy  1)0  due  to  direct  irritation  of  the  vagi,  to  diminished  excitability  of 
the  cardiac  ganglia,  to  reflex  iidluences  acting  ujxm  the  vagus  centre,  or 
to  weakness  of  the  hoart-musclo  itself.  The  ])ulsi'-bi'at  rarely  sinks  be- 
low 20.  I'rentiss,  at  the  Association  of  American  Physicians  at  Wash- 
ington, showed  a  2)atient  with  attacks  of  u: consciousness,  who  had,  par- 
ticularly during  the  attacks,  but  also  in  the  iidervals,  a  pulse  as  low  as 
li  per  nunute.  Such  cases  arc  extrenu'ly  rare.  Cases  are  on  record  in 
which  the  pulso  has  fallen  to  8  or  !)  beats  in  the  nunute.  At  the  dis- 
cussion which  followed  the  exhiblu(*u  of  Prentice's  patient,  both  Jacobi 
and  Kinnicutt  referred  to  similar  cases  associated  w  ith  epileptic  seizures, 
in  one  of  which  the  pulse  fell  as  low  as  ','  in  the  nnnute. 

Treatment  of  Palpitation  and  Arrhythmia.— An  important 
element  in  many  cases  is  to  get  the  patient's  mind  (piieted,  and  he  can  bo 
assured  that  there  is  no  actual  datiger.  The  mental  element  is  oftentimes 
very  strong.  In  palpitation,  before  using  medicines,  it  is  well  to  try  the 
cfl'oct  of  hygienic  moasuriis.  As  a  rule,  moderate  exei-cise  may  be  taken 
with  advantage.  Regular  hours  should  be  kept,  and  at  least  ten  hours 
out  of  the  twenty-four  should  bo  spent  in  the  recumbent  posture.  A  tepid 
bath  may  bo  taken  in  the  morning,  or,  if  the  i)atient  is  weakly  and  nerv- 
ous, in  the  evening,  followed  by  a  thorough  rubbing.  Hot  baths  and  the 
Turkish  bath  should  bo  avoided.  The  dietetic  nuinagement  is  most  im- 
portant. It  is  best  to  prohibit  absolutely  alcohol,  tea,  and  colTee.  The 
diet  should  be  light  and  the  patient  slundd  avoid  taking  large  meals. 
Articles  of  food  known  to  cause  flatulency  should  not  be  used.  If  a 
smoker,  tho  patient  should  give  up  tobacco.  Sexual  Ciilemcnt  is  par- 
ticularly pernicious,  and  the  patient  sliould  be  warned  specially  on  this 
point.  For  the  distressing  attacks  of  palpitation  which  occur  with  neur- 
asthenia, particularly  in  women,  a  rigid  Weir-ilitchell  course  is  the  most 
Siitisfactory.  It  is  in  these  cases  that  we  find  the  most  distressing  throb- 
bing in  the  abdomen,  which  is  apt  to  come  on  after  meals,  and  is  very 
mueii  aggravated  by  flatulency.  The  cases  of  paljtitation  due  to  excesses 
or  to  errors  in  diet  and  dyspepsia  are  readily  remedied  by  hygienic  meas- 
uring. 


( •  ii .. 


h  J 


I  tl 


GOO 


DISEASKS  OF  TIIK   (  IllcrriATORY   SYSTH^f. 


A  ooursp  of  iron  is  cftcn  useful.  Strychnia  is  particularly  vuluahlp, 
and  is  perhaps  best  administered  as  tlie  tincture  of  nux  vomica  in  ]ar;,'o 
doses.  Very  little  f^'ood  is  obtained  friim  the  smaller  quantities.  It  hIiouM 
bo  ji^iven  freely,  "^Ml  minims  tiiree  tiiiu's  a  day. 

If  there  is  great  rapidity  of  action,  aconite  may  be  triid  or  vcralruiii 
virido.  Tiiere  are  cases  associated  with  sleeplessness  and  restlessness  wliicli 
are  {jreatly  Itenefited  by  bromide  of  ]»otassium.  I)i;.''italis  is  very  rarely 
indicated,  but  in  ol)stinat(!  cases  it  may  hv  tried  with  the  nux  vomica. 

Casi's  of  heart  hurry  are  often  extremely  obstinate,  as  may  be  jiHl,i,'ed 
from  the  case  of  the  physician  re])ortod  by  II.  C.  Wood,  in  whom  tlie  eoii- 
dition  persisted  in  .spito  of  all  measures  for  fifty  years.  The  bromides  aro 
Hometimes  useful ;  tlie  jreneral  condition  of  neurasthenia  sliould  be  treated, 
and  durinj;  the  paroxysm  an  ice-ba<;j  may  be  placed  ujion  the  heart,  or 
Leiter's  coil,  throufjh  which  ice-water  may  be  passed.  Electricity,  in  the 
form  of  pdvanism,  is  sometimes  serviceable,  and  for  its  mental  elTect  tlio 
Franklinic  current.  For  the  condition  of  slow  jiulse  but  little  can  bo 
done.     A  great  majority  of  the  cases  are  not  dangerous. 


Anuixa  Pi:(rrouis. 

Stenocardia,  or  the  b?east-])ang  described  by  TIeberden,  is  not  an  inde- 
pendent aU'ection,  but  a  symptom  associated  with  a  number  of  morhid 
conditions  of  the  heart  and  vessels,  more  particularly  with  scleros'  f 
the  root  of  the  aorta  and  changes  in  the  coronarj'^  arteries.  'J'nie  a 
which  is  a  rare  disease,  is  characterized  by  paroxysms  of  agoiu;;ing  [..na 
in  the  region  of  the  heart,  extending  into  the  arms  and  neck.  In  violent 
attacks  there  is  a  sensation  of  impending  death. 

Etiology  and  Pathology. — It  'is  a  disease  of  adult  life  and  occurs 
almost  exclusively  in  men.  Arterio-sclerosis,  hypertroi)hy  of  the  heart, 
increased  arterial  tension,  or  aorti(^  insutHciency  are  often  present,  whilo 
anatomical  changes  in  the  aorta,  arteries,  and  myocardium  aro  almost 
constant.  Xo  instance  oi  true  angina  has  come  under  my  observation  in 
which  there  were  not  signs  of  cardio-vascular  changes.  Tho.  immediate 
exciting  cause  of  an  attack  is  most  frequently  sudden  exertion  or  enio- 
tioiud  excitement.  Tho  paroxysm  may  come  on  in  the  daytime,  l)ut  in 
some  of  the  worst  cases  they  occur  at  night.  Tho  nature  of  the  airoctiou 
is  doubtful.     The  following  views  have  boon  entertained. 

(1)  That  it  is  a  neuralgia  of  the  cardiac  nerves.  In  the  true  form  the 
agonizing  cram})-liko  character  of  the  pain,  the  suddenness  of  tlie  onset, 
and  tilt  associated  features,  aro  unlike  any  nenralgic  aifoction.  The  piiin, 
however,  is  undoubtedly  in  the  cardiac  plexus  and  radiates  to  adjai'eiit 
nerves.  It  is  interesting  to  note  in  connection  with  the  almost  constant 
sclerosis  of  tho  coronary  arteries  in  angina  that  Thoma  ha:',  found 
marked  sclerosis  of  the  temporal  artery  in  migraine  and  Dana  has  met 
with  local  thickening  of  the  arteries  in  some  cases  of  neuralgia    (2)  Hob- 


!  I     I 


NF'UntOSKS  OP  TFIK    IIKAIiT. 


(UH 


onlcn  lj('li(n-('(l  tlmi  it  wns  a  rnuni)  of  the  lioart-tiuisolc  it.'i(>lf.  Tramp  of 
(!crl;iiii  iiiiisciiliir  territories  would  liettiT  explain  tlie  attack.  (;{)  That  it 
is  line  to  tile  extreme  tension  of  tlio  ventrieular  walls,  in  eonse(|iienp('  of 
an  aeiile  dilatation  associated,  in  tlio  majority  of  cases,  with  atTi'ction  of 
the  coronary  arteries,  Trauhe,  who  supported  this  view,  held  that  the 
iiijniiizini,'  jtain  resulte(l  from  the  jjreat  stret(diinfj  and  tension  of  the 
nerves  in  the  muscular  substance.  A  modified  form  of  this  view  is  that 
there  is  a  spasm  of  the  coronary  arteries  with  great  increases  of  the  iutra- 
eanliac  ])ressur(!. 

(4)  'I'lie  theory  of  Allan  Hums,  revived  by  Potain  and  others,  that  the 
condition  is  one  of  transient  ischaMiiiii  of  the  heart  muscle  in  conse- 
(|uenco  of  disease,  or  spasm,  of  the  coronary  arteries.  'I'lie  condition 
known  as  intermittent  claudication  illustrates  what  may  take  place.  In 
mall  (and  in  the  horse),  in  consefjuence  of  thrombosis  of  the  abdoniiind 
aorta  or  iliacs,  transient  paraplegia  and  spasm  may  follow  exertion.  The 
collateral  circulation,  anijile  when  the  limbs  arc  at  rest,  is  insiillicient  after 
the  inuscles  are  actively  used,  and  a  state  of  relative  ischannia  is  induced 
with  loss  of  power,  which  disappears  in  a  short  time.  This  "intermittent 
claudication"  theory  has  been  applied  to  explain  the  aiiirina  paroxysm.  A 
lieart  the  coronary  arteries  of  which  are  sclerotic  or  calcilii'il,  is  in  an  aiial- 
n(,'ons  state,  and  any  extra  exertion  is  likely  to  be  followed  by  a  relative 
isoluemia  and  spasm.  In  Allan  Uurns's  work  on  The  Heart  (ISd!))  the 
theory  is  discussed  at  length,  but  he  does  not  think  that  spasm  is  a  neces- 
sary accompaniment  of  the  ischu'inia. 

In  fatal  cases  of  angina  the  coronary  arteries  are  almost  invariably 
diseased  either  in  their  main  divisions,  or  there  is  chronic  endarteritis  with 
groat  narrowing  of  the  orifices  at  the  root  of  the  aorta.  Experinientally, 
occlusion  of  the  coronary  arteries  produces  slowing  of  the  heart's  action, 
gradual  dilatation,  and  death  within  a  very  few  minutes.  Cohnheim  has 
shown  that  in  tlie  dog  ligation  of  one  of  the  large  coronary  branches  pro- 
duces within  a  minute  a  condition  of  arrhythmia,  and  within  two  ininutes 
the  heart  ceases  in  diastole.  These  experiments,  however,  do  not  throw 
much  light  upon  the  etiology  of  angina  pectoris.  Extreme  .sclerosis  of 
the  coronary  arteries  is  common,  and  a  large  majority  of  the  cases  jiresent 
no  symptoms  of  angina.  Even  in  the  cases  of  sudden  death  due  to  block- 
ing of  an  artery,  particularly  the  anterior  branch  of  the  coronary  artery, 
there  is  usually  no  great  ]iaiii  either  Ijcfore  or  during  the  attack.  The 
lusions  of  the  nerves  described  by  Ijancereaux,  lladden,  an<l  others  cannot 
yet  be  correlated  satisfactorily  with  the  symptoms  of  true  angina.  Vari- 
ous forms  have  been  recognized,  but  the  dilTerences,  in  the  majority  of 
instances,  are  not  sufliciently  marked  to  permit  a  separation.  Reference 
luay  be  made,  however,  to  the  angina  })ectoris  vnxo-vtoforia  described 
by  Xothnagel.  In  this  the  attack  may  come  on  after  exposure  to  cold. 
There  is  general  spasm  of  the  peripheral  arteries  with  a  sense  of  stiffness 
aud  deadness  in  the  extremities,  and  pallor,  cyanosis,  and  lowering  of 


Ml; 


\AUM 


y 


' 


692 


DISKASKS  OF  THE  CIRCULATORY   SYSTEM. 


the  trtnponitnre.  Tlio  iirtories  are  small  and  contracted.  There  is  sonic- 
tiinos  a  feeling  of  faintness  or  even  a  loss  of  consciousness.  Willi  tili^^ 
there  is  a  sense  of  pressure,  tension,  or  even  agonizing  j)ain  in  the  c;ii-- 
diac  region.  The  pulse,  however,  is  regular,  and  there  are  no  signs  of 
disease  of  the  heart.  IMie  condition  is  supposed  to  depend  upon  a  wiiic- 
si)r('ad  spasm  of  the  peripheral  arteries.  Tobacco  angina  is  a  rare  hut 
well-recognized  form,  in  which  the  paroxysm  may  he  typical  and  of  grciit 
intensity;  more  commonly  we  meet  with  attacks  of  heart-pain  with  iiicg- 
uhir  action. 

Symptoms. — Usually  during  exertion  or  intense  mental  emotion  tiic 
patient  is  seized  with  an  agonizing  pain  in  the  region  of  the  heart  and  a 
sense  of  constriction,  as  if  the  heart  had  been  seized  in  a  vise.  The  pains 
radiate  up  the  neck  and  down  tlie  arm  and,tiiere  may  he  numbness  of  the 
lingers  or  in  the  cardiac  region.  The  face  is  usually  i)allid  and  may  as- 
sume an  ashy-gray  tint,  and  not  infrei|uenlly  a  pr()fuse  sweat  breaks  out 
over  the  surface.  Dyspiuea  is  not  usually  present.  The  paroxysm  lasts 
from  several  seconds  to  a  minute  or  two,  during  whicli,  in  severe  attacks, 
the  patient  feels  as  if  death  were  imminent.  As  pointed  out  by  Latiiani, 
there  are  two  elements  in  the  paroxysm,  the  jiain — iltihr  jwrtoris — ;iiid 
the  indescribable  feeling  of  anguisli  and  sense  of  imminent  dissolution— 
aiij/iir  auiini.  There  are  great  restlessness  and  anxiety,  and  the  patient 
may  drop  dead  at  the  height  of  the  attack  or  faint  and  pass  away  in  syn- 
cope. The  condition  of  the  heart  during  the  attack  is  variable;  the  pul- 
sations may  be  uniform  and  regular.  The  pulse  tension,  however,  is  usu- 
ally increiised,  l)iit  it  is  surprising,  even  in  lases  of  extreme  severity,  how 
slightly  the  character  of  the  pulse  may  be  altered.  After  the  attack  there 
may  be  eructations,  or  the  passage  of  a  large  fjinintity  of  cK'ar  urine.  The 
patient  usually  feels  exhausted,  and  foi'  a  day  or  two  may  be  badly  shaken  ; 
in  other  instances  in  an  hour  or  two  tin;  patient  feels  himself  again.  The 
attacks  may  recur  at  intervals  of  a  few  weeks,  or  perhaps  not  for  many 
years.  There  are  individuals  who  have  well-marked  anginal  attacks  fur 
years,  and,  exce;/t  during  the  paroxysms,  suffer  but  slight  inconvenieiiee. 

AVith  reference  to  the  radiation  of  pain  in  anginii  the  studies  of  Mac- 
kenzie and  of  llc'd  are  of  great  interest.  Head  concdudes  that  (1)  in  dis- 
casi'S  of  the  heart,  and  more  j)articularly  in  aortic  disease,  the  pain  is  re- 
ferred along  the  tirst,  second,  third,  and  fourth  dorsal  areas;  {'i)  in  angina 
pectoris  tiie  pain  may  be  referred  in  addition  along  the  tiftli,  sixth,  and 
seventh,  and  even  the  eighth  and  ninth  dorsal  areas,  an<l  is  always  ac- 
ccMiijianied  by  ])ain  in  certain  cervical  areas  (see  page  H'-iH). 

Diagnosis. — 'i'here  are  many  grades  of  true  angina.  A  man  may 
liave  slight  pra'cordial  pain,  a  sense  of  distre.s8  and  uneasiness,  and  radia- 
tion of  the  ])ain8  to  the  arm  and  neck.  Such  attacks  following  slight  ex- 
ertion, an  indiscretion  in  diet,  or  a  disturbing  emotion  may  alternate  with 
attacks  of  mucii  greater  severity,  or  they  nniy  occur  in  connection  with 
a  pulse  of  increased  tension  and  signs  of  gouerui  urterio-sclerosis.     In  the; 


NEUROSES  OF  THE  HEART, 


G93 


a  irtvtr- 


iiiiMcr  grades  tho  duignosis  cannot  rest  n[)()n  tlu-  synii)t(inis  of  tlio  atfjick 
itsi'lf,  since  tliey  may  l)e  simulated  ity  'lie  iiscudo-aiiiriiia ;  hut  the  diiig- 
Udsis  should  he  based  upon  the  examination  of  the  eireul"t()ry  system. 
In  true  an^iiKi,  even  in  the  milder  forms,  signs  of  artei  '-  /lerosis  are 
usually  ])resent.  In  a  ease  presenting  attacks  of  jira'cordiai  pain  or  pains 
ill  the  cervical  or  brachial  plexuses,  if  the  aortic  secon  '  :o',  .d  is  clear,  not 
ringing,  the  iiulse  tension  low,  and  the  peripheral  artci  .i  soft,  the  diag- 
nosis of  true  angina  should  not  be  made.  After  all,  the  chief  ditticulty, 
liowever,  arises  in  the  eases  of  the  hysterical  or  ])scii(lo-((ii(ji)iu. 

This  is  a  common  atTection  in  women,  but  may  occur  also  in  nonras- 
theiiic  men.  It  is  in  this  form  particularly  that  we  sec  vaso-motor  phe- 
iiiiuieiia.  The  jiatieiit  may  comjilain  of  great  coldness  of  the  hands  or 
feet,  or  a  general  feeling  of  deadness  and  stiffness,  often  with  pain  in  the 
hack  of  the  head  and  neck.  The  attacks  recur  frequently,  and  sometimes 
liocome  worse  at  each  monthly  period.  They  may  conu'  on  with  great 
severity  at  the  menopause.  Worry  and  disturbing  emotions  of  all  kinds 
may  at  any  time  ])reci[)itate  an  attack.  Iluchard  has  given  in  concise 
form  the  following  points  in  diagnosis  between  tlio  true  and  hysterical 


1' 


^  1  t 


angina : 


TRUE   AXOIXA. 

!Most  common  between  the  ages 
of  forty  and  iifty  years, 

Most  common  in  men.  Attacks 
brought  on  by  exertion. 

Attacks  rarely  periodical  or  iioe- 
tiirual. 

Is'ot  associated  with  other  symii- 
toms. 

Vaso-motor  form  rare.     Awniz- 


PSEUDO-AXOIXA. 

At  every  age,  even  six  years. 

^[ost  common   in   women.     At- 
tacks spontaneous. 

Often  peri(ulieal  and  nocturnal. 

Associated  with  nervous  symp- 
toms. 

Vaso-motor     form     comni(»n. 


ing  ])ain  and  sensation  of  compres-     Pain   less  severe ;  sensation  of  dis- 


sion  by  a  vise. 

Pain  of  short  duration.  Atti- 
tude: silence,  immobility. 

Lesiona :  sclerosis  of  coronary 
artery. 

Prognosis  grave,  often  fatal. 

Arterial  medication. 


tention. 

Pain  lasts  one  or  two  hours. 
Agitation  and  activity. 

\eiiralgia  of  nerves  and  carJio- 
plexus. 

>«ever  fatal. 

Antineural<fic  medication. 


There  are  cases  in  women  which  are  sometimes  very  puzzling;  for 
instance,  when  the  patient  presents  a  combination  of  marked  hysterical 
manifestations  and  attacks  of  angina  and  has  aortic  insutlicicncy.  In 
such  instances  the  patient  should  receive  the  benefit  of  the  doubt  and 
he  treated  for  true  an<rina. 


■'F  'i     'li,.  ■ 


694 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


Prognosis. — Cardiac  pain  M'ithout  evidcnco  of  arterio-sclerosis  or 
valve  disease  is  not  of  much  moment.  'JVue  angina  is  almost  invariably 
associated  witli  marked  eardio-vasf^ular  lesions  h\  whicli  the  prognosis  is 
always  grave.  With  judicious  treatment  the  attacks,  however,  mav  lie 
long  deferred,  and  a  few  instances  recover  completely,  'llw  ])rogn(>sis  is- 
naturally  more  serious  with  aortic  iusutticiency  and  advanced  arterio- 
sclerosis. Patients  who  have  had  well-marked  attacks  may  live  for  muny 
years,  hut  mucli  depends  upon  the  care  with  which  they  regulate  their 
daily  life. 

Treatment. — T'atients  subject  to  this  aflfcction  should  live  a  ([uiet 
life,  avoiding  particularly  excitement  and  sudden  muscular  exertion. 
During  the  attack  nitrite  of  amyl  should  be  inhaled,  as  advised  I)y  LauiU'i- 
Bruntoii.  From  two  to  five  drops  may  be  jdaced  upon  (;otton-wool  in  a 
tumbler  or  upon  the  handkerchief.  This  is  fre({uently  of  great  service  in 
the  attack,  relieving  the  agonizing  pain  and  distress.  Subjects  of  the  dis- 
ease should  carry  the  perles  of  the  nitrite  of  amyl  with  them,  and  use  tliciu 
on  the  lirst  indication  of  an  attack.  In  some  instances  the  nitrite  of  amyl 
is  quite  powerless,  though  given  freely.  If  within  a  minute  or  two  n-lief  is 
not  obtained  in  this  way,  chloroform  should  at  once  be  given.  A  few  in- 
halations act  promptly  and  give  great  relief.  Should  the  pains  continue, 
a  hypodermic  of  morphia  may  be  a^lministered.  In  severe  and  repeated 
paroxysms  a  patieui  may  display  remarkable  resistance  to  the  action  of 
this  drug. 

In  the  intervals,  nitroglycerin  may  be  given  in  full  doses,  as  recom- 
mended by  MurrelljOr  the  nitrate  of  sodium  (Matthew  Ilay).  The  nitro- 
glycerin should  be  used  for  a  long  time  and  in  increasing  doses,  begiiuiiiig 
with  one  minim  three  times  a  day  of  the  one  per  cent  solution,  and  in- 
creasing the  dose  one  minim  every  five  or  six  days  until  the  patient  com- 
plains of  flushing  or  headache. 

Iluchard  recommends  the  iodides,  believing  that  tlieir  prolonged  use 
inlluenccs  the  arterio-sclerosis.  Twenty  grains  three  times  a  day  may  be 
given  for  several  years,  omitting  the  medicine  for  about  ten  days  in  each 
month.  In  sonu;  instances  this  treatment  is  certainly  beneficial.  Two 
men,  both  with  arterio-sclerosis,  ringing,  accentuated  aortic  sound,  and 
ai tacks  of  true  angina,  liave  under  its  use  remained  practically  free  from 
attacks — one  case  for  nearly  three,  and  the  other  for  fully  eight  years. 
This  treatment  is,  however,  not  always  satisfactory,  and  I  have  had  sev  ul 
cases  in  which  the  condition  has  not  been  at  all  relieved  by  it. 

For  the  pseudo-angina,  the  treatment  nuist  be  directed  to  the  general 
nervous  condition.  Electricity  is  sometimes  very  beneficial,  particularly 
the  Fraukliuic  form. 


CONGENITAL   AFFECTIONS  OF  THE   HEART. 


695 


'I.', 


1  -V( 

I 
f 

■  lui 

i 

■•a:  •* 

I 

'.ir^ 

1 

VI.  CONGENITAL  AFFECTIONS  OF  THE  HEART. 


fH, 


I 

i   ( 


These  luivo  only  a  limited  cliiiiciil  iiitcrt'st,  iis  in  a  larjTo  propor- 
tion of  the  cases  tlie  anomaly  is  not  eomj)atihle  with  life,  and  in  otiiers 
iiotiiing  caii  be  done  to  remedy  the  defect  or  even  to  relieve  tlie  symp- 
toms. 

The  congenital  affections  result  from  intcrniptinn  of  tlir  normal  conrse 
of  (li-volopment  or  from  inllammatory  j  •  .-st-.- — eiiddinrdilis  ;  sometimes 
from  a  eondniiation  of  both. 

{(i)  Oi  f/dieral  cninmalics  of  develo])moiit  tlir  follnwiiifj  ronditions  may 
bo  mentioned  :  Ararilifi,  absence  of  tlie  heart,  win.  li  has  been  met  with 
ill  the  monstrosity  known  by  the  .same  name;  diiithi'  //fv^/7,  whu  !i  has 
occiisioiudly  ])een  found  in  extreme  grades  of  f(etal  deformity;  (/i.ifin- 
('(irdid,  in  which  the  heart  is  on  the  right  side,  either  alone  or  as  part  of 
a  general  transposition  of  the  viscera;  I'rtopin  cordis,  n  condition  avsso- 
ciatod  Avith  fi.ssioii  of  the  chest  wall  and  of  the  abdomen.  'I'ln'  heart  may 
1h'  situated  in  the  cervical,  ])cctoral,  or  abdominal  regions.  Kxcipt  in  tho 
abdominal  variety  the  condition  is  very  rarely  eom])atible  with  Lra- 
uteriue  life. 

(/')  Anomalies  of  the  Cardiac  Septa.— 'I'he  septa  of  both  auricle.s  and 
ventricles  may  be  defective,  in  whi(di  case  the;  heart  consists  of  but  two 
cliandu'rs,  the  cor  bilocnhire  or  reptilian  heart.  In  the  s^eptum  of  the  auri- 
cles there  is  a  very  common  defect,  owing  to  the  fa<'t  that  the  metnbrane 
cl(»sing  the  foramen  ovale  has  failed  at  one  i)oint  to  l)ecome  attached  to  the 
ring,  and  leaves  a  valvular  slit  which  may  be  large  eiiough  to  admit  tho 


U 

! 
'i 


M 


I 


'  ''*  \! 


.12 


Ki^n 


606 


DISEASES  OF  THE  CIRCULATORY  SYSTEM. 


handle  of  a  scalpel.     Xi'ithor  this  nor  the  small  cribriform  perforations  of 
the  membrane  are  of  any  signiiicance. 

'I'he  foramen  ovale  may  be  patent  without  a  traee  of  meml)rane  clos- 
ing it.  In  some  instances  this  exists  witb  other  serious  defects,  such  as 
stenosis  of  the  pulmonary  artery,  or  imperfection  of  the  ventricular  sep- 
tum. In  others  the  patent  foramen  ovale  is  tiie  only  anomaly,  and  in 
many  instances  it  does  not  appear  to  have  caused  any  embarrassment,  as 
the  condition  has  been  found  in  persons  who  have  died  of  various  alTectious. 
The  ventricular  septuni  may  l)e  absent,  the  condition  known  as  trilocular 
heart.  ]\Iuch  more  frecpiently  tlicre  is  a  small  defect  in  the  upper  portion 
of  the  septum,  either  in  the  situation  of  the  membranous  portion  known 
as  the  "  undefended  si)ace "'  or  in  the  region  situatetl  just  anterior  to  this. 
The  anomaly  is  very  fre(|uently  associated  with  narrowing  of  the  pul- 
moiuiry  oriice  or  of  the  conns  arteriosus  of  the  right  ventricle, 

(6-)  Anomalies  and  Lesions  of  the  Valves.— Numerical  anomalies  of  the 
valves  are  not  uncommon.  The  senulunar  segments  at  the  arterial  orifices 
are  not  infretpuMitly  increased  or  dinunishcd  in  nund)er.  Superinuiu'r- 
ary  segnu'nts  are  more  frequent  in  the  ],)ulinonary  artery  than  in  the  aoita. 
Four,  or  sometinu^s  live,  valves  have  been  found.  The  segments  may  bo  uf 
equal  size,  but,  as  a  rule,  the  supernumerary  valve  is  small. 

Instead  of  three  there  may  be  only  two  semilunar  valves,  or,  as  it  is 
termed,  the  bicuspiil  aDidition.  In  my  experience,  this  is  most  fretjuent 
in  the  aortic  valve.  Of  twenty-one  instances  oidy  two  occurred  at  the 
pulmonary  orifice.  Two  of  the  valves  have  muted,  and  from  the  ventricu- 
lar face  show  either  no  trace  of  division  or  else  a  slight  depression  indicat- 
ing where  the  union  had  occurred.  From  the  aortic  side  there  is  usually 
to  be  seen  some  traee  of  division  into  two  sinuses  of  Valsalva.  There  has 
been  a  discussion  as  to  the  origin  of  this  condition,  whether  it  is  really  an 
anomaly  or  whether  it  is  not  due  to  endocarditis,  fatal  or  j)ost-natal.  The 
combined  segment  is  usually  thickened,  but  the  fact  that  this  anomaly  is 
met  with  in  the  fuitus  without  a  trace  of  sclerosis  or  endocarditis  shows 
that  it  may,  in  some  cases  at  least,  result  from  a  developmental  error. 

Clinically  this  is  a  very  important  congenital  defect,  owing  to  the 
liability  of  the  cond)ined  valve  to  sclerotic  changes.  Except  two  fo'tal 
specimens  all  (d'  my  cases  sliowed  thickening  and  dcf(»rmity,  and  in  iit'leen 
of  those  which  I  have  reported  dciuh  resulted  directly  or  indirectly  from 
the  lesion. 

The  little  fenestrations  at  the  margins  of  the  sigmoid  valves  have  no 
significance;  they  occur  in  a  consideral)le  proportion  of  all  bodies. 

Anomalies  of  the  auriculo-ventriciilar  valves  are  not  often  met  with. 

Foetal  endocarditis  nmy  occur  either  at  the  arterial  or  auriculo-vcii- 
tricular  orihces.  It  is  nearly  always  of  the  chronic  or  sclerotic  variety. 
Very  rarely  indeed  is  it  of  the  warty  or  verriu  '-c  form.  There  are  little 
nodular  bodies,  sometimes  six  or  eight  in  nunilier,  on  the  mitral  ami  tri- 
cus])id  segments — the  nodules  of  Albini — whieh  represent  the  remains  of 


iiidii'iit- 
usuiiUy 

'liorc  has 
•cally  iiii 
111.    The 

iioiualy  is 
is  shows 

•ror. 
to  the 

wo  fo'tal 
11  lifttrii 
lly  fniiu 

have  no 

with. 

■iihi-VfU- 

varii'ty. 

tiiv  liltlo 

aiiti  tri- 

iiiaiiis  of 


COXGEXITAL  AFFECTIONS  OF  THE  HEART. 


607 


fo'tal  striu'turos,  and  must  not  bo  mistaken  for  endocardial  outgrowths. 
The  little  rounded,  bead-like  luemorrbages  of  a  deep  purjile  eolor,  which 
are  very  common  on  the  heart  valves  of  children,  are  als((  not  to  he  mis- 
taken for  the  i)roduct.s  of  endocarditis.  In  fcvtal  endocarditis  the  segments 
ai'e  usually  thickened  at  the  edges,  shrunken,  and  smooth.  In  the  mitral 
and  tricuspid  valves  the  cusps  are  fouiul  united  and  the  chordie  teiidiiu-iB 
are  thickened  and  shortened.  In  the  semilunar  valves  all  trace  of  the 
segments  luis  disappeared,  leaving  a  stiff  membranous  dia])hragm  perfo- 
rated by  an  oval  or  rounded  oritiee.  It  is  sometinu>s  very  dillicult  to  tuy 
whether  this  condition  has  resulted  from  foetal  endocarditis  or  whether  it 
is  an  error  in  development.  In  very  many  instances  the  jirocesses  are 
coiiil)iiied  ;  an  anomalous  valve  becomes  the  seat  of  chronic  si-lerotic 
changes,  and,  according  to  Kauchfuss,  endocarditis  is  more  common  on 
the  right  side  of  the  heart  oidy  because  the  valves  are  here  most  often  the 
seat  of  developmental  errors. 

Lesions  at  the  Pulmonary  Grifice.—Sf oiokIs  of  this  oi  ifice  is  otic  of  the 
connnonest  and  most  important  of  congenital  heart  ad'ections.  A  slow 
endocarditis  causes  gradual  union  of  the  segments  and  narrowing  of  the 
orifice  to  such  a  degree  that  it  only  admits  the  smallest-sized  jirobe.  In 
some  of  the  cases  the  smooth  membranous  condition  of  the  conibiiied 
wgiiients  is  such  that  it  would  appear  to  be  the  result  of  faulty  <levelop- 
nieiit.  In  some  instances  vegehitions  develop.  The  condition  is  com- 
patihle  with  life  for  many  years,  and  in  a  considerable  proportion  of  the 
cases  of  heart-disease  above  the  tenth  year  this  lesion  is  ])resent.  With  it 
there  may  ])e  d(>fi'ct  of  the  ventri<'ular  septum.  Obliteration  or  atresia  of 
the  pulmonary  orifice  is  less  frofpient  but  a  more  serious  conditi(;n  than 
stenosis.  It  is  associated  with  defect  of  the  vcMitricular  septum  or  patency 
of  the  foramen  ovale  and  persistence  of  the  ductus  arteriosus  with  hy])er- 
trophy  of  the  right  heart.  Stenosis  of  tlie  conns  arteriosus  of  the  right 
venlricle  exists  in  a  considerable  proi)ortion  of  the  cases  of  obstruction  at 
the  pulmonary  orifice.  At  the  outset  a  developmental  error,  it  may  be 
combined  witii  sclerotic  changes.  The  ventricular  sejitum  is  imperfect, 
the  foramen  ovale  is  usually  open,  and  the  ductus  arteriosus  patent. 
These  three  lesi(His  at  tiie  pulmonary  orifice  constitute  the  Tuost  important 
group  of  all  congenital  cardiac  alfections.  Of  181  instances  of  various 
congenital  anomalies  collected  by  Peacock  119  cases  came  under  this  cate- 
gory, and,  according  to  this  author,  in  eighty-six  per  cent  of  the  patients 
living  beyond  ttie  twelfth  year  the  lesion  is  at  this  orilice. 

Conijenital  lesions  of  the  aortic  orifice  are  not  very  frequent.  Ilauch- 
fiiss  has  collected  5i4  ca-ses  of  stenosis  and  atresia,  and  stenosis  of  the  left 
conns  arteriosus  may  also  occur,  a  condition  which  is  not  incompatible 
with  ])roloiiged  life.  Ten  of  the  sixteen  cases  tabulated  by  Dilg  were 
over  tliirty  years  of  age. 

Symptoms  of  Congenital  Heart-disease.— C'yanosis  occurs 
in  over  ninety  per  <'ent  of  the  cases,  and  forms  so  distinctive  a  feature 
that  the  terms  "  blue  disease  "  and  "  morbus  coeruleus  "  arc   practically 


f 

1 

i 

1 

1 

1 

11 

i :  .■. 


li  • 


V  ,m\ 


1 1 
ti 


'-% 


098 


DISEASES  OP  THE  CIRCULATORY  SYSTEM. 


synonyms  for  congenital  heart-disease.  The  lividity  in  a  majority  of 
cases  ajjpears  early,  within  the  first  week  of  life,  and  may  be  general  or 
confined  to  the  lips,  nose,  and  ears,  and  to  the  fingers  and  toes.  In  some 
instances  there  is  in  addition  a  general  dusky  suffusion,  and  in  the  nio^t 
extreme  grades  the  skin  is  almost  pur])le.  It  may  vary  a  good  deal  and  may 
only  be  intense  on  exertion.  The  external  temperature  is  low.  Dyspno'a 
on  exertion  and  cough  are  common  symptoms.  A  great  increase  in  tlie 
number  of  the  red  corpuscles  has  been  noted  by  Gibson  and  by  Vatju  v,. 
In  a  case  of  Gibson  there  were  above  eight  millions  of  red  corpuscles  to 
the  cubic  millimetre.  The  children  rarely  thrive,  and  often  disjjjay  a 
lethargy  of  both  mind  and  body.  The  fingers  and  toes  are  clubljud  in 
a  grade  rarely  met  with  in  any  other  affection.  The  cause  of  the  cyanosis 
has  been  much  discussed.  Morgagni  referred  it  to  the  general  conges- 
tion of  the  venous  system  due  to  obstruction,  and  this  view  was  supported 
in  a  paper,  one  of  the  ablest  that  has  been  written  on  the  subject,  by 
Moreton  Stille.  Morrison's  recent  analysis  of  75  cases  of  congenital 
heart-disease  shows  that  closure  of  the  pulmonary  orifice  and  patency  of 
the  foramen  ovale  and  the  ventricular  septum  arc  the  lesions  nuist  fre- 
fjuently  associated  with  cyanosis,  and  he  concludes  that  the  deficient  aera- 
tion of  the  blood  owing  to  diminished  lung  function  is  the  most  important 
factor.  Another  view,  advocated  by  William  Hunter,  was  that  the  dis- 
coloration was  due  to  the  admixture  in  the  heart  of  venous  and  arteri.il 
blood ;  but  lesions  may  exist  which  permit  of  very  free  mixture  without 
producing  cyanosis. 

Diagnosis. — In  the  case  of  children,  cyanosis,  with  or  without  en- 
largement of  tlio  heart,  and  the  existence  of  a  murmur  are  sufticient,  as  a 
rule,  to  determine  the  presence  of  a  congenital  heart-lesion.  The  cyano- 
sis gives  us  no  clow  to  the  precise  nature  of  the  trouble,  as  it  is  a  symptom 
common  to  nuiny  lesions  and  it  may  be  absent  in  certain  conditions.  The 
murmur  is  usiudly  systolic  in  character.  It  is,  however,  not  always  pres- 
ent, ami  there  are  instances  on  record  of  complicatud  congenital  lesions  in 
which  the  examimition  showed  normal  heart-sounds.  In  two  or  three 
instances  fo.'tal  endocarditis  has  been  diagnosed  i)i  gravida  by  the  j)res- 
ence  of  a  rough  systolic  murmur,  and  the  condition  has  been  corroborated 
subsequent  to  the  birth  of  the  child.  Hypertrophy  is  present  in  a  nuijor- 
ity  of  the  cases  of  congenital  defect.  It  is  remarkable  in  how  many 
instances  of  congenital  heart-disease  the  fatal  event  is  caused  by  abscess 
of  the  brain.  It  is  impossible  in  a  work  of  this  sort  to  enter  upon  ehib- 
orate  details  in  differential  diagnosis  between  the  various  congenital  heart- 
lesions.     I  here  abstract  the  conclusions  of  Ilochsinger : 

"(1)  In  childhood,  loud,  rough,  musical  heart-murmurs,  with  normal 
or  only  slight  ituirease  in  the  heart-dulness,  occur  only  in  congenital  heart- 
disease.  The  acquired  endocardial  defects  with  loud  heart-murmurs  in 
young  children  arc!  almost  always  associated  with  great  increase  in  the 
heart-dulncss. 

"  (3)  In  young  children  heart-murmurs  with  great  increase  in  the 


DEGENERATIONS. 


<;!»9 


niiiliiiP  (Inlncss  and  focblo  apox  boat  sup:gost  eonpfonital  clianjjos.  Tlio 
imrcasod  duliu's.s  is  cliii'fly  of  the  ri<jlit  heart,  whereas  the  li^i't  is  only 
sliLihtly  altered.  On  the  other  liand,  in  the  acquired  enthjcarditis  in  chil- 
ilivii.  the  left  Iieart  is  cliietly  atTeeted  and  tlie  apex  beat  is  visible ;  the 
(lihitiition  of  the  ri<;ht  heart  eoines  late;  and  does  not  materially  t'han<^e 
tlir  increased  stren,ifth  of  the  apex  heat. 

"  (:i)  The  entire  absence  of  murmurs  at  the  apex,  with  their  evident 
incscnce  in  the  region  of  the  auricles  and  over  the  pulmonary  orifice,  is 
always  an  important  element  in  ditferential  diagnosis,  and  points  rather 
to  septum  defect  or  judmonary  stenosis  than  to  endo'-arditis. 

"  (4)  An  abnornuiHy  weak  second  jjulmonic  s(m-hi  associated  with  a 
distinct  systolic  murmur  is  a  syni})tom  which  in  early  childhood  is  oidy  to 
ln'  ('X[)lained  by  the  assumption  of  a  congenital  pulmoiuiry  stenosis,  an<l 
)i()ssess;'S  therefore  an  importance  from  a  point  of  dill'erential  diagnosi-s 
wliicli  is  not  to  be  underestimated. 

'•  (."»)  Al)sence  of  a  palpable  thrill,  despite  loud  murmurs  which  are 
liiMiil  over  the  whole  pra?cordial  region,  is  rare  except  with  congenital 
(lofocts  in  the  septum,  and  it  speaks  therefore  against  an  acquii'ed  cardiac 
atfection. 

"  ((!)  Loud,  especially  vibratory,  systolic  murmurs,  with  the  ])oint  of 
maximum  intensity  over  the  upper  third  of  the  sternum,  associated  with 
a  lack  of  mai'ked  symptoms  of  hypertrophy  of  the  left  ventricle,  are  very 
important  for  the  diagnosis  of  a  persistence  of  the  ductus  Botalli,  and  can- 
iKit  he  explained  by  the  assumption  of  an  endocarditis  of  the  aortic  valve." 

Treatment. — The  child  should  be  warndyclad  and  guarded  from  all 
circunishmces  liable  to  excite  bronchitis.  In  the  attacks  of  urgent  dysp- 
iui>a  with  lividity  blood  should  be  freely  let.  Saline  cathartics  are  also 
useful.  Digitalis  must  be  used  with  care,  and  it  is  sometimes  beneficial  in 
tilt'  later  stages.  When  the  compensation  fails,  the  indications  for  treat- 
ment are  those  of  valvular  disease  in  adults. 


I'l  I 

1,',. 


»'    si   1 


.iS 


iS'  :> 


III.  DISEASES  OF  THE   AETERIES. 


I.   DEGENERATIONS. 


Fift/i/  dcriencralion  of  the  ijitinui  is  extremely  common,  and  is  seen  in 
the  form  of  yellowish-white  spots  in  the  atn'ta  and  larger  vessels.  Cttlcijira- 
liiiii  of  the  arterial  wall  follows  fatty  degeneration,  atheromatous  changes, 
and  sclerosis.  It  occurs  in  either  the  intima  or  the  media.  In  the  latter 
it  jirorluces  what  is  sometimes  known  as  annular  calcification,  which  oc- 
curs particularly  in  the  middle  coat  of  medium-sized  vessels  and  nniy  con- 
vert them  into  firm  tubes.  Calcificatiou  of  the  intima  is  a  common 
terminal  process  of  arterio-sclcrosis. 
45 


700 


DISEASES  OF  THE  CIRCULATOUY  SYSTEM. 


IfijaUtic  <Jrf/e)iera/ion  may  attack  citlicr  tlio  largiT  or  the  smaller 
vessels.  In  the  former  the  iiitima  is  eonverted  into  a  smooth,  homo^'ncoin 
substance,  and  it  is  et)niinonly  an  initial  staj^e  of  arterio-sclerosis.  In  the 
smaller  arteries  and  capillaries  the  hyaline  de;,r(.|n.i-.iti<)n  is  often  seen, 
j)artieularly  in  the  glomeruli  of  the  kidney.  Its  exact  ])ro(lnction  is  still 
a  matter  of  some  doubt.  "■  It  appears  to  arise  princi])ally  by  hoinogeneous 
coagulation  of  an  albuminous  lluid,  either  within  the  vessels  or  inlillrating 
the  cells  and  the  hyaline  transformation  of  proliferating  cells  and  ol'  luu- 
cocvtes." 


II.   ARTERIO-SCLEROSIS  (Arterio-capillanj  Fibrosis). 

The  conception  of  arterio-sclerosis  as  an  independent  atfection — a  gen- 
eral disease  of  the  vascular  system — is  due  to  Gull  and  Sutton. 

Definition. — A  condition  of  thickening,  diffuse  or  circumscrihed,  of 
the  intima,  consequent  u})on  primary  changes  in  the  media  and  advcntitia. 
The  process  leads,  iji  the  larger  arteries,  to  what  is  known  as  atheronia  nr 
endarteritis  deformans. 

Etiology. — (1)  As  an  involution  process  arterio-sclerosis  is  an  a<- 
companitnent  of  old  age,  and  is  the  expression  of  the  natural  wear  and 
tear  to  which  the  tubes  are  subjected.  Longevity  is  a  vascular  (|uesti(m, 
and  has  been  well  exju'cssed  in  the  axiom  that  "a  man  is  only  as  old  as 
his  arteries."  To  a  majority  of  men  death  comes  i)rinuirily  or  secondarily 
through  this  portal.  The  onset  of  what  may  be  called  physiological 
arterio-sclerosis  depends,  in  the  first  place,  ujjon  the  quality  of  arterial  tis- 
sue (vital  I'ubber)  which  the  individual  has  inherited,  and  secondly  u()on 
the  amount  of  wear  and  tear  to  wiiich  he  has  subjected  it.  That  the 
former  plays  the  most  im{)ortant  I'ole  is  shown  in  the  cases  in  wlii(  h 
arterio-sclerosis  sets  in  early  in  life  in  iiulividuals  in  whom  none  of  the 
recognized  etiological  factors  can  be  found.  Thus,  for  instance,  a  man 
of  twenty-eight  or  twenty-nine  may  have  arteries  of  a  man  of  sixty,  and  a 
man  of  forty  may  present  vessels  as  much  degenerated  as  they  should  be 
at  eighty.  Entire  fiimilies  sometimes  show  this  tendency  to  early  arterio- 
sclerosis— a  tendency  which  cannot  be  explained  in  any  other  way  than 
that  in  the  make-up  of  the  machine  bad  material  was  used  for  the 
tubing. 

More  commonly  the  arterio-sclerosis  results  from  the  bad  use  of  itimhI 
vessels,  and  among  the  circumstances  which  tend  to  i)ri)duce  tiiis  cmiili- 
tion  are  the  following  : 

(2)  C'/troiiic  Iitfoxiralions. — Alcohol,  lead,  gout,  and  syphilis  play  an 
important  role  in  the  causation  of  arterio-sclerosis,  although  the  prei  i-^e 
mode  of  their  action  is  not  yet  very  clear.  They  may  act,  as  Traube  siiir- 
gests,  by  increasing  the  peripheral  resistance  in  the  snudler  vessels  and  in 
this  way  raising  the  blood  tension,  or  possibly,  as  Bright  taught,  they  aUt.r 


u — ii  sr«'ii- 


ARTEniO-Sf'I.RROSIS. 


701 


Hir  iiUiilit}'  of  tho  blood  and  roiidiT  more  diHiciilt  its  iiassago  tlirou<,'h  tlio 
ciiiiillarii'S. 

'I'lic  ixtisoii  of  sypliilis  and  of  ji'out.  may  act  directly  on  tiic  iii'trrics, 
prddiiciiij,'  degenerative  changes  in  tlie  media  and  adveiititia. 

{.))  (h'cird/in;/. — Many  authors  iittrihiite  an  imixirtiint  ]iiii't  of  ilio 
ctiiildgy  of  arterio-sclerosis  to  tlie  overtilling  of  tlie  hlood-vessels  wluch 
(icciirs  wlien  nnnecessarily  hirge  (jnantities  of  food  and  drink  are  taken, 
riirliculiiriy  is  tins  the  ease  in  stout  j)ersons  who  tal<e  very  litth'  exercise. 

(t)  Overwork  of  t/ie  musrlfs,  wh'wh  iii'in  liy  increasing  tiu"  iieripheral 
irsislance  and  by  raising  the  blood-pressure. 

(■))  lii'ind  lJi'.s>'(isr. — The  relation  lu'tween  the  arterial  and  kidney 
lesions  has  been  much  discussed,  some  regarding  the  arterial  degenera- 
tion iis  secondary,  others  as  ])rimary.  I'hero  are  certaiidy  two  gronps  of 
cases,  one  in  which  the  arterio-sclerosis  is  the  first  change,  and  the  other 
in  wiiieli  it  a])i)ears  to  bo  secondary  to  a  prinuiry  iilTection  of  the  kidneys. 
The  former  occurs,  I  believe,  with  much  greater  fre([uency  than  has  been 

SlIjMinsed. 

Morbid  Anatomy. — Thoma  divides  the  oases  mio  priiiKinj  arterio- 
wlcnisis,  in  which  there  are  local  changes  in  the  arteries  leading  to  dilata- 
tidu  and  a  com])ensatory  increase  of  the  connective  tissue  of  the  hitima; 
sirundavy  arterio-sclerosis,  due  to  changes  in  the  arteries  which  follow 
increased  resistance  to  the  blood-flow  in  the  peripheral  vessels.  This  in- 
creased tension  leads  to  dilatation  and  to  slowing  of  the  blood-stream  and 
;i  sccoutlary  compensatory  development  of  the  intima. 

In  a  recent  study  of  41  antopsies  upon  arterio-sclerotic  cases  from  my 
wards,  Councilman  *  follows  the  nseful  division  into  nodular,  seiule,  and 
(lill'iise  forms. 

(")  yodnlar  Form. — In  the  circnmscribed  or  nodular  variety  the  ma- 
cr()S((»[)ie  changes  are  very  characteristic.  I'he  aorta  ])resents,  in  the  early 
stuiTcs,  from  the  ring  to  bifurcation,  nnmerons  flat  ]n'ojections,  yellowish 
or  yellowish  white  in  color,  henuspherical  in  outline,  and  situated  par- 
ticularly about  the  orifices  of  the  branches.  In  the  early  stage  these 
jiatelics  are  scattered  and  do  not  involve  the  entire  intima.  In  more  ad- 
vaiieed  grades  the  patches  undergo  atheromatous  chajiges.  The  material 
''nii>tituting  the  button  undergoes  softening  and  breaks  up  into  granu- 
lar material,  consisting  of  molecular  deOris — the  so-called  atheromatous 
ahseess. 

Ill  the  circumscribod  or  nodular  arterio-sclerosis  the  primary  alteration 
ciiiisists  in  a  degeneration  or  a  local  infiltration  in  the  media  and  adven- 
tiiia,eliietly  about  the  vasa  vasorum.  The  affection  is  really  a  mesarteritia 
mid  a  ]ieriarteritis.  These  changes  lead  to  the  weakening  of  the  wall  ii; 
the  allected  area,  at  wdnch  spot  the  proliferative  changes  commence  in  the 
lilt  i  ma,  })articularly  in  the  subendothelial  structures,  with  gradual  thick- 


I   lij 

r  ,  e  f  n 


'  W 


*  Transactions  of  the  Association  of  American  Physicians,  vol.  vi. 


702 


DISKASKH  OK   TIIK  ClIU'UI.A'n^UY  SYHTKM. 


oiling  iind  the  I'ortnutioii  of  iiii  iitlicnmiatoiis  button  or  ii  patch  of  iiuilnl.ir 
urterio-sck'rosis.  'I'Ik'  rcscarclics  oC  'I'lioma  liavo  shown  tliat  this  is  rcallv 
a  (ioniponsatory  process,  and  tliat  before  its  (U'generation  tiie  luxhilar  Imii- 
ton,  wiiich  ))ost  inorteni  ])rojeets  beyond  tlie  Innic  n,  during  lii'd  tills  up 
and  obliterates  what  W(»uld  otherwise  l)e  a  depression  ot'  the  wall  in  consc- 
(pKMKro  of  the  Aveakeiiing  of  tlio  nu'diii.  A  similar  i)ro('ess  goes  on  in  the 
smaller  vessels,  and  in  any  one  of  the  smaller  branehes  it  can  be  readily 
seen  on  section  that  each  ])ateh  of  endarteritis  corresponds  to  a  det'ect  m 
the  media  and  often  to  changes  in  the  adveiititia.  The  eondition  is  one 
which  may  lead  to  rapid  dilatation  or  to  the  production  of  an  aneurism, 
particularly  in  the  early  stage,  before  the  weakened  spot  is  thickened  and 
strengthened  by  the  intimal  changes. 

{/j)  Scuilr  Arfcrin-sch'rosi.s. — The  hirger  arteries  are  dilati'd  and  tort- 
uous, the  walls  thin  l)ut  stiff,  and  often  converted  into  rigid  tul)es.  The 
subeiulothelial  tissue  undergoes  degeneration  and  in  spots  breaks  down, 
forming  the  so-called  atheromatous  abscesses,  the  contents  of  which  con- 
sist of  a  molecular  debris.  They  may  open  into  the  bnnen,  when  tluy 
are  known  as  atheromatous  ulcers.  The  greater  portion  of  the  ititinia 
may  be  oecuj)ied  by  rough  calcareou.s  }»lates,  with  here  and  there  lisstiics 
and  losses  of  substance,  upon  which  not  infrequently  white  throinhi  aro 
deposited.  Microscopically  there  is  extreme  degeneration  of  the  coats, 
particularly  of  the  media.  Senile  atroi)hy  of  the  liver  and  kidneys  usually 
accompanies  these  changes.  Senile  changes  are  common  in  other  organs. 
The  heart  nuiy  be  small  and  is  not  necessarily  hy])ertrophied.  In  7  of  U 
oases  of  Councilman's  series  there  was  no  eidargement.  lirown  atrophy 
is  common. 

{(')  Diffuse  Arteriosclerosis. — The  process  is  wide-spread  throughout 
the  aorta  and  its  branches,  in  the  former  usually,  but  not  necessarily,  asso- 
ciated with  the  nodular  form.  The  subjects  of  this  variety  are  usually 
middle-aged  men,  but  it  may  occur  early.  Of  the  27  in  Councilman's 
series  belonging  to  this  group  the  majority  were  l)etween  the  ages  of  forty 
and  fifty-tive.  'i'he  youngest  was  a  negro  of  twenty-three  and  the  oldest  a 
man  of  sixty.  The  atTection  is  very  prevalent  among  negroes ;  less  than 
fifty  per  cent  Avere  in  whites,  whereas  the  ratio  of  colored  to  white  patients 
in  the  wards  is  one  to  seven.  The  afTection  is  met  Avitli  in  strongly  huilt, 
muscular  men  and,  as  Councilman  remarks,  they  rarely  present  on  the 
autopsy  table  signs  of  general  anasarca  or,  if  anlema  exists,  it  has  coiuu 
on  during  the  last  few  days  of  life. 

The  aorta  and  its  branches  are  more  or  less  dilated,  the  branehes  sonu- 
times  more  than  the  trunk.  The  intima  may  be  smooth  and  show  very 
slight  changes  to  the  naked  eye;  more  commonly  there  are  scattered  ele- 
vated areas  of  an  opaque  white  color,  some  of  which  may  have  undeigone 
atheromatous  changes  as  in  the  senile  form.  Microsco})icaliy  the  ninllii 
shows  necrotic  and  liyaline  changes,  involving  in  the  larger  arteries  both 
muscular  and  elastic  elements,  and  the  intima  presents  a  great  incieuje 


AIITKHIO-SCLKUOSIS. 


r(  »;5 


ill  llic  siilioTidoHiclial  cotincctivc  tissue,  wliicli  is  piu'ticularly  miirkod  opjx). 
sih  iirctis  of  iidvuiu'cd  dcijciu'rutioii  in  tlu'  incdiii.  'I'lic  small  iirtcrioH — 
tlhi-cc  (if  tlu'  kidneys,  for  example — sliow  "  u  tliiekeiiiiii,'  of  the  wall,  due  to 
till'  formalioii  of  u  iioniojjeiu'ftiis  livaliiie  tissue  within  the  inuseular  coat. 
'I'liis  tissue  contains  but  few  cells,  is  faintly  striated,  and  stains  a  lijiht, 
liriiun  in  the  osniic!  acid  used  in  the  hardening  solution.  In  manv  of  the 
,>;iii;illest  vessels  )\othin<;  can  he  seen  of  the  elastic  lamina,  in  others  oidy 
fiiiirinents  can  he  made  out,  in  others  it  is  presi'rved.  .  .  .  The  nuiscniar 
tiliivs  of  the  media  show  marked  atrophic  (dian<;es.  Katty  dem-neratioii 
ef  the  cells  can  he  made  out  hoth  in  fresh  st'ctioiis  and  after  hardening; 
ill  l'lemin,i,''s  .solution.  'I'he  nuclei  are  thin  and  atro])hic  and  vacuoles  are 
sniiii'times  seen  in  them.  In  .some  arti'ries  the  muscle-(il)res  have  almost 
ihsiippeared  and  the  media  is  chan<red  into  a  liomo_i:cneoiis  tissue,  sindlar 
til  that  in  the  thickeiu-d  intima"  (Councilman).  'I'he  dep'in'nition  of 
the  media  is  most  marked  in  the  .smaller  arteries.  The  capillaries  are 
tliickeiied,  particularly  those  of  the  <flomeruli  of  the  kidneys,  which  are 
orieii  nl)literated  and  involved  in  extensive  hyaline  dejfcneration. 

ll  is  in  this  fjfroup  of  cases  that  the  heart  shows  the  most  important 
cliiniires.  The  average  wei<,dit  in  the  cases  referred  to  was  over  4r)(t 
firaiiiiiies,  and  there  were  two  cases  in  which  without  valvular  disease 
the  weijfht  was  over  800  jrrammes.  Fihrous  myocarditis  is  often  present, 
piirticularly  when  the  coronary  arteries  are  involved.  The  semilunar 
valves  are  sometimes  opaque  and  sclerotic,  and  may  he  incompetent.  The 
kiiliu'vs  may  show  extensive  sclerosi.s,  hut  in  many  cases  tlu^  chaufjes  are 
so  slijflit  that  nuicro.scopically  they  mi<rht  he  overlooked.  They  may  he 
iiicrciised  in  size.  The  ca])sule  is  usually  adherent,  the  surface  a  little 
I'lMiifJi,  and  very  often  presents  atrophic,  areas  at  a  lower  level  of  a  deeji- 
rrd  color.     Increased  consistence  is  always  ])re.sent. 

Srl('ro,si'ti  of  the  jntlmoiutrij  artery  is  met  with  in  all  conditions  whicli 
for  a  lonj?  time  increase  the  tension  in  the  lesser  circulation,  ])articularly 
ill  mitral-valve  di.sease  aJid  in  emjdiy.sema.  Sometimes  the  .sclerosis  reaches 
a  liiiih  grade  and  is  accom])anied  with  aneurisnial  dilatation  of  the  jirimary 
and  secondary  branches,  more  rarely  with  insutliciency  of  the  ])ulnionary  , 
vahc  In  a  remarkable  case  of  a  young  man  (d'  twenty-four,  reported  by 
iJoiiiiierg  from  Curschmann's  clinic,  the  ])ulmonary  arteries  were  involved 
ill  most  extensive  arterio-scdero.sis  ;  tlie  main  branches  were  dilated,  and  tlu* 
smaller  branches  were  the  seat  of  the  most  extreme  sclerotic  changes.  On 
the  oilier  Inind,  the  aorta  and  its  branches  were  normal.  The  lieart  Avas 
greatly  hypertropliied,  and  the  cliincal  symptoms  were  those  of  a  congeni- 
tal heart  affection.  In  many  cases  of  arterio-.sclerosis  the  condition  is  not 
ci>iiHiied  to  tlie  arteries,  but  extends  not  oidy  to  the  capillaries  but  also  to 
the  vi'ins,  and  may  properly  be  termed  (nif/io-srtcrosis. 

Sclerosis  of  the  veins — pldcho-sclt'nmt^ — is  not  at  all  an  uncommon 
iicioiiipaniuient  of  arterio-sclerosis,  and  is  a  condition  to  wdntdi  of  late  a 
good  deal  of  attention  has  been  paid.     It  is  seen  in  conditions  of  heiglit- 


r''!  ;H' 


■;  ,-''U  I 


1.  vMu  \ 


704 


DISKASKS   OI-'  TIIK   flliCL'LATOIlV   SVSTHM. 


oned  bhxnl-prt's.siiro,  lis  in  the  porliil  Kystiiin  in  cirrlin^iji  of  tlid  liver  ami  in 
tlio  i»iilni()nury  veins  in  niitrul  stenosis.  Tiio  alTeeted  vessels  are  nsiialK 
(lilati'd,  iind  tlio  intitnii  sliows,  us  in  tlio  arteries,  iv  eonipensatory  thicken- 
in;;,  whieli  is  particularly  nnirked  in  those  ri'<;ions  in  which  the  media  i.; 
thinned.  The  new-formed  tissue  in  the  endophlehitis  may  under*,'*)  liva- 
line  de^'eneration,  and  is  sonu'times  extensively  caleiHeil.  In  a  ease  of 
fihroid  obliteration  of  the  portal  vein  of  long  standing,  I  found  the  intinia 
of  the  greatly  dilated  gastric,  splenic,  and  mesenteric  extensively  euleilled. 
Without  existing  arterio-sclerosis  the  j)eripheral  veins  nuiy  be  sclfintic 
usually  in  conditions  of  debility,  l)ut  occasionally  in  young  j)ersons. 

Symptoms. — Inornsiul  '/'oisiun.—  'Vhe  pressure  with  which  the  hloml 
flows  in  the  arteries  depends  upon  the  degree  of  peripheral  resistance  and 
the  force  of  the  ventricular  contraction.  A  high-tension  pulso  nuiy  exist 
with  very  little  arterio-sclerosis  ;  but,  a.^  a  rule,  when  the  condition  has  hrcn 
persistent,  the  sclerosis  and  liigh  tension  are  found  together.  The  judsu 
wavo  is  slow  in  its  ascent,  enduring,  subsides  slowly,  and  in  the  intervaU 
of  the  beats  the  vessel  renuiins  full  and  lirm.  It  nwiy  be  very  dillicult  to 
obliterate  the  ])ulse,  and  the  firmest  pressure  on  the  radial  or  tlie  tem- 
poral may  Tiot  be  sidlicient  to  annihilate  the  pidso  wave  beyond  the  point 
of  j)ressure.  This  is  not  always  a  sign  of  high  tension.  Tins  anastoninlic 
or  recurrent  pulso  nuiy  be  felt  even  when  the  tension  is  low,  as  in  the 
early  stage  of  typhoid  fever.  Pressure  on  the  ulnar  at  once  obliterates 
it.*  The  si)liygtnographic  tracing  shows  a  sloping,  short  up-stroke,  no 
percussion  wave,  and  a  slow,  gradual  descent,  in  which  the  dicrotic  wave 
is  very  slightly  nuirkod.  It  may  be  dillicult  to  estimate  how  much  f)f  the 
hardness  and  firmness  is  due  to  the  tension  of  the  blood  witliin  the  vessel, 
and  how  much  to  the  thickening  of  the  wall.  Jf,  for  example,  when  tlic 
radial  is  compressed  with  the  index-tingcr  the  artery  can  be  felt  beyuiid 
the  point  of  compression,  its  walls  are  sclerosed. 

Iliipcrlrophy  of  the  Heart. — Tu  consequence  of  the  ]>erii)heral  resist- 
ance and  increased  work  the  left  ventricle  increases  in  size,  and  some  of 
the  ])urest  examples  of  sim])le  hy])ertrophy  occur  in  this  condition.  The 
chandler  may  be  little,  if  at  all,  dilated.  The  apex  l)eat  is  dislocated  in 
advaiiccd  cases  an  inch  or  more  beyond  the  nijiple  line.  The  impulse  is 
luuiving  and  forcible.  Tlie  aortic  second  sound  is  clear,  ringing,  iiiil 
at'ceiituated. 

The  combination  of  increased  arterial  tension,  a  palpable  thickcuuig 
of  the  arteries,  hypertrophy  of  the  left  ventricle,  and  accentuation  of  tlic 
aortic  second  sound  are  signs  pathognomonic  of  arterio-sclerosis.  Vv^m 
this  period  of  establishment  the  course  of  the  disease  may  be  very  varied. 
For  years  the  jiatient  may  maintain  good  health,  and  be  in  a  conilitinii 
analogous  to  a  ])ersou  with  a  well-compensated  valvular  lesion.  Tli<  re 
may  bo  no  renal  symptoms,  or  there  may  be  the  passage  of  a  larger 

*  The  student  is  referred  to  Ewart  On  the  Pulse,  and  to  his  larger  Heart  SUidiis. 


ivcr  and  In 
iiro  usually 
■y  tliicki'ii- 
ic  media  i« 
dorjjo  liya- 

il  case  (if 
tlio  intiiiia 
y  culcilitil. 

10  Hcll'I'otic 

oils. 

11  tllO  1)1(1(1(1 

slanco  and 
!  may  exist 
m  has  bcfii 
The  ]iidsc 
le  intervals 
ditlieiilt  to 
ir  the  teiii- 
.1  the  pimit 
iiastdiiiiilii' 
V,  as  in  tliu 
obliterates 
-stroke,  no 
'I'otic  \va\(' 
inch  ?)f  the 
the  vessel, 
,  when  the 
'elt  beyond 

•ral  vesist- 
id  some  of 
:ioi\.  'i'lie 
docateil  ill 
impulse  is 

;injr,  mid 

hiekenuif; 
ioli  of  the 
is.  {'"roiii 
■ry  varied. 
eondili"ii 
11.  There 
f  a  largur 

L  Sludirs. 


AKTKIUO  SCl.KIiOSlS. 


7(1.-. 


mint  of  urine  than  nornial,  with  traiiHieiit  all)itiiiiniiria,  and  now  and 


urn 

then  hvaline 


tnb 


easts.     I  he  snl)se(|iieiit  history  is  extraordinarily  diverse 


lin 


dr|iendin;^  141011  the  vaseiilar  territory  in  whitdi  the  siderosis  is  most  ad- 
vaiieed,  or  Upon  tlu*  aeeideiils  Avhi(di  are  ho  liable  to  happen,  and  the 
svmptoms  inuy  be  (cardiac,  eereiiral,  renal,  etc. 

(!)  ('lU'ilitic. — 'I'lio  involvement  (d'  the  eoi'oiiary  arteries  may  lead  to 
the  varions  symptoms  already  referred  to  under  that  section — thrombosis 
with  sudden  death,  (Ibroid  de;;eneratioii  of  the  heart,  aneurism  of  the 
heart,  rnpture,  and  anj:;ina  iieetori-  Angimi  pectoris  is  not  unoommoii, 
ami  in  the  rue  variety  is  almost  always  associated  with  arterio-sclorosis. 
\  .second  important  ;j;roup  of  cardiac  symptoms  results  from  the  dilatation 
whiidi  ultiniiittdy  imiy  follow  the  hypertrophy.  'I'he  ptiticnt  then  presents 
ail  the  .symptoms  of  cardiac  insullicieiicy — dyspiucii,  scanty  urine,  and  very 
often  serous  ciriisions.  If  the  case  has  (;ome  under  observation  for  the  first 
time  tho  clinical  pi(;tnru  is  that  of  chronic  valvular  disease,  and  the  exist- 
ence of  a  loud  blowing;  murmur  at  the  apex  may  throw  the  jiractitioiicr  oil 
his  ijuiinl.     Many  cases  terminate  in  this  way. 

Ci)  The  cin'vbvdl  symptoms  of  tirterio-sclerosis  are  varied  and  important, 
iind  embrace  tliose  of  many  degenerative  processes,  acute  and  chronic  (which 
follow  sclerosis  of  the  smaller  branches),  and  cerebral  hicmorrhiige. 

Transient  hemiph'gia,  monoplegiji,  or  aphasia  may  occur  in  advanced 
arterio-sclerosi.s.  Hecovery  may  be  perfect.  It  is  dilVmnlt  to  say  upon 
uiiat  these  attacks  depend.  Sptisin  of  the  arteries  has  been  suggested,  but 
the  condition  of  the  smaller  arteries  is  not  very  favorable  to  this  view. 
I'laliody  has  recently  called  attention  to  these  cases,  \vhi(di  are  more  com- 
mon than  indicated  in  the  literature.  Vertigo  occurs  frecpiently,  aiivl 
may  l)e  either  simple,  or  is  associated  with  slow  pulse  and  sync('pal  or 
eiiileptiform  attacks  ((Jrasset,  Church). 

(:'))  liciKil  .symptoms  supervene  in  a  large  number  of  the  cases.  A 
sclerosis,  ptitidiy  or  dilTuse,  is  j)reseiit  in  ti  mtijority  of  the  ciiscs  at  the  time 
of  aiitop.sy,  and  the  condition  is  practically  that  of  contracted  kidneys.  It 
is  seen  in  a  typical  manner  in  the  senile  form,  and  not  infrcfpiently  devel- 
o[)s  early  in  life  as  a  <lircct  sc(|iience  of  the  dilT'use  variv-ty.  It  is  often 
(liili'-iilt  to  decide  (dinically  (and  the  (|Ucstion  is  one  upon  whicdi  good  ol)- 
^•ervel•s  might  not  iigrcc  in  a  given  case)  whether  the  arterial  or  the  renal 
disease  has  been  ])rimary. 

(4)  Among  other  events  in  arterio-s(derosis  may  be  mentioned  gan- 
grene of  the  extremities,  due  either  directly  to  endarteritis  or  to  the  dis- 
lodgment  of  thrombi.  Respiratory  symptoms  are  not  nnconinion,  particii- 
liii'ly  bronchitis  and  the  .symptoms  as.sociated  with  emphysema. 

Treatment. — In  the  late  .stages  the  conditions  must  be  treated  as 
tlii\v  arise  in  connection  Avith  the  various  viscera.  In  the  early  stages,  he- 
fore  any  local  symiitoms  are  manifest,  the  patient  sliould  he  enjoined  to 
live  a  quiet,  well-regulated  life,  avoiding  excesses  in  food  and  drink.  It 
is  usually  best  to  explain  frankly  the  condition  of  affairs,  and  so  gain  his 
intelligent  co-operation.     Special  attention  should  be  paid  to  the  state  of 


'I , 


i1' 


m 


m 


I  t 


t 


•!    'i 


'■'1ili^;f^ 


■  -s; 


Si  '  ! 


!:■ 


]" 


%\ 


vt 


t,\ 


ttj:« 


706 


DISEASES  OF  TllH  ('IRCULATOIIY  SYSTEM. 


the  bowels  and  urine,  and  tlie  secretion  of  the  skin  shoiihl  be  kept  active 
by  daily  baths.  Alcoliol  in  all  forms  should  be  prohibited,  and  the  fuinl 
siiotdd  be  restricted  to  ])lain,  wliolesoine  articles.  'J'lie  use  of  iniiicral 
waters  or  a  resitk-nce  every  year  at  one  of  the  mineral  sprinj^s  is  usiiallv 
serviceable.  If  there  has  been  a  syjdiilitie  history  aJi  occasional  course  of 
iodide  of  jjotassium  is  indicated,  and  whenever  the  ])ulse  tension  is  hii^h 
nitroglycerine  may  ])e  used. 

In  cases  wliich  come  under  observation  for  tlie  first  time  with  dyspiid'a, 
'digiit  lividity,  and  siirns  of  cardiac  insuliiciency,  venesection  is  indicated. 
In  some  instances,  with  very  hiijii  tension,  striking  relief  is  afforded  l)y  the 
abstraction  of  twenty  ounces  of  blood. 


III.  ANEURISM. 


The  following  forms  of  aneurism  are  usually  recognized  : 

{(i)  'l'lu>  /nir,  in  which  tiic  siic  is  formed  of  one  or  more  of  the  arterial 
coats,  'i'his  may  l)c  fnsiforn),  cylindrical,  or  cirsoid  (in  which  the  dilatatidii 
is  in  an  artery  and  its  branches),  (jr  it  may  bo  circiiinseribed  or  sacculated. 
Aneurisms  are  usually  fusiform,  resulting  from  uniform  dilatation  of  the 
vessel,  or  .saccular. 

{/))  'J'lie  /W/,sr  aneurism,  in  which  there  is  rupture  of  all  the  coats,  and 
the  blood  is  free  (or  circumscribed)  in  the  ti.ssues. 

(r)  The  disscr/iiifj  aneurism,  which  results  from  injury  or  laeoratioii 
of  the  internal  coat.  The  blood  dissects  be^veen  the  layers;  hence  the 
name,  dissectiiig  aneurism.  This  occurs  usually  in  the  aorta,  j)ersistiiii,f 
for  years. 

(d)  Ar/(ri(i-irnoiis  aneurism  results  when  o  oonim'.:.\icati()n  is  estali- 
lished  between  an  artery  and  a  vein.  A  sac  may  intervene,  in  which  case 
it  is  called  a  varicose  aneurism;  but  in  many  cases  tie  comnninici'.iion  is 
direct  and  the  chief  (diange  is  in  the  vein,  whi(di  is  dilated,  tortuous,  and 
pid.sating,  and  is  ternud  an  aneurismal  varix. 

Etiology  and  Pathology. — Aneurisms  ari.se  :  (a)  By  the  gradual 
ditfu.-;e  distention  of  liie  arterial   coats,  which  have  been   weakeneti   liy 
arterio-.-^tderosis,  ])articidarly  in  its  early  stages,  before  compen.'^atiiry  eu 
darteritis  tlevclops.     The  andi  of  the  aorta  is  often  dilated  in  this  waj'  so 
as  to  f(trm  an  irregu'.ar  ancrism. 

(b)  In  conse(pience  of  circumscribed  lo.ss  of  resisting  jiower  in  the 
media  and  advctiiitia,  aiul  diUM)ften  to  laceration  of  the  media.  Thi-  i-* 
the  most  common  cause  of  sacculated  aiu'urism.  The  laceration  is  tV'- 
quently  found  iii  the  ascending  ])ortion  of  the  arch  and  occurs  early  in 
the  process  of  arterio-Siderosis,  before  the  (iomi)ensatory  thickening  h:i- 
taken  phwe.  Occasionally  one  meets  with  remarkable  specii;  enr  illustrat- 
ing the  important  part  played  by  this  process,  'i'he  intima  may  al-" 
be  torn.     ii.  a  L-ase  of  Daland's  there  was  just  above  the  aortic  valves 


'pt  active 

.     lllO   t'(li)(| 

t'  miiuTiil 

is  usual l\ 

course  of 

11  is  liiuii 

(lyspiiii'ii, 
iiuliciitiil. 
-lod  1)V  llie 


ho  arterial 
1  (lilatatimi 
sucrulaldl. 
ion  of  the 

coats,  ainl 

laceration 
hence  the 
l)ersistini,' 

is  estah- 
hicii  case 
liciuiou  is 
uous,  ami 


ANEl'IlISM. 


ro- 


an ohl  transvorso  tear  of  the  intinia,  cxtondiiiE^  almost  the  entire  oiroum- 
f(  reiico  of  the  vessel.  Sclerosis  of  the  iiiedia  and  adventitiu  had  taken 
place  and  the  process  was  evidently  of  some  standing.  An  inch  or  more 
a'ltove  it  was  a  fresh  transverse  rent  which  had  produced  a  dissecting  an- 
eurism. These  arterio-sclerotic  aneurisms,  as  they  are  called,  are  found 
also  in  the  smaller  vessels. 

(r)  Einhi>Ur  Aiicnrixm. — When  an  emholus  has  lodged  in  a  vessel  and 
|Hiiiianently  i)lugged  it,  aneurismal  dilatation  may  follow  on  the  proximal 
side.  The  emholus  itself  may,  if  a  calcified  fragment  from  a  valve,  lacer- 
ate the  wall,  or  if  infected  may  produce  inllammation  and  softening. 

{(I)  Mi/roiir  A)i('Hi'ism. — The  imjtortance  of  this  form  has  heen  spe- 
cially considered  hy  Eppinger  in  his  cxiiaustive  monograph.  The  occur- 
rence of  multiple  aneurisms  in  malignant  endocarditis  has  heen  observed 
by  several  writers.  Probably  the  first  case  in  which  the  mycotic  nature 
was  recognized  was  one  which  o(!ciirred  at  the  Montreal  (leneral  irosj)ital 
ami  is  reported  in  full  in  my  lectures  on  malignant  endocavlilis.  In  addi- 
tion to  the  ulceration  of  the  valves  there  were  four  aneurisms  of  the  arch, 
of  which  one  was  large  and  saccular,  and  three  were  not  bigger  than 
cherries.     An  extensive  growth  of  micrococci  was  present. 

A  form  of  parasitic  aneurism  which  occurs  witii  great  frefpiency  in  the 
niesoiiteric  arteries  of  the  horse  is  due  to  the  development  of  the  utruHtjijlia^ 
aniuifus. 

Thoma  has  described  a  "  traction  "  aneurism  of  the  concavity  of  the 
ai'i'h  at  the  point  of  insertion  of  the  remnant  of  the  ductus  H(jtalli  (\'ir- 
chow's  Arehiv,  Bd.  l'.".'). 

And,  lastlv,  there  are  cases  in  whicli  without  anv  definite  cause  there 


IS 


I  tendency  to  the  development  of  aneurisms  in  var 


ions  parts  of  the 


lioily.  A  remarkalile  instance  of  it  in  our  profession  was  afforded  by  the 
lirilliant  Thomas  King  (,'liainbers,  who  first  had  an  aiu'urism  in  the  left 
liopliteal  artery,  eleven  years  subseipu'iitly  an  aneurism  in  the  right  k'g 
which  was  cured  by  pressure,  and  finally  aneurism  of  both  carotid  arteries. 


/     II 


grailual 
•cclietl    liy 
;atory  en 
lis  \va    so 

'r  ill  the 
This  is 
(in  is  fi'"- 
•s  early  in 
•iiing  li:i- 
illustrat- 
may  al-o 
tic  valves 


AxKriiisM  oi-  TiiK  Tiiouack;  Aoktv. 

The  causes  which  favor  the  dcvelopincwt  of  arterio-sclcrosis  prevail  in 
tKM'tic  aneurism,  ])articularly  alcohol,  syphilis,  ami  overwork.  The  great- 
est danger  ])r()bably  is  in  strong  iniiscular  iiwii  with  coniinciicing  ilcgcn- 
ei'ative  processes  in  .lie  arteries  (a  conse(|uence  of  syphilis  or  alcohol  or  a 
result  of  hereditary  weakness  of  the  ai'icrial  tissues),  who  during  a  sudden 
iiuiscular  exi'rtion  are  lialile  to  lacerate  the  media,  the  intinia  not  yet  being 
strengthened  by  co."!,)ensatory  thickeiiin  r  over  a  spot  of  incsarteritis. 
Aneurisms  of  the  thoracic  aorta  vary  g''":itly  in  si/e  and  shape.  A  major- 
ity of  them  are  saccular.  They  may  be  small  and  situated  just  above  tlu! 
iioitic  ring.  Others  form  large  tumors  which  project  externally  and  occupy 
ii  large  portion  of  the  upper  thorax.  Small  sacs  from  the  descending  por- 
tion of  the  arch  may  compress  i\w  trachea  t)r  the  br-'iichi.     lii  the  tho- 


!  I ; 


7<iS 


DISKASKS  OF   TIIK  CIRCULATORY  SYSTEM. 


rucic  pni  t  ii in  tlu'  siir  may  eroilo  the  vortobni)  or  ^tow  into  the  iilenral  cuvii  \ 
and  (•onii)iTss  tlio  liinj,'.  In  .some  instaiu'cs  it  j^rows  throii^rli  tlio  ribs  jiiul 
apjii-ars  in  tlic  liack. 

Symptoms. — 'I'lic  cliicr  inlliicnec  of  an  aneurism  is  manit'esteil  in 
wiiat  arc  known  as  pressure  elTeets.  In  the  absence  of  these  the  aneurisms 
attain  a  iarire  size  witliout  ]>n)ilucin<,'  symptoms  or  seriously  intertVriii;; 
with  the  eirculalion.  liKh-ed,  a  useful  clinical  subdivision  as  ^nvcn  li\ 
Bramwcll  is  into  tl)ree  frroups — atu'urisms  which  are  entirely  latent  iind 
jlive  no  ]»hysical  si,<,nis ;  aneurisms  which  present  siyjis  of  intratlionicic 
pressure,  but  it  is  diflicult  or  impossible  to  determine  the  luiture  of  the 
lesion  produciuf;  the  pressure;  and,  lastly,  aneurisms  which  produce  (li>- 
tin<'t  tumors  with  well-marked  oressure  sym])toms  and  external  sijriis.  ji  is 
perhaps  best  to  consider  aneurisjus  of  the  aorta  according  to  the  situatiun 
of  the  tumor. 

(a)  A)H'Hristiis  of  Ihv  Asccndbuj  Portitui  of  iJtc  ArrJi. — "When  just 
above  the  sinuses  of  Valsalva  they  are  often  small  and  latent.  The  tiist 
symjitom  nuiy  In'  rupture,  which  usually  takes  place  into  the  ])ericar(liiim 
and  causes  instant  death.  Above  the  siiniscs,  alonij  the  convex  border  of 
the  ascendinj;  part,  aneurism  frecjuently  develoj)s,  and  may  jj;row  to  a 
larf]fe  size,  either  passing  out  into  the  riirlit  pleura  or  forward,  pointing  ;it 
the  second  or  third  interspace,  eroding  the  rii)s  and  sternum,  and  prochn- 
ing  large  external  tumors.  In  this  situation  the  sac  is  liable  indeeil  in 
compress  the  su))erior  veiui  cava,  causing  engorgement  of  the  vessels  of 
the  iicad  and  arm,  sonuHimes  ('oini)ressing  oidy  the  subclavian  vein,  nml 
c:uisiug  eidargeuu'ut  and  (edenui  of  the  right  arm.  TVrforation  may  l;ike 
))Iace  into  tlu>  superior  vena  cava,  of  whicli  acciih'ut  Pepper  and  (ii'itlitli 
have  collected  twenty-nine  cases.  Large  aneurisms  in  this  situation  iikiv 
cause  nnich  dislocation  of  the  Iicart,  pushing  it  down  and  to  the  Id'f, 
and  somctinu's  com|)ressing  tlu^  inferior  vena  cava,  and  causing  swelh'ng 
of  the  fei't  aiul  ascites.  Tlie  right  recurrent  laryngeal  lU'rve  is  often  in- 
volved in  thi'se  tumors.  Deatii  commonly  follows  from  rupture  into  the 
ple\ira,  or  into  the  snpi'rior  cava;  less  commonly  fr(»m  rupture  exteruallv, 
sonu'tinu's  from  heart-failui'c. 

(fj)  A/ii'iin'siiis  of'  llir  Truiisrrrsi'  Arrli. — These  may  grow  for\v;inl. 
erode  the  sternum,  and  produce  large  iumors.  ^lore  commonly  thev  iuv 
small  and  products  no  external  tumor,  l)ut  cause  marked  pressure  signs  in 
their  growth  backward  toward  tiie  spine,  involving  the  tradica  and  thi' 
(esophagus,  producing  cough,  which  is  often  of  a  paroxysmal  chanictcr. 
and  dyspliagia.  The  left  recurrent  laryngeal  is  often  i:ivolved  in  il^' 
course  round  the  arch.  .V  small  aneurism  from  the  lower  or  ])ostejiiir 
wall  of  tlic  arch  may  compress  a  bronchus,  inducing  broiudiorrhn;i. 
gratlual  bronchieetasy,  and  suppuration  in  the  lung — a  ]>rocess  which  bv 
no  means  infre(|uently  causes  death  in  aneurism,  and  a  condition  wliii  h 
at  tiie  .Montreal  (ieiu-ral  Hospital  we  were  in  the  haiiit  of  terming  Jincn- 
risund  phthisis.     Uccasioiudly  enormous  aneurisms  develop  i'l  this  situa 


fc 


ANEUIUSM. 


Toy 


tioii,  iiiitl  ;rr()\v  into  hotli  plciinv,  cxtoKliiiLr  Ix'twcon  tlic  nianubriuin  and 
llu'  vi'rU'l)i'a',  and  may  juTsist  for  yi'ar.s.  'I'lii!  sac  may  l)t'  evident  at  the 
.-liTiial  noteli.  The  innominate,  les.s  eonimotdy  the  left  carotid  and  suh- 
chniaii,  may  be  involved  in  the  sac,  and  tiie  radiii!  or  carotid  pulse  may 
ill'  absent  or  retarded.  I'ressiire  on  the  sympatiietic  may  at  first  cause 
(lilatation  and  sul)se(|iu'ntly  contraction  of  tlic  pupil.  Sometimes  the 
ihorai'ic  duct  is  ('om|)i'essed. 

(r)  ANi'iirixnis  of  the  Desccndiiid  /'nr/inii. —  I'ressiire  sijxns  are  not  so 
marked.  The  })ain  is  often  intense,  owiiij^  t(t  erosion  of  the  vertebrae 
l>ys|)ha;,na  may  occur.  Compression  of  the  lunj;  or  compression  td'  ecr- 
tiiiu  bronchi  imiy  induce  bronchiectasy,  retention  of  secretions,  and  fever. 
A  tumor  may  a})])ear  exti'rnally  in  the  region  of  the  scapula,  ami  hero 
attain  i'.n  enormous  size.  Occasionally  the  aneurisms  in  this  re<fioii  are 
siiiall  and  latent,  and  })r(ne  fatal  by  rupture  into  the  o'sophajrus.  I  have 
reported  a  case  of  sudden  death,  in  which  the  heart  and  arch  of  the  aorta 
were  normal  and  the  storiuich  was  distended  with  blood,  which  could  not 
!»(■  accounted  for  until  the  ojsopha.ifus  was  slit  ojien,  when  it  was  found 
tliat  a  small  aneurism  in  the  thoracic  aorta,  Kmuller  than  a  walnut,  liatl 
ni|)tured  into  the  jrullet.  The  sac  may  erode  the  vertel)ra'  and  open  the 
s|iiiial  canal,  producinff  compression  of  the  cord.  Death  not  infre<iuently 
occurs  from  rupture  into  the  ])leura. 

Diagnosis  and  Physical  Signs.— /t/sprrf ion.— \u  many  instaiu-es 
this  is  negative.  On  either  sidt'  of  the  sternum  there  may  be  abiu)rmal 
|iiilsation,  due  to  dislocation  of  the  heart  or  to  detormity  (tf  the  thorax. 
The  aneurisnud  jjulsation  is  usually  above  the  level  of  the  third  rib  and 
most  commonly  to  the  riji;lit  of  the  sternum,  either  in  the  first  or  second 
iiiicrspace.  It  nuiy  bo  oidy  a  diffuse  heavin<r  impulse  without  any  exter- 
nal tumor.  Often  the  impulse  is  noticed  only  when  the  chest  is  looked 
at  (>bli(juely  in  a  favorable  lij,d>i.  W  hen  the  innominate  is  involved  the 
tln'ohl)in.if  may  ])ass  into  the  ne(d<  or  be  apparent  at  the  sternal  notch. 
I'listeriorly,  when  jtulsation  occurs,  it  is  most  commonly  found  lU  the  left 
scapular  rej^ion.  An  external  tutnor  is  present  in  immy  cases,  project inif 
either  throuLdi  the  u|)per  ))arl  of  the  sternum  or  to  the  right,  sometimes 
involving  the  sternum  and  costal  cartilages  on  both  sides,  forming  a  tumor 
I  he  size  of  a  eoeoa-nut  or  even  larger.  The  skin  is  thin,  often  blood- 
stained, or  it  may  have  rn])ture(l,  exposing  the  lamina'  of  the  sac.  The 
apex  beat  may  be  much  dislocated,  particularly  when  the  sac  is  large.  It 
i-;  more  commoidy  a  <lislocation  from  ]>ressurc  than  from  eidargement  of 
the  heart  itself. 

PdJpafioii. — The  area  and  degree  of  pulsation  are  best  determined  by 
jialpation.  When  the  aneurism  is  deep-seated  and  not  apparent  exter- 
nally, the  biniiinual  method  should  be  used,  oiu'  hand  upon  the  spine  and 
the  other  on  the  sternum.  When  the  sac  has  perforated  the  chest  wall 
tlic  impulse  is,  as  a  rule,  forcible,  slow,  heaving,  and  expansile,  'i'he  re- 
sistance mav  b(!  very  great  if  there  are  thick   lamina' beneath  the  skin  ; 


'i 


4  j"    " 
-  J  Si  V  i 


<  i 


710 


DISEASES  OF   THE   CIRCULATOIIY  SYSTEM. 


ill  f\ 


more  raroly  tlie  sao  is  soft  and  nnctuatiiig.  The  hand  upon  tlic  -iac,  or 
on  the  region  in  wliicli  it  is  in  contact  witli  the  clicst  wall,  fools  in  nianv 
cases  ii  diastolic  shock,  often  of  great  intensity,  which  forms  one  of  the 
valuable  physical  signs  of  aneurism.  A  systolic  tiirill  is  sometimes  pres- 
ent, not  so  often  in  saccuhir  aneurisms  as  in  the  dilatation  of  the  arch. 
The  pulsation  may  sometimes  he  felt  in  the  suprasternal  notch. 

Prrcitssioii. — The  small  and  deep-seated  aneurisms  are  in  this  res|)i(i 
negative.  In  the  larger  tumors,  as  soon  as  the  sac  reaches  the  chest  wall, 
tliere  is  produceil  an  area  of  ahnormal  dulness,  the  position  of  which  de- 
pends upon  the  part  of  the  aorta  atfected.  Aneurisms  of  tlie  asceiidiiiir 
arch  grow  forward  and  to  the  right,  producing  duliu'ss  on  one  side  of  the 
nuinuhriuiu  ;  those  from  the  truiisverse  arch  produce  dulness  in  the  mid- 
dle line,  extending  toward  the  left  of  the  sternum,  while  aiu'urisms  <>( 
the  descending  jjortion  most  commonly  ]troduce  dulness  in  the  k'ft  inter- 
scapular and  scapular  regions.  The  ])ercussion  note  is  flat  and  gives  a 
feeling  of  increased  resistance. 

Aitsriilffi/idii. — Adventitious  sounds  are  not  always  to  bo  heard.  Mveu 
in  a  large  sac  there  may  be  no  murmur.  Much  depends  upon  the  tliiek- 
ness  of  the  hunina?  of  fibrin.  An  important  sign,  particularly  if  lieani 
over  a  dull  region,  is  a  ringing,  accenluaied  second  sound,  a  phenonieimn 
rarely  missed  in  large  aneurisms  of  the  aoriic  arch.  A  systolic  nuir'niii 
may  be  present;  sonu'tinu's  a  double  murmur,  in  which  case  tln'  diaslolii 
Indt  is  usually  <bie  to  associated  aortic  insufliciency.  The  systolic  iiiiir 
niur  alone  is  of  little  monuMit  in  the  diagnosis  of  an  aneurismal  sac.  With 
the  single  stethoscope  the  shock  of  the  impulse  with  the  first  sound  is 
sometimes  very  marked. 

Anutng  other  jihysical  signs  of  importance  are  slowing  of  the  |)ulse  in 
the  arteries  beyond  the  aneurism,  or  in  those  involved  in  the  sac.  Tlieiv 
nuiy,  for  instance,  be  a  marked  ditference  lietween  the  right  antl  left  radial, 
both  in  volume  and  time.  A  jthysical  sign  of  large  thoracic  aneurism 
which  I  have  not  seen  referred  to  is  <»bliterat ion  of  the  |)idse  in  the  ali- 
doininal  aorta  and  its  branches.  ^Fy  attention  was  called  to  this  in  a 
patient  who  was  stated  to  have  aortic  insutliciency.  'I'liere  was  a  well- 
marked  diastidic  murmur,  ])ut  in  the  fcmorals  and  in  the  aorta  I  was 
surprised  to  find  no  trace  of  ])ulsation,  and  not  the  slightest  throbliing  ir 
the  abdominal  .lorta  or  in  the  peripheral  artei'ies  of  tlie  leg.  Tlii'  cireula- 
tioii  wa.s,  however,  unimpaired  in  them  and  tiiero  was  no  dilatation  of  ihe 
veins.  Attracted  by  this,  I  then  made  a  cari'ful  exaiuimition  of  the  pa- 
tient's back,  when  tlu'  circumstance  Mas  discovered,  which  ncitlier  llie 
])atient  himself  nor  any  of  his  j)hysicians  had  noticed,  that  he  had  a  \t  rv 
large  area  of  i»ulsation  in  the  K'ft  scapular  region.  'I'he  sac  ])robal'ly 
was  large  enough  to  act  as  a  reservoir  annihilating  the  ventricular  systole, 
and  converting  the  intermittent  into  a  contimious  stream. 

The  trarlind  ifii/r/in;/,  a  valuable  sign  in  deep-seated  aneurisni.",  was 
described  by  Surgeon-Major  Oliver,  and  has  been  specially  studied  by  my 


m 


u. 


AXF.U11ISM. 


711 


(nll(>:ignos  li()S:4  iuid  MiicDoiiiu'll  *  at  tlu-  Montreal  (ienonil  Hospital. 
Oliver  gives  tin*  follo\viii<(  directions:  "  I'lace  the  patient  in  tlie  erect 
liDsitioii,  ami  direct  hint  to  close  his  inoutii  and  elevate  liis  idun  to  almost 
till' t'ldl  extent ;  tiien  fjrasp  the  cricoid  cartilage  between  the  linjjjer  ami 
tliiniil),  and  iis(^  steady  and  jientlo  npward  pressure  on  it,  when,  if  dilata- 
tiMii  or  aneiu'ism  exists,  the  pidsation  of  the  aorta  will  be  distinctly  felt 
ti'iinsnutted  throiifj^h  the  trachea  to  the  hand."  On  several  occasions  I 
have  known  this  to  be  a  sisxn  of  jjreat  value  in  the  diairnosis  of  deep- 
seated  aneurisms.  1  have  never  felt  it  in  tumors,  or  in  the  extreme 
(1\  tiainic  dilatation  of  aortic  insufliciency. 

Occasionally  a  systolic  nuirmur  nniy  be  heard  in  the  trachea,  as  pointed 
out  liy  David  Drummond,  or  even  at  the  patient's  mouth,  when  o]»ened. 
'I'liis  is  either  the  .sound  conveyed  from  the  .<ac,  or  is  produced  by  the  air 
as  it  is  driven  out  of  tin;  wind-pipe  durin<f  the  systole. 

An  important  but  variable  feature  in  thoracic  aneurism  is  jxtiit^  which 
is  particularly  marked  in  deei)-seated  tumors.  It  is  usually  paroxysmal, 
sharp,  and  lancinatin<r,  often  very  severe  when  the  tumor  is  eroding  the 
vertelme,  or  perforating  tlie  chest  wall.  In  the  latter  case,  after  jjcrfora- 
tiuii  the  pain  may  cease.  Anginal  attacks  are  not  nnconnnon,  particularly 
ill  aneurisms  at  the  root  of  the  aorta.  Frecpicntly  the  })ain  radiates  down 
the  left  arm  or  u[)  the  neck,  sometimes  along  the  upi)er  intercostal  nerves. 
('i)U(jh  results  either  from  the  direct  pressure  on  the  wind-pi|)e,  or  is  as- 
sociated with  bronchitis.  The  ex])ectoration  in  these  instances  is  abundant, 
thill,  and  watery;  Kub.serpiently  it  becomes  thick  and  turbid.  Paroxysmal 
iiiiigh  of  a  peculiar  l)razen,  ringing  character  is  a  characteristic  .symptom 
ill  somi^  cas(!S.  i)articularly  when  there  is  })ressure  on  the  recurrent  laryn- 
geal nerves. 

I>i/spn(P(i,  whi(di  is  common  in  cases  of  aneurism  of  the  transverse 
imrtion,  is  not  neces.sarily  associated  with  pressure  on  the  recurrent  laryn- 
geal nerves,  but  may  be  due  directly  to  comjiression  of  the  trachea  or  the 
left  iintncluis.  It  may  occur  with  marked  stridor.  Loss  of  voice  and 
Imarseness  are  consequences  of  ])re.ssure  on  the  recurrent  laryngeal,  usually 
llie  left,  inducing  either  a  spasm  in  the  mu.scles  of  the  left  vocid  cord  or 
para  lysis. 

Paralysis  of  an  abductor  on  one  side  may  be  present  without  any 
symptoms.  It  is  more  ])articularly,  as  Si-mon  states,  when  the  paralytica 
contractures  supervene  that  the  attention  is  called  to  laryngeal  .symptoms. 

JI(('morrJi(/i/r  in  thoracii'  aiu'urism  may  come  from  (ti)  the  soft  granula- 
tions in  the  trachea  at  the  ])oint  of  compression,  in  which  case  the  s|)nta  are 
liloiMl-tinged,  but  large  fpnintities  of  blood  are  not  lost;  (//)  from  ru))ture 
of  tlie  sac  into  the  trachea  or  bronchi  ;  (r)  from  perforation  into  the  lung 
or  erosion  of  the  lung  tissue.  The  bleeding  may  be  profuse,  rapidly  prov- 
ing fatal,  and  is  a  common  cause  of  death.     It  nniy  persist  for  weeks  or 


1  * 


11 


i    5.     i 


I.;  I  ill  I 


V 


V 


til 


f.-Mr.    H 


*  London  Lancet,  ISOL 


if 


712 


niSEASKS  OF  THK  ("IIirULATOUY   SYSTEM. 


mniitliia,  in  wliicli  oaso  it  is  sim])ly  luvmorrluigin  wpoping  tlirouirli  the  .sac, 
wliicli  i.s  oxposcfl  ill  tlio  tnichca.  In  some  instances,  even  al'ter  a  vcrv 
j)rofiise  lia'tnorrliaj^'e,  tlie  patient  recovers  and  may  live  for  years.  .\ 
patient  witii  well-niarketl  thoracic  aneurism,  whom  I  sliowed  to  my  class 
at  tlie  University  of  Pennsylvania  and  who  had  had  several  brisk  liMinor- 
rhaires,  died  four  years  after,  having  in  the  meantime  enjoyed  avera,i,'c 
health. 

Dilliculty  of  swallowing  is  a  comparatively  rare  symptom,  and  niav  lu' 
due  either  to  s[iasm  or  to  direct  compression.  The  sound  should  never 
he  ]»asscd  in  these  cases,  as  the  oesophagus  nuiy  he  almost  eroded  and  a 
l)erforation  may  he  made. 

Among  (jther  signs  and  symptoms  venous  compression,  which  hii,-' 
already  been  nu-ntioned,  nuiy  involve  one  subclavian  or  the  superior  veiiu 
cava.  A  curious  phenomenon  in  intrathoracit'  aneurism  is  the  elubbiii" 
of  the  lingers  and  itu'urving  of  the  nails  of  one  hand,  of  which  two  e\- 
ami»les  have  been  under  my  care,  in  both  without  any  special  distention 
or  signs  of  venous  engorgement.  'J'unu)rs  of  the  arch  may  iiivolve  the 
])ulmonary  artery,  producing  compression,  or  in  some  instances  adhesion 
of  the  pulmonary  segments  and  insuf!iciency  of  the  valve;  or  the  sac  iiuiv 
ru[)ture  into  the  artery,  an  accident  which  happened  in  two  of  my  cases, 
producing  instantaneous  death. 

Pressure  on  the  syni[»athetic  is  ])articularly  liable  to  occur  in  growths 
from  the  ascending  portion  of  the  arch.  Either  the  upper  dorsal  or  the 
lower  cervical  ganglion  is  involved.  The  sym|)toms  are  variable.  If  the 
nerve  is  simply  irritatcfl  there  is  stimulation  of  the  vaso-dilator  til)rcs  and 
dilatation  of  the  pupil.  With  this  may  be  iissociated  ])allor  of  the  same 
side  of  the  face.  On  the  other  hand,  destruction  of  the  cilio-s|)iii;il 
branches  causes  j»aralysis  of  the  dilatt)r  fibres,  in  consequence  of  which 
the  iris  contracts,  the  vessels  on  the  side  of  the  head  ililate,  causing  con- 
gestion, and  in  sonic  instances  unilateral  sweating.  It  is  much  more  com- 
mon to  see  the  pupillary  symptoms  alone  than  in  combination  either  with 
pallor,  redness,  or  sweating. 

The  clinical  ])icture  of  aneurism  of  the  aorta  is  extremely  varied. 
^fany  cases  present  characteristic  symi)toms  and  no  jdiysical  signs,  while 
others  have  well-marked  jjliysical  signs  and  no  symptoms.  As  Hroadlnnl 
remarks,  the  aneurism  of  p/ii/siml  sitpis  springs  from  the  ascending  ])nr- 
tioii  of  the  aorta;  the  aneurism  of  sijnipfoms  grows  from  the  transverse 
arch. 

Aneurism  of  the  aorta  may  be  confounded  with:  (a)  The  violent 
throbbing  impulse  of  the  arch  in  aortic  insullicieiu'V.  I  have  aln-ady  re- 
ferred to  a  case  of  this  kind  in  which  the  diagnosis  of  aneurism  was  ni.nle 
by  several  good  ol)servers.  In  a  case  I'ecently  under  observation  didne:  s 
and  ]Mdsation  existed  in  the  second  right  interspace  Avith  a  well-mark>(l 
systolitr  and  a  loud  diastolic;  nuirmur,  which  was  heard  far  out  in  the  riglii 
mammary  region.     The  (piestion  arose  whether  aneurism  was  present  in 


ANEURISM. 


13 


ttildition  to  the  aortic  iiisuiliciency.  The  post-mortem  sliowed  tlie  mnr- 
;:iii  (if  the  rij^lit  lull}?  rctriictetl  aiitl  adherent  to  tiic  |K'riciinliiim,  Iciiviii!? 
('\|i()si'(l  tile  ii(»rta,  which  must  have  hccn  _tri"<'atly  (listeiidcij  duriuir  each 
sy-ti>lc. 

(//)  Sinijih'  IhitHtniir  J'lifsdfiaii. — Mo  instance  of  tliis,  wliicli  is  com- 
iiiiiii  in  the  ahdomiual  aorta,  has  ever  come  under  my  notice.  One  \vliicl\ 
ciuiie  iiiuier  the  care  of  William  Murray  and  Bramweil  ]»ri'scnti'd,  witiiout 
luiy  pain  or  ])ressure  symptoms,  ])ulsatioii  and  dulnessover  tlie  aorta.  The 
(■(indition  jjrachiaiiy  disappeared  and  was  tliouirlit  to  l>e  neurotic. 

(r)  Dislocation  of  the  heart  in  curvature  of  the  spine  may  cause  ^xri'at 
(lisplaeeiiient  of  the  aorta,  so  that  it  has  heeii  known  to  i>ulsate  forcil)ly 
tn  the  riifht  of  tile  sternum. 

('/)  So/id  7'iiinors. — When  the  tumor  j)rojccts  externally  and  pulsates 
the  dilliculty  may  he  eonsiderahle.  In  tumor  the  heavin<i:,  cr/xinsilr  ])ul- 
siitioii  is  ahsent,  and  there  is  not  that  sense  of  force  and  power  which  is  so 
strikin^i'  in  the  tlirol)l)in<?  of  a  jierforated  aneurism.  'J'here  is  not  to  be 
j'clt  as  in  aortic  aneurism  the  shock  of  the  heart-sounds,  ]»articularly  the 
diastolic  sliock.  Auscultatory  sounds  are  less  deiinite,  as  lari^e  aneurisms 
iiiMV  occur  without  murmur;  and,  on  the  other  hand,  murmurs  maybe 
heard  over  tumors.  The  fjreatest  ditliculty  is  in  the  deep-seated  thoracic 
tniiiors,  and  here  the  dia,<;;nosis  may  lu;  impossible.  I  have  already  re- 
f;'i'reil  to  the  ease  which  was  rej^arded  by  Skoda  as  aneurism  and  by  ()p- 
polzer  as  tumor.  'I  he  physical  sii^ns  may  be  indelinite.  The  rin<rin<,' 
aoi'tii-  second  sound  is  of  f^reat  imi)ortanee  and  is  randy,  if  ever,  heard 
over  tumor.  Tracheal  tii^jt^ing  is  here  a  valuable  sijjfii.  Pressure  jdie- 
iiuinena  aVe  less  common  in  tumor,  whereas  pain  is  more  fre(|uent.  'J'lie 
:r"Heral  appearance  of  the  ])atient  in  aneurism  is  miudi  l)etter  than  in 
minor.  There  may  be  Hi<;ns  of  eiilarirement  of  the  fjlands  in  the  axilla  or 
ill  the  neck.  Healthy,  strong  males  who  have  worked  hard  and  have  had 
.-yiijiilis  are  the  most  common  subjects  of  aneurism.  Occasionally  cancer 
III'  tile  (esopha<?iis  may  simulate  aneurism,  prodiKMiii?  ])res^^.re  on  the  Itd't 
lu'oiichiis,  and  in  one  instance  at  the  JMiiladelphia  Hospital,  with  a  husky, 
hiiizeii  I'ough,  the  symptoms  were  very  suggestive. 

('•)  Piilsdh'ii;/  Plrun'si/. — In  cases  of  rnijii/cniti  ui'rt'sfiiftffis,  if  the  pro- 
jecting tumor  is  in  the  neighborhood  of  the  heart  and  ]tulsatt's,  the  condi- 
timi  may  readily  be  mistaken  for  aneurism.  'I'he  absi'iice  of  the  heaving, 
linn  distention  and  of  the  diastolic  shock  would,  together  with  the  his- 
t'nyand  the  existence  of  pleural  effusion,  determine  the  nature  of  the  case. 
If  necessary,  ])unctnre  may  be  made  with  a  fine  hypodermic  needle.  In  a 
iiiajority  of  the  cases  of  ])ulsating  pleurisy  the  tlir(d)l)ing  is  ditfuse  ami 
Widespread,  moving  the  whole  side. 

Prognosis. — The  outlook  in  thoracic  aneurism  is  always  grave.  Life 
may  l)e  prolonged  for  some  years,  hut  the  patients  are  in  constant  jeopardy, 
'^|"»ntaneous  cure  is  not  very  infre(|uent  in  the  small  sacculated  tumors  of 
tile  ascending  and  thoracic  portions.     The  cavity  becomes  tilled  with  lani- 


'  "''  !' 


' 


t 


714 


DLSKASKS  OV  THE  CIllCULATOllV  SVSTK.M. 


iiia>  f)f  firm  fibrin,  wliicli  bcconu*  inoro  aiid  more  doiisc  and  lianl,  llio 
WK!  shrinks  considt-raljly,  and  tinaily  Unit!  salts  arc  di'itositcd  in  tlic  olii 
lihrin.  Tlio  lamina'  (»!'  lihrin  may  lie  nii  a  level  with  tlii'  limu'ii  of  the  vcs- 
st»l,cuiisinj(  complete ohlitcratidii  (»1.  the  sac.  'i'he  cases  which  viiptiirc  e.\- 
ternaily, as  a  rule  run  a  ra])id  course, although  to  this  there  are  exceptions; 
the  sac  may  contract,  become  linn  and  hard,  and  the  patient  may  live  fur 
five,  or  even,  as  in  a  cast'  mentioned  by  Balfour,  for  ten  years.  'J"he  cu.ms 
which  have  lasted  lonj^est  in  my  experience  have  been  those  in  which  a 
saccular  aneurism  Inis  ])rojeeted  from  the  ascenilinj^  arch.  One  patient  in 
Afontreal  had  l)een  known  to  have  aneurism  for  eleven  years.  'J'he  aneu- 
rism mav  be  enormous,  occnpyin;f  a  larj^e  area  of  the  chest,  and  yet  life  lie 
ju'olouj^i'd  for  many  years,  as  in  the  case  mentioned  as  under  the  care  of 
Skoda  and  Oppolzer.  One  of  tlie  most  rennirkable  instances  is  the  case  of 
dissectiiif;  aneurism  reported  by  (Irahain.  'I'he  patient  was  invalided  after 
the  Crimean  War  with  aneurism  of  the  aorta,  and  for  years  was  under  I  lie 
observation  of  .J.  H.  Jfichardson,  of  Toronto,  under  wliose  care  he  (lie(l 
in  1885.  'riie  autopsy  showed  a  healed  aneurism  of  the  arcli,  with  a  dis- 
sectinjif  aneurism  passing  the  whole  length  of  the  aorta,  which  formed  a 
double  tube. 

Treatment. — In  a  large  ]»roportion  of  the  cases  this  can  only  be  piil- 
liative.  Still  in  every  case  measures  should  be  taken  which  are  known  to 
promote  clotting  and  consolidation  within  the  sac.  In  any  large  series 
of  cured  aneurisms  a  considerable  majority  of  the  j)atients  have  not  been 
known  to  be  subjects  of  the  disease,  but  the  obliterated  sac  has  been  found 
accidentally  at  the  post  mortem. 

The  most  satisfactory  plan  in  early  cases,  when  it  can  be  citrried  out 
thoroughly,  is  that  advised  by  the  late  Mr.  Tufnell,  of  Dublin,  the  essen- 
tials of  which  are  rest  and  a  restricted  diet.  Kest  is  essential  an<l  should, 
as  far  as  possible,  be  absolute.  The  reduction  of  the  daily  nnnil)er  ef 
heart-beats  when  a  patient  is  recumbent  ami  makes  no  exertion  whatever 
amounts  to  many  thousands,  and  is  one  of  the  principal  advaidages  of 
this  ])lan.  Mental  quiet  should  also  be  enjoined.  The  diet  advised  by 
Tufnell  is  extremely  rigid — for  breakfast,  two  ounces  of  bread  and  buitir 
and  two  ounces  of  milk;  for  dinner,  two  or  three  ounces  of  meat  anil 
three  or  four  ounces  of  milk  or  claret;  for  supper,  two  ounces  of  l)it;id 
and  two  ounces  of  milk.  This  low  diet  diminishes  the  blood-volume 
and  ia  thought  also  to  render  the  blood  more  fibrinous.  It  reduces 
greatly  the  l)lood-pressure  within  the  sac,  in  tbis  manner  favoring  coagii- 
hition.  This  treatment  should  l)e  pursued  for  several  months,  but,  exeeiii 
in  persons  of  a  goo<l  deal  of  mental  stamina,  it  is  iin])ossible  to  carry  it 
out  for  more  than  a  few  weeks  at  a  time.  It  is  a  form  of  treatment 
adapted  only  for  the  saccular  form  of  aneurism,  and  in  cases  of  large  siu-; 
communicating  with  the  aorta  by  a  com))aratively  small  orifice  the  chaiiiis 
of  consolidation  are  fairly  good.  Unquestionably  rest  and  the  restriitieii 
of  the  liquids  are  the  important  parts  of  the  treatment,  and  a  gre.  t.r 


Hi. 


ANEURISM. 


T16 


vai'i<'iy  and  qnantity  of  food  iiiiiy  )»('  allowed  w  itli  adviintaf^o.     If  tlii.s  ))l;m 
niiiiiot  bo  tliorou;^hly  (•arried  out,  the  jKiticnt  sliould  at  any  rate  he  ad- 
vised to  live  a  very  (iiiict  life,  moving  about  witli  deliberation  and  uvoiding 
all  niiddiiu  mental  or  bodily  exeitement.    The  bowi'ls  should  be  ke|  t  regu- 
lar, and  eonstipation  an<l  straining  sliould  lie  earefiilly  avoided.     Of  nieili- 
ciiics,  iodide  of  potassium,  as  advised  by  iJalfour,  is  of  great  value.     It 
may  be  given  in  doses  of  from  ten  to  fifteen  or  twenty  grains  three  times 
a  (lay.     Larger  doses  are  not  neeessury.     'I'lii-juode  of  action  is  not  well 
umlcrstood.     It  may  act  by  inci'easing  the  secretions  and  so  inspissating 
the  blood,  by  lowering  the  blood-pressure,  or,  as  Jialfour  thinks,  by  causing 
thickening  and  contraction  of  the  sac.     The  most  striking  cll'ect  of  the 
iodidi!  in  my  e.xjjerienee  has  been  the  relief  of  the  pain.     The  evidi'iu-e  is 
not  conclusive  that  the  syphilitic  eases  are  more  benefited  than  the  non- 
sypliilitic.     All  these  nu'asures  have  little  value  unless  tlu-  sac  is  of  a  suit- 
alilo  form  and  size.     The  large  tumors  with  wide  mouths  comnmiucating 
with  the  ascending  portion  of  the  aorta  niay  be  treated  on  the  most  ap- 
proved i)lans  for  months  without  the  slightest  influence  (jther  than  reduc- 
tion in  the  intensity  of  the  throbbing.     A  [latieiit  with  a  tumor  ])roject- 
u\<f  into  the  right  pleura  remained  on  the  most  rigid  Tufnell  treatment 
for  more  than  one  hundi'cd  days,  during  which  lime  lie  also  took  iodide 
of  potassium  fidthfully.    'i'lie  ]iulsations  were  greatly  reduced  and  the  area 
of  (lulness  diminishcil,  and  we  congratulated  ourselves  that  the  sac  was 
probably  consolidating.     Sudden  death  folUnved  ru])ture  into  the  jdeura, 
anil  the  sac  contained  only  tluiil  blood,  not  a  shred  of  fibrin.     In  cases  in 
vliieli  the  tumor  is  large,  or  in  which  there  seems  to  be  very  little  prosjiect 
of  consolidation,  it  is  perhaps  better  to  advise  a  man  to  go  on  quietly  with 
Lis  occupation,  avoiding  excitement  and  worry.     Our  })rofession  has  of- 
fered manv  examples  of  ijood  work  thoroucfhlv  and  conscientiouslv  carried 
out  by  men  with  aneurism  of  the  aorta,  who  wisely,  I  think,  ])referred,  as 
(lid  |he  late  Hilton  Fagge,  to  dio  in  harness.     Other  measures  to  iiuluco 
coairidation  in  the  sac  are  electricity,  which  has  occasionally  proved  suc- 
cessful;  the  insertion  of  horse-hair,  thin  wire,  or  needles;  the  injection  of 
an  astringent  licpiid,  su(di  as  perchloride  of  iron,  into  the  sac.     In  u  few 
cases  only  these  have  been  followed  by  cure.     The  tine  silver  wire  pushed 
through  a  hypodernuc  needle  is  ])rol)ably  the  most  satisfactory  method, 
and  may  be  conibine:l  with  electrolysis,  the  juethod  known  as  Loreta's. 
Kerr  and  Kosenstein,  of  San  Francisco,  have  recently  reported  cases  in 
wliieli  cure  Avas  effected  in  this  way. 

OlJicr  Sympfo'ivs  ref/in'iin;/  Tri'afnioif. — Pressure  on  veins  causing  en- 
gorfienient,  particnlarly  of  the  head  and  arms,  is  sometimes  ])romptly  ro- 
lioved  by  free  venesection,  ami  at  any  time  during  the  course  of  a  thonicic 
aneurism,  if  attacks  of  dyspnoea  with  lividity  supervene,  bleeding  may  bo 
resorted  to  with  great  benefit.  It  has  the  advantage  also  of  promptly 
clieeking  the  pain,  for  which  symptom,  as  already  mentioned,  the  iodido 
of  potassium  often  gives  relief.  In  the  final  stages  morphia  is,  as  a 
4U 


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1 

1 

II 


710 


DISEASKS   OF   TIIK   CIIICULATOIIV   SYSTEM. 


rule,  nooossiiry.  T)_vspna'ft,  if  nssofiiitod  witli  cyarKwia,  is  best  relieved 
by  l)lctuliii;,'.  CMiIorofoi-Jii  iiiliiilatiotis  niiiy  bo  iioceHSiiry.  The  (|Mesti(iri 
souu'tiine.s  coriics  up  with  rercrcnce  to  triuheotoiiiv  iti  these  cases  of  tirirciit 
(lyH2)ii(eii.  If  it,  can  i)e  shown  ]>\  laryn^^'oscopic  i-xainiuiition  tliat  ii  is  (hio 
to  bihitoral  abdnctor  paralysis  tlie  trachea  maybe  opentsd,  but  this  is  ox- 
tremely  rare,  and  in  nearly  every  instance  the  nr^'cnt  dyspncea  is  eaiiscd 
l)y  pressure  al)ont  tiie  bifurcation.  W  lien  the  s;ic  appears  exteriuilly  ami 
grows  lari^e  an  ice-cap  may  lu^  applied  n|)on  it,  or  a  heiladoiina  plaster  to 
allay  the  pain.  In  some  instaix-es  an  elastic?  su|)))ort  nuiy  bo  used  HJtli 
udvantajjje,  and  I  saw  a  jdiysician  with  an  enormous  external  anourisni  in 
the  rij^lit  mammary  region  who  fttr  many  months  ha<l  obtained  f^Tcat 
relief  by  the  clastic  support,  passinj^  over  the  shoulder  and  uiuier  the  arm 
of  tiio  opposite  side. 

Digitalis,  ergot,  aconite,  and  venitrum  viride  uro  rarely,  if  ever,  of 
service  in  thoracic  aneurism. 

ANKflUSM     OF   TFIR    AhDOMIXAI,    AoRTA. 

The  sac  is  most  common  in  the  neighborhood  of  the  coeliac  axis,  ft 
is  rare  in  comparison  with  thoracic  aneurism.  The  tumor  may  be  fusi- 
form or  sacculateil,  and  it  is  sometimes  multipl(>.  Projecting  backwanl,  it 
erodes  the  vertebra;  and  may  cai  numbness  and  tingling  in  the  Ic^m 
and  finally  ])araplegia,  or  it  may  pass  into  the  thorax  and  burst  into  tiio 
pleura.  More  commonly  the  sac  is  on  the  anterior  wall  and  projects  for- 
ward as  a  definite  tumor,  which  may  be  either  in  the  middle  line  or  a 
little  to  the  left.  The  tumor  may  bo  large  and  evident,  or  when  high  up 
beneath  the  pillar  of  the  diaphragm  it  may  attain  considerable  size  with- 
out being  very  apparent  on  palpation. 

The  symptoms  are  chiefly  paiti,  very  often  of  a  eardialgio  nature, 
passing  round  the  sides  or  localized  in  the  back,  and  gastric  symptyni;;, 
particularly  vomiting.  Retardation  of  the  pulse  in  the  femoral  is  a  vi'ry 
common  symptom. 

Diagnosis  and  Physical  Signs. -Inspection  may  show  marked 
pulsation  in  the  e])igastric  rei'ion,  sometime-;  a  delii\ite  tumor.  A  'tlirill 
is  not  uncommon.  The  pulsation  is  forcible,  expansile,  and  sometiinis 
double  when  the  sac  is  large  and  in  conta<;t  with  the  pericardium.  On  pal- 
pation a  dvfinilo  tumor  can  be  felt.  If  large,  there  is  some  degree  of  diil- 
ness  on  percussion  which  usually  merges  with  that  of  the  left  lobe  of  tlio 
liver.  On  auscultation,  a  systolic  murmur  is,  as  a  rule,  audible,  ami  i^ 
sometimes  best  heard  at  the  back.  A  diastolic  murmur  is  occasionally 
present,  usually  very  soft  in  quality.  One  of  the  commonest  of  clinical 
errors  is  to  mistake  a  throbbing  aorta  for  an  aneurism.  It  is  to  be  retnem- 
bered  that  no  pulsation,  however  forcible,  or  the  presence  of  a  thrill  era 
systolic  murmur  Justifies  the  diagnosis  of  abdominal  aneurism  unless  tlure 
is  a  definite  tumor  which  can  be  grasped  and  tvhich  has  an  expansile jjuka- 


ANKUltlSM. 


1 


til 


l)ost   rolicM'il 

'J'llO     (|ll('Snnl| 

r*asos  of  urircnt 
I  that  it  is  iliio 
l)iit  this  is  cx- 
)ntra  is  fini-i('{l 
cxtcnuillv  mihI 
onna  plasltT  to 
\'  1)0  used  with 
lal  aiicurisTii  m 
i)l)tuine(l  j,M'(;it 
uiuk'i'  the  anil 

"ly,  if  ever,  nf 


r-a'liaf  axis.  It 
or  may  bo  fiisi- 
[ig  bac;k\vanK  it 
n«j;  ill  the  ii';„'s 
[  burst  into  tlr? 
(1  projects  for- 
iddle  line  or  n 
when  high  up 
rable  size  witli- 

■(iialgio  natiiiv. 
trie  symptyiii!!. 
moral  is  a  vrvy 

V  shoAV  marked 
iiior.  A  'thrill 
ind  sometiiiH's 
Mum.  On  pal- 
degree  of  il Ill- 
eft  lobe  of  tlie 
ludible,  ami  i'^ 
is  occasionally 
lest  of  elinii'al 
s  to  be  retiu'iii- 
of  a  thrill  era 
m  unless  there 
•pansilepKlsa- 


(inn.  Attention  to  tliis  rule  will  save  many  errors.  The  throbbing  aorta 
—the  "  preternatural  pulsation  in  the  epigastrium,"  as  Allan  Burns  rails 
it— is  met  with  in  all  neiiiasthenii:  conditions,  j)artieulurly  in  woiru-n. 
in  anaemia,  {)articularly  aomo  instunues  of  truunuitic  una>miu,  the  throb- 
liiiig  nuiy  be  very  great.  In  the  case  of  a  largo,  stout  man  with  severe 
liiiniorrhages  from  a  duodenal  ulcer  the  throbbing  of  the  abdonunal  aorta 
not  only  shook  violently  the  whole  abdomen,  but  communicated  a  i)ulsa- 
tion  to  the  bed,  the  shock  of  wliich  was  distinctly  perceptible  to  any  oiu' 
sitting  upon  it.  Very  frequently  a  tumor  of  the  pylorus,  of  the  pancreas, 
or  of  the  left  lobe  of  the  liver  is  lifted  with  eacli  impulse  of  the  aorta  and 
may  be  confoumled  with  aneurism.  The  absence  of  the  fonuble  expansile 
impulse  and  the  examination  in  the  knee-elbow  position,  in  which  the 
tumor,  as  a  rule,  falls  forward,  and  the  pulsation  ia  not  then  communi- 
cated, sufiice  for  diiferentiation.  The  tumor  of  abdominal  aneurism, 
though  usually  il.xed,  may  be  very  freely  movable. 

The  outlook  in  abdomitud  aneurism  is  had.  A  few  cases  heal  sj)on- 
taneoiisly.  Death  may  result  from  (tt)  comjtlete  olditeration  of  the  lunu'ii 
hy  (lots ;  (/>)  compression  paraplegia;  {<:)  rupture  either  into  the  pleura, 
n troperitoneal  tissues,  j)eritona'um  or  the  inti'stines,  very  commonly  the 
duodenum  ;  {(/)  l)y  eird>olism  of  the  superior  mesenteric  artery,  j)roducing 
infarction  of  the  intestines. 

The  trcntinoHt  is  such  as  already  advised  in  thoracic  aneurism.  When 
the  aneurism  is  low  down  pressure  has  been  successfully  applied  in  a  case 
hy  Murray,  of  Newcastle.  It  must  be  kept  u]»  for  many  hours  under  chlo- 
idfonn.  The  plan  is  not  witiiout  risk,  as  patients  liuve  died  from  bruising 
and  injury  of  the  sac. 

AXEURISM   OF  THE    BUAT^^CHES   OF  THE    .\BI)0MIXAL   AoRTA. 

The  cmliac  axis  is  itself  not  infrequently  involved  in  aneurism  of  the 
first  [lortion  of  the  alxlominal  aorta.  Of  its  hranches,  the  .splenic  arferif  is 
occasionally  the  seat  of  aneurism.  T'his  rarely  causes  tumor  large  enough 
to  he  !';  it;  sonietimes,  however,  the  tumor  is  of  large  size.  I  have  reported 
a  case  in  a  man,  aged  thirty,  who  had  an  illness  of  several  months'  dura- 
tion, severe  epigastric  pain  and  vomiting,  which  led  his  physicians  in  New 
York  to  diagnose  gastric  ulcer.  'I'here  was  a  deep-seated  tumor  in  the  left 
liypochondriac  region,  the  dulnessof  which  merged  with  that  of  the  spleen. 
Tiiere  was  no  pulsaticm,  but  it  wiis  thought  on  one  occasion  that  a  liniii 
was  heard.  The  chief  symptoms  while  under  observation  were  vomiting, 
severe  ei)igastric  pain,  occasional  ha>matemesis,  and  finally  severe  hemor- 
rhage from  the  bowels.  An  aneurism  of  the  splenic  artery  the  size  of  a 
cocoa-mit  was  situated  hetween  the  stomach  above  aiul  the  transverse  cohm 
below,  and  extended  to  the  left  as  far  as  the  level  of  the  navel.  The  sac 
crmtained  densely  laminated  fibrin.  It  had  perforated  the  colon.  I  have 
twic;  seen  small  aneurisms  on  the  splenic  artery.    Of  thirty-nine  instances 


m 

ii 


'•I 


miA-n 


*, 


M 


.^>'i 


m-^- 


: 


lis 


DISKAHKS  OK  THE  rillCUI-ATOIlY  SVSTKM. 


of  aneurism  on  the  hniiu'lios  of  the  ul)(loniiim]  nortii  collcchul  by  Ficliort 
tun  were  of  tlio  Hplciiit'  arti'ry. 

Ani'iirisni  of  tlio  hi'imlic  nrferif  i«  very  rare,  and  there  are  only  ten  or 
twelve  eases  on  record.  'I'lie  syinj)tonis  arc  extremely  indeliiiite;  tlie  ((iii- 
dition  eould  rarely  he  diajfnosed.  In  the  case  reported  by  Hoss  and 
myself,  a  man  aged  twenty-one  had  the  symjitoins  of  jtya'inia.  The  liver 
was  greatly  enlarged,  weighed  nearly  5,000  grammes,  and  i)resente<l  iiimi- 
merahle  small  absoesses.  An  oval  aneurism,  half  the  size  of  a  small  lemon, 
involved  the  right  and  part  of  the  left  branehes. 

A  few  eases  of  aneurism  of  the  superior  inrsi'nfcric  (trfcrytivo  on  rwon], 
'J'hediagiUKsis  is  scarcely  possible.  IMugging  of  the  hnmchesor  of  the  main 
stern  nuiy  cause  the  symptoms  of  infarction  of  the  bowels  which  have  al- 
ready been  eonsidercHl. 

Small  aneurisms  of  the  renal  (irtery  are  not  very  Jincommon.  Large 
tumors  are  rare.  The  sac  may  rupture  and  give  rise  to  extensive  retro- 
peritoneal hajuiorrhage. 


>  i 


AUTKKIO-VEXOIS   ANEURISM, 

In  this  form  there  is  abnormal  communication  between  an  artery  and 
a  vein.  When  a  tumor  lies  between  the  two  it  is  known  as  varicose  aneu- 
rism ;  when  there  is  a  direct  communication  without  tumor  the  vein  is 
cliii'fly  distended  and  the  condition  is  known  as  aneurisnud  varix. 

An  aneurism  of  the  ascending  pcntion  of  the  arch  may  open  directly 
into  the  vena  cava.  Twenty-nine  cases  of  this  lesion  have  been  analyzed 
by  Pepper  and  (jriflith.  Cyanosis,  (edema,  and  great  distention  of  tlie 
veins  of  the  upper  part  of  the  body  are  the  most  frequent  symjjtoms,  and 
develop,  as  a  rule,  with  suddenness.  Of  the  pln'sical  signs  a  thrill  is  ])res- 
ent  in  .some  cases.  A  continuous  murmur  with  systolic  intensification  is 
of  great  diagnostic  value.  In  a  recent  case,  after  the  existence  for  somo 
time  of  pressure  symptoms,  intense  cyanosis  developed  with  engorgement 
of  the  veins  of  the  head  and  arms.  Over  the  aortic  region  there  was  a 
loud  continuous  murmur  with  systolic  intensification. 

A  majority  of  the  cases  of  arterio-venous  aneurism  and  of  aneurisnud 
varix  result  from  the  accidental  opening  of  an  artery  and  vein  as  in  vene- 
section, and  are  met  with  at  the  bend  of  the  elbow  or  sometimes  in  the 
temporal  region.  The  condition  may  persist  for  years  without  causing 
any  trouble.  Pulsation,  a  loud  thrill,  and  a  continuous  humming  nuir- 
mur  are  usually  present. 


Congenital  Aneurism. 

In  consequence  of  failure  of  proper  development  of  the  elastic  coat  in 
many  places  in  the  arterial  system,  multiple  aneurisms  may  develoj).  In 
the  well-known  case  described  by  Kussmaul  and  Maier,  upon  many  of  the 


ANEURISM. 


1!) 


nicdimn-sizod  arteries  there  were  iKHlular  i)rotninonce8,  which  cdiisisteil  of 
tlii('keiUM<;  of  the  iiitiiini  and  iiililtnition  of  th(;  adveiititia  and  of  tlie 
iiicdiii,  witli  a  iiueU'ar  jjrowtii  whieii  in  phiees  h)ol\ed  (|uite  sarcoiiiatoiis. 
Tliey  called  it  a  case  of  pcriartcrifis  itmlimt,  and  Kppiii^er  holds  that  it 
lu'loiifjs  to  tlie  category  which  he  makes  of  congeiutul  uneurisiii.  As 
iiiiiiiy  as  sixty-three  aneiirisiiial  tumors  liave  been  found  in  one  case.  In 
ttic  smaller  branches,  such  as  the  coronary  and  the  mesenteric  arteries  or 
ill  the  })ulmoiiary  arteries,  there  juay  he  numerous  elongated  or  saicidar 
aneurisms  varying  in  size  from  a  cherry  to  a  hazel-nut.  'I'hese  are  tnu» 
aiu'urismal  dihitations,  aiul,  according  to  Eppinger's  can'ful  study,  consist 
of  the  intinui  and  the  advi-ntitia,  the  elastic  lamina  having  disappeared. 
Tiie  eoiulition  has  been  im-t  with  in  children.  Some  of  the  eases,  iiow- 
ever,  luive  b((en  in  adults;  but  the  term  us  ii[)pliod  by  Kppinger  ex- 
presses, ujul  probably  correctly,  the  deep-seated  fundamental  error  in 
(h'Vclitpment  which  must  })e  at  the  basis  of  this  condition.  'J'he  coronary 
iirteries  is  a  favorite  situation ;  a  case  has  been  reported  by  (Jee  in  a  boy 
of  seven. 


m 


.  u 


;s|:|i^; _-. 


SECTION   VI. 

DISEASES  OF   TUE   BLOOD   AND   DUCTLESS 

GLANDS. 


I,  ANyEMIA. 

Av.KMrA  imiy  l)o  defined  us  a  reduction  in  the  amount  of  the  Wood  as 
a  whole  or  of  its  c^orpuscdes,  or  of  eertain  of  its  more  ini])ortant  eonstitu- 
eiits,  su<di  as  alhunien  and  huMuof^lohin.  'The  condition  Jiiay  he  gencnil 
or  local.  'I'he  former  alono  wo  are  here  eonsiderinj^.  It  is  interesting 
to  note,  however,  that  the  pallor,  particularly  of  the  face,  which  is  oiio 
of  the  most  striking  symptoms  of  ana'inia,  is  just  as  eharacteristic  of  loial 
ana'uiia  due  to  fright  or  to  nausea.  There  are  persons  persistently  pale 
without  ac^tual  anaunia  in  whom  the  condition  niiiy  l)e  <lue  to  inh(>rii";l 
peculiarities. 

Our  knowhidge  is  not  yet  sufllciently  advanc;.Ml  to  classify  satisracturily 
the  various  forms  of  aiuemia.  The  following  provisional  grouping  may 
he  made:  (1)  Soeoiulary  or  symptonuitic  auicmia;  {'i)  primary,  essential, 
or  cvtoifonic  anaunia. 


UikUm"  this  div 


SeOONDAKY    Ay.T-IMIA. 

ision  come 


large  i)roi)ortion  of  ail  cases.     The  follow- 


ing are  the  most  important  groups,  liased  on  the  etiology  : 

(!)  Ainvinui  fntni  hirmurrlnujp^  either  traumatic  or  spontam'ous.  The 
loss  of  hlood  may  1)e  rapid,  as  in  lesions  of  large  vessels,  in  injury  or  in 
rupture  of  aneurisms,  or  in  cases  of  nicer  of  the  stonuudi  or  duodeuiuii, 
or  post-partuni  lisemorrhage.  If  the  loss  is  exoossive,  death  results  fnnii 
lowering  of  tiio  arterial  ])ressure.  In  sudden  profuse  luejuorrhage  the 
loss  of  thnu'  or  four  pounds  of  hlood  nniy  ])rove  fatal.  In  the  ru|'.turr  of 
au  aneurism  into  the  [ileura  the  loss  of  hlood  nuiy  amount  to  seven  poumls 
and  a  half,  the  largest  (piantity  I  have  known  to  he  shed  into  one  cavity. 
In  a  case  of  liaMuatemesis  the  patient  lost  over  ten  ])ounds  l)y  measiin'- 
mei\t  in  oTto  week  and  yet  recovered  from  the  immediate  elTeets.  Kvi  ii 
after  very  seven!  luemorrhage  the  nund)er  of  red  hlood-corpuscles  is  not 
reduced  so  greatly  as  in  forms  of  idiopathic  anaMuia.     Thus  in  a  ease  just 


iisractiirilv 


AN.KMIA. 


721 


mentioned,  at  tlie  termination  of  the  week  of  hlcodijiff  tiuTo  wciv  nearly 
1,;{1H),(K)()  red  l)lood-(.'ori)usc;Ies  to  tiie  ciihic  niillimetre.  'i'lie  process  of 
rejjeneration  goes  on  witii  great  rapidity,  and  in  some  "bleeders"  a  weeic 
or  ten  days  sntliee  to  ro-estahlisii  tiie  normal  amonnt.  The  watery  and 
saline  (lonstituents  of  the  blood  are  readily  restored  l»y  abs(»rption  from 
the  gastro-intestinal  fract.  The  albuminous  elements  al.Ao  are  (luickly  re- 
newed, but  it  may  take  weeks  or  months  for  the  eor]»  iscKs  to  reach  ilio 


APRIL.       ,                                MAY.                          1                        JUNE,                              j    JULV. 

SKSS5gU,..2?I5SS2SSSS',-»K,  =  -StSS:StSU--,.- 

110« 

11'                                                                '                   i       '       1 

._ .._    ^..lj__  _.^  1  1  _i    _.     1 .      _    1 .  ^ -    - 

100;t 

r..i><K),ix)o       i                            1                                                  j 

'                                                                              1     1 

\)0% 

i 

SOX 

l.ooo.nnn  |          !         [    \         T                  1'^"*"^' 

70% 

-ri"-^^! It    ^^  ''\'  ''  1-"' 

11  i        .J       L-^^'               '      •■  ■   ' 

CO* 

a,o(M),()oo  '    *^  1        /   i             i                       -  "1    1 

50;< 
40« 

L     0  1^.,H:4,J::     1  .1 

2.000  000           \       /f    1     ;              !     i 

V        !     1                            1 

80;( 

*  — * — *---JI---!--*---/>-4--'/|--*--*---ir--  *--♦-■)••;•      *     j-J'       *        * 

11,000        '     1     i     :     '     I     1^  I     i     i     1                   1     ;     ' 

v^^,^^     jk^^l  T    4..1J-IL-L.L  i    -J  I  1-  ,    -- 

lo.odo     /    ,   N           _!      ^X-l -■    — -      -T  + - 

^.'^^  ji     1      \         i       '       1    ■                    !  

0.000     !        '^  "^"^  "i"  ~+- -t- -t«    ■                '  .    ... 

2,000       1                         1                        ^  :             1         ;    ! 

MIAN  NORM. 
NUMSCR  OF 

WHITE 

conpuscLit 


BLACK,  RED  CORPUSCLES.  RED,  HAEMAGLOBIN,  BLUE,  COLORLESS  CORPUSCLES. 

i'li Aur   XV. — lllustrat(*s  tho  rapidity   \vitl»   wliicli    anaMiiia    i^    pruiliiii'd    in    imrpiira 
ha'inori'ha  :i<'H  and  the  L^adiial  i-ccovrrv.* 


1 

19 

H'lisi 

mn 

Mm 

^  f » 

fi  ■  1 

^  il 

I" 


Hi 


i.'.'ij 

■  ft'  if' 


,n'i 


'3 


\ 


/J  I 


li  : 


iiniiiial  standard.     The  accompanying  chart  illustrates  the  rapid  fall  and 
i:i!iiliial  restitution  in  a  ciise  of  severe  i)ur()ura  lueuiorrhagica. 

The  microsco[)ical  characters  of  the  blood  after  si>vere  ha-morrliage 
liiiiy  not  be  greatly  changed.  'I'he  red  corpu.scles  show,  usually,  rather 
iimre  marked  dilTerences  in  size  than  normally,  while  the  average  size 
iiniy  be  a  trifle  reduced  ;  there  may  be  a  moderate  poikilocytosis.     'i'he 


*  <'ii  Si>ptciTil)or  27tli  the  piititMit  rcliirncil  fi'diii  llic  (•(Pimtrv,  wlicrc  slir  liml  spt'iit 
tlif -uiiinuT,  'I'he  lil()()(i-<Mniiit  was  then:  IJed  I'oi-piiscle!;,  5,155(1,000;  while  eoriniscles, 
5,")iiO;  luDinoglohiii,  iiinely-four  per  eciit. 


I    ' 


t    14'*-  •-      < 


¥ 


(22 


DISEASES    OF  THE   BLOOD  AND   DUCTLESS  GLANDS. 


corpuscles  are  paler  than  normally.  Nucleated  red  <!()rpuscle,s  appear, 
almost  always,  soon  after  the  luemorrhaj^e  ;  they  are,  however,  not  numer- 
ous. These  are  small  bodies  of  about  the  same  size  as  a  normal  red  cor- 
puscle with  a  small,  round,  deeply  staiuiuij  nucleus.  Free  nuclei  luay  lie 
found.  The  colorless  corpuscles  are,  at  first,  increased  iii  number.  There 
is  a  moderate  leucocytosis,  the  differential  count  showinj,'  an  increase  in 
the  multiiuuilear  neutrophiles  with  a  diiuinution  in  the  snuiU  monounclear 
elements.      Duriuir  recovery  the  leucocytosis  diuiinishes. 

The  reduction  in  htciiioglobin  is  always  2)roportionatcly  greater  than 
that  in  the  corituscks. 

In  some  instances  a  rapidly  fatal  ana3mia  may  follow  a  single  severe 
ha?morrhage,  or  repeated  small  luKmorrhages  as  in  purpura.  Here  the 
appearances  of  the  red  corpuscles  are  much  the  sanu',  excejit  in  the  total 
absence  of  nucleated  red  corjjuscles. 

'J'he  leucocytes  in  these  cases  are  usually  reduced  in  number;  tlie  polv- 
nuclear  elements  are  present  in  a  I'ldativelv  diminished  proportion,  wiiile 
the  small  inoiu)nuclear  forms  arc  nuni'U'ous.  The  autopsy,  in  these  cases, 
reveals  usually  a  total  absence  of  an_\  r»-i;enerative  activity  on  the  })art  of 
the  bone-Miarrow. 

(2)  Amemia  is  frcf|uent]y  prod m^ I  by  long-continued  drain  on  the 
albuminous  materials  of  the  blood,  as  in  chronic  guppuration  and  liright'.s 
disease,  rmloiiged  lactation  acts  in  the  same  way.  Hapidly  growini: 
tumor.:  may  cause  a  profound  anaemia,  as  in  gastric  cancer,  'i'he  charac- 
ters of  the  blood  here  nuiy  be  much  the  same  as  in  the  acute  cases.  I'sn- 
ally.  though,  the  poikilocytosis  is  much  more  marked  ;  in  .several  «'awK  it 
nuiy  be  excessive.  The  presence,  however,  of  the  very  large  corpuscle:, 
sucli  as  one  sees  in  j)ernicious  aiuvn;ia,  is  not  noted,  the  average  size  ap- 
pearing to  be  rather  suuiiler  than  normal. 

Nucleated  red  corpuscles  are  usually  .scanty.  In  long-continued  cliroiiic 
secoiuiary  anannias  occasiotial  larger  nucleated  red  (;orpu8cles  may  be  .<een, 
bodies  with  larger  palely  staining  nuclei;  in  some  of  the.se  cells  kar\e- 
kinetic  ligurcs  occur.  >iucleate<l  re<l  cor])Uscles  with  fragmentary  nuclei 
may  also  be  seen. 

The  leucocytes  may  he  increased  in  number,  though  in  some  severe 
chronic  cases  there  juay  be  a  dimiinition. 

(.'5)  AiKPinia  fr<i)n  Jiutiiilio)!. — This  may  be  brought  about  by  defecl- 
ive  food  supply,  or  by  conditions  which  interfere  with  the  proper  recej*- 
tion  and  jireparation  of  the  food,  as  in  catu'cr  of  the  o'sophagus  ami 
chronic  dysp'.'psia.  'i'he  reduction  of  the  blood  imiss  may  be  extreme,  hul 
the  i)lasina  siilTcrs  proportionately  more  than  the  corituscles,  which,  even 
in  tlie  wasting  of  (cancer  of  the  «i'so|)hagiis,  may  not  be  rediu-ed  more  llian 
one  half  or  three  fourths.  In  some  instances  the  rctluction  in  the  j)lasriia 
may  be  so  great  that  the  corpusch's  show  an  apjtarent  iiu;rea.se. 

(4)  Toxic  (UKrtin'a,  imiuiied  by  the  action  of  certain  poisons  on  the 
blood,  such  as  lead,  mercury,  and  arsenic,  among  iiujrgauic  substances. 


ANJ'IMIA. 


72B 


kiic  sevt'rc 


and  the  virus  of  syphilis  and  malariii  among  orjjanic  poisona.  Thoy  act 
citlier  by  directly  dL'stroyiiiij  tlie  red  hlood-corpiisclcs,  as  in  nialaria,  or  by 
ini'n'asin<,'  tlio  rato  of  ordinary  consmiiption.  The  ana'inia  of  pyrexia 
may  in  part  bo  duo  to  a  t(».\ic  action,  but  is  also  caused  in  part  by  the 
«listurl)ance  of  digestion  and  interforenco  with  the  function  of  tlie  blood- 
making  organs. 

PllIMAHY    Oil    I-'SSIATIAI,    Ax.KMFA. 

1.  Chlorosis. — An  essential  unaiinia  met  with  chiefly  in  young  girls, 
characleri/ed  l)y  a  marked  relative  diininulion  nf  the  ha-nioglobin. 

Etiology. — Cases  are  rarely  seen  in  men.  Blondes  are  more  fre- 
(|iuiilly  alTected  than  brunettes.  The  age  of  onset  is  usually  between  the 
fnurieonth  and  the  seventeciiith  years,  llecurreneos  throughout  the  third 
(licade  are,  fiowever,  not  uncommon.  Chlorosis  is  e.xtromoly  rare  in 
vdiiiig  children. 

Hereditary  influences  probably  play  a  part.  Vircliow  pointed  out  that 
in  many  cases  there  was  a  defective  developrtieiit  of  the  circ  ulatory  sys- 
ttiii.  either  congenital  or  residting  in  a  failure  <^f  the  \iormal  state  of 
irnnvth.  In  some  instances  a  compensatory  hypertrophy  of  the  heart 
lias  been  found. 

The  disease  is  most  common  amcuL''  tiic  ill-fed,  overworked  girls  of 
large  towns,  who  are  confined  all  day  iti  close,  liadly  lighted  rooms,  or 
have  to  do  much  stair-climbing.  Cases  are  frc'|Uent,  however,  utider  the 
iimst  favorable  conditions  of  life.  Lack  of  proper  exercise  and  fresh  air 
ami  impioper  food  are  important  f'ai'tors.  Kinotional  and  nervous  dis- 
turbances nuiy  bo  })rominent  -so  |irominent  tluit  certain  writers  have 
ivgardeil  the  disease  as  a  neurosis.  Menstrual  disturbances  art'  not  un- 
common, but  are  prol»ably  a  sequence,  not  a  cause,  of  chlorosis.  Su" 
.\ndrew  Clark  believed  that  constipation  plays  an  im|iortant  /•//'',  and  that 
tln'  condition  is  in  reality  a  copni'inid  ilue  to  the  absorption  of  poiaons — 
Itiicomaities  and  ptomaines — from  the  large  bowel. 

Morbid  Anatomy.— Fortunately,  tlie  diHease  is  rarely  fatal.  Tiie 
fut  is  well  retainetl.  1!  poplasia  of  the  aorta  and  larger  arteries  has  been 
found  in  some  cases,  and  tlu^  vi'sscis  have  had  a  remarkable  degree  of  elas- 
tiiily.  The  heart  is  usually  dilated  and  the  left  \fiitri(dc  hypertroplued. 
ilviioplasia  of  the  uterus  and  defective  development  of  tlu-  genitalia  have 
also  boon  found. 

Symptoms. — The  blood  examination  :  J<»liann  Dunfaii  in  18»r7  first 
lailcil  attention  to  the  fact  that  the  essenid  feature  was  not  a  (puili- 
tativc  but  a  quan.itative  change  in  the  Inemoglobin.  This  has  been 
aliumiantly  (^ontirjued.  The  red  blorxj-corp'.iweles  may  show  only  a  mod- 
erate grade  of  reduction,  but  the  corpuscles  tlntmstdves  are  very  poor  in 
liii'moglobin.  Thus  in  sixty-three  .'ons«'cutive  cases  examined  at  my  clinic 
hy  Tliayer,  the  average  number  pfr  cubic  millinu'trc  of  the  red  bloo(|-cor- 
pu.scles  was  •i,0lJ(),544,  or  over  eighty  per  ccut,  whereas  the  percentage  of 


mm 


J?  i      !'   ■ 


E;jf 


,rj«ijyj 


(24 


DISKASES   OF   'VUK    I'.LOOI)    AND    DUCTLESS   GLANDS. 


ha'inofjlohiii  for  the  totiil  miiiibcr  was  4"^-.'}  per  cent.  The  accompanying,' 
clnirl  illustrates  well  these  striking,'  (lilTereiices.  There  may,  liowever,  lie 
well-nnirked  actual  ana'Miia.  'The  least  blood-count  in  tlie  series  of  cmxs 
referred  to  above  was  1,9:{2,()0().     'I'iioro  may  bo  all  the  physical  eliarac- 


BLACK,  RED  CORPUSCLES. 


RED,  HAEMAQLOaiN. 

CuAKT  XV[, — ("hlorosis. 


MEAN  NORM. 

NUMBER  OF 

WHiTt 

CONPUSCLt^ 


BLUE,  COLOBLESS  CORPUSCLES. 


teristics  and  symptoms  of  a  profound  ana'inia  witli  blood-corpn,<5cles  nearly 
at  tlie  iinrnial  standard.  'I'lnis  in  one  instance  tlic  ^jlobidar  richness  u,i- 
over  eighty-live  per  cent  with  the  ha'inoglobin  about  thirtv-tive.  Tlu'^' 
(diaracteristics  are  distinctive,  1  believe,  and  not  found  in  tlie  same  irr:i'li' 
in  any  other  form  of  ana'mia.  'I'he  importance  of  the  reduction  in  ili' 
ha'moglobin  de|iends  \ip(»n  the  fact  that  it  is  tlie  iron-containing  eleimiit 
of  the  blood  with  which  in  respiration  the  oxygen  enU'r<  into  conihination- 
This  marked  diminution  in  the  iron  has  also  been  determined  by  cheiiii'-il 
unuly^id  of  the  blood.     'J'iie  microscopical  characteristics  of  the  blood  iu-' 


IS  CORPUSCLES. 


ANAEMIA. 


725 


as  follows :  In  severe  cases  the  corpuscles  may  be  extremely  irrepnlar  in 
size  and  shape — poikilocytosis — which  may  occasionally  be  as  inarkcil  as 
ill  soiiu'  I'ascs  of  ])eriiici()iis  ana'tiiia.  Tlu'  lar;E;e  forms  of  red  blood-ccUs 
iin«  not  as  c<»mmoM,  and  the  avera;i,'e  size  is  stated  to  be  below  normal. 
The  color  of  the  corpuscles  is  noticeably  pale  and  the  deliciency  may  be 
seen  either  in  individual  corpuscles  or  in  the  blood  nuxture  prejjared  for 


ooiinliiiL' 


'i'l 


le  leucocytes  may  show  a  sli<;ht  increase;  the  averaf^e  o 


f  th 


sixtv-three  cases  above  referred  to  was  8,4(iT  ])er  cubic  millimetre.  'J'houirli 
there  is  no  espe(;ial  diU'erence  between  the  blood  of  any  case  of  chlorosis 
,111(1  one  of  ordinary  si'condary  amemia,  yet  the  relatively  ^reat  diminution 
ill  lia'iiioglobin  and  the  absence  of  special  factors  serve  to  distinj^uish  the 
former. 

The  general  symptoms  of  chlorosis  are  those  of  an  ana;miaof  moderate 
jrrade.  The  srl)cutaneoi's  fat  is  well  retained  or  even  increased  in  amount, 
'riic  comi)Iexion  is  peculiar ;  neither  the  blanched  aspect  of  ha'tnori'liage 
nor  the  muddy  j)ailor  of  grave  amemia,  but  a  curious  yellow-grt^en  tinge 
wiiicli  has  given  tiie  name  to  the  disease,  and  •^o  its  popular  designation, 
the  green  sickn<'ss.  In  cases  of  moderate  grao  >  tiie  color  may  be  decep- 
tive, as  the  (dieeks  have  a  reddish  tint,  particularly  on  exertion  (chlorosis 
luliia).  The  subjects  complain  of  breath lessness  and  palpitation,  and 
there  may  be  a  tendency  to  fainting.  The  paljtitaiion  and  breathle.ssness 
oflcn  lead  to  the  suspicion  of  heart  or  lung  disease.  The  eyes  have  a  pe- 
culiar l)rilliaru'y  and  tlu!  sclerotics  are  of  a  sky-blue  color.  Occasionally 
the  sluu  shows  areas  of  pigmentation,  particularly  about  the  joints. 

Digestive  symptoms  are  common.  The  ai)petite  is  capricious  atul  tho 
patients  often  hav(^  a  longing  fo.  unusual  article-^,  particularly  ac^ds.  In 
.some  instances  they  tsit  all  soris  of  indigestil)le  things,  such  as  chalk  or 
even  earth.  Superacidity  of  the  gastric  juice  is  (Hunmonly  ji.^'sociated  with 
chlorosis.  In  nineteen  out  of  twonty-one  cases  in  Riegers  clinic  this  con- 
tliiioii  was  found  to  exist.  \n  the  other  two  instances  the  acidity  was 
iiiirmal  or  a  trille  increa.sed.  CoJistipation  is  a  common  symjttom,  and, 
as  already  mentioneil,  has  been  I'lgarded  as  an  important  elenu-nt  in  caus- 
ing the  di.sease.  Knicropfosis  with  palpabl(>  right  kidnev  is  frecpuMitly 
seen.  Contouricr  has  noted  the  common  association  of  dilatation  of  the 
stomach  with  chlorosis,  and  states  that  in  some  cases  this  may  be  an  etio- 
Icgical  factor,  while  in  others  it  mav  be  a  result. 


(Ml 


The  circulatory  .symptoms  are  imjiortant.     Palpitation  of  the  heart  ite- 
rs on  exertion,  and   may  be  the  most  distressing  .symj)toni  of  which  ihe 


patient  complains 


UlUI'L'SS. 


I'ercussion  may  show  slight  increase  in  tlu*  transvi  I'hO 
A  systolic  murninr  is  heard  at  the  apex  or  at  the  base;  more 
("eiimionly  at  the  latter,  hut  in  extreme  cases  at  both.  A  diastolic  murmur 
1^  i;iivly  hoard.  The  systolic  murmur  is  usually  loudest  in  the  second  hd't 
intercostal  space,  where  there  la  Rometimes  a  distinct  pulsation.  'JMie 
<".ai't  mode  of  production  is  still  in  ilispiite.  iJalfour  holds  that  it  is  pro- 
•lueed  lit  the  mitni)  orilice  by  relative  insuniciency  of  the  valves  in  the 


ru' 


1  s 


I 


!  I 


r 


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i'i  ]l- 


t 


)  r 


m;. 

.0 

.;!f 

jl 

f".: 

V 

•*i* 

,      1   ■ 

%  I: 

}i 

Vir, 

726 


DISEASKS  OF  TIIK    BLOOD   AND    DUCTLHSS  OLANDS. 


t 


dilated  condition  of  the  voiitiiclc.  On  tlie  rij^lit  side  of  the  ncelv  ovor  Uu- 
juguliir  vein  a  continiions  niiirnuir  is  licard,  the  finiii  liv  diabh,  or  liuiii- 
niing-t,()|t  tniiriniti'. 

Tiie  i)Mlsr  is  nsuii'Iy  fidl  and  soft.  Pulsation  in  the  peripheral  veins  i,s 
sometimes  seen.  'I'liere  is  ii  tendency  to  thrombosis  in  tiie  veins;  ino.st 
commonly  in  the  femoral,  hut  in  other  instances  in  the  lonf^itiKJiiial  sinus, 
or  the  thromliosis  nniy  he  mnltiple.  Kxeept  in  the  siinises,  the  I'liiitiitidn 
is  rarely  serious.  Tnekwell  has  reported  an  instance  in  wliieii  there  was 
embolism  of  the  rif^ht  axillary  artery  with  the  lo.ss  of  u  thumb  and  part 
of  the  lingers.  I^ruyton  Hall  has  recently  called  attention  to  the  impor- 
tance of  tliis  feature  of  chlorosis. 

As  in  all  forms  of  essential  ana'inia,  fever  is  not  niieommon.  Ks|)ecial 
attention  has  of  late;  been  directed  to  this  by  French  writers.*  Chlorotic 
patients  sulTer  frequently  from  hcridache  and  neuraliria,  which  may  he 
puroxysm.il.  Hysterical  numifestations  are  not  infrequent.  .Mcn>tiiial 
disturbances  are  very  common — amenorrhica  or  dysmeiiorrhoii.  W'itii  the 
improvement  in  the  blood  condition  this  function  is  usually  restoretl. 

Diagnosis. — The  green  sickness,  as  it  is  sometimes  called,  is  in  many 
instances  recognized  at  a  glance.  The  well-nourishe(l  condition  of  thu 
girl,  the  pecidiur  complexion,  which  is  most  nuirked  in  brunettes,  and  the 
wliite  s(!lenjtics  are  very  (diaiacteristic,  A  sjiecial  danger  exists  in  mis- 
taking the  amvmia  of  the  early  stage  of  pulmonary  tidn-rcidosis  for  chlo- 
rosis. The  i)alj)itation  of  the  heart  and  shortness  of  breath  frequently 
suggest  heart-disease,  and  the  cedema  of  the  feet  and  geiu'ral  pallor  cause 
the  cases  to  be  mistaken  for  Tu'lght's  disease.  In  the  great  majority  of 
cases  the  characrters  of  the  blood  icadily  separate  chlorosis  from  other 
forms  of  ana-mia. 

''i.  Idiopathic  or  Progressive  Pernicious  Anaemia.—'rhe  disease  wa.s 

first  clearly  dcscrilicd  by  .\ddison,  who  called  ir,  idiopathii;  ana-mia.  Chaii- 
ning  and  (Jus.serow  describee]  the  cases  oc  \irring  post  partum,  but  to  Bier- 
mer  we  owe  a  revival  of  interest  in  the  subject. 

Etiology. — 'I'he  exi.steiice  of  a  separate  disease  worthy  of  the  term 
progressive  jjcrnicions  amemia  has  been  doubted,  but  there  are  unques- 
tionably cases  in  which,  as  Addison  says,  there  exist  none  of  the  usnid 
canses  or  concomitants  of  amemia.  Clinically  there  are  several  dilTerent 
groups  which  present  the  characters  of  a  progressive  and  pernicious  auM'- 
mia  and  are  etiologically  dilTerent.  Tims,  a  fatal  anaemia  nuiy  be  y\w.  to 
the  presi'iu'c  of  parasites,  or  imay  follow  luemorrhage,  or  be  associated 
with  chronic  atropliy  of  the  stomach ;  but  when  we  have  excluded  all 
those  can.soa  there  remains  a  group  which,  in  the  words  of  Addison,  is 
characterizeil  by  a  " general  ana'mia  occnrriug  without  any  discoverable 
cause  whatever,  cases  in   which  there  had  been  no  previous  loss  of  blood, 


*  Trazit,  Paris  Thesis,  18«8. 


AN.KMIA. 


727 


110  ('xliaustiiijT  (liiirrhd'a,  no  chlorosis,  jio  purpurn,  no  renal,  splenic,  mius- 
iiiiitio,  fjlandnliir,  stnirnoiis,  or  malignant  (lisi-aso." 

l(li(»])utliii!  una'tnia  is  widely  distributctl.  Tt  is  of  frequent  oeeurronoo 
in  the  Swiss  Cantons,  and  it  is  not  nnconnnon  in  tliis  country.  It  alTects 
iniiMle-ai:e<l  persons,  hut  instances  in  children  have  i)een  descrihed.  (!rif- 
liili  mentions  ahout  ten  eases  occurrin<r  under  twelve  years  of  a^fc.  The 
vniniu'est  patient  I  have;  seen  was  a  girl  of  twenty.  .Malts  :ir<'  more  fre- 
(jU 'iitiy  alTected  than  females.  Of  my  ^*7  cases.  Id  weic  females  and  17 
well'  males.  Of  110  cases  collected  by  Coupland,  afi  were  in  men  and  T)! 
in  women. 

With  the  followinij  conditions  may  he  associated  a  in'ofound  ana-mia 
nut  to  he  distin<iuished  cliiueally  from  Addison's  idiopathic  form  : 

{ii)  J'rrf/innirif  (tint  Ptirfiirili'nii. — 'IMie  sym|)toms  may  develop  durin<? 
pn'irnancy,  as  in  lit  of  'I',)  cases  of  this  <jr<uip  in  Kicjdiorst's  talile.  More 
commonly,  in  my  experience,  the  condition  has  U-en  post  i)artum  ;  tluus, 
of  my  27  oases.  5  followed  delivery, 

{/))  Afrupliji  iif  Ihr  Stoniarli. — This  condition,  early  recognized  hy  Flint 
ami  Fenwick,  may  certainly  cause  a  ])rogressivc  [)ernicious  aiuenua.  Hy 
moilcrn  methods  it  may  now  bo  po.ssible  to  exclude  this  extreme  gastric 
atrophy. 

('•)  PdvasUcs. — Tiie  most  severe  form  may  ht>  due  to  the  presoneo  of 
parasites,  and  the  accounts  of  cases  depeiuling  upon  \\\v.  anchylostoma  and 
the  Ijothriocephalus  describe  a  pivtgressive  and  often  pernicious  amemia. 

After  the  exclusion  of  these  forms  there  remains  a  large  j)roportion, 
miinheriiig  eighteen  r-ases  in  my  .series,  whi(di  correspond  to  A(l<lison's 
description.  'I'he  etiology  of  the.se  eiises  is  still  dark.  Tlu'  rcsca'-ches  of 
'^lincke  atid  his  student  Peters  .showed  that  there  was  an  enormous  in- 
rrcaso  in  the  iron  in  the  liver,  and  ho  suggested  that  the  alTii'tion  was 
probably  duo  to  increa.sed  ha'inolysis.  '^i'his  has  been  strongly  supported 
l)y  the  extetisive  observations  (»f  Hunter,  who  has  also  shown  that  tho 
urine  excreted  is  darker  in  color  and  contains  pathological  urobilin.  The 
lemon  tint  of  the  skin  or  the  actual  jaundice  is  attributed,  on  this  view, 
t'l  the  changes  in  the  liver  cells  produced  by  the  excessive  amount  of  pig- 
niiiit,  ])iit  in  the  light  grades  it  is  i'nquesli(inably  luennitogenous.  To 
explain  the  Invmolysis,  it  has  been  thought  that  in  the  condition  of  faulty 
gastrointestinal  digestion,  which  is  .so  commoidy  as.sociated  with  theso 
cases,  poisonous  nniteriids  are  developed,  whii  h  when  absorbed  cause  de- 
struction Oi  the  corpuscles.  Certainly  the  evideiuH?  for  Inemolysis  is  very 
i^trnng,  hut  we  are  still  far  away  from  a  full  knowletlge  of  the  comlitiims 
undei-  which  it  is  produoed. 

Stocknnui  sugirests  that  repeated  small  cajiillary  Ineinorrhages — chiefly 
internal — play  an  important  role  in  the  causation  of  the  disease,  which 
also  explains,  ho  holds,  the  existence  of  a  grout  oxce.«s  of  iron  in  the  liver. 

On  the  other  hand,  l'\  I',  llonry,  Stephen  Macken/ic,  h'indlleisch,  and 
other  authorities  imdino  to  tiio  belief  that  tho  essence  of  the  disease  is  iu 


mi 


M 


ih., 
■•■it 


If         ^'    '*■■»» 


{■^ 


t! 


\i 


728 


niSRASES  OF  TIIK   BLOOD   AND   DUCTLKSS  GLANDS. 


(lofective  ha'tnogoncsis,  in  oonseqiiiMice  of  wliicli  tin.'  rod  Mood-corpuscK's 
nre  abnorniiilly  vulncriibk'.  A  point  noted  by  Copcmaii,  that  the  hifiiid- 
gh)bin  crVstallizo.s  from  the  blood-eorpusclcs  with  ^n'cat  readiness,  ciiii 
scarcely  l)e  rejarded  as  favoring  the  view  of  imperfect  luvmogene.sis,  since 
this  is  a  featiini  specially  characteristic  of  the  blood  of  the  young. 

Morbid  Anatomy. — The  body  is  rarely  enuiciatccl.  A  lemon  tint 
of  the  skill  is  present  in  a  majority  of  the  cases.  Tlw*  muscles  often 
arc  intensely  red  in  c()lur,  like  liorse-tlesh,  while  the  fat  is  light  yellow. 
HaMuorrhages  are  common  on  the  skin  and  .serous  surfaces.  The  heait  is 
usually  large,  llabby,  and  empty.  In  one  instance  I  obtaine(|  only  two 
drachrjis  of  blood  from  tiic  riglit  heart,  and  between  three  and  fuiii'  from 
tlio  left.  The  muscle  substance  of  the  heart  is  intensely  fatty,  and  of  a 
pale,  light-yellow  color.  In  no  alTection  do  we  see  more  extreme  fativ 
degeneration.  'I'hc  hing.s  sliow  no  special  changes.  The  stoma<di  in  many 
instances  is  normal,  but  in  some  (;ases  of  fatal  anicniia  the  mucosa  lins 
been  extensively  atrojiliied.  In  the  case  described  by  Henry  and  mvself 
the  mucous  membrane  had  a  smooth,  cuticular  appcaraJice,  and  there  was 
complete  atrophy  of  the  secreting  tubules.  The  livi-r  may  be  enlarged 
and  fatty.  In  most  of  my  autopsies  it  was  normal  in  si/e,  i)iit  usu- 
ally fatty.  Th(!  iron  is  in  excess,  anil  in  striking  contrast  to  cases  of 
secondary  aiuemia.  It  is  dejiosited  in  the  outer  ami  middle  zones  of  the 
lobules,  and  in  two  sjiecinu'iis  which  1  examined  seemed  to  have  such 
a  distribution  that  the  bile  cai)illaries  were  distinctly  outlined.  This 
Hunter  states  is  a  special  and  characteristic  lesion,  jiossibly  ju'culiiir  to 
pernicious  ajuemia.  A.  J.  Scott  examiiu'd  for  me  the  livers  in  forty-live 
consecutiv('  autopsies  without  tinding  (excejit  in  pernicious  ana'iuia)  this 
sjteeial  distribution  of  lugment. 

The  spleen  sliows  no  im[)ortant  changes.  In  one  of  Palmer  Howard's 
cases  the  organ  weighed  only  an  ounce  and  live  dracdims.  The  iron  pig- 
ment is  usually  in  excess.  The  lymph-glands  nuiy  be  of  a  deep  red  color. 
The  amount  of  iron  pigment  is  increased  in  the  ki<lneys,  (duelly  in  the 
convoluted  tubules,  'i'ho  bone  nuirrow,  as  pointed  out  by  II.  ('.  Wood, 
is  usually  red,  lymphoid  in  character,  showing  great  numl)ers  of  nucleated 
red  corpns(des,  especially  the  larger  forms  called  by  Khrlich  gig;intoblasts. 
Cluinges  in  the  ganglion  cells  of  the  symi)atheti(!  have  been  reported  on 
several  oceasiims.  liiiditheim  ha.s  found  s(  Icrosis  in  the  [losterior  coluniiis 
of  the  cord.  Htirr  has  recently  (University  Med.  Magazine,  IS'l,"))  de- 
scribed a  series  of  cases.  The  subject  is  referred  to  again  under  diseases 
of  the  spinal  cord. 

Symptoms.  -The  patient  nniy  have  beeji  in  ])revious  good  iienltli, 
but  in  many  cases  there  is  ahistory  of  gaslro-intestimd  disturbaiu'c,  meiit::) 
shock,  or  worry.  The  description  given  by  Addison  presents  the  chief 
features  of  the  disease  in  a  masterly  way.  "It  makes  its  approach  in 
.so  slow  and  insidious  a  manner  that  the  patient  can  hardly  lix  a  <late  i" 
the  earliest  feeling  of  that  languor  which  is  shortly  to  become  so  extrcuie. 


< 


niHWijiriiiiiim 


ANvKMIA. 


r29 


Tlio  countcnanco  gots  palo,  the  wliitcs  of  tlio  oyos  booonio  pearly,  the 
gi'tionil  frame  llabby  rather  than  wasted,  the  pulse  perhaps  lar<,'e,  hut 
reinarkahly  soft  and  eonipressihle,  and  oeeasionally  with  a  slight  jerk, 
(■sjtecially  under  the  sli<,'htest  exeiteinent.  Theni  is  an  inereasiii<:  indis- 
jiosition  to  exertion,  with  an  nneonifortahle  feelinj^  of  faintness  or  hreatli- 
Icssness  in  attempting  it ;  the  heart  is  readily  made  to  palpitate  ;  the  wliolo 
surface  of  the  body  jtresents  a  blaniduMl,  smooth,  and  waxy  appearanee ; 
till'  lips,  gums,  and  tongU(!  seem  bloodless,  the  llal)biiiess  of  the  solids 
increases,  the  a|)petit((  fails,  extri'me  languor  and  faintness  supervene, 
lireaihlessness  and  palpitations  are  produced  hy  the  most  trilling  exertion 
(!!•  euioiion  ;  some  slight  (edema  is  prohal)ly  perceived  about  tiie  ankles; 
the  debility  becomes  extreme — the  patient  can  no  longer  rise  from  bed  ; 
the  mind  occasionally  wanders ;  he  falls  into  a  i)rostrate  and  half-torpid 
state,  and  at  length  expires;  nevertheless,  to  the  very  last,  and  after  a 
sickness  of  several  months' duration,  the  bulkiness  of  the  general  frame 
and  the  amount  of  oln-sity  often  present  a  most  striking  contrast  to  the 
failure  and  exhanstion  observable  in  every  (tther  respect." 

The  liliioil. — 'The  eori)Useles  may  fall  to  one  lifth  or  less  of  the  normal 
muuber.  'I'hey  may  sink  to  r)(M»,0(M)  per  euhie  millimetre,  and  in  a  ease 
111'  (^tuineke's  the  number  was  re(luced  to  14.'?,0()()  per  cubic  millimetre. 
Tlie  ha'mog!.)bin  is  relatively  increased,  so  that  the  individual  globular 
richness  is  plus,  a  condition  exactly  the  opposite  to  that  which  occurs  in 
chlorosis  and  the  secoiulary  ami'mia,  in  which  tlu'  <  ()rj)useular  richiu'ss  in 
ciilnriiig  matter  is  minus.  'I'he  relative  iiu'reaso  in  the  ha'moglobin  is 
|ir(il)ahly  associated  with  the  average  increase  in  the  size  of  the  red  blood- 
<()r|ius(des.  'I'he  aeeompanying  (duirt  illustrates  these  points.  Microscop- 
ically the  red  blood-eorpiisck's  present  a  great  variatimi  in  size,  and  there 
ran  l)c  si'cn  large  giant  forms,  megalocytes,  which  are  often  ovoid  in  form, 
inoasuring  eight,  eU'ven,  or  even  fifteen  micromillimetres  in  diameter — a 
liicumstance  whieli  Henry  regards  as  indicating  a  reversion  to  a  lower 
type.  Laache  thinks  these  pathognomonic,  ami  tliey  eertaiidy  form  a 
cuiistanl  feature.  There  are  also  snuiU  round  cells,  mieroeytes,  from  two 
til  six  mi(!romillinu'tres  in  diameter,  and  of  a  deep  red  color.  The  corpus- 
cles show  a  renuirkable  irregularity  in  form,  elongated  and  rodlike  or  pyri- 
forni;  one  end  of  a  corpuscle  may  retain  its  shapi'  while  the  other  is  nar- 
row and  extended.  To  this  condition  of  irregularity  (Quincke  gave  the 
name  poikilocvtosis. 

Nucleated  red  blood-corpuscles  arc  almost  always  present,  as  pointed 
out  liy  Khrlieh.  Resides  the  ordimiry  form,  which  is  of  the  same  size  as  the 
<'iiiiniion  corpuscle  and  which  has  a  small,  di'cply  stained  nucleus  (normo- 
hliists),  there  are  very  large  forms  with  palely  wt'.iining  nuclei  (giganto- 
hiasLs),  which  resemble  somewhat  the  larger  megalocytes.  Ehrlich  re- 
'SM\U  the  presence  of  th(!,se  as  almost  distinctive  of  progressive  ])ernicious 
aiKi'iuia.  .  Though  these  large  forms  are  most  characteristic,  occasionally 
fiiiins  closely  similar  to  them  may  be  found  in  the  graver  secondary  an- 


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DISKASKS   OF  TIIH    lU.OOD    AND    DIU'TLKSS  (JI-ANDS. 


nemias — i.  o.,  atiohylostoniiasis — ami  in  li'iika'iuia.  KarvokiiiclU!  li^iin-.s 
may  lio  soi-ii  in  tla'fio  bodii's.  Ucd  corimsclcs  willi  IVaifiiwntiii;,'  niicln 
arc  coinirion  in  pernicious  ana'tiiia.  Tlu'  li'iK^ocytcs  arc  ircncrully  ncr- 
uial  or  diniinislicil  iu  nunibur;  aiul  in  tho  graver  eases  a  marked  iiicreasu 


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RED,  HAEMOGLOBIN. 

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in  the  small  mononnclear  forms,  witii  a  diminution  in  the  jiolymiclcar 
Icneocytes,  is  ol'ten  noted.  Tlie  blood-plates  arc  either  absent  or  very 
scanty. 

The  cardio- vascular  symptoms  vro  important  and  are  noted  in  the  <\>-- 
scription  given  above.  Hu'tnic  muiniurs  are  constantly  present,  'i'lu' 
larger  arteries  pulsate  visibly  iiml  the  throbbing  in  them  may  be  dislicss- 
ing  to  the  patient.     The  i)ulsc  is  full  and  frequently  suggests  the  water 


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ANvKMIA. 


781 


lianinior  boat  of  aortic  iiisiifTirioiicv.  'V\\o  rapillary  piilso  is  froqiiontly  to 
li(^  seen.  'I'lic  siipcrlii'lul  vcitH  arc  often  j)roiiiiiifiit,  atul  in  two  cases  I 
liiivc  seen  well-marked  pulsation  in  tlieni.  Ila-rnorrhages  nmy  occur,  either 
in  tile  skin  or  from  tlio  mucous  surfaces.     IJctinal  lia'tnorrluiji^es  are  com- 


IIlOll. 


There  arc  rarelv  symptoms  in  the  respiratory  or<'ans. 


(Jastro-intestinal  symptoms,  snch  as  dyspepsia,  nausea,  and  yomitiii,L,% 
tiiiiy  lie  present  tliroiij^hoiit  the  disease.  IHarrho'U  is  not  iiifreciiient.  'I'lie 
mini'  is  usinilly  of  a  low  .^pcci^ic  grayity  and  sometimes  pale,  hut  in  other 
iii-taiice.s  it  is  of  u  deep  sherry  color,  shown  by  Hunter  and  Mott  to  bo 
(Inc  to  preat  excess  of  urobilin.  Fcyer  is  a  yariablc  .xymjttom.  For  weeks 
ill  a  time  the  temperature  may  be  normul,  and  then  irre<,ndar  pyrexia  may 
develop.  Nervon.s  symptoms  may  occur,  numbru-.ss  and  tinglin<r,  and  oc- 
easjimally  symptoms  rcsi-mbling  tho.se  of  tabes.  Lepiiu-  reports  a  case  of 
extensive  paralysis. 

Diagnosis.  —  From  chlorosis  the  di.sea^e  is  readily  disti?i<fuished.  I 
have  not  .seen  a  ca.se  in  which  the  two  diseases  could  hav<'  been  con- 
I'ennded.  Two  jniints  in  tlu!  blood  examination  arc  of  especial  impor- 
tiiiiee,  namely,  the  relative  increase  in  the  lia'moijlobin  and  tlie  presence  of 
the  larire  formsof  nucleated  red  blood-cor[)uscles.  the  ^i_:,'antoblasts  of  Khr- 
lii'li.  I'oikilocytosis  may  oceur  in  any  scyere  aujemia.  'I'lic  separation 
(if  the  dilTerent  (dinical  forms  aboye  referred  to  can  usually  lie  made.  'I'ho 
junfuuiid  secondary  aiKcmia  of  eanccr  of  tlie  stomach  may  sometimes  bo 
|iiiz/.liuij,  but  the  skin  is  rarely,  if  ever,  lemon-tinted,  and  the  blood  has 
the  characteristics  of  a  seconilary,  not  a  primary,  aiuemia. 

Prognosis. —  In  llietrue  Addisonian  cases  the  outlook  is  bad,  thou gh 
of  late  years  on  the  arsenic  treatment  the  proportion  of  recfjvery  is  incrca.sed. 
My  personal  experience  is  as  follows :  Of  the  27  cases  4  are  now  under  ob- 
.S'Tvation,  2  of  lhes(>  hayinjj;  recovered  with  ar.-^enic.  Of  the  remaining;  'ili 
the  foUowinj^  statement  maybe  made:  Four  of  the  5  post-partiim  cases 
recovered,  aiul  when  I  left  Montreal  ',)  of  these  cases  had  renuiined  in  good 
lie;ilth  for  several  years.  Of  the  reimiining  18  ca.ses  li  were  lost  sight  of; 
1  had  improved  very  much.  The  remaining  10  are  dead.  Six  of  these 
fat;d  cases  recovered  from  the  first  attack;  one  had  an  interval  of  nearly 
three  years,  and  another  nearly  two  years,  before  the  return.  I  know  of 
110  instance  in  a  male  in  wliicdi  the  recovery  has  lasted  for  five  years.  In 
I'ye-Siuith's  article  in  (luy's  Ilosjjital  Keports,  ho  mentions  twenty  ca.ses 
(if  recdvery.  Ilale  White,  in  a  recent  article,  states  that  one  of  these 
("i-es,  treated  by  arsenic  in  1(S8<I,  remained  alive  and  well  .January,  181H. 
<hie  of  my  i)atients  made  an  apparently  complete  recovery  aiuI  resumed 
active  business  and  ))olitical  duties.  So  (dniraoteristic  are  recurrences  in 
tills  aHectitm  tliat  St(!phen  Mackenzie,  in  his  recent  lectures,  considered 
tlieiii  un('cr  a  separate  heading  of  ridapsing  pernicious  auivmia.  The  ex- 
aiuiiiation  of  li.e  blood  may  give  us  some  help.     The  presence  of  numer- 


ous normobhisLs  appears  in  some  in 
rcgeneratiou  iu  the  marrow.     Cases 


stances  to  be  indicative  of  an  active 
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DISEASES  OF  THE  BLOOD   AND  DUCTLESS  GLANDS. 


rod  corpuscles  are  gigiuitobhists arc  generally  more  malignant.  A  maikiMl 
relative  increase  in  the  small  mononuclear  leucocytes  ai)poar-  to  be  also 
an  unfavorable  sign. 

Treatment  of  AnsemiSi.—Srcondari/  Anfcmid. — The  traumatic 
cases  do  best,  and  with  plenty  of  good  food  and  fresh  air  the  liloml 
is  readily  restored.  The  extraordinary  rapidity  with  wliich  the  normal 
percentage  of  rtd  blood-corpuscles  is  reached  without  any  medication 
whatever  is  an  important  lesson.  The  cause  of  the  luvmorrhage  should  ho 
sought  and  the  necessary  indications  met.  The  large  group  deponding 
on  the  drain  on  the  albuminous  materials  of  the  blood,  as  in  Briglii's 
disease,  suppuration,  and  fever,  is  difficult  to  treat  successfully,  and  so  long 
as  the  cause  kee})s  up  it  is  impossible  to  restore  the  normal  blood  con- 
dition. The  anaemia  of  inanition  requires  plenty  of  nourishing  l'o(jiI. 
When  dependent  on  organic  changes  in  the  gastro-intestinal  mucosa  not 
much  can  be  expected  from  either  food  or  medicine.  In  the  toxic  cases 
due  to  mercury  and  lead,  the  poison  must  be  eliminated  and  a  nutritious 
diet  given  with  full  doses  of  iron.  In  a  great  majority  of  these  cases 
there  is  deficient  blood  formation,  and  the  indications  are  briefiy  throe : 
plenty  of  food,  an  open-air  life,  and  iron.  As  a  rule  it  makes  but  little 
difference  what  form  of  the  drug  is  administered. 

The  treatment  of  cMorosis  affords  one  of  the  most  brilliant  instances— 
of  which  we  have  but  three  or  four — of  the  specific  action  of  a  reino(ly. 
Apart  from  the  action  of  quinine  in  malarial  fever,  and  of  mercury  and 
iodide  of  potassium  in  syphilis,  there  is  no  other  remedy  the  benetioial 
effects  of  which  we  can  trace  with  the  accuracy  of  a  scientific  experiment. 
It  is  a  minor  matter  how  the  iron  cures  chlorosis.  In  a  week  we  give  to  a  case 
as  much  iron  as  is  contained  in  theentire  blood,  as  even  in  the  worst  case 
of  chlorosis  there  is  rarely  more  than  a  deficit  of  two  grammes  of  this  nu'tal. 
Iron  is  present  in  the  fa-ces  of  chlorotic  patients  before  they  are  placed 
upon  any  treatment,  so  that  the  disease  does  not  residt  from  any  deficiency 
of  available  iron  in  the  food.  Bunge  believes  that  it  is  the  sulphur  which 
interferes  with  tiie  digestion  ami  assimilation  of  this  natural  iron.  'I'lie 
sulphides  are  produced  in  the  process  of  fermentation  and  decomposition 
in  the  fa;ces,  and  interfere  with  the  assimilation  of  the  normal  iron  con- 
tained in  the  food.  By  the  administrsition  of  an  inorganic  preparation  of 
iron  with  which  these  sulphides  unite  the  natural  organic  combinations 
in  the  food  are  spared.  In  studying  a  number  of  charts  of  chlorosis,  it  is 
seen  that  there  is  an  increase  in  the  red  blood-corpuscles  under  the  inlhi- 
ence  of  the  iron,  and  in  some  instances  the  globular  richness  rises  above 
nornud.  The  increase  i)i  the  hamioglobin  is  slower  and  the  maximum 
percentage  nniy  not  be  reached  for  a  long  time.  I  have  for  years  in  tlio 
treatment  of  chlorosis  used  with  the  greatest  success  Bland's  pill.^,  made 
and  given  according  to  the  formula  in  Niemeyer's  text-book,  in  whioli 
eatdi  pill  contairis  2  grs.  of  the  sidphate  of  iron.  During  the  first  week  ono 
pill  is  given  three  times  a  day  ;  in  the  second  week,  two  pills ;  in  the  third 


LEUKAEMIA. 


733 


w(H'k,  three  pills,  three  times  a  day.  This  dose  should  be  eon  tinned  for 
four  or  five  weeks  at  least  before  reduction.  An  important  feature  in  the 
treatment  of  chlorosis  is  to  persist  in  the  use  of  the  iron  for  at  least  three 
months,  and,  if  necessary,  subsetiuently  to  resume  it  in  smaller  doses,  as  re- 
currences are  so  common.  'J'he  diet  should  consist  of  good,  easily  digi'stcd 
food.  Special  care  sh  )uld  be  directed  to  the  bowels,  and  if  constij)ati()u 
is  present  a  saline  ])urge  should  be  given  each  morning.  Such  sti'css  does 
Sir  Andrew  Clark  lay  on  the  importance  of  constipation  in  chlorosis,  that 
he  states  that  if  limited  to  the  choice  of  one  drug  in  the  trt>atmcut  of  the 
disease  he  woidd  (dioose  a  purgative.  The  good  iailtu'uce  of  alkaline 
waters  in  association  with  the  treatment  by  iron  has  been  noted  by  von 
Jaksch.  In  juany  instances  the  dyspei)tic  symptoms  may  be  relieved  l)y 
alkalies  ami  a  treatment  directed  toward  a  moderate  hyperacidity.  Dilute 
hydrochloric  acid,  manganese,  phosphorus,  and  oxygeJi  have  been  recom- 
nu'Uiled. 

Trcd/iiioif  of  J\'r)iicim(H  Anccmin. — Since  the  introduction  by  Byrom 
Braiuwell  of  arsenic  in  this  affection  a  large  number  of  cases  have  been 
temporarily,  a  few  jiernianeutly,  cured  by  it.  It  should  be  given  as  Fowler's 
solution  in  increasing  doses.  It  is  usually  well  borne,  aii'l  patients,  as  a 
rule,  take  up  to  twenty  miniuis  three  times  a  day  without  any  distu;'l)auce. 
I  usually  begin  with  three  minims  and  increase  to  five  at  the  end  of  the 
first  week,  to  ten  at  the  end  of  the  second  week,  to  fifteen  at  the  end  of 
the  third  week,  and,  if  necessary,  increase  to  twenty  or  twenty-five.  In  a 
case  in  whi(di  the  recovery  persisted  for  nearly  three  years  the  dose  was 
gradually  increased  to  thirty  minims.  These  patients  seem  to  l)ear  the 
arsenic  extremely  well.  It  is  sometimes  better  borne  as  arsenious  acid  in 
pill  form.  Vomiting  and  diarrhu>a  are  rare;  occasionally  putfiness  of  the 
face  is  produced,  and  in  some  cases  ]ngnientation  of  the  skin. 

Ilest  in  bed  and  a  light  but  nutritious  diet  (giving  the  food  in  small 
amounts  and  at  fix^'d  intervals)  are  the  first  indications.  I  always  prefer 
to  begin  the  treatment  of  a  case  of  pernicious  anannia,  whatever  the  grade 
may  be,  with  rest  in  bed  as  one  of  the  essential  elements.  The  beiudicial 
cfToct  of  massage  has  been  shown  by  J.  K.  Mitchell.  I  have  abandoned 
the  use  of  rectal  injecitions  of  dried  blood.  Iron  rarely  acts  well  in  this 
form,  but  in  a  case  in  which  the  arsenic  disagrees  it  may  be  tried.  Rone 
marrow  has  been  recommended.  It  is  best  given  as  a  glycerin  extract. 
I  have  not  seen  any  benefit  follow  its  administration. 


II.   LEUKi^EMIA. 

Definition. — An  affection  characterized  by  persistent  iucrcaso  in  the 
white  blood-corpuscles,  associated  with  changes,  either  alone  or  together, 
in  the  spleen,  lymphatic  g^..ids,  or  bone  marrow. 

The  disease  was  described  almost  simultaneously  by  Virchow  and  by 


■m 


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734 


DISEASES  OP  THE   BLOOD  AND   DUCTLESS  CxLANDS. 


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Bennett,  who  gave  to  it  the  Tuune  loucocythieiiiia.     It  is  onliiuirily  seen  in 
two  main  types,  tliougli  combinations  and  variations  nniy  occur: 

(1)  Spleno-medulhiry  leukivmia,  in  wliich  tlie  changes  are  espcciallv 
locaiizeil  in  the  spleen  and  tlie  bone  nnirrow,  wliih'  the  blood  shows  a 
great  increase  in  elements  which  are  derived  esjtecially  from  the  lailur 
tissue. 

(2)  Lymphatic  leukannia,  in  which  the  changes  are  chiefly  localized  in 
the  lymphatic;  apparatus,  the  blood  showing  an  especial  increase  in  tlidse 
elements  derived  from  the  lymph  glands. 

Etiology. — We  know  n^jthing  of  the  conditions  under  which  the  dis- 
ease develops.  It  is  not  uncommon  on  this  continent.  Of  26  cases  of  wiiiuli 
I  have  notes,  11  occurred  in  Montreal,  2  in  Pliiladeiphia,  and  13  in  li(»s- 
pital  and  private  work  in  Baltimore.  It  does  not  seem  more  frequent  in 
the  southern  parts  of  the  country. 

Tiie  disease  is  most  common  in  the  middle  period  of  life.  The  young- 
est of  my  patients  was  a  child  of  eight  months,  and  cases  are  on  record  of 
the  disease  as  early  as  the  eighth  or  tenth  week.  It  may  occur  as  late  as 
the  seventieth  year.  Males  are  more  prone  to  the  aifection  than  females. 
Of  my  cases  17  were  iu  males  and  0  in  females.  Birch- Ilirschfeld  states 
that  of  :iUO  cases  collected  from  the  literature,  135  were  males  and  (i") 
females. 

A  tendency  to  haemorrhage  has  been  noted  in  many  cases,  and  some 
of  the  patients  have  suiTered  repeatedly  from  nose-bleeding.  In  woiuon 
the  disease  is  most  common  at  the  climacteric.  There  are  instances  in 
which  it  has  developed  during  pregnancy.  The  case  described  by  .1. 
Chalmers  Cameron,  of  Montreal,  is  in  this  respect  remarkable,  as  the  pa- 
tient passed  through  three  preg!iancies,  bearing  on  each  occasion  non- 
leukoitnic  children.  The  case  is  interesting,  too,  as  showing  the  heredi- 
tary character  of  the  affection,  as  the  grandmother  and  mother,  as  well 
as  a  brother,  sulTered  from  symptotns  strongly  suggestive  of  leukaMiiiii. 
One  of  the  patient's  children  had  leuka^iua  before  the  mother  showed  any 
signs,  and  a  second  died  of  the  disease.  At  the  last  report  this  j  diont 
had  gradually  recovered  from  the  third  confinement,  and  the  red  blood- 
corpuscles  had  risen  to  4,000,000  per  cubic  millimetre,  and  the  ratio  of 
white  to  red  1  to  200.  Siinger  has  reported  a  case  in  which  a  heaUliy 
mother  bore  a  leukaemic  child. 

Malaria  is  believed  bv  some  to  be  an  etiological  factor.  Of  150  cases 
analyzed  by  Gowers,  there  was  a  history  of  malaria  in  30;  in  my  series 
there  was  a  history  in  at  least  9.  Syidiilis  appears  in  some  cases  to  have 
been  closely  associated  with  leukxnnia.  Tlie  disease  has  followed  injury 
or  a  blow. 

The  lower  animab  are  subject  to  the  affection,  and  cases  have  been 
described  in  horses,  dogs,  oxen,  cats,  swine,  and  mice. 

Morbid  Anatomy. — The  wasting  may  be  extreme,  and  dropsy  is 
sometimes  present.     There  is  in  many  cases  a  remarkable  condition  of 


LEUKAEMIA. 


735 


polvivmia;  the  heart  and  voins  are  (listemled  with  largo  Idood-ckits.  In 
('use  XI  of  my  series  tlie  weight  of  blood  in  the  heart  chambers  alone 
vas  (i20  grammes.  There  may  be  remarkable  distention  of  the  portal, 
cerebral,  pulmonary,  and  subcutaneous  veins.  The  blood  is  usually  clotted, 
iiiul  the  enormous  increase  in  the  leucocytes  gives  a  i)us-like  appearance 
t(i  the  coagula,  so  that  it  has  happened  jnore  than  once,  as  in  Virchow's 
inomorable  ca.se;  that  on  o]K'ning  the  right  auricle  the  observer  at  first 
tliouglit  he  had  cut  into  an  abscess.  The  coagula  have  a  peculiar  greenish 
color,  somewhat  like  the  fat  of  a  turtle.  The  alkalinity  of  the  blood 
i..  iliminislied.  The  fibrin  is  iiici'eascd.  The  character  of  the  corpuscles 
will  be  described  under  the  symptoms.  Charcot's  octohedral  crystals  may 
separate  from  the  blood  after  death.  The  specific  gravity  of  the  blood  is 
somewhat  Ic     red.     There  may  be  pericardial  ecchymoses. 

The  spleen  in  the  great  nuijority  of  cases  is  eidargcd.  Strong  adhe- 
sions may  unite  it  to  the  abdomimd  wall,  the  diaphragm,  or  the  stonnich. 
The  capsule  may  be  thickened.  The  vessels  at  the  hilus  are  eidarged ; 
the  weight  may  range  from  two  to  eighteen  pounds.  The  organ  is  in  a 
condition  of  chronic  hyjierjilasia.  It  cuts  with  resistance,  has  a  uniformly 
rcMJdish-brown  color,  and  the  ISIalpighian  bodies  are  invisible,  (irayish- 
wliite,  circumscribed,  lymphoid  tumors  may  occur  throughout  the  organ, 
contrasting  strongly  with  the  reddish-brown  nuitrix.  In  the  early  stage 
the  swollen  spleen  pulp  is  softer,  and  it  is  stated  that  rupture  has  occurred 
from  the  intense  hyperannia. 

In  association  Avith  these  changes  in  the  spleen  the  bone  marrow  is 
involved,  the  lieno-medullary  form  of  the  Germans.  The  marrow*  may  be 
involved  alone,  forming  a  pure  myelogenous  leukannia.  Instead  of  a  fatty 
tissue,  the  medulla  of  the  long  bones  may  resemble  the  consistent  matter 
which  forms  the  core  of  an  abscess,  or  it  may  be  dark  brown  in  color.  In 
Ponfick's  case  there  were  Inemorrnagic  infarctions.  There  may  be  much 
expansion  of  the  shell  of  bone,  and  localized  swellings  whicdi  are  tender  and 
miiy  even  yield  to  firm  pressure.  Histologically,  there  are  found  in  the 
medulla  large  numbers  of  nucleated  red  corpuscles  in  all  stages  of  develop- 
ment, numerous  cells  with  eosinophilic  granules,  and  also  many  large  cells 
with  single  large  nuclei — the  cellules  medullaires  of  Cornil — the  nnjc- 
loryfcs  which  are  found  in  the  blood.  Polynuclcar  leucocytes  are  also 
present,  as  well  as  a  certain  number  of  small  mononuclear  elements. 

Enlargement  of  the  lymphatic  glands  may  occur,  either  in  c(uiJunction 
with  splenic  enlargement  or  alone.  In  only  one  of  my  cases  was  the  en- 
largement notable.  In  the  cases  of  lymphatic  leukaMuia  the  cervical,  axil- 
liUT,  mesen>,iric,  and  inguinal  groups  may  be  much  enlarged,  but  t' o 
glands  are  usually  soft,  isolated,  and  movable.  They  may  vary  consider- 
al)ly  in  size  during  the  course  of  the  disease.  The  tonsils  and  the  lymph 
fiiUicles  of  the  tongue,  pharynx,  and  mouth  may  be  enlarged.  Numerous 
mitoses  may  bo  found  in  the  small  cells  of  the  lymphatic  tissue. 

In  some  instances  there  are  leukremic  enlargements  in  the  solitary  and 


r?5 


I  .',\ 


in 


i  i 
I 


i^i;     'm 


'>      V 


736 


DISEASES  OF  THE   BLOOD  AND   DUCTLESS  GLANDS. 


m 


ni^tniniitod  glaiuls  of  Poycr.  In  a  caso  of  Willcocks  thoro  were  growtlis 
on  tli(!  surface  of  the  stomach  uikI  rrastro-.s{)lcnie  onientiiin.  The  thymus 
is  rarely  iiivolvcil,  though  it  has  been  enhirged  in  some  of  tlie  cases  of  acuiu 
lympliatic  knikiemia. 

The  liver  may  be  enlarged,  and  in  a  ease  described  by  Wclrli  jt 
■weighed  over  tliirteen  poiiiids.  Thi!  eidargeinent  is  usually  due  to  a 
diffuse  leuka'Uiic  inliltratioii.  The  columns  of  liver  cells  are  widolv 
separated  by  leucocytes,  which  are  ])artly  within  and  partly  outside  the 
lobular  capillaries.     There  may  be  definite  leuka3niic  growths. 

There  are  rarely  changes  of  imjiortance  in  the  lings.  The  kidneys 
are  often  enlarged  and  jiale,  the  capillaries  may  be  distended  with  leu- 
cocytes, and  leukamuc  tumors  may  occur.  The  skin  may  be  involved,  as 
in  a  case  described  by  Kaposi. 

Leuka>mic  tumors  in  the  organs  are  not  common.  They  were  present 
in  only  one  of  the  twelve  autopsies  in  my  series.  In  la'J  ca^-es  collected 
by  (tower's  there  were  only  thirteen  instances  of  leuka-mic  nodules  in  the 
liver  and  ten  in  the  kidneys.  These  new  growths  probably  develop  from 
leucocytes  which  leave  the  capillaries.  Bizzozero  has  shown  that  the  celk 
which  compose  them  arc  in  active  fission. 

Symptoms. — Tlie  onset  is  insidious,  and,  as  a  ride,  the  jiatieiit 
seeks  advice  for  })rogressive  enlargement  of  the  abdomen  and  shortness 
of  breath,  or  for  the  enlarged  glands  or  the  pallor,  paljiitation,  and  other 
symptoms  of  anaemia.  Bleeding  at  the  nose  is  common.  Gastro-intestinid 
sym})toms  may  precede  the  ouse^.  Occasionally  the  first  symptoms  are  cf 
a  very  serious  nature.  In  one  of  the  cases  of  my  series  the  boy  played 
lacrosse  two  days  before  the  onset  of  the  final  haunatemesis  ;  and  iu  an- 
other case  a  girl,  who  had,  it  was  supposed,  only  a  slight  chlorosis,  died  of 
fatal  luemorrhage  from  the  stoinacJi  before  any  suspicion  had  been  aroused 
as  to  the  true  condition. 

Anicmia  is  not  a  necessary  accomiianiment  of  the  disease;  the  subjects 
may  look  very  healthy  and  well. 

As  has  been  stated,  the  disease  is  most  commonly  seen  in  two  main 
types,  though  combinations  may  occur. 

(1)  Spleno-medullary  Leukaemia. 

This  is  much  the  commonest  type  of  the  disease.  The  gradual  in- 
crease in  the  volume  of  the  spleen  is  the  most  prominent  symptom  in  a 
majority  of  the  cases.  Pain  and  tenderness  are  common,  though  the  }>rn- 
gressive  eidargement  may  be  painless.  A  creaking  fremitus  may  be  felt 
on  palpation.  The  enlarged  organ  extends  downward  to  the  right,  and 
may  be  felt  just  at  the  costal  edge,  or  when  large  it  may  extend  as  far 
over  as  the  navel.  In  many  cases  it  occupies  fully  one  half  of  the  abdo- 
men, reaching  to  the  pubes  below  and  extending  beyond  the  middle  line. 
As  a  rule,  the  edge,  in  some  the  notch  or  notches,  can  be  felt  distinctly. 
Its  size  varies  greatly  from  time  to  time.  It  may  be  perceptibly  larger 
after  meals.     A  ha?morrhage  or  free  diarrhoea  may  reduce  the  size.    The 


%Ll^ 


3ases  (if  aciiU' 


LEUKJ-^MIA. 


r37 


pi'o.ssure  of  the  enlarged  organ  may  cause  distress  after  eating ;  in  one 
ca.-c  it  caused  fatal  obstruction  of  the  bowels.  A  nnirmur  may  soiiu-tinies 
lie  hoard  over  the  S2)leen,  and  (ierhardt  has  described  a,pulsatinn  in  it. 

The  pulse  is  usually  rapid,  soft,  compressible,  but  often  full  in  volume, 
'riicre  are  rarely  any  cardiac  symptoms.  The  apex  beat  may  be  lifted  an 
iiitiTsjiace  by  the  eidarged  spleen.  Toward  the  close,  as  a  conse(|uence  of 
the  fcel)le  circulation,  (i.'dema  may  occur  in  the  feet  or  there  may  be  gen- 
I'lal  anasarca.  llaMuorrhage  is  a  common  symptom  aiul  may  be  either 
\\\W  or  early.  Epistaxis  is  the  most  frequent  form.  IlaMuoptysis  and 
ha'iiiaturia  arc  rare.  Bleeding  from  the  gums  may  be  present.  Iliema- 
tciiicsis  proved  fatal  in  two  of  my  cases,  and  in  a  third  a  largo  cerebral 
hieiiiorrhage  rapidly  killed.  The  leuka'inic  retinitis  is  a  part  of  tlie  luem- 
orrhagic  numifestations. 

There  are  very  few  pulmonary  symptoms.  The  shortness  of  breath  is 
duo,  as  a  rule,  to  the  anannia.  Toward  the  end  there  juay  be  o'dema  of 
the  lungs,  or  pneunu)nia  nuiy  carry  off  the  patient.  The  gastro-intestinal 
symptoms  are  rarely  absent.  Nausea  and  vomiting  are  early  features  in 
.some  cases.  Diarrha^a  may  be  very  troublesome,  even  fatal.  Intestinal 
liivmorrhage  is  not  common.  There  nuiy  be  a  dysenteric  process  in  the 
colon.  Jauiulice  rarely  occurs,  though  in  one  case  of  my  series  there  were 
rocnrrent  attacks.  Ascites  nuiy  be  a  prominent  symptom,  proljably  due 
to  the  presence  of  the  splenic  tumor..  A  lenka-mic  peritonitis  also  nuiy 
be  present,  due  to  new  growths  in  the  membranes. 

The  nervous  system  is  not  often  involved.  Headache,  dizziness,  and 
fainting  spells  are  due  to  amvmia.  The  patients  are  usually  tranquil  and 
i'osigaed.     Sudden  coma  may  follow  cerebral  haMuorrhage. 

The  special  senses  are  often  affected.  There  is  a  peculiar  retinitis, 
due  chiefly  to  the  extravasation  of  blood,  but  there  may  be  aggregations 
of  lou(,'ocytes,  forming  small  leukaMuic  growths.  Optic  neuritis  is  rare. 
IKafnoss  has  frequently  been  observed  ;  it  nuiy  appear  early  and  possibly 
is  due  to  luvmorrhage. 

The  urine  presents  no  constant  changes.  The  uric  acid  excreted  is 
always  in  excess,  and  possibly,  as  Salkowski  suggests,  stands  in  direct 
rolation  to  the  splenic  tumor,  or  to  the  abundant  leucocytes. 

Priapism  is  a  curious  .-symptom  which  has  lieen  present  in  a  largo 
luimhor  of  cases.  It  nuiy,  as  in  one  of  Edes'  cases,  be  the  first  symptom. 
Poabody  reports  a  case  in  which  it  jjcrsisted  for  six  weeks.  The  cause  is 
not  known. 

Might  fever  is  i)resent  in  a  majority  of  cases.  Periods  of  pyrexia  may 
altLTuate  with  prolonged  intervals  of  freedom.  The  temperature  may 
nuiiro  from  10Ji°  to  10;r. 

llhind. — In  all  forms  of  the  disease  the  diagnosis  must  be  made  by  the 
exaniiiuition  of  the  blood,  as  it  alone  offers  distinctive  features.  In  the 
normal  blood  there  may  be  distinguislied  the  following  varieties  of  color- 
less elements :  («)  Small  mononuclear  leucocytes — small  cells  about  the 
47 


738 


DISEASES  OF  THE    BF.OOD   AND  DUCTLESS  GLANDS. 


i;        ;'    9|> 


si/,0  of  a  rt'd  blood-c^orpiisole,  uiid  jirnbiil)!}' (lerivcil  from  tlio  lympliiiiic 
glands,  wlii^h  have  a  siiiglo  largo,  rctiiiid,  deeply  staining  nucleus,  sur- 
rounded by  u  narrow  rim  of  non-granular  [irotoplasm  (lym|)ho(;yt,es) ;  ajsu 
cells  a  trilic  larger  tli.ui  these,  witii  similar  small  round  nuclei,  Inn  a 
larger  amount  of  clear,  pale  jirotoplasm.  (A)  Large  mononiu'lear  leiuo- 
cytes — cells  several  times  as  large  as  the  red  l>loo(l-corpuscle,  wilii  an  nvnl 
or  elliptical  nucleus  and  a  relatively  larger  amount  of  ungranulated  |iiii- 
toplasin.  {(•)  Transitional  forms — cells  which  resemble  the  last  Viuidy. 
but  liave  iiidentatioJis  and  irregularities  in  the  nucleus.  (d)  I'oly- 
nuelear  leucocytes — these  are  about  the  same  size  or  a  little  smaller  than 
the  last  variety.  The  nucleus  is  a  long,  deeply  staining  body  which  is 
bent  and  twisted  on  itself  into  irregular  shapes.  The  protoplasm  of  tliese 
(iclls  is  filled  with  granules,  wliich  are  stained  not  by  acid  or  basic  color- 
ing matters  alone,  but  oidy  by  a  combined  iluid.  The  gnmules  are  there- 
fore termed  neutrophilic,  and  the  mune  "  iieutrophiles  "  is  given  to  these 
cells,  (e)  Cells  about  the  same  size  as  the  last,  but  contaiidng  large, 
highly  refractile,  fat-like  granidcis,  which  have  an  affinity  for  acid  coloring 
matters.  On  account  of  their  affinity  for  eosin  Khi'lich  terms  them  ms///^j- 
philes.  In  normal  blood  these  cells  occur  in  a  fairly  definite  proportion 
to  each  other;  the  small  mononuclear  fifteen  to  twenty-live  per  cent,  the 
polynuclear  sixty-live  to  eighty  per  cent,  the  mononuclear  and  transitional 
forms  about  six  per  cent,  and  the  eosinophilos  two  to  four  per  cent  or  less. 

The  jnost  striking  change  in  the  more  common  form,  the  liene- 
myelogenic,  is  the  increase  in  the  colorless  corpuscles.  The  average  num- 
ber of  white  per  cubic  millimetre  is  estimated  at  about  0,(H)0-'(',000  ;  thus 
the  proportion  of  white  to  red  is  1  to  500-1,000.  In  leukiemia  the  pro- 
portion may  be  1  to  10,  or  1  to  5,  or  the  ratio  may  reach  1  to  1.  There 
are  instances  on  record  iu  which  the  number  of  leucocytes  has  exceeded 
that  of  the  red  corpuscles. 

The  character  of  the  cells  in  splenic  myelogenous  leuka^nia  is  as 
follows:  The  small  mononuclear  forms  are  little  if  at  all  increased;  rela- 
tively they  are  greatly  dimiiushed.  The  eosinophiles  are  present  in 
normal  or  increased  relative  proportion,  so  that  there  is  a  great  total 
increase,  and  their  presence  is  a  striking  feature  in  the  stained  blood- 
slide.  The  polynuclear  neutrophiles  uiay  be  iu  normal  proportion  ;  mme 
frequently  they  are  relatively  diminished,  and  in  the  latter  stages  they 
may  form  but  a  small  ])roportion  of  the  colorless  elements.  ^Marked  dif- 
ferences in  size  between  individual  polymiclear  leucocytes  may  be  )ioteil ; 
the  same  is  true  of  the  eosinophiles.  The  most  characteristic  features  (jf 
the  blood  in  this  form  of  leuka'mia  is  the  presence  of  cells  which  do  not 
occur  in  normal  blood.  They  appear  to  be  derived  from  the  marrow,  and 
are  called  by  Ehrlich  myelocytes.  They  are  considerably  larger  than  tiie 
largo  mononuclear  leucocytes,  and  are  similar  to  them  in  appearance,  hut 
differ  from  them  in  the  fact  that  the  protoplasm  is  filled  with  the  line 
neutrophilic  granules.     Miiller  has  recently  found  many  large  nioiumu- 


mm 


[DS. 

10  lynni1i:ilic 
mu'lciis,  snr- 
ocvU's) ;  iilso 
iiiii'k'i,  liul  a 
lui'lciir  IciHo- 

witii  <ni  oviil 

iUiuliitiMl  pru- 

'  last  variety, 

{<!)    IN.ly- 

siiialK'i'  than 
oily  which  is 
(liism  of  tln'sc 
)V  basic  color- 
ih'S  arc  ihci'c- 
rivoii  to  these 
lainiiiir  larire, 

acid  coloring; 
i  thoni  ciisiiKi- 
ite  proporiidii 

por  ooiit,  till' 
111  transit iiiiial 
;r  cent  or  less. 
m,  the  lieiio- 

averago  iiiiiii- 
:',()()() ;  thus 

iiiia  the  pro- 
to  1.     There 

has  oxccedeil 

ikaMiiia  is  as 
creased ;  rela- 
0  present  in 
a  great  total 
tained  blood- 
lortion  ;  more 
r  stages  they 

;Marked  dif- 

iiay  lie  noted  ; 

,io  features  of 

which  do  not 

marrow,  and 
■rfer  than  the 
pcarance,  hut 

with  the  line 
irge  monoiiu- 


LEUK.KMIA. 


7;'.o 


clear  elements  with  karyokinetio  figtirea  in  leiika'mic  blnnil  and  in  the 
iiia'-row.  'I'heso  probably  eorrespoml  to  the  niyeloeytes  of  Khrlich  as  well 
a>  lo  the  "cellules  nu'diiUaires"  of  ('ornil. 


EP 

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MEAN  NOnMt 
NUMBER  OP 

COnPUSCLES 


BLACK,  RLD  CORPUSCLES. 


RED,  HAEMOQLOaiN. 

Chart  XVIII. — Lcukiemia. 


BLUE,  COLORLESS  CORPUSCkES. 


Xucleatcd  red.  blood-corpuscles  are  present  in  considerable  num- 
bers. These  are  usually  "normoblasts,"  but  cells  with  larger  paler 
mielei,  some  showing  evidences  of  mitosis,  may  be  seen.  Red  cells  with 
fragmented  nuclei  are  common,  while  true  gigantoblasts  may  be  found. 


I' 

'   •;' 

t  .1 
1  ■(»  I 


^If 


^  \ 


.J 


1 .  i  '■» 


740 


DISKASKS   Ol^   THK    IJLOOl)    AND    DICTIJISS   (iLANDS. 


If- 


There  is,  us  ii  rule,  only  :i  iiioilcratt'  rediuftioi;  in  Uk  iiiiiiilH'r  of  red  l)|()(](l. 
corpiiHclos,  rarely  iimler  Iwo  iiiillioii  per  euhie  iiiilliiiietre.  The  liieniu. 
{^•Iol)iii  is  nsimlly  rediieeil  in  ;i  somewhat,  greater  [troportion.  Tliu  arcum- 
panyiii<j  hlood  chart  is  from  a  ease  of  ieiika'inia  with  an  enoriniiii>lv 
enlarged  spleen.  Amon;,'  other  j)oiiits  ahoiit  leukieiiiie  l)lood  niav  Ijc 
mentioned  (he  feebleness  of  the  am(el)oi(l  niovonienl,  as  noted  hy  Cafinv, 
which  may  he  aeeonnted  for  hy  tlu^  lar^'e  number  of  mononuclear  ch- 
inents  jjresent,  the  polynuelear  alou'.*  possessinij  this  ])o\ver.  'I'he  hldnd- 
]»lates  exist  in  variable  numbers;  they  may  be  remarkably  al)undant.  TIn' 
librin  lu'twork  l)etweeii  the  corpuscles  is  usually  thick  and  dense,  hi 
blood-slides  which  are  kept  for  a  short  time,  Cluircot's  oetohedral  crysiuls 
separate,  and  in  the  l)lood  of  leuka-inia  the  luemoglobin  shows  a  rcniiirk- 
able  tendency  to  crystalli/e. 

'2.  Lymphatic  Leukaemia. 

This  foi'm  of  leuka'Miia  is  rare.  As  mentioned,  in  l)Ut  4  of  my  sciics 
of  20  cases  were  the  ^dands  enlari^cil.  The  sujierlieial  groups  jire  usually 
most  involved,  and  even  when  alTected  it  is  rare  to  see  su(di  large  buuclus 
us  in  llodgkin's  disease.  Kxteriuil  lyin|ih  tumors  are  rare.  Lym]p|iatic 
leuktennu  is  often  more  rapid  aiul  fatal  in  its  course,  though  chronic  cases 
may  occur.     It  is  more  common  in  youJig  subjects. 

Tlu'  histological  characters  of  the  /jhioi/  in  lymphatic  leuka-nua  dilTrr 
nuiterially  from  those  in  the  sph'uo-medullary  form.  Tlu;  increase  in  I  lie 
colorless  elements  is  never  so  great  as  in  the  i)receding  form  ;  a  j)roii(ir- 
tion  of  one  to  ten  would  be  extreme.  This  increase  takes  place  solely  in 
the  lymphocytes,  all  other  forms  of  leucocytes  being  jiresent  in  greatly 
diminished  relative  proj)ortion.  In  oiu'  of  my  cases  over  iiS  per  ct'Ut  of 
all  the  leucocytes  were  lymj)hocytes.  Eosim)philes  and  nucleated  red 
corpuscles  are  rare.     ^Myelocytes  ar6  not  present. 

The  j)ure  myelogenous  cases  without  associated  enlargement  of  tlie 
spleen  are  rare.  The  nu)st  extreme  hyperj)lasia  of  the  bone  mai'row  may 
exist  without  any  tenderness.  Oecasioiudly  the  sterinun,  ribs,  and  llat 
bones  show  great  irregularity  and  deformity,  owing  to  definite  tunu)rdike 
expansions. 

Combined  forms  of  leukamiia  may  occur  thougli  they  are  not  comuinii. 
One  such  instance  occurred  at  the  .Johns  IIo})kins  Hospital.  Here  tlir 
s})leen,  marrow,  ami  lym^diatic  glands  all  showed  marked  changes.  The 
blood  in  this  instance  showed,  besides  a  large  proportion  of  lymphocytes 
aiul  myelocytes,  a  considerable  number  of  large  mononuclear  leucocytes. 

Diagnosis. — The  recognition  of  leuka-mia  can  be  detennined  only 
by  microscojdcal  examination  of  the  blood.  The  clinical  features  may  be 
identical  with  those  of  ordiiuiry  splenic  ansemia,  or  with  llodgkin's  disease. 
An  interesting  question  arises  whether  real  increase  in  the  leucocytes  is 
the  only  criterion  of  the  existence  of  the  disease.  Thus,  for  instance,  in 
the  case  whose  chart  is  given  on  page  T3!),  the  patient  came  under  obsei'- 
vation  in  September,  18UU,  with  2,000,000  red  blood-corpuscles  per  cubic 


rrfiwi-^iiiiirfi 


LKI'K.KMIA. 


741 


iiiillimotrc,  tliirty  por  cent  of  li;i'iti()<,'l()l)iii,  ami  riOO,000  whiti-  blood-cor- 
|iii-cU'H  per  ciiltic  Miillinictri' — a  proportimi  of  one  to  four.  As  slinwn  by 
till'  clmrt,  tliroiii,f|ioiit  Scptciiil)"!',  Octohcr,  N'ovi'iiitxT,  ami  DfCfUilitT,  llii!! 
nilio  WHS  iiiiiiiitaim'tl.  Marly  in  Jamiary,  iiikUt  treat tiiriit  with  arsoiiic, 
the  wliiti'  corpiKscli's  hopm  to  dccroasp,  and  ;,'ra(hially,  as  shown  in  the 
chart,  the  normal  ratio  was  reached.  At  this  time  conld  it  bi>  said  that 
the  case  was  one  of  lenka'niia  withont  increase  in  the  nnml)i'r  of  leuco- 
cvtcs?  '{"lie  blood  examination  l)y  Mlirlii'irs  Tnetl'od,  as  made  by  Thayer,- 
sliiiwed  that  nucleated  red  corpuscles  in  larj,'e  nn.       '-s  as  well  as  the  char- 

lutcristie  myeloeytos,  elements  which  are  but  rarely  found  in  normal  1)1 1, 

were  still  present  in  numbers  snllicient,  at  any  rate,  to  snir^^'cst,  if  the  pa- 
tidit  liad  come  under  observation  for  the  first  time,  that  leukaunia  mi;,dit 
(icciir.  Hy  KlirliclTs  method  of  blood  examiiuition  a  condition  of  len- 
cocytosis  can  readily  be  distinguished  from  that  of  leuka'/nia,  for  in  all 
onlinary  leucoeytoses  the  increase  takes  jdaee  solely  in  the  polynuclear 
iiciitropliilic  leucocytes. 

The  remarkable  "green  cancer"  or  chloroma  is,  according  to  Dock,  "a 
lyiiiphomatous  process  similar  in  its  classical  features  to  leuka-mia  ami 
psicudodouku'mia." 

Prognosis. — Recovery  occasiomdly  occurs.  A  great  majority  of  the 
f'iisfs  })roV(!  fatal  within  two  or  three  years.  Unfavorable  signs  are  a  teiul- 
ciicy  to  haunorrhage,  persistent  diarrluea,  early  dropsy,  and  high  fever./ 
lii'iiiarkable  variations  are  disjdayed  in  the  course,  and  u  transient  im- 
prDvement  may  take  place  for  weeks  or  even  months.  The  pure  lym- 
phatic form  seems  to  be  of  particular  malignancy,  some  cases  ])roving 
fatal  in  from  six  to  eight  weeks;  but  there  are  exceptions,  and  I  have 
I'ocently  seen  a  case  in  which  the  diagnosis  was  made  ten  years  ago  by 
\V.  H.  I)rai)or.  The  patient  has  had  eidarged  glands  ever  since,  and, 
though  not  anaMTiic,  the  leucocytes  were  242,000  per  cubic  millimetre, 
ahiivc  ninety  per  cent  of  them  lymphocytes. 

Treatment. — Fresh  air,  good  diet,  and  abstention  from  mental  worry 
ami  care,  are  the  important  general  iiulications.  The  inilicatio  morbi  can- 
not be  met.  There  are  certain  remedies  which  have  an  influence  upon  the 
dispasp.  Of  these,  arsenic,  given  in  large  doses,  is  the  best.  I  have  re- 
peatedly seen  improvement  under  its  use.  On  the  other  hand,  there  are 
<'ini()us  remissions  in  the  disease  which  render  therapeutical  deductions 
very  fallacious.  I  have  seen  such  marked  improvement  without  special 
treatment  that  the  patient,  from  a  l)ed-ridden,  wretched  condition,  recov- 
eivtl  strength  enough  to  enable  him  to  attend  to  light  duties. 

(^tinine  may  be  given  in  cases  with  a  malarial  history.  Iron  may  be 
of  value  in  some  cases,  as  may  also  inhalations  of  oxygen. 

Kxcision  of  the  leuka3mic  spleen  has  been  performed  twenty-four  times, 
with  one  recovery — the  c.tse  of  Franzolini.  Fussell  gives  the  statistics  of 
!'•')  cases  of  splenectomy  with  48  deaths.  Of  the  cases  of  simple  hyper- 
'I'liphy,  28  in  number,  9  recovered.  Of  16  cases  of  floating  spleen,  15 
recovered. 


1   '    ''. 


}■■ 


U'2 


DISEASKS  OF  TIIK   FILOOI)  AND   DUCTLKSS  GLANDS. 


if 


III.   HODGKIN'S  DISEASE. 

Definition.  —  An  iiiTcction  cliiinictcriziMl  liy  |iruj,'rfssiv('  liypcriilasiij 
of  till'  Iviiipli  ;rlaiuls,  with  aiiii'iiiia,  ami  occasioiiallv  tlic  (Ifvi'ldpiiicat  (if 
iHiH'oiidary  lyiiipliKid  j,'r(t\vtli.s  in  iivcr,  spU'iMi,  ami  otlicr  or^oiiis.  'I'lic  dis- 
ease lian  alsi)  the  iianiurf  pseuUu-leukcemiu,  (jenvnil  lijiiipltKdviiiiiiKi,  ainl 
tide  11  ill. 

ll()d;,d<iii,  tiie  well-known  niorhid  anatdnust  dl"  (!uy's  llosiiitid.  lirst 
de8eril)i'd  eases  in  detail,  ami  liy  the  lalini's  (d"  \\  ilks,  N'iivhuw,  i>illrutli, 
anil  Cohnheiin  tlie  disease  attained  delinite  I'eeoffnition. 

Etiology. — A  majority  of  tho  eases  are  in  youny  persons.  In  (Jowiis' 
table  of  ltt<)  eases,  JJd  were  under  twenty  years,  134  between  twenty  and 
forty,  and  IJti  idxf  •  forty.  Three  fourths  of  the  eases  are  in  males,  in  a 
few  iiistanees  heredity  has  been  a(Mueeil  as  a  possible  cause,  and  aiitirc- 
dont  disease,  such  as  syphilis,  but  this  is  doubtful.  More  important  is  Iik  al 
irritation,  ui)on  wdiieh  Trousseau  lays  special  stress,  und  gives  instanies  in 
which  chroiuc  irritation  of  the  skin,  chronic  nasal  catarrh,  or  the  irrita- 
tion of  a  decayed  tooth  gJiVe  rise  to  locid  gland  swellings,  which  preet'did 
a  general  development  of  the  disease.  In  a  largo  majority  of  the  cases  the 
disease  comes  oi.  '•  lidiously,  without  any  recognizable  cause. 

Morbid  Anatomy. — The  Lumph  Ghtitdx. — In  a  few  cases  the  cn- 
largo  1  glands  an  hard  and  firm,  but  in  a  majority  the  growth  is  soft  and 
elastic.  In  the  early  stage  tlie  individual  glands  are  iscdated,  not  largci' 
than  almonds  or  walnuts,  and  readily  separated  and  movable.  When  ad- 
vanced the  glands  fuse  together,  and  a  group,  as  iu  the  neck,  may  foiiii  u 
large  tumor,  the  size  of  an  orange  or  even  of  a  cocoa-nut.  About  such 
masses  the  cai)sidar  tissues  are  hard  and  dense,  forming  a  linn  investment. 
A  growth  may  perforate  the  cajistde  and  invade  contiguous  })arts,  such  as 
the  muscles,  skin,  or  the  solid  organs.  On  section,  the  tnmor  has  a  gray- 
ish-white aj)pearance  ;  it  is  smooth,  and  of  variable  consistence,  either  linn 
and  dry  or  soft  aiul  juicy.  Suppuration  is  most  frequently  soon  when  the 
growth  reaches  the  skin.  In  the  deep  glands  the  formation  of  })us  is  rare. 
Caseation  is  not  common ;  occasionally  there  are  areas  of  necrosis  very 
like  it.  The  sujierticial  glands  are  most  often  attacked,  particularly  the 
cervical  groups,  and  the  glands  may  be  traced  as  continuous  chains  along 
the  trachea  and  the  carotids,  uniting  the  axillary  and  mediastinal  glands. 

The  axillary  group  is  involved  next  in  order  of  frecpiency,  antl  the 
masses  may  pass  beneath  the  pectorals  and  beneath  the  scajjuhe.  The 
inguinal  glands  occasionally  form  very  large  nuisses.  Of  the  inti'iiial 
groups,  those  of  the  thorax  are  most  often  affected,  either  the  (diain  in  the 
posterior  mediastinum  or  the  bronchial  group,  or  those  of  the  anterior 
mediastinum.  The  trachea  and  the  aorta  with  its  branches  may  be  ei>ni- 
pletely  snrrounded  by  the  growths,  and  be  but  little  compressed.  Fntni 
the  anterior  mediastinum  the  masses  may  perforate  the  stern"  m  and  ap- 
pear as  an  external  tumor. 


WM 

fl 

■■* 

nODGKINS   DISKASE. 


:v.i 


Of  tho  abdominnl  proiipH,  tlie  rctiniK'ritoMciil  i.^  most  frof|uciitly  iii- 
Vdhrd  and  iiiay  form  ii  (•(iiitimiuiis  eliiiiii  from  flic  (liii|>lini;,'m  to  Mm 
iiiLriiiiial  ciiiials,  itiid  cxti'iid  into  the  in-lvis.  'I'lic  j^'landn  may  coiiiiJrcss  tho 
iiittcrs,  iiivolvt'  till'  sa<'nil  or  liimhar  iicrvi's,  (»r  <'om|»ivss  tin*  iliac  veins. 
Oiciisioiially  tlicy  adlicrc  to  tlic  iilcru.-?  and  hroad  ligament  so  as  to  simu- 
late lll)roids.  I  saw,  some  years  ago,  one  of  the  most  distingiiislieil  gyna'- 
cnloLfists  of  (iermany  perform  laparotomy  in  a  case  of  this  kind,  in  which 
the  diagiKjsis  of  myomatous  tninors  of  the  uterus  had  been  maile.  Occa- 
sionally the  mc'SCMiteric  or  he[iatic  lyinph  glands  nuiy  form  large  aixlominal 
tiiniors. 

//is/ijlii)/ini//i/  th(^  chief  change  is  an  increase  in  the  cells,  with  or 
without  thickening  of  the  reticulum.  Jn  the  eai'ly  stage  there  is  simple 
liyperjilasia  and  the  relations  of  the  lymph  i)aths  are  maintained,  hut  wiicn 
tile  gland.s  are  greatly  enlarged  the  normal  arrangement  is  disturlicd.  The 
reticulum  varies  extn'iiiely  ;  in  tho  softer  growths  it  is  expanded  and  can 
scarcely  he  found;  in  the  harder  stiun  ures  the  network  of  lil)res  is  vciy 
(H-tinct,  and  there  is  probably  an  inereuM  il  devt'lo^tment  of  the  adenoid 
tissue. 

Splerii. — In  soventy-five  per  cent  of  the  cu:Hes  collected  by  Ciowers  this 
ori,':iii  was  hypertrophied,  ami  in  fifty-six  of  tliest'  cases  it  presented  lym- 
pliiiid  growths.  The  enlargement  is  rarely  great,  and  does  not  approximate 
to  the  large  leuka'mic  spleen.  The  lym))hoid  tumors  form  grayish-white 
bodies  ranging  in  size  from  u  pea  to  a  walnut,  and  may  resemble  lym})h 
jrlaiids  ill  apj)earance  and  consistence.  Histologically,  they  consist  of 
iyiiiph  corpuscles  in  a  fibrous  reticulum. 

The  marrow  of  the  long  bones  may  be  converted  into  a  rich  lymidioid 
tissue ;  in  a  few  instances  the  pyoid  form,  such  as  is  more  common  in  leu- 
kit'iTiia,  has  been  found.  The  tonsils  may  be  involved  and  the  follicles  at 
the  root  of  the  tongue.  Occasionally  secondary  growths  are  seen  in  the 
intestines. 

The  livci'  is  often  eidarged  and  may  present  scattered  lyniplioid  tumors. 
The  kidneys  are  occasionally  involved  and  are  the  seat  of  groAvths  similar 
to  tli(/se  of  tlie  spleen  and  liver.  The  lungs  are  occasionally  directly  at- 
tacked from  the  bronchial  glands  at  the  root,  and  secondary  nodules  may  be 
foiiiid  throughout  their  substance.  Pleural  effusions  are  not  uncommon. 
Involvement  of  the  nervons  system  is  rare,  but  paraplegia  may  be  induced 
by  invasion  of  the  spinal  canal.  The  skin  may  be  the  seat  of  adenoid 
growths,  as  in  a  case  reported  by  Greenfield. 

Symptoms. — Enlargement  of  the  glands  of  the  neck,  axilla,  or 
groins  is  usually  the  first  symptom  noticed.  In  a  few  cases  the  anaemia 
and  constitutional  symptoms  attract  attention  before  the  glandular  in- 
volvement is  evident.  AVlien  the  trouble  begins  in  the  deeper  groups, 
pressure  effects  may  be  first  noticed  ;  thus,  paroxysmal  dyspnoea  with  pain 
in  the  chest  may  result  from  enlargement  of  the  bronchial  glands  before 
any  physical  signs  can  be  detected.     (Edema  of  the  feet  and  shooting 


f  I     'I 

,  --4  -• . :  - 1  k" 


744 


DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 


pains  in  the  nerves  were  tlie  first  symptoms  in  one  case  which  I  dis^ 
sectod  for  Iloss,  and  in  anotlier  case  at  the  Montreal  (ieneral  If(»s])itul 
there  was  parapk'gia  from  pressure  on  the  cord.  Such  instances,  howevci', 
arc  exceptional,  and  in  the  majority  of  cases  the  swelling  of  the  suporlicial 
glands  is  the  earliest  symptom.  E])istaxis  has  occasionally  been  noted,  hut 
not  so  fref{iiently  as  in  leukannia.  With  progressive  enlargement  of  tlu- 
glands  the  patient  becomes  auiumic. 

Usually,  the  cervical  group  is  first  affected,  and  it  may  be  imi)ossiblc 
to  decide  whether  the  enlargement  is  syphilitic,  tuberculous,  or  lympliad- 
enomatous.  One  side  is  first  affected  as  a  rule,  and  it  may  be  numtlis,  or 
even,  as  in  one  of  my  cases,  three  years  before  the  affectioTi  extends  to 
othei  groups  Ultimately  huge  tumors  may  develop,  which  obliterate  tlu' 
neck  and  extend  u])on  the  shoulders  and  over  the  clavicles  and  stenuini. 
The  trachea  is  surrounded,  great  dyspncea  is  jiroduced,  and  not  infre- 
quently tracheotomy  is  necessary.  In  the  later  stages,  the  skin  becomes 
involved  and  ulcerates.  Tlie  axillary  grou})  nuiy  form  large  tumors,  which 
compress  the  brachial  or  axillary  veins  and  cause  swelling  of  the  arms. 
The  inguinal  glands  may  form  large  or  even  pendulous  tumors. 

In  the  thoracic  glands,  as  mentioned,  the  various  groups  may  be  in- 
volved and  produce  pressure  upon  the  veins  or  upon  the  trachea.  In  u 
case  recently  under  observation  the  superior  cava  was  completely  obliter- 
ated and  a  very  extejisive  collateral  circulation  was  established  by  means 
of  the  mammary  and  epigastric  veiiis.  The  skin  over  the  sternum  was  a 
mass  of  fluctuating  veins,  some  of  which  contained  phleboliths.  In  the 
abdomen  the  mesenteric  glands  nniy  be  enlarged,  or  more  commonly  the 
retroperitoneal  group.  When  the  j)atient  is  thin  there  may  be  no  diffi- 
culty in  detecting  these,  but  in  stout  persons  the  diagnosis  may  be  inipcis- 
sible.  In  connection  with  the  affections  of  the  abdominal  glands  therc^ 
may  be  bronzing  of  the  skin,  which  was  well  marked  in  Case  IV  of  my 
series.  A  remarkable  feature  is  the  variations  in  the  rate  of  growth  and 
in  the  size  of  the  glands.  They  may  reduce  rapidly  and  almost  disappear 
from  a  region,  and  before  death  the  tumors  may  diminish  very  much. 
The  spleen  may  be  eidarged  and  readily  palpable.  The  thyroid  also  may 
be  involved,  and  in  a  few  instances  the  thymus  has  been  affected.  Ti.ongh 
present  in  a  majority  of  the  cases,  there  may  be  enormous  enlargement  of 
the  lymph  glands  without  nuirked  anaMuia.  In  one  of  my  cases  the  blood- 
corpuscles  did  not  sink  below  4,000,000  per  cubic  millimetre,  and  -ii  only 
one  instance  have  I  counted  the  blood  below  2,000,000.  The  red  bUxul- 
corpuscles  rarely  show  extreme  poikilocytosis.  The  white  corpuscles  may 
be  moderately  increased  and  the  lymphocytes  abundant,  though  usually 
there  is  little  characteristic  in  the  blood.  Occasionally  the  leucocytes  are 
greatly  increased  and  the  characters  of  the  blood  become  those  of  a  lym- 
phatic leukiemia.  Nucleated  red  blood-cor])uscles  may  be  present,  but 
not  in  such  numbers  as  in  leukaemia. 

Of  cardiac  symptoms,  palpitation  is  common.     IIii?mic  murmurs  are 


iiifi m> 


IIODGKIN'S  DISEASE. 


r45 


luinnurs  are 


often  hoard  over  tho  licavt.  Sliortncss  of  breath  may  he  due  to  the  anaemia, 
i(\  jirossure  upon  tho  trafhea,  or,  in  some  instances,  to  i)U'uritic  effusion 
u.v-ociated  with  mediastinal  growths.  Fever  is  observed  in  nearly  all  eases; 
even  in  the  tarly  stages  there  is  slight  elevation.  It  n)ay  be  of  an  irregu- 
liir  hectic  type,  or  continuous,  witli  evening  exacerbation.  Very  rennirka- 
ble  are  the  cases  with  ague-like  ])aruxy.sms,  whicli  may  jiersist  for  weeks 
or  ujonths.  'J'hey  were  present  in  Case  I  of  my  series.  I'el,  of  Amster- 
dam, lias  given  a  tliorough  description  of  these  atticks,  and  Kbstein  has 
described  a  case  under  the  remarkable  title  of  "  Chronic  Heeurrent  Fever,  a 
New  Infectious  Disease."  In  his  case  during  nine  montlis  the  attacks  were 
present  for  j)eriods  of  from  twelve  to  fourteen  days  and  alternated  with 
uj»yrexia  for  ten  or  eleven  days. 

The  digestive  Kyraptoms  are  usually  not  marked.  It  is  not  uncommon 
to  find  albumen  in  the  urine.  Headache,  giddiness,  and  noises  in  the  ear 
niiiy  be  associated  with  the  anaemia.  Delirium  ai'd  coma  may  be  present. 
Deafness  may  be  produced  by  growth  of  the  adenoid  tissue  in  the  phar- 
ynx close  to  the  Eustachian  tubes.  Inequality  of  the  inipils  may  be  ])res- 
eiit,  owing  to  pressure  of  the  glands  on  the  cervical  sympathetic.  The  skin 
may  show  definite  secondary  lymphatic  tumors,  bronzitig  may  occur,  and 
occasionally  a  most  intense  and  troublesome  ])rurigo. 

Diagnosis. — A  tubercuh)us  adenitis  may  at  fir.st  be  very  diflicult 
10  dill'orentiate.  The  chief  points  of  distinction  .-Lre  as  follows:  Tuber- 
culous  adenitis  is  more  common  in  the  young  and  involves  the  submaxil- 
lary group  of  glands  more  frequently  than  those  of  the  anterior  and  pos- 
terior cervical  triajigles,  which  are  usually  art'ected  first  in  (lodgkin's 
disease.  Tlie  enhirgement  may  last  for  years  in  a  group  witliout  extend- 
ing. The  bunches  are  often,  when  small,  welded  togethei  and,  most  im- 
portant of  all,  tend  to  sujipurate — a  feature  rarely  seen  in  true  lymphade- 
nonia,  except  when  it  has  attained  very  large  size.  Strict  limitation  to 
one  side  of  the  neck  or  to  the  axilla  is  suggestive  of  tuberculous  disease 
rather  than  lymjdiadenoma. 

'I'liore  is  an  acute  tuberculous  adenitis,  which  may  involve  the  lymph 
glands  of  the  neck,  producing  enormous  enlargement.  A  man,  aged  twenty- 
four,  was  admitted  to  the  (leneral  Hospital,  ^lontrcal,  with  great  swelling  of 
the  cervical  glands  on  both  sides  onsillitis,  and  sloughing  pharyngitis, 
with  irregular  fever  and  diarrluea.  The  case  was  at  first  regarded  as  one 
of  lli.dgkin's  disease.  The  occurrence  of  rigors  and  intermittent  pyrexia 
is  in  favor  of  lymphadenoma.  There  are  cases  iji  which  it  may  for  a 
tinn-  1)0  impossible  to  make  a  diagnosis.  Wlien  the  glands  are  only  mod- 
erately enlarged  on  one  side  of  the  neck  or  axilla,  they  should  be  removed, 
i-ud  the  diagnosis  can  then  be  thoroughly  established. 

Prognosis. — Recovery  is  very  rare.  The  course  of  the  disease  is  ex- 
tremely variable.  Early  and  rapid  growth  in  the  mediastinal  groups  may 
produce  pressure  effects  and  cause  death  before  the  develoj)ment  is  ex- 
treme.   In  some  cases  the  enlargements  spread  rapidly  and  group  after 


I  -i 


746 


DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 


group  becomes  involved  in  a  lew  month!!.  These  acute  cases  may  run  a 
course  in  three  or  four  months.  Chronic  cases  may  last  for  three  or  four 
years.  Periods  of  (luiescence  are  not  uncommon.  I'he  tumors  muy  not 
only  cease  to  grow,  but  gradually  diminish  and  even  disaj)pear,  without 
special  treatment.  Usually  a  cachexia  develops,  the  anaemia  progresses, 
and  there  are  dropsical  symptoms.  The  mode  of  death  is  usually  by 
asthenia  ;  less  commonly  by  pressure  from  a  tumor  ;  and  occasionally  by 
coma. 

Treatment. — When  small  and  localized  the  glands  should  be  removed. 
Local  applications  are  of  doubtful  benefit.  I  have  never  seen  si)eeiul  im- 
provement follow  the  persistent  use  of  iodine  or  the  various  ointments. 

Arsenic  has  a  positive  value  in  the  disease.  It  should  be  given  in  in- 
creasing doses,  and  stopped  Avhen  unpleasant  effects  are  nuuiifested.  Tlu' 
results  have  in  many  instances  been  striking.  Due  allowance  must  be 
made  for  the  iluctuations  in  the  size  of  the  growths  which  occur  sponta- 
neously. Ill  effects  from  the  administration  of  Fowler's  solution,  even 
for  months  at  a  time,  are  rare,  but  I  have  had  a  case  in  which  neuritis 
followed  the  use  of  3  iv  3  j  iUxviij  within  a  period  of  less  than  three 
months.  Kecoveries  have  been  reported  under  this  treatment.  Person- 
ally, no  instance  of  recovery  has  come  under  my  notice  in  the  cases  of 
which  I  have  notes.  Phosphorus  is  recommended  by  Gowers  and  Broad- 
bent,  and  should  be  used  if  the  arsenic  is  not  well  borne.  Quinine,  iron, 
and  cod-liver  oil  are  useful  as  tonics.  Every  possible  means  nuist  be 
taken  to  support  the  patient's  strength. 


m 


IV.  ADDISON'S  DISEASE. 

Definition. — A  constitutional  affection  characterized  by  asthenia, 
depressed  circulation,  irritability  of  the  stomach,  and  pigmentation  of  tlie 
skin.  Tuberculosis  of  the  adrenals  is  the  common  anatomical  change. 
Recent  observations  indicate  that  the  symptoms  may  be  due  to  loss  of 
function  of  the  suprarenal  bodies. 

The  recognition  of  the  disease  is  due  to  Addison,  of  Guy's  Hospital, 
whose  monograph  on  The  Constitutional  and  Local  Effects  of  Disease  of 
the  Suprarenal  Ca})sule3  was  published  in  1855. 

etiology. — Males  are  more  frequently  attacked  than  females.  lu 
Grcenhow's  analysis  of  183  cases  119  were  males  and  ()4  females.  A  ma- 
jority of  the  cases  occur  between  the  twentieth  and  the  fortieth  year.  A 
congenital  case  has  been  described  in  which  the  skin  had  a  yellow-gray 
tint.  The  child  lived  for  eight  weeks,  and  post  mortem  the  adrenals  weiv 
found  to  be  large  and  cystic.  Injury  such  as  a  blow  upon  the  abdomen 
or  back,  and  caries  of  the  spine,  have  in  many  cases  preceded  the  attack. 
The  disease  is  rare  in  America.  Nine  cases  have  come  under  my  personal 
observation,  either  clinically  or  anatomically,  eight  in  men. 


ADDISON'S  DISEASE. 


l-ii 


Morbid  Anatomy  and  Pathology.— There  is  rarely  etnjiciution 
or  aiiivmiu,  Kolle-ston*  tliiis  siiinniarizes  tlie  oonditiou  of  the  supriironal 
boilii'S  ill  Addison's  disease  : 

'•  1.  The  fibro-caseons  lesion  due  to  tuberculosis — far  the  commonest 
condition  found.  2.  Simple  atrophy.  3.  Chronic  interstitial  inllainma- 
tiou  leading  to  atrophy.  4.  Malignant  disease  invading  the  capsules, 
inchuling  Addison's  case  of  malignant  nodule  compressing  the  suprarenal 
vein.  5.  Blood  extravasated  into  the  suprarenal  bodies.  G.  No  lesion  of 
the  suin'arenal  bodies  themseh-es,  but  pressure  or  inflamnuition  involving 
the  semilunar  ganglia. 

''  The  first  is  the  only  common  cause  of  Addi.-on's  disease.  The  others, 
with  the  exception  of  simple  atrophy,  may  bo  considered  as  very  rare." 

Among  other  anatomical  features  the  condition  of  the  abdominal  sym- 
pathetic has  been  specially  studied.  The  nerve-cells  of  the  semilunar 
giuiglia  have  been  described  as  degenerated  and  deeply  pigmented,  ami 
the  nerves  sclerotic.  The  ganglia  are  not  uncommonly  entangled  in  the 
cicatricial  tissue  about  the  adrenals.  The  spleen  has  occasionally  been 
found  enlarged ;  the  thymus  may  persist  and  be  larger  than  normal. 

It  is  difficult  to  explain  satisfactorily  all  the  symptoms  of  this  remark- 
able disease.  The  two  chief  theories  which  have  been  advanced  are  briefly 
as  follows:  (a)  That  the  disease  depended  upon  the  loss  of  fuiu-tiim  of 
the  adrenals.  This  was  the  view  of  Addison.  The  balance  of  experimental 
evidence  is  in  favor  of  the  view  that  the  adrenals  are  fnnciio'ial  glands, 
whieli  furnish  an  internal  secretion  essential  to  the  normal  metabolism. 
Sehiifer  and  Oliver  have  shown  that  the  human  adrenals  contain  a  very 
powerful  extract,  which  is  not  to  be  obtained  in  cases  of  Addison's  dis- 
ease; they  have  also  studied  the  toxic  effects  on  animals  of  the  extracts  of 
tlie  glands.  In  the  cases  in  which  the  adrenals  have  been  found  involved 
without  the  symptfmis  of  Addison's  disease,  accessory  glands  may  have 
been  present ;  while  in  the  rare  cases  in  which  the  symptoms  of  the  dis- 
ease have  been  present  with  healthy  adrenals  the  semilunar  ganglia  and 
adjacent  tissues  have  been  involved  in  dense  adhesions,  which  may  have 
interfered  readily  with  the  vessels  or  lymphatics  of  the  glands.  On  this 
view  Addison's  disease  is  due  to  an  inadequate  supply  of  the  adrenal  secre- 
tion, just  as  myxoedema  is  caused  by  loss  of  function  of  the  thyroid  gland. 
"Wiu>ther  the  deficiency  in  this  internal  secretion  leads  to  a  toxic  condi- 
tion of  the  blood  or  to  a  general  atony  and  apathy  is  a  question  Avhich 
must  remain  open"  (Ilolleston).  {h)  That  it  is  an  affection  of  the  ab- 
tlominal  sympathetic  system,  induced  most  commonly  by  disease  of  the 
adrenals,  but  also  by  other  chronic  disorders  which  involve  the  solar 
plexus  and  its  ganglia.     According  to  this  view,  it  is  an  affection  of  the 


1 

1 

§/. 

1 

i 

f 

r 

1 

i! 

1 

'J:  S 

s    ^  U  I' 

\ 

;i  ■  '  •] 

1 

M 

K 

*  fiiiulstonian  Lectures,  Roynl  College  of  Physicians,  Hritisih  Medical  Journal, 
ISyr),  i,  to  which  the  student  is  referred  for  an  exhaustive  consideration  of  the  entire 
qut'silion. 


748 


DISEASES  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 


i  1 


ih 


nervous  system,  and  tlie  pigmentation  has  its  origin  in  clningps  indimod 
tlirongh  the  troi^liic  nerves.  The  pronounced  debility  is  the  outcuiiic  df 
disturbed  tissue  metabolism,  and  the  eireuhitory,  respiratory,  and  I'lgcstivc 
symptoms  are  due  to  implication  of  the  i)neumogast.ric.  The  clinnLrcs 
found  in  the  abdominal  sympathetic  are  held  to  support  this  view,  and  its 
advocates  urge  the  occurrence  of  pigmentation  of  the  skin  in  tuberculnsis 
of  the  peritonaium,  cancer  of  the  i)ancreas,  or  aneurism  of  the  abdoniiii.il 
aorta.  Opposed  to  it  are  tlie  facts  that  the  lesions  described  in  tlie  syni- 
liathetio  system  are  indefinite,  and  identical  changes  occur  without  the 
symptoms  of  Addison's  disease. 

Symptoms. — In  the  words  of  Addison,  the  characteristic  symptoms 
are  "  ana3mia,  general  languor  or  debility,  remarkable  feebleness  of  tiic 
heart's  action,  irritability  of  the  stomach,  and  a  peculiar  change  of  color 
in  the  skin." 

The  pigmentation  is  the  symptom  which,  as  a  rule,  first  attracts  at- 
tention. The  grades  of  coloration  range  from  a  light  yellow  to  a  deep 
brown,  or  even  black.  In  typical  cases  it  is  diffuse,  but  always  deeper  on 
the  exposed  parts  and  in  the  regions  where  the  normal  pigmentation  is 
most  intense.  At  first  it  may  be  confined  to  the  face  and  hands.  Occa- 
sionally it  is  absent.  Patches  of  atrophy  of  pigment,  leucoderma,  may  oc- 
cur. The  pigmentation  is  found  on  the  mucous  membranes  of  the  moutli, 
conjunctivas,  and  vagina.  A  patchy  pigmentation  of  the  serous  membranes 
has  often  been  found.  The  ana-mia,  upon  which  Addison  laid  stress,  is  of 
a  .noderate  grade.  It  was  not  present  in  a  marked  degree  in  any  of  my 
cases. 

Gastric  disturbances  are  common ;  nausea  and  vomiting  may  he  early 
and  jirominent  symptoms;  diarrluea,  too,  is  frequent,  and  may  come  on 
without  cause.  The  pulse  is  sriiall  and  rapid,  and  the  heart's  action 
feeble.  Sometimes  there  is  a  special  liability  to  syncope.  One  of  the 
most  pronounced  features  of  the  disease  is  the  profound  asthenia,  wliiiii 
is  out  of  all  proportion  to  the  general  condition.  The  patient  complains 
of  a  lack  of  energy,  both  mental  and  bodily;  the  least  exertion  is  an 
effort,  and  may  be  followed  by  giddiness  or  noises  in  the  ears.  Ileadaelio 
is  a  frequent  syniptom.  With  the  advancement  of  the  disease  the  prustra- 
tion  becomes  more  marked,  the  patient  remains  in  bed,  the  voice  gets 
weak,  the  intelligence  dulled,  and  death  occurs  either  by  syncope  or  gri"'- 
nal  asthenia.  Occasionally  there  are  convulsions.  'I'he  urine  is  usually 
normal.  Polyuria  has  been  described.  The  urinary  pigments  have  Wvn 
found  increased. 

Diagnosis. — Pigmentation  of  the  skin  is  not  confined  to  Addison's 
disease.  The  following  are  the  conditions  which  may  give  rise  to  an  in- 
crease in  the  i)igment : 

(1)  Abdominal  growths — tubercle,  cancer,  or  lymphoma.  In  tubercu- 
losis of  the  peritonaeum  pigmentation  is  not  uncommon. 

{'Z)  Pregnancy,  in  which  the  discoloration  is  usually  limited  to  the  face, 


'•''•IMtiMif'i -' 


ADDISON'S  DISEASE. 


749 


the  so-called  virtsque  den  femmcs  oirehifc.  Utoritie  disciise  is  a  common 
ciiu-    of  a  patcl' y  mt'lasma. 

(:!)  Hepatic  disease,  ^vllicll  may  imliico  definite  pifrmentation,  as  in  the 
iliiilHtic  ciirliosis.  More  commonly  in  overworked  persons  of  constipated 
hiihir  and  \vitli  slnggisli  livers  then,  is  a  patcliy  staining  about  the  face 
iiiul  forehead. 

(4)  'J'he  vagabond's  discoloration,  caused  l)y  the  irritation  of  lice  and 
iliit.  uliieli  may  reach  a  very  high  grade,  and  has  sometimes  been  mistaken 
fdi'  Addison's  disease. 

(,"))  In  rare  instances  there  is  deep  discoloration  of  the  skin  in  mela- 
notic cancer,  so  deep  and  general  that  it  has  l)een  confounded  with  itirhisiiKt 
.injirdri'iKih'. 

(('»)  In  certain  cases  of  exophthalmic  goitre  abnormal  pigmentation 
occurs,  as  noted  by  Drummond  and  others. 

In  any  case  of  unusual  pigmentation  these  various  conditions  must 
be  soiiglit  for,  and  tiie  diagnosis  of  Addison's  disease  is  scarcely  jus- 
tifiiihle  without  the  asthenia.  In  many  instances  it  is  ditlicult  early 
ill  the  disease  to  arrive  at  a  definite  conclus^ion.  The  occurrence  of 
fainting  fits,  of  nausea,  and  gastric  irritability  are  important  indica- 
tions. 

Prognosis. — The  disease  is  usually  fatal.  'I'he  cases  in  which  the 
bronzing  is  sliglit  or  does  not  occur  run  a  more  rapid  course.  There  are 
occasionally  acute  cases  which,  with  great  weakness,  vomiting,  and  diar- 
rbo'a,  prove  fatal  in  a  few  weeks.  In  a  few  cases  the  disease  is  much 
prolonged,  even  to  six  or  ten  years.  In  I'are  instances  recovery  has  taken 
place,  and  periods  of  improvement,  lasting  many  months,  may  occur. 

Treatment. — The  causal  indications  canjiot  be  met.  Wiien  there 
i^  [ji'ofound  asthenia  the  patient  should  be  confined  to  bed,  as  fatal 
syncope  may  at  any  time  occur.  In  three  of  my  cases  death  was  sudden. 
W'lu'u  aniv?mia  is  presejit  iron  tiiay  be  given  in  full  doses.  Arsenic  and 
strychnia  are  nseful  tonics.  For  the  diarrho'a  large  doses  of  bismuth 
should  be  given  ;  for  the  irritability  of  the  stomach,  creosote,  hydrocyanic 
acid,  ice,  and  champagne.  The  diet  should  be  light  and  nutritious. 
Many  patients  thrive  best  on  a  strict  milk  diet.  An  extract  of  the  gland 
has  been  given — in  two  cases  of  Oliver's  with  benefit,  in  one  case  of 
(irainger  Stewart's  without  any  noticeable  benefit.  In  a  case  at  pres.-^nt 
luulcr  treatment  in  my  wards  the  patient  says  that  he  f(;els  much  stnniger, 
and  in  six  weeks  has  gained  fifteen  pounds  in  weight.  The  equivalent 
of  about  two  glands  a  day  should  be  given.  The  glands  may  be  eaten 
cooked,  or  a  glycerine  extract  or  a  dried  extract  may  be  made. 


11 


'  I 


1    '  1 


4 


fevJi 


:■  1 


I  i: 


750 


DISK  ASKS  OF  THE  BLOOD  AND  DUCTLESS  GLANDS. 


V.    DISEASES    OF   THE    THYROID   GLAND. 

CJOITHK. 


1  liil 


II IM 


i'f.  J 


iiii' 


Definition. — Ilyportrophy  of  the  tliyroid  glaml,  occurring  spoi'iul. 
ically  or  eudemically, 

111  tliis  country  sporadic  cases  are  common.  Tlio  endemic  centres  re- 
ferred to  in  Burton's  monograj)!!  (18l(i)  and  in  llirscirs  fieograpliicul 
Pathology  no  longer  exist.  Tiie  disease  is  very  ju'evaient  about  the  ciistcni 
end  of  Lake  Ontario,  and  in  parts  of  Michigan  (Dock).  Endemically  it 
is  found  i)articularly  in  the  mountainous  regions  of  Switzerland  and  in 
l)arts  of  Italy.  Xo  satisfactory  explanation  has  been  given  of  the  existoiicc 
of  the  disease  in  this  form. 

Anatomically  the  following  varieties  may  be  distinguished  :  (n)  Paren- 
chymatous, in  which  the  enlargement  is  general  and  the  follicles,  usually 
newly  formed,  contain  a  gelatinous  colloid  material.  (/))  Vascular,  in 
which  the  enlargement  is  chiefly  due  to  dilatation  of  the  blood-vessels 
without  the  new  formation  of  glandular  tissue.  (/■)  Cystic  goitre,  in  wliieh 
the  enlarged  gland  is  occupied  by  large  cysts,  the  walls  of  which  often 
undergo  calcification. 

Symptoms. — The  enlargement  may  be  uniform  throughout  tlie 
entire  ghind,  or  affect  only  one  lobe,  or  the  isthmus  alone.  AVhen  small, 
a  goitre  causes  no  inconvenience.  In  its  growth  it  may  compress  the 
trachea,  causing  dys])naui,  or  may  pass  beneath  the  sternum  and  conipres-; 
the  veins.  These,  however,  are  exceptional  circumstances,  and  in  a  large 
proportion  of  .all  cases  no  serious  symptoms  are  noted.  The  affection 
usually  conies  under  the  care  of  the  surgeon.  Sudden  death  oecasiotially 
occurs  in  large  bronchoceles.  In  some  instances  it  may  be  difficult  to  de- 
termine the  cause,  and  it  has  been  thought  to  be  associated  with  pressure 
on  the  vagi.  I  have  reported  an  instance  in  which  it  resulted  from  lui'tuor- 
rhage  into  the  gland  and  into  the  adjacent  tissues.  The  blood  passed  into 
the  cellular  tissues  of  the  neck  and  under  the  sternum,  covering  the  aorta 
and  pericardium.  In  regions  in  which  goitre  prevails  the  drinking-water 
should  be  boiled.  Change  of  locality  is  sometimes  followed  by  cure.  The 
medicinal  treatment  is  very  unsatisfactory.  Iodine  and  various  counter- 
irritants  externally,  iodide  of  potash,  ergot,  and  many  other  drugs  are  rec- 
ommended by  writers.  The  thyroid  extract  has  been  used  witli  success 
by  Bruns  in  nine  of  twelve  cases. 

Tumors  of  the  Thyroid. 

These  are  very  varied,  (a)  Adenomata,  either  simple  or  malignant. 
The  latter  may  form  extensive  metastases.  A  case  is  reported  by  Hay- 
ward  in  which  growths  resembling  thyroid  ti.ssue  occurred  in  the  lungs  and 
various  boner  of  the  body,     (b)  Cancer,  of  which  several  forms  have  bi.eu 


curring  pporad- 


DISEASES  OF  TIIPJ  THYROID  GLAND. 


'".'"1 


dcsoi'ibiHl.  {(')  Sarcoma.  All  of  those  have  a  purgieal  rather  than  a 
niuilical  iiitere^it. 

It  may  be  mentioned  that  tlie  aberrant  or  accessory  thyroid  gland  may 
fdiiii  large  tumors  in  the  mediastinum  or  in  the  i)leura.  I  have  reported 
two  ea.ses  of  ihis  kind,*  and  an  instance  is  on  record  in  wliieh  an  enor- 
iiious  cystic  accessory  tliyroid  occupied  the  entire  right  jjleura. 

Thijroiil  (il/sci'ss  is  rare.  In  Havers  monogra])h  on  Strunutis  (189"^) 
oases  are  given  after  nearly  every  one  of  the  specific  di'  ases,  and  he  re- 
ports eighteen  cases  from  Koclier's  clinic,  nearly  all  secondary  or  metastatic. 

Exoi'iiTiiALMic  Goitre  {Graveti''s  Disease ;  Basedow's  Disease). 

Definition. — A  disease  characterized  by  exfii)hthalmos,  enlargement 
of  the  thyroid,  and  functional  disturbance  of  the  vascular  system.  It  is 
vury  possibly  caused  by  disturbed  function  of  the  thyroid  gland  (hyper- 
thyroidism). 

Etiology. — The  disease  is  rare  in  men.  The  age  of  onset  is  usiuilly 
from  the  twentieth  to  the  thirtieth  year.  It  is  sometimes  seen  in  several 
nu'iiibcrs  of  the  same  family.  Worry,  fright,  and  depressing  emotions 
precede  the  development  of  the  disease  in  a  number  of  cases. 

The  disease  is  regarded  by  some  as  a  pnre  neurosis,  in  favor  of  which  is 
urged  tlie  onset  after  a  profound  emotion,  the  absence  of  lesions,  and  the 
cure  which  has  followed  in  a  few  cases  operations  npon  the  nose.  Others 
believe  that  it  is  caused  by  a  central  lesion  in  the  medulla  oblongata.  In 
supjtort  of  this  there  is  a  certain  amount  of  experimental  evidence,  and  in 
a  few  autopsies  changes  have  been  found  in  the  medulla.  Of  late  years 
the  view  has  been  urged,  particularly  by  ]\Ioebius  and  by  (Jreenlield,  that 
exophthalmic  goitre  is  primarily  a  disease  of  the  thyroid  gland  {hyper- 
(Iiyreii),  in  antithesis  to  myxcedema  (afhyrea).  The  clinical  contrast  be- 
tween these  two  diseases  is  most  suggestive — the  increased  excitability  of 
tlie  nervous  system,  the  flushed,  moist  skin,  the  vascular  erythism  in  the 
one;  the  dull  apathy,  the  low  temperature,  slow  j)ulse,  and  dry  skin  of  the 
otluT.  The  changes  in  the  gland  in  exophthalmic  goitre  are,  as  shown  by 
(ireeufield,  those  of  an  organ  in  active  evolution — viz.,  increased  prolifera- 
tion with  the  production  of  newly  formed  tul)ular  spaces,  and  absorption 
of  the  colloid  material  which  is  replaced  by  a  more  mucinous  fluid  (Brad- 
iiliaw  Lecture,  1893).  The  thyroid  extract  given  in  excess  produces  symp- 
toms not  unlike  those  of  Basedow's  disease — tachycardia,  tremor,  head- 
ache, sweating,  and  prostration.  Beclere  has  recently  reported  a  case  in 
which  exophthalmos  developed  after  an  overdose.  Use  of  the  thyroid 
extract  usually  aggravates  the  symptoms  of  exophthalmic  goitre.  The  most 
sui'cessful  line  of  treatment  has  been  that  directed  to  diminish  the  bulk  of 
the  goitre.  These  are  some  of  the  considerations  which  favor  the  view 
that  the  symptoms  are  due  to  disturbed  function  of  the  thyroid  gland. 


11 

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SH',ffi     ft'       M 


*  Medical  News,  1890. 


r52 


DISEASES  OF  THE  BLOOD   AND  DUCTLESS  GLANDS. 


k       i 


})robal>ly  to  a  hyperscctiou  of  certain  iimtorials,  which  induce  a  sort  of 
chronic  intoxication. 

Symptoms. — Acute  and  chronic  forms  may  bo  recognized.  In  the 
acute  form  the  disease  may  devek)p  witli  great  rapidity.  Jii  a  paticni  df 
J.  II.  Iih)yd's,  of  Philadelpliia,  a  woman,  aged  tiiirty-iiitie,  who  li.iil  lui'ii 
considered  perfectly  healthy,  but  whose  friends  had  noticed  tlmt  for 
some  time  her  eyes  looked  rather  large,  was  suddenly  seized  with  in- 
tenso  vomiting  and  diarrluea,  rapid  action  of  the  heart,  and  great  throb- 
bing of  tlie  arteries.  'I'he  eyes  were  })rominent  and  staring  and  the 
thyroid  gland  was  found  much  eidarged  and  soft.  The  gasiro-iutcstinal 
symptoms  continued,  the  i)idse  became  more  rapid,  the  vomiting  was  in- 
cessant, and  the  patient  died  on  the  third  day  of  the  illness.  Only  the 
abdominal  and  thoracic  organs  could  be  examined  and  no  changes  were 
found.  Two  rapidly  fatal  cases  occurred  at  the  Philadelphia  Hospital, 
one  of  which,  under  F.  P.  Henry's  care,  had  marked  cerebral  symptoms. 
More  frequently  the  onset  is  gradual  and  the  disease  is  chronic.  The 
three  characteristic  symptoms  vary  a  good  deal  in  their  onset.  Cardiac 
and  vascular  symptoms  are  usually  first  to  develop  and  the  patient  com- 
plains of  palpitation  with  breathlessness,  and  on  examination  the  im- 
pulse is  found  to  be  increased  in  force,  the  apex  beat  is  in  normal  ])osi- 
tion,  the  carotids  throb,  and  the  abdominal  aorta  pulsates  visil)ly.  This 
is  one  of  the  conditions  in  which  the  caj)illary  pulse  and  tlie  imlsation  in 
the  veins  of  the  hands  are  occasiomdly  seen.  The  pulse-rate  at  first  may 
not  be  more  than  95  or  100,  but  when  the  disease  is  established  may  reacti 
140  or  ICO.  Any  emotional  excitement  sets  the  heart  beating  with  groat 
intensity,  and  on  exposure  of  the  skin  of  the  upper  i)art  of  the  chest  a 
transient  hypera'mia  is  seen.  Soft  murmurs  are  not  uncommon  at  tlie 
base  of  tiie  heart.  In  the  long-standing  cases  the  heart  nniy  be  iiyper- 
trophied  and  the  sounds  very  intense.  In  rare  instances  they  may  he 
heard  some  distance  from  the  patient;  according  to  Graves,  as  far  as  four 
feet. 

Exophthalmos  usually  follows  the  vascular  disturbance.  It  is  readily 
recognized  by  the  protrusion  of  the  balls,  and  partly  by  the  fact  that  tlie 
lids  do  not  completely  cover  the  sclerotics,  so  that  a  rim  of  white  is  seen 
above  and  below  the  cornea.  The  protrusion  may  become  very  great  and 
the  eye  may  even  be  dislocated  from  the  socket.  The  vision  is  normal. 
Graefe  noted  that  when  the  eyeball  is  moved  downward  the  upper  lid  docs 
not  follow  it  as  in  health.  This  is  known  as  Graefe's  sign.  It  seems  to 
be  rare  ;  it  was  not  present  in  one  of  seventeen  cases  examined  at  my 
clinic  (Oppeidieimer).  The  palpebral  aperture  is  wider  than  in  heahh, 
owing  to  spasm  or  retraction  of  the  upper  lid  (Stellwag's  sign).  '1  hi' 
patient  winks  less  frequently  than  in  health.  Moebius  has  called  atten- 
tion to  the  lack  of  convergence  of  the  two  eyes.  Changes  in  the  pupils 
and  in  the  optic  nerves  ai'e  rare.  Pulsation  of  the  retinal  arteries  is 
common. 


tdtiikiimmi 


DISEASES  OF  TIIK  THYROID  GLAND. 


753 


'I'lio  cnlnrgonicnt  of  tlic  thyroid  cnminonly  develops  witli  the  cxopli- 
tlialiMos.  It  iiiiiy  1)0  j,'('iu'i'iil  or  iti  only  otic  lohc,  and  is  rarely  so  lar<,M'  as 
ill  (U'diiiary  goitre.  The  vessels  are  usually  iiiiich  dilated,  and  the  whole 
i:liiiiil  may  be  seen  to  jmlsute.  A  thrill  may  be  felt  on  palpation  and  on 
au.-iiiltatioii  a  loud  systolic  murmur,  or  more  commonly  a  lintit  dr  diuhlr. 
Tri'iiior  must  be  regarded  as  a  cardinal  symptom.  It  is  involuntary,  line, 
aliiiut  eight  to  the  second.  It  is  of  great  importance  in  the  diagnosis  of 
tlic  rarly  cases.  Among  other  symptoms  which  may  devcloj)  are  aiuemia, 
t'liiaiiation,  and  slight  fever.  Attacks  of  vomiting  and  diarrho-a  may 
occur.  The  latter  may  be  very  severe  and  distres.<ing,  recurring  at  inter- 
vals, 'I'he  greatest  complaint  is  of  the  forcible  throbhing  in  the  ar- 
ti'iics,  often  accompanied  with  unpleasant  Hushes  of  heat  and  ])r()- 
fiise  perspirations.  Skin  symptoms  are  not  infrc(pient — pigmentation, 
which  may  be  intense  and  simulate  Addison's  disease,  patches  of  Iciico- 
(leniia,  or  atro])hy  of  pigment,  and  urticaria.  I'atclu's  (»f  solid  ledenui  have 
bi'cii  seen.  Occasionally  myxccdema  has  l)i'en  i)resent.  In  the  very  i"''ute 
case  above  referred  to  urticaria  was  a  prominent  syni()toin.  Irritaliility 
of  temper,  change  in  disposition,  and  great  mental  depression  have  been 
(lo.^cribed.  An  important  complication  is  acute  mania,  in  whirh  the 
jiaticiit  may  die  in  a  few  days.  Weakness  of  the  muscles  is  not  uncom- 
mon, particularly  a  feeling  of  "giving  way"  of  the  legs.  If  the  }nitient 
holds  the  head  down  aiul  is  asked  to  look  uj)  without  raising  the  liead, 
the  forehead  remains  smooth  and  is  not  wiinkled,  as  in  a  normal  individ- 
ual (.lolTroy).  A  feature  of  interest  noted  by  Charcot  is  the  great  diniinu- 
tion  ill  the  electrical  resistance,  which  may  be  duo  to  the  saturation  of  the 
skin  with  moisture  owing  to  the  vaso-motor  dilatation  (Ilirt).  l^-ysoii 
has  noted  the  fact  that  the  chest  expansion  may  l)e  greatly  diminished. 
The  emaciation  may  be  extreme.  (Ilycosuria  and  albuminuria  are  not 
infrequent  complications. 

The  course  of  the  disease  is  usually  chronic,  lasting  several  years. 
After  persisting  for  six  months  or  a  year  the  symptoms  may  disappear. 
There  are  remarkable  instances  in  which  the  symptom.s  have  come  on  with 
jjivat  intensity,  following  fright,  and  have  disapjicared  again  in  a  few  days. 
A  certain  proportion  of  the  cases  recover,  but  when  the  disease  is  well  de- 
velo]ied  recovery  is  rare. 

Treatment. —  Medicinal  measures  arc  notoriously  uncertain.  The 
miiihinalion  of  digitalis  and  iron  may  bo  tried,  and,  when  there  is  an;vmia, 
oftt'ii  does  good.  I  have  never  seen  any  advantage  from  the  use  of  aco- 
nite or  veratruni  viride.  The  tincture  of  stro])hanthus  will  sometimes 
reduce  the  rapidity  of  the  heart's  action.  Ergot  is  warmly  recommended 
by  some  writers.  Belladonna  gives  relief  occasionally,  and  should  be  ad- 
ministered until  the  dryness  of  the  throat  is  obtained.  No  measures  are 
so  successful  as  rest  in  bed  with  an  ice-bag  or  Leiter's  tube  ajiplied  occa- 
sionally over  the  heart,  or,  what  is  sometimes  more  agreeable,  over  the 
lower  part  of  the  neck  and  manubrium  sterni.     I  have  known  the  pulse 


i  I!'  it. 

i    ■  I 


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764 


DISEASK.S  OF  TIIK   BliOOD   AND   DUCTLESS  GLANDS. 


to  be  n'(liic('(l  ill  this  way  from  140  to  90.  Electricity  has  hecii  imicli 
luudod  iiiid  iiistiiiices  of  euro  iiave  been  reported.  In  many  rases  trm- 
porary  improvement  certainly  follows  the  use  of  tlie  galvanic  current,  the 
(jathode  bein^f  placed  at  the  back  of  tiie  neck  and  tlu!  anode  ahnii:  iIh' 
course  of  tlu' syin]»atheti(Mir  over  the  heart.  The  use  of  the  thyroid  ex- 
tract has  not  been  successful.  Operative  treatment  has  recently  been  tried, 
with  the  following  results:  "Out  of  sixty-eijijht  oju'rutions  on  recuni, 
cijj;iiteen  comj)ietely  recovered  ;  in  twenty-six  there  was  more  or  less  im- 
provi'iiient ;  nine  showed  no  change  ;  in  live  death  was  almost  imiiieiliate; 
and  in  four  death  occurred  within  twenty-four  hours"  (Oppenheiiner). 


/c 


ili^'    *^  I 


M Y X(Kl)  10 M  A  ( .1  t/n/reti). 

Definition. — A  constitutional  alTection,  due  to  the  loss  of  fiitietioii 
of  the  thyroid  •(land.  The  disease,  which  was  descril)ed  by  Sir  WilHuin 
(Jull  as  a  cretinoid  change,  and  later  by  Ord,  is  characterized  clinically  by 
a  niyxa'deinatous  condition  of  the  subcutaneous  tissues  and  mental  failure, 
and  anatoinically  by  atroj)hy  of  the  thyroid  gland. 

Clinical  Forms. — Three  groups  of  cases  may  be  recognized:  (n) 
Co>if/c)iif(tI  form,  or  sporadic  cretinism,  hi  these  cases  there  is  congenital 
absence  of  the  thyroid,  and  the  child  is  a  dwarf,  having  a  thick  neck,  sluirt 
arms  and  legs,  and  prominent  aljdomen.  The  face  is  large,  the  lips  are 
thick,  the  tongue  is  large  and  usually  ])rotrudes.  The  mental  coiidilidii 
is  that  of  imbecility  or  idiocy.  Since  the  introduction  of  thyroid  treiit- 
ment  the  recognition  of  this  condition  is  all-important.  I  was  oidy 
able  in  1893  to  collect  eleven  or  twelve  cases  in  this  country  (American 
Journal  of  ^ledical  .Sciences,  November,  1893).  The  diagnosis  of  spo- 
radic cretinism,  though  easy  in'  advanced  and  typical  cases,  is  often,  1 
find,  not  clearly  made;  I  judge  this  from  the  number  of  descriptive  cases 
sent  to  me  as  instances  of  this  condition,  but  which  in  reality  have  been 
cases  of  various  forms  of  idiocy.  The  important  criteria  are  the  physidg- 
nomy,  the  shape  of  the  head,  the  stunted  growth,  and  the  condition  of  the 
connective  tissues.  The  mental  dodciency  is  less  characteristic,  presenting 
nothing  not  seen  in  instances  of  ordinary  idiocy.  The  appearance  of  the 
thyroid  is  uncertain.  There  are  cretins  with  and  cretins  without  g<iitre, 
while  in  others  the  gland  seems  entirely  absent.  The  most  satisfactory 
diagnostic  feature  is  the  condition  of  the  skin  and  connective  tissues. 

(/;)  Mj/.vmdema  Proper. — In  this,  women  are  very  much  more  frcfiueiitly 
affected  than  men — in  a  ratio  of  one  to  six.  The  disease  may  affect  sevei'd 
members  of  a  family,  and  it  may  be  transmitted  through  the  mother.  In 
some  instances  there  has  been  first  the  appearance  of  exophthalmic  goitre. 
Though  occurring  most  commonly  in  women,  it  seems  to  have  no  speciid 
relation  to  the  catamenia  or  to  pregnancy,  but  in  one  instance  liie 
symptoms  of  myxa3dema  disappeared  during  pregnancy.  Myxo^dema  ;md 
exophthalmic  goitre  may  occur  in  sisters.     It  is  not  so  common  in  this 


i: 

'^I 

' 

if''' 

tj 

11'  •'■ '"'  ■ 

1 

Pf.TWlll*lii,,l,. 

ANDS. 

Ims  l)('('ii  iniicli 
lany  cases  tciii- 
nic  I'lirrciit,  ihr 
node  iildiii,'  the 
tlie  tliyndd  ix- 
Mitly  bi-'t'ii  tritd, 
nils  oil  rcciini, 
iioi't'  or  less  iiii- 
lost  iiniiiodiate: 
ipeiilioiiiier). 


083  of  function 
by  .Sir  William 
I'd  clinically  li;. 
.  mental  failiirr, 

ecogiiizcd  :   (a) 

re  is  con<f('iiitMl 

lick  nock,  short 

[fc,  the  lips  aif 

eiitiil  coiiditidii 

thyroid  tfcat- 

I   AVas   (inly 

ry  (Aiiiericaii 

gnosis  of  spo- 

es,  is  (»fti'n,  F 

scrijitive  cases 

ity  iiave  been 

e  the  physicfj- 

iidition  (if  till' 

tic,  presenting 

ai'ance  of  the 

ivitlioiit  guitiv, 

ist  satisfactoiT 

e  tissues. 

)re  fro'iuently 

aifect  Severn! 

e  mother,     in 

thalmic  goitre. 

ave  no  spciial 

instance   the 

yxo'deina  mul 

nimou  in  this 


DISEASKS  OF  TIIK  TIIYIIOID   (JLANI). 


786 


country  aa  in  Knghuid.  The  symjitoms  of  this  form,  a.s  giveti  by  Onl,* 
lire  marked  increase  in  the  general  bulk  of  the  l)ody,  a  linn,  inelastic 
swelling  of  the  skin,  which  does  not  pit  on  pressure;  dryness  and  rough- 
ness, whicii  tend,  with  the  swelling,  to  obliterate  in  the  face  the  lines 
of  expression  ;  imperfect  nutrition  of  tlii'  hair;  local  tumefaction  of  the  skin 
and  subcutaneous  tissues,  i)arti(nilarly  in  the  supraclavicular  region.  The 
plivsiiignoniy  is  altered  in  a  renuirkable  way :  the  features  are  coarse  and 
iiroad,  the  lips  thick,  the  nostrils  broad  and  thick,  and  the  mouth  is  on- 
linged.  Over  the  cheeks,  sometimes  the  nose,  there  is  a  reddish  patch. 
There  is  a  striking  slowness  of  thought  and  of  niovemeiit.  The  memory 
bceoines  defective,  the  patients  grow  irritable  and  suspicious,  and  there 
may  be  headache.  In  some  instances  there  are  delusions  and  hallucina- 
tions, leading  to  a  final  condition  of  dementia.  'ITie  gait  is  heavy  and 
slow.  The  temperature  may  be  below  normal.  The  functions  of  the 
heart,  lungs,  and  abdominal  organs  arc  normal.  Jhemorrhage  sometimes 
(iieiirs.  Albuminuria  is  sometimes  present,  more  rarely  glycosuria.  J)eatli 
is  usually  due  to  some  intercurrent  disease,  most  frcciucntly  tuberculosis 
((Ireeiilield).  The  thyroid  gland  is  dlniinislicl  in  size  and  may  beconio 
eoinplctely  atrophied  and  converted  into  a  fibrous  mass.  The  subcutane- 
ous fat  is  abundant,  and  in  one  or  two  instances  a  great  increase  in  the 
iiiuein  has  been  found. 

The  course  of  the  disease  is  slow  but  progressive,  and  extends  over  tea 
or  lifiecii  years.  I  have  recently  had  under  observation  a  case  to  which 
the  term  acute  myx(edema  might  be  ai)|)lied.  A  young  man,  aged  twenty, 
pivsented  a  gradual  enlargement  of  the  face,  particularly  of  the  lips  and 
cheeks  and  nose,  without  actual  cedema.  The  backs  of  the  hands  were 
also  swollen,  but  did  not  pit.  T'ho  condition  came  on  with  enlargtunent 
of  the  thyroid,  and,  after  persisting  for  between  three  and  four  months, 
grailually  disappeared. 

{(■)  Operdtire  .Vi/.rw(h'iiifi ;  Cachexia  sintnu'priva. — llorsley,  in  a  series 
of  interesting  experiments,  showed  that  complete  removal  of  the  thyroid 
in  monkeys  was  followed  by  the  production  of  a  condition  similar  to  that  of 
niyxii'dema  and  often  associated  with  sjiasms  or  tetanoid  contractures,  and 
ftdlowed  by  apathy  and  coma.  When  the  monkeys  were  kept  warm  myx- 
a'deinawas  averted,  and,  instead  of  an  acute  myx(cdema,  the  animals  devel- 
oped a  condition  which  closely  resembled  cretinism.  An  identical  con- 
dition may  follow  extirpation  of  the  thyroid  in  man.  Kocher,  of  Hern, 
found  that  after  complete  extirpation  a  ctichectic  condition  followed  in 
many  eases,  the  symptoms  of  which  are  practically  identical  with  those  of 
myxiedema.  The  disease  follows  on^y  a  certain  number  of  total  and  a 
iniieh  smaller  proportion  of  partial  removals  of  the  thyroid  gland.  Of 
4118  eax's,  in  (!'J  the  operative  myxcedema  develo£)ed.  It  has  been  thought 
that  if  a  small  fragment  of  the  thyroid  remains,  or  if  there  are  accessory 


*  ':i-'1 1 


t;-:4'i 


it, 


k 


f^ 


{  ') 


'*  Report  on  Myxuidema,  Clinical  Society's  Transactions,  1888. 
48 


'  41 

;'^^f'' 

4 

"A> 

'?   Y 

<,  It" 

Lj}.  1 

H^^fr«* 

«-!4a|-i--- 

^i'-ifis 

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^m 

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liMlls 

4si.llk^  k 

I  Mi 


K 


750 


DISKASRS  OF  THE   BLOOD   AND   nUCTLKSS  OLaNDS. 


gliindf,  Vfh'u'h  in  iitiiiniils  iiro  vory  common,  thoso  syriiptoriiH  do  not  d,.. 
volop.  It  is  possible  tliiit  in  men,  in  the  cnaca  of  ('(xnitlt'ti'  nmoviil,  tlio 
accessory  frugtiients  subserve  tlic  function  of  the  gland.  OiuTiitivt'  mvx- 
(fdeiuii  is  very  rave  in  tliis  country;  the  only  (!iist>  of  wliirli  I  Icnow  is  u 
piitiont  of  .Mc(ini\v's,  of  Detroit. 

It  is  evident  that  the  thyroid  gland  supplies  sonu'  essential  secretion 
of  first  importance  to  normal  metiibolism.  What  this  is  or  how  it  acts  is 
at  jii-esont  heyoiul  our  knowledge. 

The  diaiiiKisis  of  the  disease  is  easy,  as  a  rule,  'i'he  general  aspect  of 
the  patient — the  subcutaneous  swelling  aiul  the  ])aIlor — siiggi-sts  r)ii;4lit's 
disease,  whitdi  may  be  strengthened  by  the  discovery  of  tube-easts  ami  of 
albumin  in  the  urine  ;  but  the  solid  character  of  the  swelling,  the  exrccil- 
ing  dryness  of  the  skin,  the  yellowish-white  color,  tlu^  low  teiupcriitiirc, 
the  loss  of  hair,  and  the  dull,  listless  mental  state  should  suflice  to  dillVi'- 
entiate  the  two  conditions. 

Treatment. — 'I'he  ])atients  suffer  in  cold  ami  improve  greatly  in 
■warm  weatlier.  'J'lu^y  should  therefore  be  kept  at  an  even  tempenitiirc, 
and  should,  if  possible,  move  to  a  warm  climate  during  the  winter  uiontlis. 
Jtepeated  warm  baths  with  shami)ooing  are  useful.  Our  art  has  inade  no 
more  brilliant  advance  than  in  the  cure  of  these  disorders  duo  to  disturbed 
function  of  the  thyroid  gland.  That  we  can  to-day  rescue  children  other- 
wise doomed  to  helpless  idiocy — that  we  can  restore  to  life  the  hopeless 
victims  of  myxcedema — is  a  triumph  of  experimental  medicine  to  which  we 
are  indebted  very  largely  to  Victor  Ilorsley  and  to  his  pupil  .Murray. 
Transplantation  of  the  gland  was  first  tried  ;  then  Murray  used  an  extract 
subcutaneously.  Hector  Mackenzie  in  London  and  Ilowitz  in  Copenhagen 
introduced  the  method  of  feeding.  We  now  know  that  the  gland,  taken 
either  fresh,  or  as  the  watery  or  glycerine  extract,  or  d/ied  and  powdered, 
is  equally  efficacious  in  a  majority  of  all  the  cases  of  myxo'dema  in  infants 
or  adults.  Many  preparations  are  now  on  the  nuirket,  but  it  nuik.>s  little 
difference  how  the  gland  is  administered.  The  dried  powdered  g'.md  and 
the  glycerine  extract  are  most  convenient.  It  is  well  to  begiii  with  the 
powdered  gland,  one  grain  three  times  a  day,  of  the  Parke-Davis  pre])ara- 
tion,  or  one  of  Burroughs  and  Welcome  tablets.  It  may  be  increased 
gradually  until  the  patient  takes  ten  or  fifteen  grains  in  the  day.  In  many 
cases  there  are  no  unpleasant  symptoms;  in  others  there  are  irritation  of 
the  skin,  restlessness,  rapid  pulse,  and  delirium ;  in  rare  instances  tonic 
spasms,  the  condition  to  which  the  term  thyroidi-tin  is  applied.  The  re- 
sults, as  a  rule,  are  most  astounding — unparalleled  by  anything  in  the 
whole  range  of  curative  measures.  AVithin  six  weeks  a  poor,  feeble-minded, 
toad-like  caricature  of  humanity  may  be  restored  to  mental  and  bodily 
health.  Loss  of  weight  is  one  of  the  first  and  most  striking  effects;  one 
of  my  patients  lost  over  thirty  pounds  within  six  weeks.  The  skin  becomes 
moist,  the  urine  is  increased,  tlie  perspiration  returns,  the  temperatiue 
rises,  the  pulse-rate  quickens  and  the  mental  torpor  lessens.     Ill  elTects 


s'  DS. 

s  do  not  dc. 

removal,  the 

Htriitivi)  niyx- 

1  1  know  i^  :i 

itial  s('(rrctiipu 
how  it  uou  is 

cral  as|i(Tf  of 

l^l'StS    lll'i^lll's 

'-casts  and  (if 

i^,  tllO  CXl'CCil- 

tomiKTatiiiv, 
ffioi'  to  dilTrr- 

iV(i  groatly  in 

I  teniporattiii', 
inter  iiioiitlis. 
t  has  made  no 
e  to  (list lulled 
hildreii  otlici'- 
B  the  hopeless 
le  to  which  we 
nipil  Murniy, 
sed  an  extract 

II  Copenhajieii 
{xhiiid,  taken 

lid  Jiowdeitd, 
ma  in  infants 
t  niak.'s  little 
rod  <i;''iii'l  !'"•! 
)egiii  with  the 
)aviri  prepara- 

he  increased 
day.    In  many 

irritation  of 
stances  toiiie 
icd.  There- 
^•thing  in  the 

cble-niinded, 
ul  and  bodily 
g  oiTects ;  one 
!  skin  becomes 
3  tempera! are 
IS.     Ill  elleets 


DI.SKASKS  OF  TlIK  TllYltOlD  GLAND. 


are  rare.  Two  nr  tliroo  canon  w  ith  old  heart  lesions  have  died  during  or 
after  the  treatment;  in  one  instunce  u  temporury  cundilion  of  tiruvcs  dis- 
ease WU3  induced. 

The  treutmetit,  as  Murray  suggests,  must  bo  curried  out  in  two  stiiges — 
one,  early,  in  whiidi  full  doses  are  given  until  the  cure  is  ciTeeted ;  the 
oilier,  the  iierimment  use  of  snnill  doses  sutlicient  to  preserve  the  normal 
iiielaholism.  'J"he  literature  of  thyroid  thera[)y  and  u  list  of  all  the  eases 
uf  niyxuidenui  and  cretinism  treated  to  Decianber  31,  18'J4,  are  given  iiy 
lleiii.sheiiner.* 


*  Dio  8chilUdrll«>eubeluiiidhiiig,  Mtiiielteii,  1803. 


1 1  i 


I    I 


H:: 


l>-.: 


■^      ^1^ 


r 

i 

IJk 

I  I:  fill 


SECTION  VII. 


DISEASES  OF  THE  KIDNEYS. 


m 


I.  ANOMALIES  IN   FORM  AND  POSITION. 

Anomalies  in  Form. — These  mroly  come  within  the  scope  of  the  pi 
sician.  Atrophy  or  congenital  absence  of  one  kidney  is  associated  \v] 
great  enlargement  of  the  other  organ.  Fiised  kidneys  may  have  a  hor 
shoe  shape,  or  both  organs  may  form  a  large  mass,  which  is  often  d 
placed,  being  either  in  an  iliac  fossa  or  in  the  middle  line  of  the  uIhIohk 
or  even  in  the  pelvis.  Under  these  cii-cuinstances  it  may  be  mistaken  J 
a  new  growth.  In  Polk's  case  the  organ  Avas  removed  under  the  bcl 
that  it  was  a  floating  kidney.*  The  patient  lived  eleven  days,  had  oo 
plete  anuria,  and  it  was  found  post  mortem  that  a  single  unsymmetrii 
kidney,  as  this  form  is  called,  had  been  removed. 

Movable  Kidney 

{Floating  Kidney;  Pulpahle  -Kidney;  lien  mohilis;  Nephroptosis). 

The  kidney  is  held  in  jiosition  by  its  fatty  capsule,  by  the  peritonei 
which  passes  in  front  of  it,  and  by  the  blood-vessels.  The  lower  (m 
of  the  left  kidney  i»  nearly  two  inches  from  the  iliac  crest,  a  little  be 
the  level  of  the  second  lumbar  spine  ;  that  of  the  right  is  usually  from  ( 
half  to  three  quarters  of  an  inch  lower.  Normally  the  kidney  is  firii 
fixed,  but  under  certain  circumstances  one  or  another  organ,  more  rait 
both,  becomes  movable.  In  rare  cases  the  kidney  is  surrouiuled,  t( 
greater  or  less  extent,  by  the  peritonitum,  and  is  anchored  at  the  hi 
by  a  mesonephron.  Some  would  limit  the  term  floating  kidney  to 
condition. 

Movable  kidney  is  almost  always  acquired.  It  is  most  common 
women.  Of  the  6G7  cases  collected  in  the  literature  by  Kuitn"'-, 
were  in  women  and  only  83  in  men.  It  is  more  common  on  tlie  ri^ 
than  on  the  left  side.  Of  727  cases  analyzed  by  this  author,  it  occiin 
on  the  right  in  553  cases,  on  the  left  in  81,  and  on  both  sides  in  93. 

*  New  York  Medical  Journal,  1883. 


■titt^y^ 


^\  ;>■  -i^ 


ANOMALIES  IN  FORM  AND  POSITION. 


759 


DNEYS. 


)  POSITION. 

Iiiii  the  scope  of  the  phy- 
kidiiey  is  associated  with 
cidneys  may  have  a  lionse- 
mass,  which  is  often  dis- 
iddle  line  of  the  ahdoincn, 
•es  it  may  he  mistaken  for 
removed  uuder  the  belief 
ived  eleven  days,  had  coni- 
fit  a  single  unsymmctrical 


obilis  ;  Nephroptosis). 

apsule,  hy  the  peritoneum 
vessels.  The  lower  ed<;e 
iliac  crest,  a  little  helow 
right  is  usually  from  one 
nally  the  kidney  is  firmly 
nother  organ,  more  rai'i'ly 
idney  is  surrounded,  to  a 
is  anchored  at  the  hilus 
ni  floating  kidney  to  this 

It  is  most  common  in 
terature  hy  Kuttn'M-,  584 
^re  common  on  die  ris^'i't 
)y  this  author,  it  occuni'd 
on  both  sides  in  93.    The 

1883. 


greater  frequency  of  the  condition  in  women  may  he  attributed  to  com- 
})rf.~>ion  of  the  lower  thoracic  zone  by  tight  lacing,  and,  more  important 
still,  to  the  relaxation  of  the  abdominal  walls  wliich  follows  repeated 
pregnancies.  This  does  not  account  for  all  the  cases,  as  movable  kidney 
is  bv  no  means  uncommon  in  nulliparae.  Drummond  believes  that  m  a 
miijority  of  the  cases  there  is  a  (;ongcnitally  relaxed  condition  of  the  peri- 
toneal attachments.  Wasting  of  the  fat  about  the  kidney  may  l)e  a  cause  in 
some  instances.  Traunuiand  the  lifting  of  heavy  weights  are  occasionally 
factors  in  its  production.  The  kidney  is  sometimes  dragged  down  by 
tumors.  The  greater  fre(|iiency  on  the  riglit  side  is  probably  associated 
with  the  position  of  the  kidney  just  beneath  the  liver,  and  the  depression 
to  which  the  organ  is  subjected  with  each  descent  of  the  diaphragm  in 
inspiration. 

And,  lastly,  movable  kidney  is  met  with  in  many  cases  whicli  present 
that  combination  of  neurasthenia  with  gastro-intestinal  disturbance  which 
has  been  described  by  Glenard*  as  odevopfosis. 

To  determine  t!ie  presence  of  a  movable  kidney  the  patient  should  be 
placed  in  the  dorsal  position,  with  the  hea<l  moderately  low  and  the  ab- 
dominal walls  relaxed.  The  left  haiul  is  placed  in  the  lumbar  region 
behind  the  eleventh  and  twelfth  ribs;  the  right  hand  in  the  hypochon- 
driac region,  in  the  nipjde  line,  just  under  the  edgi'  of  the  liver.  Bimanual 
jjalpation  may  detect  the  presence  of  a  firm,  rounded  body  just  below  the 
edge  of  the  ribs.  If  nothing  can  be  felt  the  patient  should  be  asked  to 
draw  a  deep  breath,  when,  if  the  organ  is  ])ali)al)le,  it  is  touched  by  the 
lingers  of  the  right  hand.  \'arious  grades  of  mobility  may  be  recognized. 
It  may  be  possible  barely  to  feel  the  lover  edge  on  deep  palpation — pnlpa- 
bk  kidney — or  the  organ  may  be  so  far  displaced  that  on  drawing  the 
deepest  breath  the  fingers  of  tlie  riglit  hand  may  be  in  a  thin  person 
slipjied  above  the  upper  end  of  the  orgaix,  which  can  be  I'cadily  held 
liown,  but  cannot  be  puslied  below  the  level  of  the  navel — movable  kidney. 
In  ,1  third  group  of  cases  the  organ  is  freely  movable,  and  may  ev?n  be 
felt  just  above  Poupart's  ligament,  or  may  be  in  the  middle  line  of  the 
abdomen,  or  can  even  be  pushed  over  beyond  this  j)oint.  To  this  the 
tn-mjlof/linf/  hidney  is  ap})ropriate,  whether  the  organ  has  a  mesonephron 
or  not. 

And,  lastly,  a  dislocated  kidney  may  become  fixed  in  an  abnormal  posi- 
tion. A  woman,  aged  twenty-nine,  with  four  children,  had  nervous  symp- 
toms with  abdomiiuil  pain,  and  had  been  much  worried  by  the  discovery 
of  a  tumor,  just  to  the  right  of  the  middle  line,  close  to  the  navel.  It  was 
not  movable,  but  the  distinctly  reniform  sliape  and  the  depression  at  the 
left  margin  indicated  that  it  was  doubtless  a  dislocated  kidney  which  had 
become  fixed.  Since  writing  the  above  the  tumor  has  disappeared.  It 
was  probably  a  gall-bladder ! 


i     i 


i        ! 

li, 


I     / 


*  Kevue  de  Mcdecine,  1887 ;  Pourcclot,  Paris  Thesis,  1889. 


w 


760 


DISEASES  OF  THE  KTDNEYS. 


The  movable  kidney  is  not  painful  on  pressure,  except  when  it  is 
grasped  very  firmly,  when  there  is  a  dull  pain,  or  sometimes  a  sickotiiiur 
sensjition.  Examination  of  the  patient  from  heliind  may  show  a  distinct 
flattening  in  tlie  lumbar  region  on  the  side  in  wliicli  the  kidney  is  niDbile. 

Symptoms. — In  a  large  majority  of  eases  the  condition  givi'.s  no 
trouble,  and  it  is  well,  if  detected  accidentally,  not  to  let  the  patient  know 
of  its  presence.  In  other  instances  there  is  pain  in  the  lumbar  region  or 
a  sense  of  dragging  and  discomfort,  or  there  nuiy  be  intercostal  neuralgia. 
In  a  large  group  tlie  symptoms  are  those  of  neurasthenia  with  dysiicjitic 
disturbance.  In  women  the  hysterical  symptoms  mny  be  nuirked,  and  in 
men  various  grades  of  hypochondriasis.  The  gastric  disturbance  is  usu- 
ally a  form  of  nervous  dyspepsia.  Dilatation  of  the  stomach  has  l)eeu  (tli- 
served,  owing,  as  suggested  by  Bartels,  to  pressure  of  the  dislocated  kidnoy 
upon  tlie  duodenum.  This  view  has  been  supported  by  Oser,  Laiulau,  and 
Ewald.  On  the  other  hand,  Litten  holds  that  the  dilatation  of  the  stom- 
ach is  the  cause  of  the  mobility  of  the  kidney,  aiul  he  found  in  40  easi's 
of  depression  and  dilatation  of  the  stomach  2'i  instances  of  dislocation  of 
the  kidney  on  the  r.ght  side.  My  own  experience  coincides  witli  that  of 
Drummond,  who  has  very  exceptionally  found  the  two  conditions  to  co- 
exist. While  not  denying  the  possibility  of  causal  relationship  between 
the  two,  it  seems  probable,  considering  the  frequency  of  floating  kidney, 
that  the  complication  is  only  a  coincidence.  The  association,  however, 
with  a  (loprpssed  stomach  is  certainly  not  uiu'.ommon  in  women.  Consti- 
pation is  not  infrequent.  Some  writers  have  described  pressure  upon  the 
gall-ducts,  with  jaundice,  but  it  is  not  very  likely  to  occur. 

Under  the  name  oileropfosin,  Glenard  has  described  a  special  symp- 
tom group  characterized  by  nervous  dj'spepsia,  prolapse  of  the  alxloininul 
organs,  particularly  the  transverse  colon,  with  looseness  of  the  mesent'ric 
and  peritoneal  attachments,  so  that  there  is  a  falling  down  of  the  viscera 
(splanchnopt-osis).  Dilatation  of  the  stomach  and  mobility  of  the  kidney 
are  very  commonly  associated  with  this  state.  Clenard  held  that  he  couM 
feel  the  prolapsed  transverse  colon  as  a  narrow  band,  but  Ewald  states 
correctly  that  this  is  the  pancreas,  which  in  many  of  these  cases  can  l)e 
distinctly  palpated.  According  to  (ilenard,  the  kink  in  the  colon  causes 
the  constipation,  while  the  depression  of  the  stomach  and  intestines  leads 
to  vascular  disturl)ance  and  impairment  of  the  motor  and  sccri'tory 
functions. 

DietVfi  Crises. — In  floating  kidney  there  are  attacks  charactori^ied 
by  severe  abdominal  pain,  chills,  nausea,  vomiting,  fever,  and  rollapse. 
Scarcely  any  mention  is  made  of  such  symj)toms,  which  were  first  de- 
scribed by  Dietl  in  18G4,  and  a  more  wide-spread  knowledge  of  tlnir 
occurrence  in  connection  with  this  condition  is  desirable.  My  atten- 
tion was  called  to  them  in  1880  by  Palmer  Howard  in  the  case  of  a 
stout  lady,  who  suffered  repeatedly  with  the  most  severe  attacks  of 
abdominal  pain  and  vomiting,  which  constantly  required  morphia.    A 


Mtei 


ANOMALIES  IN   FORM   AND   POSITION. 


761 


tumor  was  discovered  a  little  to  the  right  of  the  navel,  and  the  diag- 
uo.-is  of  probable  neojtlasni  was  concurred  in  by  Flint  (Sr.)  and  (iaillurd 
Thomas.  The  patiouc  lost  weight  rapidly,  became  emaciated,  and  in  the 
.sjiriiig  of  1881  again  went  to  New  York,  where  she  sa\;  Van  Biiren,  who 
tliagiiosed  a  floating  kidney  and  said  tliat  tlies'-  paroxysms  were  asso- 
cialod  with  it  in  a  gouty  2)erson.  lie  cut  oil  all  stimulants,  reassured  the 
lady  that  she  had  no  cancer,  and  inm\  that  time  she  rapidly  I'ecovered, 
ami  the  attacks  have  been  few  and  far  between.  In  this  patient  any  over- 
imlulgonce  in  eating  or  in  drinking  is  still  liable  to  be  followed  by  a  very 
severe  attack.  These  attacks  may  also  be  mistaken  for  renal  colic,  and 
the  operation  of  nephrotomy  has  been  performed. 

In  other  instances  the  attacks  of  pain  may  be  thought  to  be  due  to  in- 
testinal disease  or  to  recurring  a})pendicitis.  Tlie  cause  of  these  parox- 
ysmal attacks  is  not  quite  clear.  Dietl  thought  they  were  due  to  strangu- 
lation of  the  kidney  or  to  twists  or  kinks  in  the  renal  vessels  <lue  to  the 
extreme  mobility.  Luring  the  attacks  the  urine  is  sometimos  high-colored 
and  contains  an  excess  of  uric  acid  or  of  the  oxalates.  It  is  stated,  too, 
that  blood,  or  pus  may  be  present.  The  kidney  may  be  tender,  swollen, 
and  less  freely  movable.  Intermittent  hydronephrosis  has  sometimes 
been  associated  with  movable  kidney. 

The  diai/nosis  is  rarely  doubtful,  as  the  shape  of  the  organ  is  usually 
distinctive  and  the  mobility  marked.  Tumors  of  the  gall-bladder,  ovarian 
grouths,  and  tumors  of  the  bowels  may  iu  rare  instances  be  confounded 
with  it. 

Treatment. — The  kidney  has  been  extirpated  in  many  instances, 
but  tlie  operation  is  not  without  risk,  and  there  have  been  several  fatal 
cases.  Stitching  of  the  kidney— nephrorrhapliy — as  recommended  by  Ilahn, 
is  tiie  most  suitable  procedure,  and  statistics  recently  published  by  Keen 
show  that  relief  is  afforded  in  nuiuy  casjs  by  the  procedure.  It  does  not, 
however,  always  succeed. 

The  treatment  by  trusses  and  bandages  is  not  satisfactory,  though 
great  relief  is  sometimes  obtained.  As  a  rule,  bandages,  with  i)ads  press- 
ing to  the  right  of  the  navel,  are  not  well  borne,  as  the  kidney  is  often 
sensitive.  In  some  instances,  howc'sor,  the  greatest  relief  is  experi- 
enced by  this  procedure.  An  air-pad  beneath  the  bandage,  as  recom- 
meiuled  by  Newman,  is  probably  the  best.  In  other  cases  a  broad  bandage 
Well  jiadded  in  the  lower  abdominal  zone  i)ushes  up  the  intestines  and 
makes  them  act  as  a  support.  In  the  attacks  of  severe  colic  nu)rphia  is 
re(inired.  When  dependent,  as  seems  sonu'times  the  case,  U])on  an  excess 
of  uric  acid  or  the  oxalates,  the  diet  must  be  carefully  regulated. 


'V 


H 


1   t 


h    ', 


I  t 


m 


DISEASES  OF  THE  KIDNEYS. 


11.  CIRCULATORY  DISTURBANCES. 


iJ! '  i 


Normally  the  secretioM  of  iiriiio  is  accoinplislicd  by  the  nuiintcniiiK  e 
of  a  certain  blood -pressure  within  the  glomeruli  and  by  the  iictivitv  of 
the  renal  epithelium.  Bowman's  views  on  this  question  have  been  giii- 
erally  accepted,  and  the  watery  elements  are  held  to  be  filtered  from  tlie 
glomeruli ;  the  amount  depending  on  the  rapidity  and  the  pressure  of  the 
blood  current;  the  quality,  whether  nonnal  or  abnormid,  depending  uj>ou 
the  integrity  of  the  capillary  and  glomerular  epithelium  ;  while  the  greater 
portion  of  the  solid  ingredients  are  excreted  by  the  epithelium  of  the  con- 
voluted tubules.  The  integrity  of  the  epithelium  covering  the  cajiillary 
tufts  within  Bowman's  capsule  is  essential  to  the  i)ro(hu'tion  of  a  nonnal 
urine.  If  under  any  circumstances  their  nutrition  fails,  as  Avhen,  for 
example,  the  rapidity  of  the  blood-current  is  lowered,  so  that  they  arc 
deprived  of  the  necessary  amount  of  oxygen,  the  material  which  fiUcrs 
through  is  no  longer  nonnal  (i.  e.,  water),  but  contains  serum  alhumcii. 
Cohnheim  has  shown  that  the  renal  epithelium  is  extremely  sensitive  to 
circulatory  changes,  and  that  compression  of  the  renal  artery  for  only  a 
few  minutes  causes  serious  disturbance. 

The  circulation  of  the  kidney  is  remarkably  influenced  by  reflex 
stimuli  coming  from  the  skin.  Exposure  to  cold  causes  heightened 
blood-pressure  within  the  kidneys  and  increased  secretion  of  urine.  So 
also  in  the  chills  of  malaria,  after  which  a  large  amount  of  pale  urine 
may  be  passed. 

Congestion  of  the  Kidneys. — (l)  Ariit-e  Congextion  ;  Ilijperwmin.— 
Acute  congestion  of  the  kidney  is  met  with  in  the  early  stage  of  nepliriti?, 
whether  due  to  cold  or  to  the  action  of  poisons  and  severe  irritants. 
Turpentine,  cubebs,  cantharides,  'and  copaiba  are  all  stated  to  cause  ex- 
treme hyperaiinia  of  the  organ.  The  most  typical  congestion  of  tlie 
kidney  which  we  see  post  mortem  is  that  in  the  early  stage  of  aonte 
Bright's  disease,  when  the  organ  may  be  large,  soft,  of  a  dark  color,  and 
on  section  blooc  drips  from  it  freely. 

It  has  been  .leld  that  in  all  the  acute  fevers  the  kidneys  are  congested, 
and  that  this  explained  the  scanty,  high-eolored,  and  often  albuuiinous 
urine.  On  the  other  hand,  by  Roy's  oiu^ometer,  Walter  Mendclson  has 
shown  that  the  kidney  in  acute  fever  is  in  a  stak^  of  extreme  anaMnia, 
small,  pale,  and  bloodless;  and  that  this  aufBmia,  increasing  witli  tlio 
pyrexia  ami  interfering  with  the  nutrition  of  the  glomerular  epithelium, 
accounts  for  the  scanty,  dark-colored  urine  of  fever  and  for  tlie  presence 
of  allnimin.  In  the  prolonged  fevers,  however,  it  is  probable  that  relaxa- 
tion of  the  arteries  again  takes  place.  Certainly  it  is  rare  to  find  post 
mortem  such  a  condition  of  the  kidney  as  is  described  by  Mendclson.  On 
the  contrary,  the  kidney  of  fever  is  commonly  swollen,  the  blood-vessels 
are  congested,  and  the  cortex  frequently  shows  traces  of  cloudy  swelling. 
However,  the  circulatory  disturbances  in  acute  fevers  are  probably  les.s  ini- 


i  •  I'; 


ANOMALIES  OF  THE  UUIXARY  SECRETION. 


763 


portant  than  the  irritative  effects  of  either  the  specific  agents  of  tlie  dis- 
ciii^e  or  tlie  products  produced  in  their  growth,  or  in  the  altered  nietabo- 
lism  of  the  tissues.  The  urine  is  diminished  in  amount,  and  may  contain 
nlbiunin  and  tube-casts. 

(:*)  Passive  dungcstion  ;  ^fecll(lniral  Hi/prrcDiiia. — 'Pliis  is  found  in 
cases  of  chronic  disease  of  the  heart  or  lung,  with  impeded  circulation, 
uiid  as  a  result  of  pressure  upon  the  renal  veins  by  tumors,  the  pregnant 
uterus,  or  ascitic  fluid.  In  the  cardiac  kidney,  as  it  is  called,  the  cyanotic 
iiKhiration  associated  with  chronic  heart-disease,  the  organs  are  eidarged 
iuiil  fu'in,  the  capsule  strips  off,  as  a  rule,  readily,  the  cortex  is  of  a  deep 
red  color,  and  the  pyramids  of  a  purple  red.  The  section  is  coarse-look- 
ms,  the  substance  is  very  firm,  and  resists  cutting  and  tearing.  The  in- 
terstitial tissue  is  increased,  and  there  is  a  small-celled  infiltration  be- 
tween the  tubiUes.  Here  and  there  the  Malpighian  tufts  have  become 
sclerosed.  The  blood-vessels  are  usually  thickened,  and  there  may  be 
more  or  less  granular,  fatty,  or  hyaline  changes  in  the  epithelium  of  the 
tul)ules.  The  condition  is  indeed  a  diffuse  nephritis.  The  urine  is  nsu- 
allv  rediucd,  is  of  high  specific  gravity,  and  contains  more  or  less  albu- 
min. Hyaline  tube-casts  and  blood-eorpuseles  are  not  uncommon.  In 
inieomplicated  cases  of  the  cyanotic  induration  nnemia  is  rare.  On  the 
other  hand,  in  the  cardiac  cases  with  extensive  artcrio-sclerosis,  tlie  kidneys 
are  more  involved  and  the  renal  function  is  likely  to  be  disturbed. 


1 

1 

1 

i 

f 

i 

,'il 

!''' 
i[.^; 

,  . 


III.  ANOMALIES  OF  THE   URINARY  SECRETION. 

1.  AxruiA. 

Total  suppression  of  urine  occurs  under  the  following  conditions  : 

(1)  As  an  event  in  the  intense  congestion  of  acute  nephritis.  For  a 
time  no  urine  may  be  formed  ;  more  often  the  amount  is  greatly  re- 
duced. 

i'i)  More  commonly  complete  anuria  is  seen  in  subjects  of  renal  stone, 
fragments  of  which  block  both  ureters.  Curiouslv  enough,  there  mav  be 
no  discomfort,  and  cases  are  on  record  in  which  six  or  eight  days  have 
passed  before  the  function  was  restored.  Cabot  reports  an  instance  of  re- 
covery after  the  suppression  had  lasted  for  nearly  eight  days.  This  obstruc- 
tive suppression  is  the  most  common,  and  the  recent  experiences  of  sur- 
geons show  that,  as  in  Cabot's  case,  operative  interference  is  very  hopeful. 

(;5)  Cases  occur  occasionally  in  which  the  suppression  is  preienal.  The 
following  are  among  the  more  important  conditions  with  which  this  form 
of  anuria  may  be  associated  (Hensley) :  Fevers  and  inflammations;  acute 
poisoning  by  phosphorus,  lead,  and  turpentine ;  in  the  collapse  after  severe 
injuries  or  after  operations,  or,  indeed,  after  the  passing  of  a  catheter; 
in  tlie  collapse  stage  of  cholera  and  yellow  fever;  and,  lastly,  there  is  an 


i.     i    ■ 


.  f  - ; 


704 


DISEASES  OF  THE  KIDNEYS. 


hystorioal  anuria,  of  which  Oiarcot  reports  a  case  in  whicli  the  suppros- 
sion  hvsted  for  eleven  days. 

A  patient  may  live  for  from  ten  days  to  two  weeks  with  oonipleto  si,]!- 
prcssion.  In  Polk's  case,  in  M'hich  the  only  kidney  was  removed,  the 
jiatient  lived  eleven  days.  It  is  remarkable  that  in  many  instances  thuiu 
are  no  toxic  fejitures. 

In  the  treatment  of  suppression  of  urine,  in  the  obstructive  cases,  sur- 
gical interference  should  be  resorted  to.  In  the  non-obstructive  cases,  pur. 
ticularly  when  due  to  extreme  congestion  of  the  kidney,  cupping  over  tlio 
loins,  hot  aj)plications,  free  purging,  and  sweating  with  pilocari)in('  and 
hot  air  are  indicated.  AVhen  the  secretion  is  once  started  diuretin  oftt.ii 
acts  well. 

2.  ILtcmaturia. 

The  following  division  may  be  made  of  the  causes  of  haematuria  : 
(1)  General  Diseases. — The  malignant  forms  of  the  acute  specific  fevers, 
such  as  small-jiox,  malaria,  yellow  fever,  etc. ;  scurvy,  purpura,  and  luviiio- 
j)hilia.     f)ccasionally  in  Icukaimia  hicmaturia  occurs. 

{'I)  Renal  Causes. — Acute  congestion  and  infiammation,  as  in  Bright's 
disease,  or  the  effect  of  toxic  agents,  such  as  turpentine,  carbolic  acid,  ami 
cantharides.  When  the  carbolic  spray  was  in  use  many  surgeons  sulkird 
from  hiematuriii  in  consequence  of  this  poison.  Itenal  infarction,  as  in 
ulcerative  endocarditis.  New  growths,  in  wliich  the  bleeding  is  usually 
profuse.  Tubercle  rarely  causes  luvmaturia,  though  at  the  onset,  when 
the  papilhe  are  involved,  there  may  be  bleeding.  Stone  in  the  kidney  i>  a 
frequent  cause.  Parasites:  The  Filaria  satujainis  hotninis  and  the  llil- 
harzia  cause  a  form  of  hivmaturia  met  M'ith  in  the  tropics.  The  ecliiuo- 
coccus  is  rarely  associated  with  hkmiorrhage. 

(3)  Affections  of  the  Urinary  Passages. — Stone  in  the  ureter,  malig- 
nant disease  or  ulceration  of  the  bladder,  the  presence  of  a  calculus,  para- 
sites, and,  very  rarely,  ruptured  veins  in  the  bladder.  Bleeding  from  the 
urethra  occasionally  occurs  in  gonorrhu-a  and  as  a  result  of  the  lodgment 
of  a  calculus. 

(4)  Tntunnitism. — Injuries  may  produce  bleeding  from  any  part  of 
the  urinary  passages.  By  a  fall  or  blow  on  the  back  the  kidney  nuiy  lie 
ru])ture(l,  and  this  may  be  followed  by  very  free  bleeding;  less  comniouly 
the  blood  comes  from  injury  of  the  bladder  or  of  the  prostate.  Blood 
from  the  urethra  is  frequently  due  to  injury  by  the  passage  of  a  catheter, 
or  sometimes  to  falls  or  blows. 

And,  lastly,  there  are  cases  in  which  hamiaturia  occurs  for  a  long  time 
without  discoverable  cause,  particularly  in  young  persons.  The  health 
may  not  be  seriously  impaired.  Gull  has  characterized,  in  a  happy  way,  a 
case  of  this  kind  as  one  of  renal  epistaxis. 

Of  special  interest  is  the  malarial  hematuria  which  prevails  in  certain 
disti'icts  and  has  already  been  considered  in  the  section  on  paludism. 


^WI^iW<Wi^lW>WwMyl*IWlWi*l*M 


ANOMALIES  OP  THE   URIXARV  SECRETION. 


705 


ronioved,  the 
ustances  there 


Tlio  (h'fif/nosis  of  hivm.itnria  is  usually  easy.  The  color  of  tlio  uriiio 
varies  from  a  light  smoky  to  a  bright  rcil,  or  it  may  havf  a  dark  jiortor 
polor.  KxaniiiR'd  with  the  microscope,  the  blood-corpuscles  are  readily 
recognized,  either  plainly  visible  and  retiiiiiing  their  color,  in  which  case 


tl 


ated. 


lev  are  usually  crenated,  or  simply  as  shadows,  in  aininoiiiacal  uriiio 
or  urines  of  low  specilic  gravity  the  lueinoglobiti  is  rapidly  dissolved  from 
the  corpuscles,  but  in  normal  urino  they  remain  for  many  hours  un- 
changed. 

Other  tests  arc  rarely  necessary.  The  guaiaoum  test  consists  of  the 
jiililition  to  the  urine,  in  a  test-tidic,  of  a  drop  or  two  of  the  tincture  of 
giiaiacum  and  two  minims  of  ozonic  I'ther.  A  blue  color  forms  at  the  line 
of  contact  of  the  two  fluids  and  diffuses  itself  through  the  ether. 

The  spectroscopical  oxiimination  of  the  urine  may  show  cither  the  sin- 
gle band  of  reduced  lucmoglobin  or  the  double  band  of  oxyha'inoglobin 
between  the  lines  I)  and  E. 

It  is  important  to  distinguish  between  blood  coming  from  the  bladder 
and  from  the  kidneys,  though  this  is  not  alwaj-s  easy.  From  the  bhulder 
the  blood  may  be  found  only  with  the  last  jiortions  of  urine,  or  only  at  the 
termination  of  micturition.  In  lutmorrliage  from  the  kidneys  the  blood 
and  urine  tire  intimately  mixed.  Clots  are  more  commonly  found  in  the 
blood  from  the  kidneys,  and  nuiyforni  moulds  of  the  pelvis  or  of  the  ureter. 
When  the  seat  of  the  bleeding  is  in  the  bladder,  on  washing  out  this  organ, 
the  water  is  more  or  less  blood-tinged  ;  but  if  the  source  of  the  bleeding  is 
higher,  the  water  comes  awtiy  clear.  In  many  instances  it  is  ditHcult  to 
settle  the  question  by  the  examination  of  the  urine  alone,  and  the  symp- 
toms and  the  physical  signs  must  also  be  taken  into  account. 

3.  ILi;.MOGLonixiKiA. 

This  condition  is  cliaracterized  by  the  presence  of  blood-jjigmcnt  in 
the  urine.  The  blood-cells  are  either  absent  or  in  insignificant  numbers. 
The  coloring  matter  is  not  htematin,  as  indicated  by  the  old  wmu\/npina- 
fiiniria,  nor  in  reality  always  luvmoglobin,  but  it  is  most  frequently  mctlue- 
nioglobin.  The  nrine  has  a  red  or  brownish-red,  sonu>times  (piite  black 
color,  and  usually  deposits  a  very  heavy  brownish  sediment.  When  the 
hannoglobin  occurs  only  in  small  quantities,  it  may  give  a  lake  or  smoky 
color  to  the  nrine.  Microscopical  examiiuition  shows  the  presence  of 
graiuilar  pigment,  sometimes  fragments  of  blood-disks,  epithelium,  and 
very  often  darkly  pigmented  urates.  The  urine  is  also  albuminous.  The 
nuiiil)er  of  red  blood-corpuscles  bears  no  proportion  whatever  to  the  in- 
tensity of  the  color  of  the  urine.  Examined  spectroscopically,  there  are 
either  the  two  absorption  bands  of  oxylnemoglobin,  which  is  rare,  or,  more 
commoidy,  there  n'e  the  three  absorption  bands  of  metluemoglobin,  of 
which  the  one  in  the  red  near  C  ia  characteristic.  Two  clinical  groups 
niiiy  be  distinguished. 


If 
1      i 


1 


'V 


i      ' 


!', 


w 


7CC 


DISRASFIS  OP  THE  KIDNEYS. 


!■■■  ■-;  ■'  ■  ■  ii 


(1)  Toxic  Hsemoglobinuria.— Tliis  is  caused  by  poisons  which  produoo 
rapid  dissolution  of  the  blood-corpuscles,  such  as  chlorate  of  potash  in  laiiro 
doses,  pyrof^jallic  acid,  carbolic  acid,  arsetiiuretted  hydrogen,  carbon  nmii- 
oxide,  naphtliol,  and  muscarine;  also  the  poisons  of  scarlet  fever,  yclldw 
fever,  typhoid  fever,  malaria,  and  syphilis.  It  has  also  followed  seviiv 
burns.  Exposure  to  excessive  cold  arid  violent  muscular  exertion  are 
stated  to  produce  luemoglobinuria.  A  most  remarkable  toxic  form  occurs 
in  horses,  coming  on  with  great  suddenness  and  associated  with  paresis  of 
the  hind  legs.  Death  may  occur  in  a  few  hours  or  a  few  days,  llorsoa 
are  attacked  only  after  being  stalled  for  some  days  and  then  taken  out  and 
driven,  particularly  in  cold  weather.  The  affection  is  common  in  horses 
in  this  coutitry.  The  form  of  hajmoglobimiria  from  cold  and  exertion  is 
extremely  rare.  Xo  instance  of  it,  even  in  association  with  frost-bites, 
came  under  my  observation  in  Canada.  Blood  transfused  from  one  mam- 
mal into  another  causes  dissolution  of  the  corpuscles  with  the  production 
of  luemoglobinuria;  and,  lastly,  there  is  the  rpide/nic  hrnKxjhihinuritnA 
the  new-born,  associated  with  jaundice,  cyanosis,  and  nervous  symptoms. 

(^)  Paroxysmal  Haemoglobinuria.— This  rare  disease  is  characterized 
by  the  occasional  passage  of  bloody  urine,  in  which  the  coloring  matter 
only  is  present.  It  is  more  frequent  in  males  than  in  females,  and  occurs 
chiefly  in  adults.  It  seems  specially  associated  with  cold  and  exertion, 
and  has  often  been  brought  on,  in  a  susceptible  persoJi,  by  the  use  of  ii 
cold  foot-bath.  Paroxysmal  ha^moglobinnria  has  been  found,  too,  in  jior- 
sons  subject  to  the  various  fortns  of  Raynaud's  disease.  Many  regard  the 
relation  between  these  two  affections  as  extremely  close ;  some  hold  tliat 
they  are  manifestations  of  one  and  the  same  disorder.  Druitt,  the  author 
of  the  well-known  Surgical  Vade-mecum,  has  given  a  graphic  description 
of  his  sufferings,  which  lasted  for  many  years,  and  were  accompanied 
with  local  asphyxia  and  local  syncope.  The  conriection,  however,  is  not 
very  common.  In  only  one  of  the  cases  of  Raynaud's  disease  which  I 
have  seen  was  paroxysmal  hivmoglobinuria  present,  and  in  it  epileptic 
attacks  occurred  at  the  same  time.  The  relation  of  the  disease  to 
malaria  is  not  so  close  as  has  been  thought  by  many  writers,  No  doubt  it 
has  been  frequently  confounded  with  a  malarial  ha^maturia.  The  attacks 
may  come  on  suddenly  after  exposure  to  cold  or  as  a  result  of  mental  or 
bodily  exhaustion.  They  may  bo  preceded  by  chills  and  pyrexia.  In  otlicr 
instances  the  temperature  is  subnormal.  There  may  be  vomiting  and 
diarrhoea.  Pain  in  the  lumbar  region  is  not  uncommon.  The  ha-nio- 
globinuria  rarely  persists  for  more  than  a  day  or  two — sometimes,  indeed, 
not  for  a  day.  There  are  instances  in  which,  even  in  the  course  of  a  sin- 
gle day,  there  have  been  two  or  three  paroxysms,  and  in  the  intervals  ch  ur 
urine  has  been  passed.  Jaiindice  has  been  present  in  a  number  of  cases. 
According  to  Ralfe,  paroxysmal  hiemoglobinuria  may  alternate  with  gen- 
eral symptoms  of  the  same  character,  but  associated  only  with  the  passage 
of  albumin  and  an  increased  quantity  of  urea  in  the  urine.     In  such  cases 


"I  1, 


ANOMALIES  OF  THE  URINARY  SECRKTION. 


707 


vhich  prodiK'o 

)otiisli  ill  lariiu 

,  carbon  iinpti- 

;  ft'Vor,  yellow 

>llo\vo(l  .st'vi'i'e 

'  oxortidii  :iri' 

ic  form  occurs 

vitli  paresis  of 

days.     Horses 

taken  out  and 

non  in  liorscs 

ml  exertion  is 

til  frost-bites, 

•om  one  nuim- 

he  protliictidii 

(xjJdlii  nil  rill  of 

IS  syini)toins. 

cliaraeterizwl 

»loring  matter 

OS,  and  occurs 

and  exertion, 

y  tlie  use  of  a 

id,  too,  in  pcr- 

ny  regard  the 

)me  hold  that 

itt,  the  author 

lie  desoriptioii 

accompanied 

awever,  is  not 

iCase  which  I 

n  it  epileptic 

le   disease  to 

No  doubt  it 

The  attacks 

of  mental  or 

xia.    In  other 

vomiting  and 

The  liffino- 

times,  indeed, 

irse  of  a  sin- 

ntervals  clear 

Tiber  of  cat-OS. 

ate  with  gcu- 

h  the  passage 

In  such  cases 


he  supposes  that  the  toxio  agent,  Avliatevor  its  nature,  lias  destroyed  only 
a  limited  number  of  the  corpuscles,  the  (coloring  matter  of  which  is  readily 
dealt  with  by  the  spleen  and  liver,  while  the  globulin  is  excreted  in  the 
urine.     Tlio  cases  are  rarely  if  ever  fatal. 

The  essential  pathology  of  the  disease  is  unknown,  and  it  is  difTicnlt 
to  form  a  theory  whicn  will  meet  all  the  facts — particularly  the  ndation 
with  Kaynaud's  disease,  which  is  rightly  regarded  as  a  vaso-motor  disorder. 
Increased  haemolysis  and  dissolution  of  the  liaMiioglobin  in  the  blood-.serum 
(Iia'inoglobina'mia)  precedes,  in  each  instance,  the  appearance  of  the  colov- 
iug  matter  in  the  urine.  A  full  discussion  of  the  subject  is  to  be  found 
in  F.  Chvostek's  recent  monograph. 

Treatment.  —  In  all  forms  of  lurmaturia  rest  is  essential.  In  that 
produced  by  renal  calculi  the  recumbent  i)osturo  may  suflice  to  cheek 
the  l)leeding.  Full  doses  of  acetate  of  lead  and  opium  should  be  tried, 
then  ergot,  gallic  and  tannic  acid,  and  the  dilute  sul[)huric  acid,  'i'he 
oil  of  turpentine,  which  is  sometimes  recomniendod,  is  a  risky  remedy 
in  luTmaturia.  Extr.  hamamelis  virgin,  and  extr.  hydrastis  canad.  are 
also  recommended.  Cold  may  be  api)lied  to  the  loins  or  dry  cups  in  the 
lumbar  region. 

The  treatment  of  hipmoglobinuria  is  unsatisfactory.  Amyl  nitrite  will 
sometimes  cut  short  or  prevent  an  attack  (Chvostek).  During  the  par- 
o.xysin  the  patient  should  be  kept  warm  and  given  hot  drinks.  Quinine  is 
recommended  in  large  doses,  on  the  supposition — as  yet  unwarranted — 
that  the  disease  is  specially  connected  witli  malaria.  If  there  is  a  syphilitic 
history,  iodide  of  potassium  in  full  doses  may  be  tried.  In  a  warm  cli- 
mate the  attacks  are  much  less  frecpieut. 

4.  Alijumikuria. 

The  presence  of  albumin  in  the  urine,  formerly  regarded  as  indicative 
of  ^right's  disease,  is  now  recognized  as  occurring  under  many  circum- 
stances without  the  existence  of  serious  organic  change  in  the  kidney. 
Two  groups  of  cases  may  be  recognized — those  in  which  the  kidneys  show 
no  coarse  lesions,  and  those  in  which  there  are  evident  anatomical 
changes. 

Albuminuria  without  Coarse  Renal  Lesions.— (^r)  Fia/rfional  .w- 
mVcd  Plnjsinhfiind  Alhuniinuria. — I?)  a  normal  condition  of  the  kidney 
only  the  water  and  the  salts  are  allowed  to  pass  from  tlie  blood.  When 
albuminous  substances  transude  there  is  probably  disturbance  in  the  nu- 
trition of  the  epithelium  of  the  capillaries  of  the  tuft,  or  of  the  cells  sur- 
rounding the  glomerulus.  This  statement  is  still,  however,  in  dispute, 
and  Senator,  Grainger  Stewart,  and  others  hold  that  there  is  a  })hysiologi- 
cal  albuminuria  which  may  follow  muscular  work,  the  ingestion  of  food 
rich  in  albumen,  violent  emotions,  cold  bathing,  and  dyspepsia.  Tiie  dif- 
ferences of   oj)inion  on  this  point  are  striking,  and   observers  of  equal 


b '  \} 


7(58 


diseasp:s  of  the  kidneys. 


thoronglincss  and  roliuhility  liave  arrived  at  directly  opposite  conclusions. 
The  prcsciK^c  of  all)niiiin  in  the  urine,  in  any  form  mid  under  any  cir- 
eiinistiincc,  may  he  regarded  as  indicative  of  change  in  the  nnial  or  gldiii- 
crular  eiiiLheiiiini,  a  change,  liowever,  wluch  may  be  transient,  .slight. 
and  unimi)ortant.,  depending  upon  variations  in  the  circulation  or  U|i(iii 
the  irritating  elTects  of  subatancos  taken  with  the  food  or  temj)orarih- 
present,  as  in  febrile  states. 

Alhununuria  of  adolescence  and  cyclic  albununuria,  in  which  theallni- 
min  is  pn-sent  oidy  at  certain  times  during  the  day,  are  interesting  fdiins. 
A  majority  of  the  cases  occur  in  young  persons — bjys  more  cominnnlv 
than  girls — and  the  condition  is  often  discovered  accidentally.  'I'he  iiriiii', 
as  a  rule,  contains  only  a  very  small  quantity  of  albundn,  but  in  sumo 
instances  large  (juantities  are  present.  The  most  striking  feature  is  the 
varialtility.  It  may  be  absent  in  the  morning  and  only  present  after  exer- 
tion, or  it  may  be  greatly  increased  after  taking  food,  particularly  pro- 
teids.  The  quantity  of  urine  may  be  but  little  if  at  all  increased,  the  spc- 
cific  gravity  is  usually  normal,  ami  the  color  may  be  high.  Oi'casioiially 
hyaline  casts  may  be  found,  and  in  .some  instances  there  has  been  trai\siriit 
glycosuria.  As  a  rule,  the  pid,,i'  is  not  of  high  tension  and  the  secoiRl 
aortic  sound  is  not  accentuated. 

A'arious  forms  of  this  alTection  have  been  recognized  by  writers,  such 
as  neurotic,  di((tetic,  cyclic,  intermittent,  and  paroxysnud — names  whieh 
iiulicate  the  characters  of  the  dilferent  varieties.  A  large  proportion  of 
the  cases  get  well  after  the  condition  has  persisted  for  a  variable  period. 
This  in  itself  is  an  evidence  that  the  changes,  whatever  their  nature,  were 
transient  and  slight.  In  these  instances  the  albunun  exists  in  small  quan- 
tity, tube-casts  are  rarely  present,  and  the  arterial  tension  is  not  increased. 
In  a  second  group  the  albumin  is  more  persistent,  the  amount  is  largei', 
though  it  may  vary  from  day  to  day,  and  the  pulse  tension  is  increased. 
In  such  instances  the  persistent  albuminuria  probably  indicates  actual 
organic  change  in  the  kidney. 

(/>)  Fi'brili'  AlbunnuHvia.  —  Pyrexia,  by  whatever  cause  produced, 
may  cause  slight  albuminuria.  The  presence  of  the  albumin  is  due  to 
slight  changes  in  the  glomeruli  induced  by  the  fever,  such  as  cloudy  swell- 
ing, which  cannot  be  regarded  as  an  organic  lesion.  It  is  extremely 
common,  occurring  in  pneumonia,  diphtheria,  typhoid  fever,  and  even  in 
the  fever  of  acute  tonsillitis.  The  amount  of  albumin  is  slight,  and  it 
usually  disappears  from  the  urine  with  the  cessation  of  the  fever. 

{(■)  Hienn'c  C/nnii/es. — Purpura,  scurvy,  chronic  poisoning  by  lead  or 
mercury,  syphilis,  leukaemia,  and  profound  anaemia  may  be  associated  with 
slight  albuminuria.  Abnormal  ingredients  in  the  blood,  such  as  bilo- 
pigment  and  sugar,  nniy  cause  the  passage  of  snuiU  amounts  of  albu- 
min. 

The  traTisient  albuminuria  of  pregnancy  may  belong  to  this  ha'Uiic 
group,  although  in  a  majority  of  such  cases  there  are  changes  in  the  renal 


ANOMALIES  OP  THK   URINARY  SKCUKTION. 


769 


tissno.  Albuinin  may  bo  foiiiul  sometimes  after  the  inhalation  of  etlier  or 
ililoroform. 

('/)  Albiiminiiriu  occurs  in  certain  alTectioiis  of  the  iirrroiis  si/sfein. 
This  so-called  neurotic  alhuminuriii  is  seen  after  an  epileptic  si'izure  and 
ill  apoplexy,  tetanus,  exophtlialniic  <,'oitre,  and  injuries  of  tht'  head. 

Albuminuria  with  Definite  Lesions  of  the  Urinary  Organs —(^0  Con- 
irrsiiou  of  the  kidney,  either  active,  such  as  follows  exposure  to  cold  and 
is  associated  with  the  early  stages  of  nephritis,  or  ])assive,  duo  to  obstructed 
oiiltlow  in  disease  of  the  heart  or  lungs,  or  to  pressure  on  the  renal  veins 
liy  the  pregiKint  uterus  or  tumors. 

(//)  Organic  disease  of  the  kidneys — acute  and  chronic  llright's  disease, 
amyloid  and  fatty  degeneration,  suppurative  nephritis,  and  tumors. 

[r)  Alfcetions  of  the  pelvis,  ureters,  aiul  bladder,  when  associated  with 
till'  I'onuation  of  i)us. 

Tests  for  Albumin. — Both  morning  and  evening  uriiu'  should  be 
cxaiuined,  and  in  iloublful  cases  at  least  three  specimens.  If  turbid,  the 
iniiie  should  be  liltered,  though  turbidity  from  the  urates  is  of  no  moment, 
since  it  disappears  at  once  on  the  ai)plication  of  heat. 

Jfciif  and  Xitrir-dcid  Test. — The  urine  is  boiled  in  a  test-tube  over  a 
spirit-lamp,  and  a  drop  of  nitric  acid  is  then  added.  If  a  cloudiness  occurs 
1(11  boiling,  it  may  be  due  to  phosphates,  which  are  dissolved  on  the  addition 
uf  an  aci<l.     Persistence  of  the  cloudiness  indicates  albumin. 

Heller's  Test. — A  small  quantity  of  fuming  nitric  acid  is  jioured  into  the 
test-tube,  ami  with  a  pipette  the  urine  is  allowed  to  llow  gently  down  tire 
side  upon  the  acid.  At  the  line  of  junction  of  the  two  fluids,  if  all)umin 
is  present,  a  white  ring  is  formed.  'J'his  contact  method  is  trustworthy, 
ami,  for  the  routine  clinical  work,  is  probably  the  most  satisfactory.  A 
(lilTiiscd  haze,  due  to  mucin  (nucleo-albumin),  is  sometimes  seen  just 
abuM'  tiie  white  ring  of  albumin  ;  and  in  very  concentrated  urines,  or 
after  the  taking  of  balsamic  remedies,  a  slight  cloudiness  may  be  due  to 
urates  or  uric  acid,  which  clears  on  heating  or  warming.  A  colored  ring 
at  the  junction  of  the  acid  and  the  urine  is  due  to  the  oxidation  of  the 
coloring  matters  in  the  urine. 

Sir  William  Roberts  strongly  recommends  the  tnof/ncsiion-Nifric  test. 
OiK'  volume  of  strong  nitric  acid  is  mixed  with  five  volumes  of  the  satu- 
rated solution  of  suli)hate  of  magnesium.  This  is  used  in  the  same  way 
as  the  nitric  acid  in  Heller's  test. 

Picric  acid,  introduced  by  George  Johnson,  is  a  delicate  and  useful 
test  for  albumin.  A  saturated  solution  is  used  and  employed  as  in  the 
contact  method.  It  has  been  urged  against  this  test  that  it  throws  down 
the  mucin,  peptones,  and  certain  vegetable  alkaloids,  but  these  are  dis- 
solved by  heat. 

For  minute  traces  of  albumin  the  trichloracetic  acid  may  be  used,  or 
Millard's  fluid,  which  is  extremely  delicate  and  consists  of  glacial  carbolic 
iieid  (ninety-five  per  cent),  2  drachms ;  pure  acetic  acid,  7  drachms ; 
liiliior  potasste,  2  ounces  0  drachms. 


ti;!. 


T70 


DISKASKS  OP  TIIK   KIDNEYS. 


M  u 


A  qnnntitiitivo  cstitiiiitc  of  the  allMiinin  can  In'  mudo  by  moans  of  lis- 
bujli'fi  tube,  l)Ut  the  rough  nii'tliod  of  licatiiif,'  ami  boiling  a  crrtain  (|iiaii- 
tity  of  aciihiliitcil  urini'  in  u  tcst-Uibc  iiikI  allowing  it  to  stand,  is  (ifhn 
«!nij)loyi'(l.  'I'lio  depth  of  deposit  can  tluii  bo  compared  with  tlio  wliido 
amount  of  nrine,  and  the  jnoportion  irf  expressed  as  ••  •".ore  trace,  almost 
solid  —  one  fourth,  one  half,  and  so  on.  This,  of  course,  does  not  give  an 
uctMirate  Indication  of  the  proportion  of  albuniin  in  tlu'  total  quantity  of 
urine.  For  the  more  elaborate  methods  the  reader  is  referred  to  the  Wdiks 
on  urimdysis. 

The  above  tests  refer  entirely  to  serum  albuniin.  Otlu'r  all)umiiioiis 
substanf^es  occur,  sutdi  as  albuminose,  serum  globulin,  j)eptonos,  utid 
h(MuiaIbuniose  or  ])ropepton.  They  are  iU)t  of  much  clinical  importatieo. 
For  a  full  <!onsidi'ratioii,  the  ailvaiiced  student  should  consult  the  works 
on  p!iysiologi<'al  chemistry,  or  Neubauer  and  N'ogel  (;»te  .\ullage). 

'I'racos  of  jirjifoiifs  (albunioses)  are  found  in  tlu-  uriiu'  in  many  acute 
diseases  and  in  chronic  su{)puration.  Peptonuria  (albumosuria)  has  no 
clinical  siginlicance.  Kven  the  very  substance  is  called  in  (juestiou.  It  is 
an  albumosc,  and  the  condition  should  be  termed  alluimosuria.  For  a 
criticism  of  the  whole  question  the  recent  monograjth  of  Stadelmanu  may 
bo  consulted. 

Prognosis. — This  depends,  of  course,  ontindy  upon  the  cause.  Fe- 
brile albuminui'ia  is  transient,  and  in  a  majority  of  the  cases  de[iendiiig 
upon  lia'Hiio  causes  the  condition  disajjpears  and  leaves  the  kidneys  in- 
tKct.  An  occasional  trace  of  albumin  in  u  man  over  forty,  with  or  with- 
out a  few  hyaline  easts,  and  with  increased  tension  ami  thick  vessel  \vn\U, 
usually  indicates  changes  in  the  kidneys.  The  jiersistenco  of  a  sliglit 
ajuount  of  albumin  in  young  men  without  increased  arterial  tension  is 
less  fiorious,  as  oven  after  continuing  for  years  it  may  disappear.  1  have 
already  sjxiken  of  the  outlook  in  the  so-called  cyclic  albuminuria. 

Practically  in  all  cases  the  presence  of  albumin  indicates  a  change  of 
some  sort  in  the  glomeruli,  the  nature,  extent,  and  gravity  of  which  it  is 
dinicult  to  estimate  ;  so  that  other  considerations,  such  as  the  presence  of 
tube-casts,  the  existence  of  increased  tension,  the  general  condition  of  the 
patient,  and  the  in'luence  of  digestion  upon  the  albumin,  must  be  care- 
fully considered. 

Tlie  physician  is  daily  consulted  as  to  the  relation  of  albuminuria  tiiid 
life  assurance.  As  his  function  is  to  protect  the  interests  of  the  conijtaiiy, 
he  should  reject  all  cases  in  which  albumin  occurs  in  the  urine.  It  is 
even  doubtful  if  an  exception  should  be  made  in  young  persons  with 
transient  albuniinuria.  Naturally,  companies  lay  groat  stress  upon  tliu 
ju'osence  or  ab.sonce  of  albumin,  but  in  the  most  serious  and  fatal  nialady 
with  which  they  have  to  deal-chronic  interstitial  nephritis — the  albumin  is 
often  iibsont  or  transient,  even  when  the  disease  is  well  developed.  Al'tci' 
the  fortieth  year,  from  a  standpoint  of  life  insurance,  the  state  of  the 
arteries  is  far  more  important  than  the  condition  of  the  urine. 


ANOMAMKS  oF   TIIK   rUINAIlY   SKCliKTloN. 


I 


With  rofcivnco  to  tlio  si;;niflcaMi'o  of  alhiniiiiiiiriii  in  iwliilts,  I  (|iiitf 
ajjriT  with  fho  following,'  coMchisioii.-t  of  I-'.  ('.  Shut  tuck  : 

(1)  Kt'iial  iilhiimiiuiria,  us  ))rov('(i  hy  the  jiri'sciu'c  of  l»oth  iilliiiiniii  iiiid 
(•list?!,  is  iinich  inoro  comnioii  in  aiiiilts,  (|iiit('  apart  finm  Mri^fht's  disi'asc 
di' iiny  ohvions  Hoiirco  of  renal  irritation,  than  is  ^fcncrally  sii|)|i((st'(l. 

(•.')  'IMic  frciint'iicy  iiicrcast'S  steadily  and  ])ro;;n'ssi\rly  witii  a<lvan('inj:f 

(:;)  'I'his  inoroaso  with  ajjo  su<r;ri'sts  the  t-xphination  that  the  ulbiinii- 
iiuriii  is  ofton  an  indit'ution  of  senile  de^'eneratidn. 

(t)  'I'lion^rh  it  cannot  he  re;.'arded  as  yet  as  a!)sohitely  proved,  it  is 
liiirlily  prohahle  that  faint  traces  of  alhiitnin  and  hyaline  and  linely  ^fraiin- 
lar  I'lists  of  small  diameter  are  often,  especially  in  those  past  lifty  years  of 
age,  (if  little  or  no  practical  importance. 

").    PvilMA    {/'us  ill  fhr  I'riiir). 

Causes. — (1)  Pi/rJi/is  anil  J\i/rlofifp/iri/is. — In  larjjo  abscesses  of  tlie 
kiiliicy,  pyonephrosis,  the  pus  nniy  be  intermittent,  and  for  days  or  even 
wi'i'ks  the  urine  is  free.  In  calculous  and  tuberculous  pyelitis  the  pyuria 
is  usually  continuous,  though  varyinj;  in  intensity.  In  these  ciises,  as  a 
rule,  the  pus  is  mixed  with  the  urine,  which  is  acid  in  reaction.  In  the 
iiiiiy  staf,'es  of  pyelitis  the  transitional  epithelium  may  be  abundant,  but 
is  not  in  any  way  distinctive.  In  the  pyelitis  and  j)yelone])hritis  following 
tvstitis  the  urine  is  usually  alkaline,  and  contains  more  mucus;  micturi- 
ti()i\  is  usiudly  more  frequent,  and  the  history  points  to  a  previous  bladder 
iitrcction. 

(v')  Ci/sfitis. — The  urine  is  alkaline,  often  fetid,  the  pus  ropy,  and 
till'  amount  of  urine  greatly  increased.  The  ropy,  thick  nuuuis  usually 
fouu's  with  the  last  portions  of  the  urine.  Triple  i)hosphate  crystals  may 
lie  prt'sent  in  the  freshly  passed  urine. 

(:'))  Urethritis,  particularly  gonorrluea.  The  pus  appears  first,  is  in 
siiuill  (luantities,  and  there  are  signs  of  local  iiillammation. 

(4)  In  leucorrhwa  the  quantity  of  i>us  is  usually  small,  and  large  (lakes 
111'  Vii^inal  epithelium  are  numerous.  In  doubtful  cases,  when  leucorrlm-a 
is  |in'S(Mit,  the  urine  should  be  withdrawn  by  a  catheter. 

(.">)  Jiiipiure  of  Abscesses  into  tlte  Urinurii  Passaijes. — In  sucli  cases 
as  pelvic  or  pcrityphlitic  abscess  there  have  been  jirevious  sym})toms  of 
pus  formation.  A  large  amount  is  passed  within  a  short  time,  then  the 
iliscliarge  stops  abruptly  or  rapidly  diminishes  within  a  few  days. 

I'lis  gives  to  the  urine  a  white  or  yellowish-white  appearance.  On 
settling  there  is  a  heavy  grayish  sediment,  and  the  supernatant  fluid  is 
usually  turbid.  The  sediment  is  often  tenacious  ami  ropy.  The  reaction 
i'^  gouorally  alkaline,  and  the  odor  may  be  ammoniacal  even  when  passed. 
Kxamination  with  the  micr-jscope  reveals  the  presence  of  a  large  number 
<'l'  pus-corpuscles,  which  are  usually,  when  the  pus  comes  from  the  blad- 
49 


m 


i-  .'  *'■ 


;    I 


.:,  *■ 


M 


'•^^'> 


!5:-- 


ii;i 


772 


DISKASES  OP  THE  KIDNEYS. 


f  ii-> 


11    •;   '-^f 


(ler,  well  formed  ;  llie  protoplasm  is  gruiuilar,  iiiul  often  shows  niaiiv 
translucent  processes. 

The  only  sediment  likely  to  be  confounded  with  pus  is  that  nf  the 
])hosphHtes;  but  it  is  whiter  and  less  douse,  and  is  distinguisiied  iiiiiunli. 
jitely  by  niicroseoj)ical  examination. 

With  the  pus  there  is  always  more  or  less  epithelium  from  the  liladdi  r 
and  pelves  of  the  kidneys,  but  since  in  these  situations  the  forms'  of  vv\U 
ar*^  ])ractii'ally  identical,  they  ait'onl  no  information  us  to  the  locahtv  tVdin 
which  the  {)us  has  come. 

The  treatment  of  pus  in  tlie  urine  is  considered  under  the  conditions 
in  whicli  it  occurs, 

C).    ClIYLntl.V — X()X-I'AI{ASITI(\ 

This  is  a  rare  alTection,  occurrint^j  in  temperate  rejxions  and  niiassncj- 
ated  with  the  Fihtria  Uiuirnifli.  Tlie  uriiu^  is  of  an  opaque  wiiitc  cdldr; 
it  resembles  milk  closely,  is  occasionally  mixed  with  l)lood  (lui'matdclu- 
luria),  and  sometimes  coajrulates  into  a  firm,  jelly-like  mass.  In  (ttliir 
instances  there  is  at  the  bottom  of  the  vessel  a  loose  clot  which  may  lie 
distinctly  blood-tinged.  Under  the  microscope  the  turbidity  seeuis  ti>  lie 
caused  by  numerous  minute  granules — more  rarely  oil  iiroplets  similar  in 
those  of  milk.  Traces  of  albumin  are  usually  present.  The  anioiint  nf 
nrine  passed  is  generally  increased,  and  tiic  chylous  condition  is  intcnnii- 
tent.  It  may  jjcrsist  for  years  without  deterioration  of  health  or  evidoiici' 
of  serious  disease. 

Since  the  discovery  of  the  Filan'a  Bancrofti  it  has  been  incoirccilv 
lield  by  some  that  all  the  cases  of  chyluria  are  of  this  ])arasitic  iianiii'. 
I  had  an  oj)portunity  in  ^lontreal  of  making  a  careful  study  of  a  iMvih  i;- 
Canadian  woman,  a  patient  of  J.  B.  McConncll's,  who  had  had  cliyhiri;! 
for  more  than  thirteen  years.  The  urine  was  (juite  milky  in  colnr  aiiii 
occasionally  mixed  with  blood.  iVeither  ova  nor  embryos  were  t'lniinl  in 
the  urine  or  in  the  blood  examined  at  night.  After  her  death  I  was  on- 
abled  to  make  ii  thorouiih  dissection  of  the  abdominal  lvmi)li-vesst'l>. 
which  were  found  perfectly  normal.  "^I'he  thoracic  duct  was  iu)t  eiilaiLrcil. 
the  renal  lym])hatics  were  not  distended;  the  kidneyswerc  increased  in 
size,  but  showed  no  special  changes,  'i'he  most  careful  examination  of  tli^' 
lymph  glands  and  vessels  failed  to  reveal  the  presence  of  i)arasites, 

The  jtathology  of  the  condition  is  unknown.  I^'o  known  rciiicdit~ 
have  any  influence  upon  the  chyluria. 

(For  parasitic  chyluria  see  l"'ii,.\uiAsis.) 

7.   lilTiiiKiA   {Lilluvinid  ;   IJlliir-acid  Diathesis). 

The  general  relations  of  uric  acid  have  already  been  consid.icii  ir. 
speaking  of  gout. 


ANOMALIKS  OF  TIIK   URINARY  SECRi-moX. 


773 


n  shows  many 

is   tllilt  (if  the 
uislu'd  iiiiiiudi 

I'om  the  ItlaiKliT 
10  fonii:-'  of  cell-; 
,lie  locality  I'lmn 

'V  tllO  C()llilitiiill> 


ns  mid  iinii^siici- 
.que  wliiU'  rulor; 
lod  (hii'iiiatdchy- 
mass.  In  nilur 
ot  which  may  U' 
lidity  seems  to  lie 
roplets  similar  l" 
The  amount  nf 
lilioii  is  iiitennit- 
ealth  or  cvideiiri' 

l)eeii   ineoiTi'ctly 

i  iiarasitic  natiuv. 

uly  of  a  !•" ivn.il- 

id  had  chylnriM 

ky  in  color  ami 
OS  were  fonml  in 

loath   I  was  tii- 

I   lyin[)li-vfs>('l>. 

as  not  enlartri'il. 
were  ineivasi'il  in 

uiiination  ol  tlif 

parasites, 

known   ivniali^'> 


■on  considercil  iv 


OirHrroiro  in  fhe  Frii/f. — 'I'iip  uric  acid  occurs  in  cojnhinalion  cliielly 
witli  aninioniuni  and  sodium,  forming  tlic  acid  urates.  In  smaller  {|uan- 
tiiic-  are  the  potassium,  calcium,  and  lithium  salts.  The  uric  acid  may 
lit'  SI  parated  from  its  hasos  and  crystallizes  in  rhomhs  or  prisms,  Avliich 
arc  ii.-ually  of  ii  deep  red  color,  owing  to  the  staining  of  the  urinary  pig- 
iiu'Uis.  The  sediment  formed  is  granular  and  the  groujis  of  crystals  look 
like  L'rains  of  Cayenno  jioppi-r.     It  is  very  important  not  to  mistake  a  de- 


III  iSl 


t  of  uric  acid  for  an  e.\ce.> 


lie  (le 


po: 


iition  of  jiumorous  crains  it 


tu'  urine  within  a  few  liours  after  passing  is  more  likely  to  ho  due  to  con- 
(liiions  which  diminish  the  solvent  power  than  toiiU^'oase  in  the  (piantity. 
Of  till'  conditions  which  cause  precipitation  of  the  uric  acid  K'oberts  gives 
ihr  following :  "  (1)  High  acitlity  ;  ("v*)  poverty  in  mineral  salts;  (M)  low 
piLTnientation ;  and  (4)  high  })ercentago  of  uric  acid."  'I'he  grade  of 
acitliiy  is  i)rohably  the  most  important  element. 

More  common  is  the  precipitation  of  amorphous  urates,  forming  the 
sn-called  brick-dust  or  lateritious  deposit,  which  has  a  pinkish  color,  due 
to  the  prcseiu'o  of  urinary  jiigmont.  It  is  composed  cliielly  of  the  acid 
sdilimn  urates.  It  occurs  particularly  in  very  acid  urine  of  a  high  specilio 
L'ravity.  As  the  urates  are  more  soluble  in  warm  solutions,  they  fre(|iu'!itly 
(l('|iosit  as  the  urine  cools.  Here,  too,  the  deposition  does  not  necessarily, 
iiulccil  usually  does  not,  mean  an  excessive  excretion,  but  the  existence  of 
(■(iiiditioiis  favoring  the  deposit;, 

Litlnvmia. — In  addition  to  what  has  already  been  said  under  //o/^/,  we 
may  consider  here  the  hypothetical  condition  known  as  litha'inia,  or  the 
iiric-acid  tliathesis.  Murchison  introduced  the  term  to  designate  certain 
symptoms  due,  as  he  supposed,  to  functional  disturbance  of  the  liver. 
Not  only  have  his  views  been  widely  adopted,  but,  as  is  so  often  the  case 
whoii  we  give  the  rein  to  theoretical  concei)tions  of  disease,  the  so-called 
manifestations  of  this  state  have  so  multiplied  that  some  authors  attribute 
to  this  cause  a  considerable  proportion  of  the  ailments  alTecting  the  vai'i- 
oiis  systems  of  the  body.  Thus  one  writer  enumerates  not  fewer  than 
lliiriy-niiu'  sei)arate  nuirbid  conditions  associated  with  litha-mia.  l-'roiu 
(iiir  lack  of  knowledge  of  the  mode  of  formation  and  elimination  of  uri(! 
atitl  it  is  very  evident  that  the  physiology  of  the  subject  must  be  widely 
oxtoiulod  before  wo  are  in  a  position  to  draw  safe  conclusions.  Thus  it  is 
liy  no  means  sure  that,  us  Murchison  supposed,  the  essential  ih'fect  is  in 
a  functional  disorder  of  tlio  liver,  (disturbing  the  metaI)olism  of  the  al- 
luiniiiious  ingredients,  nor  is  it  aL  all  certain  that  the  only  olTcnding  snb- 
slaiicc  is  uric  acid.  Mouchard  contends  that  the  so-called  lithiasis  luis 
little  or  nothing  to  do  with  the  disturbance  in  the  function  of  the  liver, 
luid  thai  it  has  not  been  shown  that  \\v\('  acid  is  the  only  or  even  the 
chief  agent  in  pntducing  the  symptoms.  In  the  present  imperfect 
i'tatc  of  knowledge  it  is  impossible  with  any  clearness  to  dohne  the 
jiatliology  of  tho  so-called  uric-acid  diathesis.  Wo  may  say  tl  d.  certain 
symp'onis  arise  in  connection  with  defective  food  or  tissue  niotubolism, 


1        ,-i       '■ 

t    ' 
'     s 

\ 

[   j 

l!;^ 

c'< 


774 


DISKASKS  OK  TIIK   KIDNEYS. 


more  piirtioularly  of  tlii)  nilrogciiotis  clcMiieiits.  neficicnt  oxidjilimi  is 
prohiibly  the  most  essential  factor  in  tlie  process,  with  the  result  of  the 
formation  of  less  readily  soluble  ami  less  readily  eliminated  proilmts  of 
Hitrograde  metamorjjhosis.  This  faulty  metabolism  if  louij  continiinl 
may  lead  to  gout,  with  uratic  deposits  in  the  joints,  acute  inllammaliiuis, 
and  arterial  and  renal  disease.  In  a  largo  group  of  cases  the  distuilnil 
metabolism  produces  high  tension  in  the  arteries  (probably  as  a  diivct 
sequence  of  interference  with  the  capillary  circulation)  and  ultiinatclv 
degenerations  in  various  tissues,  particularly  the  scleroses. 

Overeating  and  overdrinking,  when  combined  Avith  deficient  miisiulur 
exercise,  lie  at  the  basis  of  this  nutritional  disturbance.  The  symptDiiis 
which  are  believed  to  characterize  the  uric-acid  diathesis  have  alicudv 
l)een  briefly  considered  under  the  section  ou  irregular  gout,  and  tlu'  (jiios- 
tion  of  diet  and  exercise  has  also  been  there  considered. 


i-  '     .  ,         ,  i 

i     . 

8.    Ox.VLURIA. 

Oxalic  acid  occurs  in  the  urine,  in  combination   vith  '  'pn,  forniii)ir  an 
oxalate  which  is  held  in  solution  by  the  acid  phosp    ■  oda.     Alioiu 

•01  to  "02  gramme  is  excreted  in  the  day.  It  never  forms  a  heavy  (h'jidsii, 
but  the  crystals — usually  octahedra,  rarely  dumb-bell-shaped — collect  in  the 
mucus-cloud  and  on  the  sides  of  the  vessel.  '^^^^  amount  varies  extremely 
with  the  diet,  and  it  is  increased  largely  when  such  fruits  and  vegctalilcs 
as  tomatoes  and  rhubarb  are  taken.  It  is  also  a  product  of  incomplete  oxi- 
dation of  the  organic  substances  in  the  body,  and  in  conditions  of  inereiist'd 
metabolism  the  amount  in  the  urine  becomes  larger.  It  is  sfated  also  tn 
result  from  the  acid  fermentation  of  the  mucus  in  the  urinary  pas,sa;,as, 
and  the  crystals  are  usually  abundant  in  spermatorrhea. 

When  in  excess  and  present  for  any  considerable  time,  the  cojiditioii  i> 
known  as  oxaluria,  the  chief  interest  of  which  is  in  the  fact  that  the  in-- 
tals  may  be  deposited  before  the  urine  is  voided,  and  form  a  e  .K';!!!- 
It  is  held  by  many  that  there  is  a  special  diathesis  associated  -'ii    ii' 
state  and  manifested  clinically  by  dyspepsia, particularly  the  ncv        .  '"■ 
irritability,  depression  of  spirits,  lassitude,  and  sometimes  mavKu.'   *    j'^ 
chondriasis.     There  may  be  in  addition  U'  iral'lc  pains  and  the  gei;  ■  .a 
symptoms  of  neurasthenia.     The  local  and  general  symptoms  are  i)r<ilial)ly 
dependent  upon  some  disturbance  of  metabolisni  of  which  ;   e  oxaliiri;i  i> 
one  of  the  manifestations.     It  is  a  feature  also  in  many  gouty  persoius 
and  in  the  condition  called  litha3mia. 

1).  Cystiniuia. 

Oystin  does  not  occur  in  normal  urine.     It  is  associate      >*■  'i  dinu- 
nation  of  diamines  both  in   the  fieces  and  urine.     It  is  very 'u.  \.  -n' 
with,  and  its  chief  interest  is  owing  to  the  f-a't  th!>'  it  may  form  a  '  iloii- 


ANOMALIES  OF  THE   URINARY   SECRETION. 


11i 


lus.  Its  presence  in  tlie  urine  lias  been  determined  in  many  members  of 
tliL'  -ame  family,  and  tlie  condition  appears  sometimes  to  bo  lieroditary. 
As  it  contains  siilpliur,  it  is  thought  to  be  formed  from  tlie  taurin  of  the 

bile. 

10.    PlIOSl'IIATUUIA. 

'I'iic  phosphoric  acid  is  excreted  from  the  body  in  combination  witli 
])ota>>iuin,  sodium,  calcium,  and  magnesium,  forming  two  classes,  the  alka- 
line jiliosphates  of  sodium  and  jjotassium  and  the  earthy  phosphates  of 
lime  and  magnesia.  "  T/ie  itlkdiiiie  phospfiafes  exist  in  the  blood  in  the 
I'driii  of  neutral  sodium  and  jiotassium  jihosphates  (hydrogen-disodiiim 
|iliii<;iliate>-!,  IIXaol*04),  but  appear  in  the  urine  as  acid  sodium  and  potas- 
siiiiii  [tliosjihates  (dihydrogen-sodium  phosphates,  IInNal*04),  and  thus 
laiisc  the  acid  reaction  of  that  secretion.  The  change  of  the  neutral  into 
the  aril!  salt  is  caused  by  the  decomposition  eifected  by  the  act  of  secre- 
tion, ill  which  the  bicarbonates  and  neutral  phosphates  in  the  blood 
rliaiigi'  into  carbonates  and  acid  plios])hates  respectively"  (Ualfe). 

(If  the  fdrlhii  pho^phatex,  those  of  lime  are  abundant,  of  magnesium 
scanty.  In  urine  which  has  undergone  the  ammoniacal  fermentation, 
fitlicr  inside  or  outside  the  body,  there  is  in  addition  the  amnionio- 
iiiaLnu'siiim  or  triple  phosphate,  which  occurs  in  triangular  prisms  or  in 
fcatliiTV  or  stellate  crystals;  hence  the  term  given  to  this  form  of  stellar 
phosphates.  The  earthy  phosphates  occur  as  a  sediment  in  the  i;rine 
when  the  alkiilinity  is  due  to  a  iixed  alkali,  or  under  certain  circumstances 
the  deposit  may  take  place  within  the  bladder,  and  then  the  ])hosphates 
iuv  ]iassed  at  the  end  of  micturition  as  a  whitish  lluid,  which  is  ])o})ularly 
coiifoniiiled  with  spermutorrhrt'a.  The  calcium  jihosphate  may  be  pre- 
lijiitatetl  l)y  heat  and  produce  a  cloudiness  which  may  be  mistaken  for  albu- 
iiiiii,  iiiit  is  at  once  dissolved  upon  making  the  urine  acid.  This  condition 
i-;  very  frequent  in  persons  sulfering  from  dyspe[)sia  or  from  debility  of  any 
kiiui.  Tiie  Jiliosphates  may  be  in  great  excess,  rising  in  the  twenty-four 
hours  In  from  7  to  9  grammes  (Tcssier),  whereas  the  normal  amount  is  not 
more  than  'lb  graiiinies.  And,  lastly,  the  phos])bates  may  be  deposited  in 
urine  V  hich  has  undergone  decomposition,  in  which  the  carbonate  of  am- 
monia from  llie  urea  combines  with  the  niagnesium  jiliosphates,  forming 
the  triple  salt.  This  is  seen  in  cystitis,  and  is  due  to  the  introduction  of 
a  baeterial  ferment. 

The  clinical  si'rnirH\'ince  of  an  excess  of  phosphates,  to  which  the  term 
lilinspiiaturia  is  applied,  has  been  much  discussed.  It  must  be  remem- 
lii'i't'il  that  a  deposit  does  not  necessarily  mean  an  excess,  to  determine 
"iiieli  a  careful  analysis  of  the  twenty-four  hours'  secretion  sliould  be 
"laile.  It  hiis  long  been  thought  that  there  is  a  relation  between  the 
iiiti\iiy  of  tlie  nerve-tissues  an<l  the  output  of  phosphoric!  acid;  but  the 
||iiostion  cannot  yet  b(>  considered  settled.  I'lie  amount  is  increased  in 
»iistiii:r  diseases,  such  as  phthisis,  acute  yellow  atrophy  of  the  liver,  leu- 


'    ( 


v-x 


M,      i 


"■, 


Ik      i 


.» ■  t] 


r 

InlH 

1  jln|^^H 

'1 

^m 

770 


DISEASES  OP  THE   KIDNEYS. 


kaMriia,  and  severe  ana;mia,  wlieroas  it  is  diminished  in  acute  discus*.-  anil 
during  pregnancy. 

In  a  condition  termed  by  Tessier,  Kulfe,  and  otliers  pliosphatic  dia- 
betes  tliere  are  polyuria,  tliirst,  emaciation,  and  a  groat  increase  in  tlio 
excretion  of  phosphates,  wliich  may  be  as  much  as  from  seven  to  nine 
grammes  in  the  day.  The  urine  is  usually  acid,  free  from  sngiir,  I  bo 
patients  are  nervous;  in  some  instances  sugar  has  been  present  in  the 
urine,  and  in  others  it  subsequently  makes  its  appearance. 


:  ! 


11.    IXDICANURIA. 

The  substance  in  the  urine  which  has  received  this  name  is  the  indnxvl- 
sulphate  of  potassium,  in  which  form  it  appears  in  the  urine  and  is  color- 
less. When  concentrated  acids  or  strong  oxidizing  agents  are  added  to 
the  urine,  this  substance  is  decomposed  and  the  indigo  set  free.  It  is 
J'-  so- it  only  in  small  quantities  in  healthy  urine.  It  is  derived  from  tlio 
i.  a  product  formed  in  the  intestine  by  the  decomposition  of  tlie  albu- 

men aider  the  influence  of  bacteria.  AVlien  absorbed,  this  is  oxidized  in 
the  tissues  to  indoxyl,  which  combines  with  the  potassium  sulphate,  form- 
ing the  above-named  substance. 

The  quantity  of  indican  is  diminished  on  a  milk  (and  a  Kefyr)  diet. 
Ft  is  increased  in  all  wasting  diseases,  as  carcinoma,  and  whenever  any 
large  quantities  of  albuminous  substances  are  undergoing  rapid  deeonijio- 
sition,  as  in  the  severer  forms  of  peritonitis  and  empyema.  It  is  not  in- 
creased in  constipation,  but  is  mot  with  in  ileus.  Indican  has  occasion- 
ally been  found  in  calculi.  Though,  as  a  rule,  the  urine  is  colorless  wben 
passed,  there  are  instances  in  which  the  decomposition  has  taken  ])laei' 
within  the  body,  and  a  blue  color  has  been  noticed  immediately  after  tlie 
urine  was  voided.  Sometimes,  too,  in  alkaline  urine  on  exposure  there  is 
a  bluish  film  on  the  surface. 

To  test  for  indican,  place  four  or  five  c.  c.  of  nitric  or  hydroebloric 
acid  in  a  test-tube;  boil,  and  add  an  e(|ual  quantity  of  urine.  A  blnisii 
ring  develops  at  the  point  of  contact.  Add  one  or  two  c.  c.  of  chloroform 
and  shake  the  test-tube,  and  on  separation  the  chloroform  has  a  violet  or 
bluish  color  due  to  the  presence  of  indican. 


12.   MKLAXrUIA. 

In  melanotic  cancer  the  urine,  either  at  the  time  of  voiding  or  after 
exposure  to  the  air,  may  present  a  dark  color.  This  pigment  is  known  as 
melanin,  and  it  may  occur  in  solution  or  in  the  form  of  small  granules. 
'I'he  urine  may  be  voided  clear,  aiul  subscfiuently,  on  exposure  to  tbc  air 
or  on  tlie  addition  of  oxidizing  substances,  becomes  dark.  In  these  luses 
it  contains  a  chromogen  called  melanogen  which  turns  dark  by  oxidation. 
Von  Jaksch  has  found  that  "  in  urine  containing  melanin  or  its  preeinsur, 


rr^  '^  '■' i 


ute  diseast.-  and 

j)hosplutti(  liia- 
incroiiso  in  ilio 
1  seven  to  nine 
from  sugai-,  tlie 
present  in  the 


\Q  is  the  indiiNvl- 
•ine  and  is  color- 
nts  are  added  ti> 
I  set  free.  It  is 
Llerived  from  the 
ition  of  the  all)u- 
lis  is  oxidized  in 
I  snlphate,  forni- 

lul  a  Kefyr)  diet. 

id  Avlienevcr  any 
rapid  deeonipo- 

la.  It  is  not  in- 
m  has  oceasidii- 

is  colorless  wlun 
has  taken  jdaro 
1  lately  after  tlio 
xposnre  theru  h 


}i 


or  hydrochloric 
urine.     A  liluish 

c.  of  (ddorofnrm 
ni  has  a  violet  oi' 


voiding  or  after 
nent  is  known  as 
f  small  grannies. 
[)osure  to  tlie  air 
In  these  e;ises 
irk  by  oxidation. 
I  or  its  preen isor, 


ANOMALIES  OF  TlIK   URINARY  SECRETION. 


«  1 


inelnnogcn,  Prussian  bine  is  formed  by  adding  a  nitroprusside,  aqueous 
potasli,  and  an  aeid.  This  reaction,  however,  does  not  seem  to  depend  on 
the  presence  of  melanin,  as  it  is  not  given  by  that  substance  wlien  sep- 
arated from  the  urine,  but  apparently  by  some  other  at  present  unknown 
substance,  wliich  is  present  in  traces  in  normal  urine  and  is  increased  in 
eases  of  melanuria,  and  also  in  those  conditions  where  excess  of  indigo 
occurs  in  the  urine."  (Halliburton). 

13.  OxiiKii  Sl-bstaxces. 

Fat  in  the  urine,  or  lipuria,  occurs,  according  to  Halliburton,  first, 
without  disease  of  the  kidneys,  as  in  excess  of  fat  in  the  food,  after  the  ad- 
ministration of  cod-liver  oil,  in  fat  embolism  occurring  after  fractures,  in 
tile  fatty  degeneration  in  phosphorus  poisoning,  in  prolonged  suppuration 
as  in  phthisis  and  pyannia,  in  the  lipivmia  of  diabetes  mellitus;  secondl\', 
with  disease  of  the  kidneys,  as  in  the  fatty  stage,  of  chronic  Bright's  dis- 
ease, in  which  fat  casts  are  sometimes  present,  and,  according  to  Ebstein, 
in  pyonephrosis ;  and,  thirdly,  in  the  alTection  known  as  cliyluria.  The 
urine  is  usually  turbid,  but  there  may  be  fat  drops  as  well,  and  fatty 
crystals  have  been  found. 

l/ipaciduria  is  a  term  applied  by  von  Jaksch  to  the  condition  in  which 
there  are  volatile  fatty  acids  in  the  urine,  such  as  acetic,  butyric,  formic, 
and  propionic. 

Actiiinnria. — Von  Jaksch  distinguishes  the  following  forms  of  patho- 
logical acetonuria :  The  febrile,  the  diabetic,  tiie  acetonuria  with  certain 
forms  of  cancer,  the  form  associated  with  inanition,  acetonuria  in  psy- 
choses, and  the  acetonuria  which  results  from  auto-intoxication.  It  is 
(l(uibtful,  however,  whether  the  symptoms  in  these  are  really  due  to  the 
acetone.  It  may  be  the  substances  from  which  this  is  formed,  particu- 
larly the  diacetic  acid  or  the  oxybutyric  acid.  The  odor  of  the  acetone 
may  he  marked  in  the  breath  and  evident  in  the  urine.  Le  Nobel's  test 
has  hecu  given  in  the  section  on  diabetes. 

Didci'tic  arid  is  probably  never  present  in  the  urine  in  health.  With 
a  solution  of  ferric  chloride  it  gives  a  Burgundy-red  color.  A  similar  re- 
lelioii  is  given  by  acetic,  formic,  oxybutyric  acids,  and  it  may  be  present 
ia  the  urine  of  patients  who  are  taking  antipyrin,  thallin,  and  the  sali- 
cylates. "  If,  however,  the  urine  is  previously  boiled,  diacetic  a<'id,  if  pres- 
ent, still  gives  the  ferric-chloride  reaction,  but  these  other  substances  do 
not.  Fleischer  found  that  the  substance  whi(di  gives  the  ferric-chloride 
reaction  in  diabetic  urine  is  not  taken  up  l)y  ether  after  the  urine  has 
Iteeii  acidulated  with  sulphuric  acid,  whereas  ethyl-diacetic  acid  is  soluble 
ill  ether"  (Halliburton). 

A/cfijifonuriu. — Aromatic  compounds  occur  after  the  administration 
III'  eai'l)olic  acid  or  gallic  acid,  and  the  urine  on  exposure  to  air  becomes 
(lark.     In  carboluria  the  substance  causinjj  the  black  color  is  known  as 


'ill  it 

m 

II 

If 

;■;  K 

;  !  ■'•' 

mn 

^;|! 

iff' 


:.,  'f. 


778 


DISEASES  OF  THE   KIDNEYS. 


liydrocliiiion.  !Miiny  years  ag'.  Jiocdakor  met  with  oases  in  wliicli  tlif 
urine  became  dark,  owing  to  the  presunce  of  an  aromatic  conipound  whidi 
he  called  uleapton.  It  has  been  found  in  tuberculosis,  but  it  oceur.s  in 
])atients  who  i)nsfnt  neither  local  lesions  nor  general  disease.  'I'he  urine 
may  be  clear  on  passing,  and  then  darken  on  e.\j)osure  to  the  air,  or  dii 
the  addition  of  licjuor  potassa?.  Tlie  substance  is  ap])arenf!y  without  clui- 
ical  significance  except  in  so  far  as  it,  with  the  other  aromatic  substances, 
is  capable  of  reducing  the  Fehling  solution,  and  may  be  mistaken  for  suirar. 
Clioluria  and  glycosuria  have  already  been  considered  under  jiuuidieo 
and  diabetes.* 

IV.    UR>EIVIIA. 


Under  this  term  is  grouped  a  series  of  manifestations,  chieHy  nervous, 
developing  in  the  course  of  Bright's  disease,  aiul  due  to  the  reteiitidii 
within  the  blood  of  poisonous  materials  which  should  be  eliminated  in 
the  urine. 

Urannia  is  usually  seen  in  nephritis,  but  may  occur  when  the  uictors 
are  obstructed,  or  when  the  circulation  of  blood  in  the  kidneys  is  itii- 
peded,  as  in  conditions  of  extreme  engorgement  following  compressinn  of 
the  renal  vessels  or  in  the  i)rofound  alterations  of  the  blood  in  cholei'ii. 

Two  opposite  views  are  held  ^\ith  reference  to  the  production  u( 
urajmia.  {(()  That  it  is  due  to  the  accumulation  in  the  blood  of  excre- 
mcntitious  material — body  poisons — which  should  be  thrown  olT  hy  llie 
kidney.s.  "If,  however,  from  any  cause,  these  organs  make  default,  or  if 
there  be  any  prolonged  obstruction  to  the  outflow  of  urine,  accuiuulution 
of  some  or  of  all  the  ])oisons  takes  place,  and  the  characteristic  symptoms 
are  manifested,  but  the  accumuiation  may  be  very  slow  and  the  earlier 
sym2)Loms,  corresponding  to  the  comjjaratively  snudl  dose  of  poison,  may 
be  very  slight ;  yet  they  are  in  kind,  though  not  in  degree,  as  iiulicaiivi' 
of  nra'mia  as  are  the  more  alarming,  which  appear  toward  the  eiul,  ami  to 
which  alone  the  name  ura'mia  is  often  given  "  (Carter).  Several  poisons 
having  distinct  actions  have  been  se])arated  from  the  urine  l)y  Houdianl, 
two  of  which  produce  convulsions,  and  one  of  which  is  narcotic.  15oii- 
chard's  observations  tend  strongly  to  confirm  the  view  now  generally  hclil. 
that  the  symi)toms  are  caused  by  the  retention  of  the  excretory  proiluiis. 
The  nature  of  these  poisonous  ingredients  is  not  yet  known.  It  was  for- 
merly thought  that  tlie  urea  was  the  ollending  substance,  and  it  has  Imiii 
found  increased  in  the  blood  in  uraemia.  Others  hold  that  it  is  the  aci  ii- 
mnlation  of  carboiuite  of  ammonia.  It  is  more  probable,  however,  that 
there  are  several  toxic  agents  at  work. 

(b)  Traube  suggested  that  the  chief  symptoms  of  urjemia,  particularly 


*  For  furtlier  details  coneorniiiar  the  urine  tlie  student  is  referred  to  von  .IiiNm  li  ^ 
riinieal  Diiijrnosis,  Tyson  on  llie  Urine,  and  to  IlalUburton's  Text-Book  of  Ciioiniial 
Physiology  and  Patiiology. 


hi  '   .1 


I:      I 


''I 


Ull.EMIA. 


779 


tlio  coma  and  cnnviil.sioiii5,  woro  duo  to  localized  o'donia  of  the  brain.  In 
favor  of  this  view  is  the  fact  that  obstruction  of  tin;  nrctcrs,  as  by  stone, 
(Idcs  not  necessarily  produce  ura>niia,  even  if  long  continued,  and  in  this 
(ilistructive  suppression  neither  convulsions  nor  coma  occur.  Then,  too, 
iiniiiiia  may  sui)erveno  in  a  case  of  chronic  Hright's  disease  in  which  a 
liir-r  amount  of  urine  is  being  j)assed  with  a  fair  jjroportion  of  solids. 
(Ivlnua  of  the  brain  certainly  does  occur  in  some  fatal  cases — it  may  bo 
ililTiisc  or  localized,  but  it  is  not  a  constant  lesion,  ami  cannot  exjtlain  all 
tlic  -ymptoms  of  ura'mia. 

Symptoms. — Cliuicaliy,  acute  and  elironic  unvmia  may  be  recog- 
nized, but,  for  conveiuenco  of  descrij)tion,  it  is  perhaps  best  to  follow  the 
division  of  French  writers  into  cerebral,  dijsjiiia'ic,  and  yadro-intestinnl 
furiiis. 

Among  the  cerebral  manifestations  of  nra'inia  may  be  described  : 

{(i)  Mania. — 'I'liis  inay  come  on  abruptly  in  an  individual  who  has 
sliDWii  no  previous  indications  of  mental  trouble,  and  who  may  not  be 
known  to  have  Bright's  disease.  In  a  remarkable  case  of  this  kind  which 
iiuiir  under  my  observation  the  })atient  became  suddi'uly  n.miacal  and 
(lird  in  six  days.  More  commoidy  the  delirium  is  less  violent,  but  the 
[lulicnt  is  noisy,  talkative,  restless,  ami  sleepless. 

(//)  Delusional  Lisanilj/  {Folic  Brif/Iitiqac). — Cases  are  by  no  means 
uiiiiiiiimoii,  and  excellent  clinical  rejiorts  have  been  issued  on  the  subject 
from  several  of  the  asylums  of  this  country,  ])articularly  by  Bremer, 
Cliiistian,  and  Alice  Bennett.  Delusions  of  persecution  are  common. 
One  of  my  cases  committed  suicide  by  jumping  out  of  a  window.  Tho 
(diidition  is  of  interest  medico-legally  because  of  its  bearing  on  testa- 
iiu'iitary  capacity.     Profound  melancholia  may  also  supervene. 

(r)  foil riilsinas.— 'lln'i^G  may  come  on  unexpectedly  or  be  preceded  by 
jiaiii  in  the  head  and  rcitlessness.  The  attaidvs  may  be  general  and  iden- 
ticid  with  those  of  ordinary  epilepsy,  though  tlie  initial  cry  may  not  bo 
pivsctit.  The  fits  may  recur  rapidly,  and  in  the  interval  the  patient  is 
usually  unconscious.  Sometimes  the  temperature  is  elevated,  but  more 
fn'((ii('ntly  it  is  depressed,  and  may  sink  rapidly  after  the  attack.  Local 
I'V  dacksoiiian  epilepsy  may  occur  in  most  characteristic  form  in  uraimia. 
A  ifiuarkable  sequence  of  the  convulsions  is  blindness — ara'aiic  (ttiiaiirosis 
— wliii  h  may  persist  for  several  days.  This,  however,  nuiy  occur  apart 
lioiu  the  convulsions.  It  usually  passes  oif  in  a  day  (»r  two.  There  are 
lui  ophthalmoscopic  changes.  Sometimes  nratmic  deafness  supervenes, 
.iiid  is  probably  also  a  cerebral  manifestation.  It  ir,ay  also  occur  in  con- 
iKctiuii  with  2)ersistent  headache,  nausea,  and  other  gastric  symptoms. 

('/)  Coma. — Unconsciousness  invariably  accompanies  the  general  con- 
vulsions, but  a  coma  nuiy  develop  gradually  without  any  convtdsive  seiz- 
ures. Fre(piently  it  is  preceded  by  headache,  and  the  patient  gradually 
Ihihiiu's  dull  and  apathetic;.  In  these  cases  there  may  have  been  no  pre- 
vinii<  indiciitions  of  renal  disease,  and  unless  the  urine  is  examined  the 


If" 


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iii 


780 


DISEASES  OF  TflK   KIDNEYS. 


nature  of  tlio  case  may  be  ovorlookod.  Twitchiiigs  of  tlio  mnsclps  occn;', 
particularly  in  the  face  and  hands,  but  there  arc  many  cases  of  coniu  in 
which  the  muscles  are  not  involved.  In  some  of  these  cases  a  condiiioii 
of  torpor  jHM'sists  for  weeks  or  even  months.  The  tongue  is  usually  fmicd 
and  the  l)reath  very  foul  and  heavy, 

{<•)  Local  I'alfiirs. — In  the  course  of  chronic  IJright's  disease  licini- 
plegia  or  monoi)legia  may  oome  on  spontaneously  or  follow  a  eonvul>i(iii, 
and  post  mortem  no  gross  lesions  of  the  brain  be  fouiul,  but  only  a  Idcul- 
iz.ed  or  dilTused  <cdema.  These  cases,  which  are  not  very  uncommon,  inav 
simulate  almost  every  form  of  organic  paralysis  of  cerebral  origin. 

(/)  Of  other  cerebral  symptoms,  headache  is  important.  It  is  most, 
often  occipital  and  extends  to  the  neck.  It  may  be  an  early  feature  ami 
associated  with  giddiness,  Otiier  nervous  symptoms  of  ura'inia  are  intense 
itching  of  the  skin,  numbness  and  tingling  in  the  fingers,  and  cramps  in 
the  muscles  of  the  calves,  particularly  at  night.  An  erythema  may  be 
present, 

Vrivmic  (fi/ftpiio'd  is  classified  by  Palmer  Howard  as  follows:  (1)  Con- 
tinuous dyspncea ;  (2)  paroxysmal  dyspnica;  {'.])  both  types  alternating; 
and  (4)  Cheyne-.Stokes  breathing.  The  attacks  of  dys})no'a  are  most  com- 
monly nocturnal ;  the  patient  may  sit  up,  gasp  for  breath,  and  evince  as 
much  distress  as  in  true  asthma.  Occasionally  tiie  breathing  is  noisy  iiml 
stridulous.  The  C'heyne-Stokes  type  may  persist  for  weeks,  and  is  luit 
necessarily  associated  with  coma,  I  have  seen  it  in  a  man  who  tnivellcil 
over  a  luindred  miles  to  consult  a  jihysician.  In  another  instance  a  pa- 
tient, up  aiul  about,  could  only  when  at  meals  feed  himself  in  the  apmeu 
period.  Though  usually  of  serious  omen  and  occurring  with  coma  ami 
other  symptoms,  recovery  nuiy  follow  even  after  persistence  for  weeks  el- 
even months, 

l^hv  f/asfro-ui/esiiiwl  manifestations  of  ura;mia  often  set  in  with  alii'!i|it- 
ness.  Uncontrollable  vomiting  may  come  on  and  its  cause  be  quite  nii- 
recognizablc,  A  young  married  wonum  was  admitted  to  my  wards  in  llie 
^lontreal  (Jeneral  nos{)itaI  with  jiersistent  vomiting  of  four  or  live  days' 
duration.  The  urine  was  slightly  albuminous,  but  she  had  iu)ne  of  llie 
usual  signs  of  uniMuia,  and  the  case  was  not  regarded  as  one  of  Brighi's 
disease.  The  vomiting  persisted  and  caused  death.  The  post-mortem 
showed  extensive  sclerosis  of  both  kidneys.  The  attacks  nuiy  be  prceedid 
by  nausea  and  may  be  associated  with  diarrluca.  In  some  instances  tlie 
diarrhu'a  may  come  on  without  the  vomiting;  sometimes  it  is  profuse  ami 
associated  with  an  intense  catarrhal  or  even  diphtheritic  inllammatiun  ef 
the  colon, 

A  special  urannic  stomatitis  has  been  described  (Barie)  in  Avhieh  t!ie 
mucosa  of  the  lips,  gums,  and  tongue  is  swollen  and  erythematous.  'I  lie 
saliva  may  be  increased,  aiul  there  is  ditticulty  in  swallowing  and  in  ma - 
tication.  The  tongue  is  usually  very  foul  and  the  breath  heavy  and  IV' 1 1. 
A  cutaneous  erytheiiui  nuiy  be  present  in  uraMuia. 


UR.EMIA. 


Ibi 


Diagnosis. — Unvinia  may  bo  oonfotiiKlod  with  : 

in)  ('('ri'l)nil  h'sions,  siicli  as  lia'tuorrliaf^e,  nu'iiiiigitis,  or  ovoti  tumor. 
Ill  ajKipli-xy,  which  is  so  commonly  associated  with  tcidiu'y  disease  and 
stilT  arteries,  the  siuhU'ii  loss  of  consciousness,  particularly  if  with  con- 
viil-miis,  may  simulate  a  ura'mio  attack;  hut  the  mode  of  onset,  tiie 
cxisU'iu'c  of  complete  heiniple<,da,  with  conju<;ate  deviation  of  the  eyes, 
siiL-'Licst  lui'morrhage.  As  already  noted,  tliere  a"e  cases  of  uramiie  hemi- 
|tlc;;ia  or  monoi)le<^ia  which  cannot  be  seimrated  from  those  of  orfjanic 
lisiini  ami  which  post  mortem  show  no  trace  of  coarse  disease  of  the 
brain.  1  know  of  an  in.stance  in  which  a  consultation  was  held  uj)()n  tiie 
propriety  of  operation  in  a  case  of  hemiple^xin  believed  to  be  due  to  sub- 
dural huMuorrhage  whieii  post  mortem  was  shown  to  be  uraMiiic.  Indeed, 
in  some  of  these  eases  it  is  cpiite  impossible  to  distinguish  between  the 
two  conditions.  So,  too,  eases  of  meningitis,  in  a  condition  of  deep  coma, 
with  perhaps  slight  fever,  furred  tongue,  and  without  localizing  symptoms, 
may  readily  be  confounded  with  ura>mia. 

(A)  With  certain  infectious  diseases.  Uraemia  may  persist  for  weeks 
or  iiionths  and  the  patient  lies  in  a  condition  of  torjmr  or  even  uncon- 
SL'idiisiu'ss,  with  a  heavily  coated,  perhaps  dry,  tongue,  muscular  twitchings, 
a  rapid  feeble  pulse,  with  slight  fever.  This  state  not  unnaturally  suggests 
tlk'  existence  of  one  of  the  infectious  diseases.  Cases  of  the  kind  are  not 
uiK'duimon,  and  I  have  known  them  to  be  mistaken  for  typhoid  fever  and 
for  miliary  tuberculosis. 

{(•)  UraMuic  coma  may  bo  confounded  with  poisoning  by  jdcohol  or 
upiuiu.  In  opium  poisoning  the  pupils  are  contracted;  in  alcoholism  they 
arc  more  commonly  dilated.  In  ura-mia  they  are  not  constant ;  they  nuiy 
be  either  widely  dilated  or  of  medium  size.  The  exannnation  of  the  eye- 
gruiiud  should  be  made  to  determine  the  j)resence  or  absence  of  albumi- 
nuric retinitis.  The  urine  shoidd  bo  drawn  off  and  examined.  The  odor 
of  the  breath  sometimes  gives  an  important  hint. 

The  condition  of  the  heart  and  arteries  should  also  be  taken  into  ac- 
count. Sudden  uraemic  coma  is  more  common  in  the  chronic  interstitial 
lu'phritis.  The  character  of  the  delirium  in  alcoholism  is  sometimes  ini- 
[lortant,  and  the  coma  is  not  so  deep  as  in  uraemia  or  opium  poisoning. 
It  may  for  a  time  be  impossible  to  determine  whether  the  condition  is 
diu'  to  ura;mia,  profound  alcoholism,  or  haemorrhage  into  the  pons  Varolii. 

And  lastly,  in  connection  with  sudden  coma,  it  is  to  be  remembered 
thai  insensibility  may  occur  after  prolonged  muscular  exertion,  as  after 
running  a  ten-mile  race.  Cases  have  been  reported  in  which  uncon- 
sciousness came  on  rapidly  with  stertorous  breathing  and  dilated  pui)ils. 
Cases  have  occurred  under  conditions  in  which  sun-stroke  could  be  ex- 
chuled;  and  Pooro,  who  reports  a  case  in  the  Lancet  (1894),  considers  that 
the  condition  is  due  to  the  too  rapid  accumulation  of  waste  products  in 
the  blood,  and  to  hyperpyrexia  from  suspension  of  sweating. 

i'ho  treatment  will  be  considered  under  Chronic  Bright's  Disease. 


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niSRASKS  OK  TIIK   K'IDN'KYS. 


i 


V.   ACUTE    BRIGHT'S    DISEASE. 

Definition. — Acute  dilTuse  n('])lu'itis,  due  to  the  action  of  cold  or  of 
toxic  uj^eiits  upon  the  kidneys. 

In  idl  instances  cliiiuj^es  exist  in  the  epithelial,  Viiscular,  and  ititcr- 
tubiilar  tissues,  whicli  vary  in  intensity  in  iliiTerent  forms;  hence  writcis 
have  described  a  tuhidar,  a  <i:loinenilar,  and  an  acute  interstitial  iicphriiis. 
Dolafield  recognizes  itcKtc  vxuddlirr  and  anitf  productive  forms,  tlie  liitlcr 
characterized  hy  proliferation  of  tl>e  connective-tissue  stroma  and  of  tlic 
cells  of  tin   ^ralj)!nhian  tufts. 

Etiology. —  The  following  are  the  })rincipal  causes  of  acute  iie- 
])hritis  : 

(I)  Cold.  Exposure  to  cold  and  wet  is  one  of  the  most  common  causis. 
It  is  particularly  prone  to  follow  exposure  after  a  drinking-bout. 

{'i)  The  poisons  of  the  specilic  fevers,  particularly  scarlet  fever,  less 
commonly  cyjdioid  fever,  measles,  diphtheria,  small-pox,  chicken-pox,  uia- 
laria,  cholera,  yellow  fever,  meningitis,  and,  very  rarely,  dysentery.  Acute 
nephritis  is  not  often  associated  with  syphii's.  In  acute  tuherculosi.s 
nephritis  is  not  uncommon.     It  may  also  occur  in  sejjticicmia. 

(;J)  Toxic  agents,  such  as  tur])entine,  cantharides,  chlorate  of  pota.-h, 
and  carbolic  acid  may  cause  an  acute  congestion  which  somctinu's  ter- 
minates in  neidiritis.     Alcohol  probably  never  excites  an  acute  nephritis. 

(4)  Pregnancy,  in  which  the  condition  is  thought  by  some  to  result 
from  compression  of  the  renal  veins,  althongh  this  is  not  yet  iiiudly  settleil. 
The  condition  may  in  reality  be  due  to  toxic  jiroducts  as  yet  undeteriuined. 

(5)  Acute  nephritis  occurs  occasionally  in  connection  with  exteusivo 
lesions  of  the  skin,  as  in  burns  or  in  chronic  skin-diseases. 

Morbid  Anatomy. — The  kidneys  may  ])resent  to  the  iud<ed  eye  in 
mild  cases  lu)  evident  alterations.  When  seen  early  in  more  severe  forms 
the  organs  are  congested,  swollen,  dark,  and  the  section  may  drip  hloml. 
In  other  instances  the  surface  is  pale  and  mottled,  the  capsnle  strips  mH' 
readily,  and  the  cortex  is  su^dlen,  tur])id,  and  of  a  grayish-red  color,  wliile 
the  pyramids  have  an  intense  beefy-red  tint.     The  glomeruli  in  some  in 


In  i: 

I:! 

I  '<-')     !■■■ 


1  of  cold  iir  of 

ir,  and  inlcr- 
luMice  writci's 
tiiil  ?u'])lirilis, 
■ms,  till'  liitti  r 
lU  and  of  ilic 

of   acute   i!f- 

nimoii  L'ausLs. 
out. 

I't  fovof,  !(■>> 
kon-})(>-\,  iiiii- 
itcry.  Acute 
tuberculof'Ls 

to  of  potash, 
)inotinu's  [w- 
to  noi)liritis. 
)ino  to  result 
iiially  settlnl. 
ndi'terniinrd. 
itli  cxtonsi\.' 

luiki'd  eve  in 
si'vciv  forms 

y  drip  hlool. 

uilo  stri|)s  "11 
I  color,  wlii'i' 
i  in  some  i;' 


ACUTE   niUUIIT'S   DISKASK. 


i,S3 


stam-es  stand  out  iiluinly,  lieeply  swollen  aiul  eonfjosted  ;  in  other  instaneos 
they  are  pale, 

'Pile  histology  may  he  tlui.s  sununarized  :  (d)  (llotuerular  chanj^'es.  In 
;:  uiiijority  of  tho  cases  of  nephritis  due  t(i  toxic  K<,'ents,  which  reach  the 
kidney  through  the  lilood-vessels,  the  tufts  siilTer  first,  and  there  is  either 
lUi  acute  intraeapillary  glonierulitis,  in  whiidi  the  capillaries  heeoine  lilled 
wilh  cells  and  thntinhi,  or  invdlvenicnt  of  the  epillieliuni  of  the  tuft  and 

of  Hnwman's  capsule,  the  cavity  of   wlii(di  contains  leiu ytcs  and   reil 

blood-corpuscles.  Hyaline  degeneration  of  the  contents  and  of  the  walls 
of  the  capillaries  of  the  tufts  is  an  cxtrenieiy  coininon  event.  These  pro- 
cesses are  jierhaps  hest  niarketl  in  scarlatinal  nephritis.  There  may  l)e 
proliferation  ahoiit  liowman's  capsulu.  These  clianges  interfere  with  the 
circulation  in  the  tufts  and  seriously  inJlucnce  the  nutrition  of  the  tiiliular 
structures  beyond  them. 

(A)  The  alterations  in  tlie  tulmlar  e|)itlielium  consist  in  cloudy  swell- 
iiiir,  fatty  change,  and  hyaline  degeneration.  In  the  convoluted  tulmles, 
the  aceunmlation  of  altered  cell  with  leucocytt's  and  I)lood-corpuaclcs 
causes  the  enlargeincnt  and  swelling  of  tlio  organ.  The  e]»ithelial  cells 
lose  their  striation,  the  nuclei  are  ohscured,  and  hyaline  droplets  often 
iicciiuiulate  in  tliein. 

(r)  interstitial  change-!,  lii  tho  milder  forms  a  simple  inilammatory 
c\u(late — serum  mixed  with  leucocytes  and  red  hlood-corpuscles — exists 
between  the  tubules.  In  severer  cases  areas  of  small-celled  iiililtration 
occur  about  the  ca])sulesaii<l  between  the  convoluted  tubes.  'I'hese  elianges 
may  1)0  wide-spread,  and  uniform  throughout  the  organs  or  more  iuteuso 
ill  certain  regions. 

Symptoms. — The  onset  is  usually  sudden,  and  when  the  nephritis 
follows  cold,  dropsy  may  bo  noticed  within  twenty-four  hours.  After 
fevers  tho  onset  is  less  abrujit,  I)ut  tho  patient  gradually  becomes  pale  and 
a  jiutHnoaa  of  the  face  or  swelling  of  the  ankles  is  tirst  noticed.  In  chil- 
dren there  may  at  the  outset  be  convulsions.  Chilliness  or  rigors  initiate 
the  attack  in  a  liinited  number  of  eases.  Pain  in  the  back,  nausea,  and 
vomiting  may  be  present.  Tho  fever  is  variable.  ^lany  cases  in  adults 
have  no  rise  in  temperature.  In  young  children  with  nephritis  from  cold 
or  scarlet  fever  the  temperature  may,  for  a  few  days,  range  from  1U1°  to 

iu;}°. 

The  most  characteristic  symjitonis  are  thc^  urinaiy  changes.  There 
may  at  first  be  suppression.,  nu)ro  commonh,  lie  urine  is  scanty  and 
highly  colored  and  contains  blood,  albumin,  and  tube-casts.  The  quantity 
is  I'cduced  aiul  only  four  or  five  ounces  may  be  passed  in  the  twenty-four 
hoars;  the  specific  gravity  is  high — lO:^"),  or  even  more;  the  color  varies 
from  a  smoky  to  a  deep  porter  color,  but  is  seldom  bright  red.  On  stand- 
ing there  is  a  heavy  deposit ;  microscopically  there  are  blood-corpuscles, 
epithelium  from  the  urinary  passages,  and  casts,  hyaline,  blood,  and  epithe- 
lial in  character.     The  albumin  is  abundant,  forming  a  curdy,  thick  pre- 


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DISKASKS   OF  TIIK   KIDNKYS. 


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ci|)itiit(\  Tlio  totiil  excretion  of  urea  is  reduced,  tli()U;,'li  tlie  jier(iiii,i:.r(. 
is  iii;xii. 

Aiueiiiiii  is  lui  early  and  !iiari\e(l  syiiiptum.  Tii  cases  of  e\tciiM\c 
dropsy,  efTiisioii  may  take  place  into  tiie  plenra'  and  peritoa'nnni.  There 
are  eases  of  scarlatinal  nephritis  in  wliicli  tlie  droi>sy  r)f  i|i(«  extrcinilii<  is 
trivial  and  elViision  int(»  the  })li'ura'  extensivt".  The  hint's  may  Ikcoiii,. 
(edematous.  In  rare  cases  there  is  a'deina  of  the  <(lottis.  Kpistaxis  niiu 
occur  or  cntaneons  eccliynM)ses  may  develop  in  the  course  of  the  disca.-c. 

'i'he  pidse  may  l»e  hard,  the  tension  increased,  and  the.  second  jKuiic 
sound  accentuuted.  Occasionally  dilatation  of  the  iicart  comes  on  rii|ii(|ly 
und  may  cause  sudden  death  ((Joodhart).  'i'he  skin  is  dry  and  it  may  lie 
dillicult  to  induce  s\veatillJ,^ 

TraMuie  symptoms  develop  in  a  limited  numher  of  eases.  Tlicy  iiiav 
occur  at  the  onset  with  suppression,  more  conimoidy  later  in  the  di>i'a>r. 
Ocidar  eluui^es  arc*  not  so  common  in  acute  as  in  chronic  Britrht's  dixasc, 
but  ha'morrhaj^ic  retinitis  may  occur  and  occasionally  papillitis. 

The  cours(*  of  acute  Urii,dit's  disease  varies  considerably.  The  descrip- 
tion just  ;,q\en  is  of  the  form  which  most  commoid^,  follows  cold  or  scarlri 
fever.  In  many  of  the  febrile  cases  dropsy  is  not  u  prominent  sym|itnin. 
und  the  dia^fuosis  rests  riithor  with  the  examination  of  the  urine.  .More- 
over, the  condition  may  be  transient  and  less  seriou.s.  In  otlu'r  cases,  as 
in  the  acute  ne[)hritis  of  ty])hoid  fever,  there  may  bi;  Inematuria  and  prn- 
nouneed  signs  of  interference  with  the  renal  function,  '''he  most  intense 
acut(!  nej)hritis  may  exist  without  anasarca. 

In  .scarlatinal  nephritis,  in  whii'h  the  glomeruli  ar  ..  seriously  af- 

fected, suppression  of  the  urine  may  be  an  early  .symptom,  the  drojisy  is 
apt  to  be  extreme,  and  uraMuic  manifestations  are  common.  Aeiiie 
Bright's  di.soa.se  in  children,  however,  may  set  in  very  insidiously  and  lie 
associated  with  transient  or  slight  (edema,  and  the  sym])toms  may  puiiit 
rather  to  atTection  of  the  digestive  system  or  to  brain-disea.se. 

Diagnosis. — It  is  very  important  to  bear  in  mind  that  the  most  seri- 
ous involvement  of  the  kidneys  may  l)e  manifested  oidy  by  slight  o'diMiia 
of  the  feet  or  puthness  of  the  eyelids,  without  im})airment  of  the  gen- 
eral health.  I'he  first  indication  of  trouble  may  be  a  ura?mic  convulsidii. 
This  is  particularly  the  case  in  the  acute  nephritis  of  pr(^gnancy,  and  it  is 
a  good  rule  for  the  practitioner,  when  engaged  to  attend  a  case,  invarialil\ 
to  ask  that  during  the  seventh  and  eighth  months  the  urine  should  ueea- 
sionally  be  sent  for  examination. 

In  nepliritis  from  cold  and  in  scarlet  fever  the  symptoms  are  usually 
marked  and  the  diagnosis  is  rar(dy  in  doubt.  As  already  mentioiinl. 
every  case  in  which  albumin  is  present  mu.st  not  be  called  acute  Briglits 
disease,  not  even  if  tube-casts  bo  present.  Thus  the  common  febrile  allni- 
nuiuiria,  altlunigh  it  represents  the  first  link  in  the  chain  of  events  Icatiiir.' 
to  acute  Brighfs  di.sease,  should  not  be  i)la(?cd  in  the  same  category. 

There  are  occasional  cases  of  acute  Briijht's  disease  with  anasarca,     j 


!li  ! 


ACfTK    lillKillT'S    DISKASK. 


<'' 


wlmli  iilliiiiiiiii  is  cillicr  iiliscnt  or  present  only  !is  ii  tnicc  'I'liis  is  a  rare 
coiiiiilion.  Tnlx'-casts  are  nsnally  Foniid,  and  tlie  ahsriice  of  albumin  is 
laii  i.v  permanent.     'I'iie  nrine  may  be  rediieeij  in  anmuiit. 

'I'iie  ciiaracter  of  tlie  casts  is  of  use  in  tlie  diafifnosis  of  the  form  of 
I'.iiu'lil's  disease,  Iml  scarcely  of  such  extreme  value  as  lias  been  stated. 
Tims,  the  hyaline  and  jiiannlar  casts  are  common  to  all  varieties,  'i'lu' 
lildiid  and  opithelial  casts,  particularly  tlioso  nuulu  up  of  leucocytes,  are 
iiin-t  common  in  tiu'  ucuto  cases. 

Prognosis. — The  outlook  varies  sotuewluit  with  the  cause  of  the 
disease.  Ilecoveries  in  the  form  foUowini;  exposure  to  cold  are  much 
iiKirc  fref|uent  than  after  scarlatinal  m'phrilis.  in  youn;.?  children  the 
iiKiriality  is  hi;:ii,  amountin<,'  to  ut  least  one  third  of  tlio  cases.  Serious 
symptoms  are  hnv  artoriul  tension,  the  occurrence  of  m'aMuia,  and  elTu- 
>iiin  into  the  sentus  sacs.  'I'ho  jiersistence  of  the  dropsy  after  the  first 
iiHiiith,  intense  pallor,  and  a  lar<,'e  amount  of  all)umin  in<licate  the  ])ossi- 
hility  of  the  di.sease  becomin<^  chronic.  l''or  .some  UH)nths  after  the  dis- 
iippearanco  of  the  droj)sy  there  may  bo  traces  of  albumin  and  a  few  tube- 
casts. 

in  a  week  or  ten  days,  in  a  case  of  scarlatinal  nephritis,  if  the  pi'oixross 
is  favorable,  the  dropsy  diminishes,  the  urine  increases,  the  albumin  less- 
ciis.  iiiul  by  the  end  of  a  month  the  dropsy  has  disappeari'd  and  the  urine 
is  nearly  free,  in  very  youn^  c'liKlreii  the  course  may  be  rapid,  and  I 
have  known  the  urine  to  be  free  fiom  albumin  in  the  fourth  week.  Other 
cases  are  nu)re  insidious,  ami  thouj^h  the  dropsy  may  disap{)ear,  the  albii- 
iiiiu  persists  in  the  urine,  the  ana-mia  is  nuirked,  and  the  condition  be- 
ciiiiies  chronic,  or,  after  several  recurrences  of  the  ilrojisy,  improves  and 
e(i!n|iletc  recovery  takes  place. 

Treatment. — 'I'he  i)atient  should  l)o  in  l)cd  and  there  remain  until 
all  traces  of  the  disease  have  disappeared.  As  sweatini;  plays  such  an 
important  jtart  in  the  treatment,  it  is  well,  if  possible,  to  accustom  the 
imtient  to  blankets.     lie  should  also  be  clad  in  thin  Canton  flannel. 

The  diet  should  consist  of  milk  or  butter-milk,  firuels  nuule  of  arrow- 
fiMit  or  oat-nu'al,  barley  water,  and,  if  necessary,  beef  tea  and  chicken 
lii'ntii.  it  is  better,  if  possible,  to  coniine  the  ])atient  to  a  strictly  milk 
dirt.  As  couvalescenco  is  established,  l)read  and  huttcr,  lettuce,  water- 
ii'ess,  grapes,  oranges,  and  other  fruits  may  be  jxiveii.  T'lie  return  to  a 
meat  diet  should  be  gradual. 

The  patient  should  drink  freely  of  alkaline  mineral  waters,  ordinary 
water,  or  lemonade.  The  lluids  keep  the  kidneys  Hushed  and  wa^h  out 
tile  ili'hris  from  the  tubes.  A  useful  driidc  is  a  drachm  of  creau)  of  tartar 
in  :i  [lint  of  boiling  water,  to  which  may  be  added  the  juice  of  half  a  lemon 
and  a  little  sugar.  Taken  vvheu  cold,  this  is  a  pleasant  and  satisfactory 
•liliient  drink. 

No  remedies,  so  far  as  known,  control  directly  the  changes  which  arc 
going  on  in  the  kidneys.     The  indications  are :    (1)  To  give  the  excretory 


J  4)--,-  - 


A  J 


i) 


786 


DISEASES  OF  THE  KIDNEYS. 


function  of  tlie  kidney  rest  by  util'-/;ing  the  skin  und  the  bowels,  in  liic 
liope  thiit  the  natural  processes  maybe  sufficient  to  effect  a  cure ;  (-,1)  to 
meet  the  sym])toms  as  they  arise. 

Jn  a  case  of  scarlet  fever  it  may  occasionally  be  possible  to  aviTl  nn 
attack,  the  premonitory  sym^jtoms  of  Avhich  are  marked  increase  in  ilu. 
arterial  tension  and  the  presence  of  blood  coloring  matter  in  the  mine 
(Mahomed).  An  active  saline  cathartic  may  comjiletely  relieve  tliis  <i.n- 
dition. 

At  the  onset,  when  there  is  pain  in  the  back  or  hannaturia,  the  (li\  cr 
wet  cups  give  relief.  The  latter  should  not  be  used  in  children.  W  arm 
poultices  are  often  grateful.  In  cases  Avhich  set  in  with  suppression  of 
urine,  these  nu'asures  should  be  adopted,  and  in  addition  the  hot  'naih 
with  subse(iuent  ])iick,  copious  diluejits,  and  a  free  purge.  The  dr()j)sv  is 
best  treated  by  hydrother-ipy — either  the  hot  bath,  the  wet  i)ack,  or  tlii- 
hot-air  bath.  In  children  the  wet  pack  is  usually  satisfactory.  It  is  ap- 
plied by  wringing  a  blanket  out  of  hot  water,  wrajipijig  the  child  in  it, 
covering  this  with  a  dry  blanket,  and  then  with  a  rubber  cloth.  In  tliis 
the  child  may  remain  for  an  hour.  It  may  be  repeated  daily.  In  the  case 
of  adults,  the  hot-air  bath  or  the  vapor  bath  may  be  conveniently  given  hv 
allowing  the  vapor  or  air  to  pass  from  a  funnel  beneath  tho  bed-elotlies, 
which  are  raised  cm  a  low  cradle.  3Iore  efficient,  as  a  ride,  is  a  hot  bath  df 
from  fifteen  or  twenty  minutes,  after  which  the  patient  is  wrapped  in 
blaidvcts.  The  sweating  produced  by  these  measures  is  usually  profuse, 
rarely  exhausting,  and  in  a  majority  of  cases  the  dropsy  can  in  this  way  hv 
relieved.  There  are  some  case?,  however,  in  which  the  skin  does  not  ic- 
spond  to  the  baths,  and  if  the  symptoms  are  serious,  parti(udarly  if  nrainia 
su))ervenes,  jaborandi  or  its  active  principle,  pilocar])iue,  nniy  be  nscd. 
The  latter  may  be  given  hypodermically,  in  doses  of  from  a  sixth  to  an 
eighth  of  a  grain  in  adults,  and  from  a  twentieth  to  a  twelfth  of  a  grain  in 
children  f*om  two  to  ten  years.  It  is  a  drug  to  be  used  with  care.  1 
a1>andoned  its  employment  for  many  years,  after  having  several  cases  of 
serious  collapse.     Latterly  I  have  resumed  its  use,  often  with  benefit. 

The  bowels  should  be  kept  open  by  a  morning  saline  purge  ;  in  cliildivn 
the  fluid  magnesia  is  readily  taken  ;  in  adtdts  the  sulphate  of  magnesia  may 
be  given  by  Hay's  method,  in  concentrated  form,  in  the  morning,  before 
anything  is  taken  into  the  stomach.  In  Bright's  disease  it  not  infreqnenlly 
causes  vomiting.  The  com])ound  powder  of  jalap,  in  half-drachm  doses, 
or,  if  necessary,  elaterium  may  be  used.  If  the  drojjsy  is  not  extr  mv,  the 
urine  not  very  concentrated,  and  ura>mic  symptoms  are  not  pnsent,  ihi' 
bowels  slundd  be  kept  h.ose  without  active  purgation.  If  these  mensiu'es 
fail  to  reduce  the  dropsy  and  it  has  become  extreme,  the  sk  n  nuiy  he 
punctured  with  a  lancet  or  drained  by  a  small  silver  canula  (Southey's 
tube),  w.wch  is  inserted  beneath  it.  A  fine  aspirator  Tieedle  may  I"' 
used,  and  the  fluid  allowed  to  drain  through  a  piece  of  long,  naiinw 
rubber  tubing  into  a  vessel  beneath  the  bed.     If  the  dyspna'a  is  nnirked. 


3  bowels,  in  ihi- 
•t  a  cure;  {'i)  lu 

iiblc  to  iiviM't  ;iii 

iucroiiso  in  tlu' 

ter  in  tlu'  iiriiu' 

relieve  tliis  cou- 

turiii,  tlio  (In  (ir 
•bildn'ii.     Warm 
h  siipi)ressi(Hi  ^f 
on  tlio  bdl  lialli 
>.     Tbo  (ln)])>y  is 
wet  pucli,  iir  the 
'ac'tory.     It  is  aji- 
1/  tbe  cbild  in  it. 
er  clotb.     In  this 
laily.     lu  the  case 
roniently  given  hv 
li  tb-':  betl-eldtlies, 
le,  is  a  bot  balli  nf 
lilt  is  wrai)i)e»l  in 
s  usually  iinil'iise, 
can  in  tbis  \va\  lie 
!  skin  tloos  not  re- 
ieularly  if  uraniia 
ue,  may  be  useil. 
•om  a  sixtb  to  an 
elftb  of  a  grain  in 
sed  with  care.    1 
g  several  cases  of 
witb  benefit. 
)urge;  in  eliii<bvii 
of  magnesia  may 
nu)rning,  lief  ore 
it  notinfreqni'nily 
lalf-dracbm  dci^es, 
s  not  extr  me,  the 
not  pr(  sent,  i1m' 
If  these  measures 
tbo  sk  n  rnav  he 
[•anula  (SoiitlieyV 
1)1-  needle  may  1"' 
of  long,  uan'ow 
yspna>a  is  mavluMl, 


CHRONIC   BRIGIIT'S  DISEASE. 


787 


owing  to  pressure  of  fluid  in  tbe  pleura^  aspiration  sliould  he  jiorformed. 
bi  rare  instances  tlie  ascites  is  ev'^^reiiie  ami  may  require  paracentesis,  or  a 
Southev's  tube  may  be  inserted  and  tbe  fluid  grade  My  witbdrawii.  If 
ura'inic  ecmvulsions  oe;  ur,  tbe  intensity  of  tbe  paro.  ~.iis  nniy  ])e  limited 
|)V  the  use  of  cbloroi'orni  ;  to  an  adult  a  ])ilocar]tine  injection  should  l)e  at 
iiiiec  given,  and  from  a  robust,  strong  man  twei  ,  .h  uees  of  blood  may  be 
withdrawn.  In  idiildren  tbe  loins  may  be  dry  eu^.^ied,  tbe  wet  pack  used, 
;iiui  a  brisk  piirgative  given.  Bromide  of  jxjtassium  and  ebloral  sometimes 
pyiive  useful. 

\'()mitiug  may  bo  relieved  by  ice  and  by  restricting  tbo  anu)unt  of  food. 
Drop  doses  of  creosote,  iodine,  ami  cai'bolic  acid  may  be  given.  Tbe  dilute 
hvdi'ocyanic  acid  witb  bisnuitb  is  often  effectual. 

Tbe  question  of  tbe  use  of  diuretics  in  acute  Brigbt's  disease  is  not  yet 
setth'il.  Tbe  best  diuretic,  after  all,  is  water,  wbicb  may  I)e  taken  freely 
with  tlio  citrate  of  potash  or  tbe  benzoate  of  soda,  salts  wliicb  are  lield  to 
fiivor  the  conversion  of  the  urates  into  less  irritating  and  more  easily  ex- 
ereled  compounds.  Digitalis  and  stroi)bnntbus  are  useful  diuivtics,  ami 
niav  bo  emidoyeel  without  risk  when  tbo  arterial  tension  is  low  ami  the 
eanliac  im])ulsc  is  not  forcible.  I  bavo  never  seen  any  injurious  effects 
from  their  employment  after  tbe  early  symptom.-  bad  lessi'iu'd  in  intensity. 

For  the  persistent  albuminuria,  I  agree  with  lioberts  and  liosenstein 
tlial  we  have  lU)  remedy  of  the  sligbtest  value.  Xotbing  indii'atcs  nu)ro 
elearly  our  belplessncss  in  controlling  kidney  metabolism  tluin  inability  to 
meet  this  common  symi)tom.  Astringents,  alkalies,  nitroglycerin,  and 
iiiereiiry  ba/0  been  recommended. 

For  tbe  ana-mia  always  associated  with  acute  Bi'igbt's  disease  iron 
should  bo  employed.  It  should  not  be  given  until  tbe  acute  sym])tom3 
have  subsided.  In  tbe  adult  it  may  be  used  in  tbe  fortn  of  tbe  percldorido 
in  increasing  doses,  a.;  convalescence  proceeds  In  cbildren,  tbe  syrup  of 
the  iodide  of  iron  or  tbe  syrup  of  the  pbosjduito  of  iron  are  better  prejiara- 
tioiis.  The  dilatation  of  tbe  heart  is  best  treated  with  digitalis,  stro])ban- 
tluis,  and  strycbnia. 

In  the  convaloscenco  from  acute  Brigbt's  disease,  care  should  be  taken 
to(,niard  tlu^  patient  against  cold,  'i'be  diet  should  still  consist  cbiefly  of 
milk  and  a  return  to  inixed  food  should  be  gradual.  A  change  of  air  is 
often  beueficial,  particularly  a  residoiue  in  a  warm,  equable  clinuite. 


VI,  CHRONIC   BRIGHT'S  DISEASE. 

Here,  too,  in  all  forms  we  deal  witb  a  dilTuse  process,  involving  epi- 
thelial, interstitial,  and  glomerular  tissues^  Clinically  two  groups  are  rec- 
01,'iiized — (rt)  the  chronic  parenchymatous  nephritis,  which  follows  the 
iieute  attack  or  comes  on  insidiously,  is  characterized  by  marked  dropsy, 
iiuil  ])ust  mortem  by  the  larije  white  kidney.     In  the  later  stages  of  this 


00 


t'r; 


trtj 


mm 


wm 


r-ir 


il  i 


■MJ.'I 


|l  I  "  I 
ir  t        f 


788 


DISEASES  OP  THE   KIDNEYS. 


process  the  kidney  may  be  smaller — a  condition  known  as  the  small  irhi/e 
kidney;  (/j)  chronic  inlcrstitial  nephritis,  in  which  dro[)sy  is  not  coimudu 
and  the  cardio- vascular  changes  are  pronounced.  Dclalield  rc(!()i,niixL's  a 
chronic  diffuse  nephritis  witli  exudation  and  a  chronic  productive  diaiisc 
nephritis  without  exudation,  the  latter  corresponding  to  the  contracti'd 
kidney  of  autiiors. 

The  amyloid  kidney  is  usually  spoken  of  as  a  variety  of  Brighfs  (h>- 
ease,  but  in  reality  it  is  a  degeneration  which  may  accompany  any  lonn 
of  nephritis. 

♦•w-'Tslui'miiiiiil •"'iu»- 

ClIUONIC    P.VllKNCIIYMATOUS  NEPHRITIS 

(Chronic  Desquamative  and  Chronic  Tubal  Xcphritis;  Chronic  Diffuse  Nephritis  icilh 

Exndatiiiu). 

Etiology. — In  many  cases  the  disease  follows  the  acute  nephritis  of 
cold,  scarlet  fever,  or  pregnancy.  More  fre(|ueiiUy  than  is  usually  staled 
the  disease  lias  an  insidicjus  onset  and  occurs  independently  of  any  acule 
attack.  The  fevers  may  play  an  important  role  in  certain  of  these  cases. 
Rosenstein,  Bartels,  and,  in  this  country,  I.  E.  Atkinson  have  laid  s})ccial 
stress  u])on  malaria  as  a  cause.  Acute  nephritis,  usually  lianuorrliagie,  is 
not  very  uncommon,  but  we  have  had  no  instance  of  chronic  ne|iluiiis 
following  directly  malarial  fever.  Beer  ami  alcohol  are  believed  to  lead 
to  thifc  form  of  nepliritis.  In  chronic  suppuration,  syphilis,  and  tuljcrcii- 
losis  tl.'C  diffuse  parenchymatous  nephritis  is  not  uncommon,  and  is  usu- 
ally associated  v/ith  amyhjid  disease.  Males  are  rather  more  subject  to 
the  affection  tlian  females.  It  is  met  with  most  commonly  in  yoiiii;' 
adults,  and  is  by  no  means  infrecpient  in  cliildren  as  a  sequence  of  scar- 
latinal nephritis. 

Morbid  Anatomy.— Several  varieties  of  this  form  have  been  reco^- 
nizO(i.  The  most  common  is  the  larup  white  kidnejj  of  Wilks,  in  whicli 
the  organ  is  enlargiMl,  the  capsule  is  thin,  and  the  surface  wliitc  with 
the  stellate  veins  injected.  On  section  tlie  cortex  is  swollen  and  ycli(i\vi>h 
white  in  color,  and  (»ften  presents  o})a(jue  areas.  The  pyramids  may 
be  deeply  congestc<l.  On  microscopical  examiiuition  it  is  seen  that  the 
epithelium  is  granular  and  fatty,  and  the  tubules  of  the  cortex  are  dis- 
tended, and  contain  tube-ca.sts.  Hyaline  changes  are  also  present  in  tlic 
epithelial  cells.  TJie  glomeruli  are  large,  the  capsu'"s  thickeiu'il,  tlio 
capillaries  show  hyaline  changes,  and  the  epithelium  of  the  tuft  and  <d 
the  ca])suli'  is  extensively  altered.  The  interstitial  tissue  is  everywlieie 
increased,  though  m»t  to  an  extreme  degree. 

Tlie  second  variety  of  this  form  results  from  the  gradual  increase  in 
the  coniu>ctive  tissue  and  the  subsequent  sjirinkage,  forming  wliut  is  calKd 
the  smiill  v'hite  kiihieji  or  the  pale  granular  kidney.  It  is  doiditfu! 
Avhether  this  is  always  preceded  by  the  large  white  kidney.  Some  observers 
hold  tiiat  it  may  be  a  primary  independent  form.     The  capsule  is  tliiek- 


any  any  tonn 


e  Nephritis  with 


u'lice  of  s'ur- 


CHRONIC  BRIGHT'S   DISEASE. 


789 


encd  and  the  surface  is  roiigli  and  granular.  On  section  tlie  resistance 
is  fjrratly  increased,  the  cortex  is  rechiced  and  jtresents  numerous  opa(|ue 
white  or  whitish-yellow  foci,  consisting  of  accuniidations  of  fatty  epithe- 
liimi  ill  the  convoluted  tuhulcs.  This  lioinbination  of  coiitractcd  kidney 
with  llic  areas  of  niarkcMl  fatty  degeneration  has  given  tlie  name  of  small 
ifniinilar,  fatty  kidney  to  this  form.  The  interstitial  (changes  are  marked, 
manv  of  the  glomeruli  are  tlestroyed,  the  degeneration  of  epithelium  in  the 
(.diivoiuted  tubules  is  wide-spread,  and  the  arteries  are  greatly  thickened. 

Hi'longing  to  this  chronic  tubal  nephritis  is  a  variety  known  as  the 
rhroiiir  hwniorrhayic  nephritis,  in  which  the  organs  are  eidarged,  yellow- 
isli  wiiite  in  color,  and  in  the  cortex  are  many  brownish-red  areas,  due  to 
hivniorrhage  into  and  about  the  tubes.  In  other  respects  the  changes  are 
iik'ntical  with  those  in  the  large  white  kidney. 

Of  changes  in  the  other  organs  the  most  marked  are  thickening  of  the 
bldod-vessels  and  hypertrophy  of  the  left  heart. 

Symptoms. — Following  an  acute  nephritis,  the  disease  may  present, 
ill  a  iiioditicd  way,  the  symptoms  of  that  atfection.  In  many  cases  it  sets 
ill  insidiously,  and  after  an  attack  of  dyspepsia  or  a  [leriod  of  failing  health 
anil  h)ss  of  strength  the  patient  becomes  pale  and  putliness  of  the  eyeliiLs 
or  swollen  feet  are  noticed  in  the  morning.  '"     ~    "^^^ 

The  symptoms  are  as  follows:  The  urine  is,  as  a  rule,  diminisheu  in 
qiiimtity,  often  scanty.  It  has  a  (lirty-yellow,  sometimes  smoky,  color 
and  is  turbid  from  the  presence  of  urates.  Oii  standing,  a  heavy  sediment 
falls,  ill  which  arc  found  numerous  tube-casts  of  various  forms  and  sizes, 
hyaline,  both  large  and  small,  epithelial,  granular,  and  fatt^y  casts.  Leuco- 
cytes are  ahundant;  red  blood-corpuscles  are  frequently  met  with,  and 
(■[litheliiim  from  the  kidneys  and  judves.  The  albumin  is  abumlaul  and 
miiy  amount  to  one  half  or  (mi  lird  of  the  urine  boiled.  It  is  more 
abiindiuit  in  the  urine  passed  duiinL'  the  day.  The  sjiecitic  gravity  may 
1)1'  high  in  the  early  stages — from  [VZ\^  to  I -O".'.") — though  in  tin-  later 
stages  it  is  lower.     The  urea  is  always  reduci  .  in  (puintity. 

Dropsy  is  a  marked  and  obstinate  symptom'!  this  forin  »>f  Bright's 
disease.  The  face  is  pale  and  pulTy,  and  in  the  morning  the  eyilids  ;ire 
uHleiiiatous.  The  anasarca  is  general,  and  there  may  he  involvement  of 
the  serous  sacs.  In  these  chronic  cases  associated  with  Inu'e  white  kidney 
there  is  often  a  distinctive  apjiearance  in  the  face;  the  cuinpK'xioii  is  pasty, 
the  [lidlor  marked,  and  the  eyelids  are  (edematoiKs^  ''''^I'li'iiL'^y  l^.  iiecul- 
iarly  obstinate.  Ura!mic  8ym])toms  are  common,  though  con \  ilsious  are 
perhaps  less  frequent  than  in  the  interstitial  nephritis. 

The  tension  of  the  pulse  is  usually  increased  ;  the  vessels  ultimately 
lioeoiiie  stiff  and  the  heart  hypertroidiied,  though  there  are  instances  of 
this  form  of  nephritis  in  whi(di  the  heart  is  not  enlarged.  'llhiLliortic^ 
sceiiiid  sound  is  accentuated.  Hetinal  changes  though  less  frequent  than 
in  the  chronic  interstitial  nephritis,  occur  in  a  considerable  nundier  of 
cases. 


h 


:N-i 


W 


ij- 


i    -1 


,  i 


in 


'  ( 
■i-^ 


:|  feiii 


790 


DISEASES  OF  THE  KIDNEYS. 


Gastro-intestinal  syniijtoms  are  oommon.  Vomiting  is  frcfiuciith  ;i 
distressing  and  serious  symptom,  and  diarrluea  may  be  profuse.  I'lctiii- 
tion  of  tile  colon  may  occur  and  j)rove  fatal. 

it  is  sometimes  impossible  to  iletermine,  even  by  the  most  careful  ix- 
aniination  of  the  urine  or  by  analysis  of  the  symptoms,  whether  Ijic  (on- 
ditioii  of  the  kidney  is  that  of  the  large  white  or  of  the  small  while  luim. 
In  cases,  however,  which  have  lasted  for  several  years,  with  the  progressive' 
increase  in  the  renal  connective  tissue  and  the  cardin-vascular  cli;ui"es 
the  clinical  i)icture  may  approach,  in  certain  respects,  that  of  the  cdii- 
tracted  kidney.  The  urine  is  increased,  with  low  siiecilic  gravity,  h  is 
often  turbid,  may  contain  traces  of  ])lood,  the  tube-casts  are  iiuiueiuus 
aiul  of  every  variety  of  form  and  size,  and  the  albumin  is  ahuuihiiit. 
])ro|)sy  is  usually  present,  though  not  so  extensive  as  in  the  early  shii^es. 

The  yyrw//io.s/,s' is  extremely  grave.  In  a  case  which  has  persisted  f(]r 
morL^tfcin  a  year  recovery  rarely  takes  place.  Death  is  caused  either  \>\ 
great  elfusion  with  u'dema  of  the  lungs,  by  ura-mia,  or  by  secondary  iullam- 
matiim  of  the  serous  membranes.  Occasionally  in  children,  even  when 
the  disease  has  persisted  for  two  years,  the  symptoms  disappear  and  recdv- 
ery  takes  j)lace. 

Treatment. — Essentially  the  same  treatment  should  be  carried  (nit 
as  in  acute  Bright's  disease.  Milk  or  l)utter-milk  should  coiistitiite  tlie 
chief  article  of  food.  The  dr(»psy  should  be  treated  hy  hydrotlu  liijiy. 
Iron  preparations  should  be  given  freely.  1'he  acetate  of  ])otash  and 
digitalis  are  useful  in  increasing  the  How  of  urine,  liasham's  niixturo 
given  in  ])lenty  of  water  will  be  found  beneficial. 

ClIROXIC    iNTEUSTITrAL   NEPHKITrS. 

{Contracted  Kidnci/;  (iianular   h'ldiu'i/ ;  ('iirIio.si,s  of  the  Kidnci/ ;  (loiili/  Kidmy; 

licnal  Svlnoxiti). 

Sclerosis  of  the  kidney  is  met  with  {a)  as  an  occasional  se(iuciice  nf 
thc^hirgcijvhitc  kid ney,  forming  the  so-called  pale  granular  or  secoiularv 
contracted  kidney;  {h)  as  an  iudependent  primary  alfection ;  (r)  as  u 
sequence  of  arteriq-sclerosis. 

Etiology. — The  primary  form  is  chronic  from  the  outset,  and  is  ;i 
slow,  creeping  degciu  I'atidu  of  the  kidney  substance — in  many  resjieets 
only  an  anticipation  of  the  gradual  changes  which  take  place  in  the  nigiiii 
in  extreme  old  age.  In  many  eases  no  satisfactory  cause  can  be  assigned. 
In  others  there  are  hereditary  intluences,  as  in  the  remarkable  hiinily 
studied  by  Dickinson,  in  which  a  pronounced  tendency  to  chronic  Hriirlit's 
disease  occurred  in  four  generations.  Families  in  which  the  arteries  tend 
to  degenerate  early  are  more  jirone  to  interstitial  nephritis.  Syphilis  i^ 
lield  by  some  to  be  a  cause.  Alcohol  probably  ])lays  an  important  part, 
particularly  in  conjunction  with  oHicr  factors.  Dietetic  influences  arc  at 
work  in  many  eases.  Some  belii  '.  e  excessive  use  of  mjat  is  injurious,  since  it 


frcqiuMitls    ;i 
;'use.     Ulaia- 

ist  careful  cx- 
'tluT  the  mu- 
ll   Wllilf    flil'IH. 

liu  pro^n'cssivi.' 
LHiliir  cliunjii's. 

it    of    tlu'  CdU- 

fimvity.  1 1  is 
are  mmu'idus 
is  abuiuhuil, 
early  sta<rcs. 
5  poi-sisti'd  for 
iisod  iMtlicr  liy 
fiiulary  intlaiii- 

L'll,    (.'Veil   when 

)('ar  and  rccuv- 

hv  cari'ied  out 
coiistitute  the 
liydrothei'iiiiy. 
of  potasli  and 
liuin's  mixture 


(ioutij  Kidney ; 

ill   se<|iieiiee  ef 

or  seeoiulary 

ioti ;   {(■)  as  a 

:»utsi't,  and  i- ;: 
many  respeets 
•e  ill  the  nrLraii 
m  be  assiiriu'd- 
arkable  fniiiily 
iroiiie  15iit:iifs 
e  arteries  tend 
is.  Sypliili-  i- 
mportant  part. 
Iliieuces  ai'e  at 
jurious,  sineeit 


CHRONIC   BRIOnrS   DISEASE. 


791 


iiicreasos  the  materials  out  of  vvhicdi  uric  acid  is  formed.  V>\  many  a  fnnc- 
tieiial  disorder  of  the  liver,  leading  to  litlia'iiiia,  is  rcifardcd  as  the  most 
clTieient  factor.  It  is  quite  possible  that  in  persons  who  habitually  eat 
and  drink  too  much  the  work  thrown  upon  tliis  organ  is  exci'ssivc,  and 
tlie  (daboration  of  certain  mail  rials  so  defective  that  in  their  excretion 
freni  the  ifeneral  circulation  they  irritate  the  kidneys. 

Aettuil  gout,  which  in  England  is  a  common  cause  of  interstitial  ne- 
pliriii-,  i^  nf>t  an  important  factor  here.  On  the  other  hand,  the  nutri- 
timial  disorder  known  as  litha-mia  is  very  common,  either  with  or  without 
dvspepsia.  Lead,  as  is  w(dl  known,  may  produce  renal  sclerosis,  but  it 
is  a  minor  factor  in  coin})arison  with  other  causes.  It  is  doubtfid  if 
ili:;!ati'  luis  any  iiiHuence.  I'lirdy  regards  the  cold,  moist  regions  of  the 
Northeastern  States  as  specially  favoraI)le  to  the  disease. 

Among  factors  wdiich  nuiy  account  for  the  ))revalence  of  chronic 
Hriglit's  disease  in  the  better  classes  in  this  country  may  be  mentioned 
the  intense  worry  and  strain  of  business,  combined,  as  they  often  are, 
with  lial)its  of  hurried  :vn<l  over  eating  and  a  Ia(d\  of  proper  exercise. 
Males  are  more  commonly  attacked  than  females.  l''nder  twenty-live 
years  of  age  it  is  a  rare  disease;  betwe(>n  twenty-live  and  forty  a  few  well- 
iiKirked  cases  occur;  between  foi'ty  and  sixty  it  is  common. 

Morbid  Anatomy. — 'I'he  kidneys  are  usually  small,  and  together 
may  weigh  no  more  than  an  ounce  and  a  half.  T he_caps.ulii is. .thick  uud 
adherent ;  the  surface  of  the  organ  irregular  and  covered  with  small  nod- 
tiTes,  wliichhaye  given  to  it  the  name  of  granular  kidney.  In  stripj^'il'o  '^^^ 
tFo  capsulej  portions  of  the  kidney  substajice  are  removed.  Small  cysts 
iire  frequently  seen  on  tHe  surface.  The  color  is  usually  reddish,  often  a 
veiT  (lark  red.  On  section  the  substance  is  tough  and  resists  cutting; 
the  eiirtex  is  thin  and  may  measure  no  more  than  a  cou|)le  of  millinietri^s. 
The  [jyramids  are  less  wasted.  The  small  arteries  are  greatly  thi(d\ened 
and  stand  out  prominently.     The  fat  about  the  pelvis  is  greatly  increased. 

Microscopically  there  is  seen  a  marked  increase  in  the  connective  tis- 
siK^  aii'l  degeneration  and  atrophy  of  the  secreting  structures,  glomendar 
and  tubal,  the  former  Ixdng  most  predomiiumt  and  giving  the  main  (diar- 
aeters  to  the  l(>sion.     'i'he  f<dlowing  are  th.e  most  impiortant  (dianges  : 

{n)  An  increase  in  thejjijrons  elements,  wid(dy  distributed  throughout 
the  organ,  buTmTrfe  advah(~t^TrTi"rtT\e  cortex,  particulaidy  in  the  tissue  be- 
tween the  medullary  rays.  In  the  pyramids  the  distribution  of  new  growth 
is  less  pat(diy  and  more  diffuse.  In  the  early  stages  of  the  process  there 
is  a  small-celled  infiltration  between  the  tubes  and  around  the  glonu'ruli, 
aiiij  linally  this  becomes  fi])rillated  atid  is  seen  encircling  the  tubules  and 
HiHvmau's  capsules,  around  the  latter  often  forming  c(mcentric  liiyers. 

[h)  The  changes  in  the  giomeruli  are  striking,  and  in  advanced  cases 
a  very  c(msiderable  nundjer  of  thein  havi^  umlergonc  complete  atrophy  and 
are  represented  as  densely  encapsulated  liyaline  structures.  The  atrophy 
is  partly  due  to  changes  in  the  capillary  walls  and  midtiplicivtion  of  cells 


T 


!     i 


w 


792 


DISEASES  OF  THE   KIDNEYS. 


'■ 

i  mm 

iflH 

t 


between  the  loops,  partly  to  extensive  hyaline  degeneration,  and  in  part, 
no  doubt,  to  the  altcnitidtis  in  the  afferent  vessels.  The  normal  gloimruli 
usually  show  some  thickeniii!^  (if  tlie  capsule  and  inerease  in  tho  ct'lls  df 
the  tufts. 

('')  The  tubules  show  changos  in  the  epithelium,  which  vary  a  irodd 
deal  in  ditTcrent  localities.  Wliere  the  eonneetive-tissuo  growth  is  most 
advanced  they  ari'  greatly  atro])hicd  and  the  epithelium  may  be  repre- 
sented by  small  cultical  cells.  In  othiM'  instaiujes  the  epithelium  Ims 
entirely  disap])eared.  On  tho  other  hand,  in  the  regions  represeiitc(l  h\ 
the  projecting  granules  the  tubules  are  usually  dilated,  and  the  epitiieliiim 
sliows  hyaline,  fatty,  an(l  granidar  .changes.  Very  many  of  tlu-m  contuin 
dark  masses  of  ej)it!ie!ial  drbris  and  tube-casts.  In  the  interstitial  tissue 
and  in  the  tubules  there  may  be  pigmentary  changes  due  to  lueiuorrliaire. 
The  dilatation  of  the  tubules  may  reach  an  extreme  grade,  forming  delinite 
cysts. 

{(l)  Xlic  arteries  show  an  advanced  sclerosis.  The  intima  is  greatly 
thjckened  and  there  are  changes  in  the  adventitia  and"  in  the  media,  con- 
sisting in  increase  in  the  thickness  due  to  pioliferation  of  the  coiuieclive 
tissue,  in  the  latter  coat  at  the  expense  of  the  muscular  elements. 

The  view  most  generally  entertained  at  present  is  that  the  essential 
lesi(m  is  in  the  secreting  tissues  of  the  tubules  and  the  glomeruli,  and  that 
the  connective-tissue  overgrowth  is  secondary  to  this.  CJreenlield  liolils 
that  the  primary  change  is  in  most  instances  in  the  glomeruli,  to  wliich 
both  the  degeneration  in  the  epithelium  of  the  convoluted  tubules  ami  ilic 
increase  in  the  iutertubular  connective  tissue  are  secondary. 

Associated  M'ith  contracted  kidney  are  general  arterio-sclerosis  and 
h)j)ertro2)lij,_of  the  heart.  The  changes  in  the  arteries  have  already  hein 
described  in  the  section  on  arterio-sclerosis.  "i'lie  hypertrophy  of  the  lieail 
is  almost  constant.  I  do  not  remember  ever  to  have  seen  a  well-niiukcd 
instance  of  contracted  kidney  without  some  hypertrophy  of  the  left  ven- 
tricle, and  the  eidargcmcnt  may  reach  an  extreme  grade.  The  vaiia- 
tions  depend,  no  doubt,  in  part  up(m  the  extent  of  the  ditfiise  arterial 
degeneration,  and  there  are  instances  in  which  the  term  cor  bovimini  may 
be  applied  to  the  enlarged  organ.  In  such  cases  the  hypertrophy  is  not 
confined  to  the  left  ventricle,  but  involves  the  entire  heart.  The  explana- 
tion of  this  hypertrophy  has  been  mucdi  discussed.  It  was  at  first  held  t(t 
be  due  to  the  increased  work  thrown  upon  the  organ  in  driving  the  iiii]»ure 
blood  through  the  capillary  system.  Basing  his  opinion  upon  the  sii|i- 
posed  muscular  increase  in  the  smaller  arteries,  Johnson  regarded  the 
hypertrophy  as  effort  to  overcome  a  sort  of  stop-cock  action  of  these  ves- 
sels, which,  under  the  influence  of  the  irritating  ingredient  in  the  blood, 
contracted  and  increased  greatly  the  peripheral  resistance.  Traidie  be- 
lieved that  the  obliteration  of  a  large  number  of  capillary  territories  in 
the  kidney  materially  raised  the  arterial  j)reaRure,  and  in  this  way  led  to 
the  hypertrophy  of  the  heart ;  an  additional  factor,  he  thought,  was  the 


M:*' 


,  and  in  |iart, 
nal  gloiiKTuli 
ill  thu  colls  (if 


\  vary  a  jroml 
rowth  is  most 
nay  be  rcprc- 
)itli('liuiii  liiis 
epivscntfil  by 
ho  o[iitlicliiim 
tlioin  coiilMiii 
crstitial  tissue 
I  ha'inorrliago. 
rmingdolinite 

iina  is  groat ly 
10  niodia,  omi- 
tho  ooniioitivi' 
lents. 

:  tho  ossontiiil 
cruli,  and  that 
rocniiold  liolils 
eriili,  to  wliich 
ubulos  and  the 

)-wlor()sis  and 

0  alroady  Ihh'U 

by  of  tbe  bonrt 

a  woll-niarkcd 

tbo  loft  vcii- 

Tlio  varia- 

ilTiiHO  arterial 

boriitHiii  iiiiiy 

rtropby  is  not 

riio  exiilmia- 

it  first  hold  to 

iig  the  impure 

ipon  tho  su|i- 

rcgardod   the 

of  those  vcs- 

in  tho  blooil. 

Traubo  hv- 

territories  in 

,his  way  led  to 

)ught,  was  tho 


CHRONIC  BRionrs  disease. 


793 


(liniinishod  excretion  of  water,  which  also  lieightcned  the  pressure  within 
the  hlood-vesstds. 

In  our  present  knowledge  the  most  satisfactory  explanation  is  that 
given  by  ('ohnheini,  whi<'h  is  thns  clearly  and  succinctly  put  by  Fagge : 
''lie  gives  reasons  for  thinking  tiiat  the  activity  of  tho  circulation  through 
tiie  kidiutys  at  any  inoinciit — in  other  words,  the  state  of  the  smaller  renal 
jirtirios  as  regards  contraction  or  dilatation — depeiuls  not  (as  in  the  case 
(if  the  tissues  generally)  upon  the  need  of  those  organs  for  blood,  but 
solelv  ui)on  the  amount  of  material  for  the  urinary  secretion  that  tbo  cir- 
culatory fluid  hai)pons  then  to  contain,  'i'his  suggestion  has  bearings 
.  .  .  upon  tho  development  of  liy])ertro[)hy  \n  lie  kidney  when  the  other 
has  been  entirely  destroyed.  Hut  another  consequence  deducible  from  it  is 
tliiit  when  parts  of  both  kidneys  have  uiidorgoue  atrophy,  the  blood-flow 
to  the  parts  that  remain  must,  ewteris  paribus,  he  as  groat  as  it  wonld 
hav(!  been  to  the  whole  of  the  organs  if  they  had  been  intact.  But  hi 
order  that  such  a  fpumtity  of  blood  should  jiass  through  the  restrictetl 
eapillary  area  now  open  to  it,  an  excessive  iiressurt!  must  obviously  be 
noeossary.  This  can  bo  brought  to  boar  only  by  th(>  exertion  of  more  than 
the  normal  degree  of  force  on  the  i)art  of  the  loft  ventricle,  combined  witli 
the  maintenance  of  a  corresponding  resistance  in  all  other  districts  of  the 
arterial  system.  And  so  one  can  account  at  once  for  the  high  arterial 
pressure  and  for  the  cardio-vascular  changes  that  are  secondary  to  it." 

Symptoms.  —  IVrhaps  a  majority  of  the  cases  are  latent,  and  are  not 
re((!gnizod  until  the  occurrence  of  one  of  the  serious  or  fatal  complica- 
tions. Even  an  advanced  grade  of  contracted  kidney  may  be  compatible 
with  great  mental  and  bodily  activity.  There  may  have  been  no  symptoms 
whatever  to  suggest  to  the  patient  the  existence  of  a  serious  malady.  In 
other  cases  the  general  health  is  disturbed.  The  i)atient  complains  of 
lassitude,  is  slee})loss,  has  to  got  up  at  night  to  micturate ;  the  digestion  is 
disordered,  the"  tongue  is  furred  ;  there  are  complaints  of  headache,  failing 
vision,  and  breatliTossness  on  exertion. 

So  complex  and  Viiric<T~!a"fTie  (ninical  picture  of  chronic  ^right's  dis- 
ease that  it  will  be  best  to  consider  the  symptoms  under  the  various 
systems. 

Vrlnarti  Siistem. — The  amount  of  urine  is  usually  increased,  and  from 
t"vo  to  four  litres  may  be  })assed.  Frequently  the  patient  has  to  get  up 
two  or  three  times  during  the  night  to  empty  the  Idaddor,  and  there  is  in- 
creased thirst.  It  is  for  these  symptoms  occadonally  that  relief  is  sought. 
It  !;■  to  be  remembered,  however,  that  fref(uent  micturition  at  night  may 
l)e  a;  sociated  with  irrital)ility  of  the  prostate  and,  in  certain  cases,  with 
hyperacidity  of  tlie  urine.  The  secretion  is  clear,  the  mucus  cloud  is 
well  marked,  but  there  is  no  definite  sediment.  The  color  is  a  light  yellow, 
and  the  specific  gravity  ranges  from  1-005  to  1-012.  Traces  of  albumin 
are  found,  but  may  be  absent  sit  times,  particularly  in  the  early  morning 
urine.    It  is  often  simply  a  slight  cloudiness,  and  may  be  apparent  only 


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794 


DISEASES  OF  TIIK   KIDXEYS, 


witli  the  more  (U'liciito  tests.  The  sediment  is  scantv,  imd  in  it  a  frw  li\;i. 
lino  or  grumiliir  oasts  are  found.  The  quantity  of  tlie  solid  constitiunis 
of  tile  nrino  is,  as  a  imiIc,  diminished,  thonjj;h  in  sonio  iiistant'os  tiic  iiicii 
may  1)0  oxcretcd  in  full  amount.  In  attacks  of  dyspepsia  or  hroiic'niti-:, 
or  in  the  later  stii<:;es  when  the  heart  fails,  the  (pnintity  of  alhuniin  muv 
be  greatly  increased  and  the  urine  dimitiishetl.  Occasionally  blood  occurs 
in  the  urine,  and  there  nuiy  evi'U  he  luematuria  (8.  West).  Sliglii  liak- 
uge,  reitri'seiited  by  the  constant  pres-cnce  of  a  few  red  cells,  may  i)e  pres- 
ent early  in  the  disease  and  persist  for  years.  In  other  instances  there 
may  be,  particularly  after  exercise,  flecks  of  blood  in  a  pale,  smoky  urine. 

C'ircii/(i/(ir//  Si/sfnii. — The  pulse  is  hard,  the  tension  increased,  uihI 
the  vessel  wall,  as  a  rule,  thiidvcned.  As  already  mentioned,  a  dislineiidn 
must  be  made  between  increased  tension  and  thickening  of  the  arterial 
wall.  Tlie  tension  nuiy  be  jilus  in  a  normal  vessel,  but  in  chronic  Ihiglit'.! 
disease  it  is  more  common  to  have  increased  tension  in  a  stiff  artery. 

A  pulse  of  increased  tension  has  the  following  characters :  It  is  lianl 
and  ineompre.>isible,  requiring  a  good  deal  of  fon/e  to  overcome  it; 
it  is  persistent,  and  in  the  intervals  between  the  beats  the  vessel  feels 
full  and  can  be  rolled  beneath  the  linger.  These  characters  m;iv  he 
pre.sent  iu  a  vessel  the  walls  of  whi(di  are  little,  if  at  all,  increased  in 
thickness.  To  estimate  the  latter  the  pulse  wave  should  be  obliterateil  in 
the  fadial,  aiul  the  vessel  wall  felt  beyond  it.  In  a  j)erfectly  normal  ves- 
sel the  arterial  coats,  under  these  circumstances,  cannot  be  diflferentiatcd 
from  the  surrounding  tissue;  whereas,  if  thickeiu'd,  the  vessel  c;in  he 
rolled  beneath  the  linger.  I'e'*sistent  high  tension  is  one  of  the  earliest 
and  most  important  symi)toms  of  interstitial  nephrilia.  The  cardiac  feat- 
ures arc  ecjually  important,  tlunigh  often  less  obvious.  Ilvj^ertrophy  ef 
the  left  ventricdo  occurs  to  overcome  the  resistance  ofTeretl  in  the  arteries. 
The  enlargement  of  the  heart  ultimately  becomes  more  generaL  The 
apex  is  disj)laced  downward  and  to  the  left ;  the  im))ulse  is  forcihie  ami 
may  be  heaving.  In  elderly  persons  with  cmjdiysc^ma,  the  displacement 
of  the  apex  may  not  be  evident.  The  first  sound  at  the  apex  may  hi' 
duplicated ;  more  commonly  the  second  sound  at  the  aortic  cartilage  is 
accentuated,  a  very  characteristic  sign  of  increased  tejision.  The  son  ml 
in  extreme  cases  may  have  a  bell-like  (piality.  In  many  cases  a  systnlie 
murmur  develops  at  the  apex,  probably  as  a  result  of  relative  insulli<'ieiiey. 
It  may  be  loud  and  transmitted  to  the  axilla.  Finally  the  hypertrophy 
fails,  the  heart  becomes  dilated,  gallop  rhythm  is  present,  and  the  genenil 
condition  is  that  of  a  chronic  heart-lesion. 

IiCKjn'rafori/  Si/xfeii>. — Sudden  anlema  of  the  glottis  may  occur,  llf- 
fusion  into  tlie  pleurae  or  sudden  (edema  of  the  lungs  may  ])rove  ImIuI. 
Acute  pleurisy  and  pneumonia  are  not  uncommon.  Bronchitis  is  a  t'i>- 
quent  accompaniment,  j)articularly  iji  the  winter.  Sudden  attacks  ef 
oppressed  hreliHTThg,  particularly  at  niglit,  are  not  infrequent.  TIr.-  is 
often  a  uritmic  symptom,  but  is  sometimes  cardijic.  The  patient  may  sit 
up  in  bed  and  gasp  for  breath,  as  in  true  asthma.     Cheyne-Stokes  breadi- 


lent.     Tli^s  i.s 


CHRONIC  RiiiGnrs  disease. 


795 


iiiiT  iiKiy  1)0  prosont,  most  coiniiioiily  toward   tliu  close,  but  llu>  patient 
may  he  \v;;lkin,<,'  about  and  even  attendiii;^  to  liis  occupation. 

/''W-'Uli-''  '^'^■'''''tW- — I^y''<i'<^'l*'''i'yii'.''l  '••''^  "I"  iippet  ill  arc  conunon.  jSevero_ 
ami  uncontrollable  vomiting  may  be  the  iirst  symptonu  This  is  usually 
rcpinleil  as  a  manifestation  of  uraMuia,  but  it  may  be  present  ivithout  any 
(itiui' indications,  and  1  have  known  it  to  jjiove  fatal  without  any  suspi- 
cion (hat  chroni(!  I?riy-ht's  disease  was  pri'sent.  Severe  and  even  fatal 
(iiiirrhooa  may  develop.  The  tongue  may  l)e  coated  and  the  breath  heavy 
jiiul  m'inous. 

.Wrrdiis  Si/s/cDi. — \'arious  cerebral  manifestations  have  already  been 
iiicn'ioned  under  ura-inia,  and  they  are  among  the  most  important  of  the 
fi'iiiiires  of  chronic  ^right's  disease.  Cerebral  apopU-xy  is  closely  related  to 
iiiti'istitial  lu'phritis.  TIu^  ha'tuorihage  may  take  ))laci'  into  tlie  meninges 
():•  the  cerebrum.  It  is  usually  associated  with  iiuirkecl  changes  in  the 
vusscls.     Mcuralgius,  in  various  regions,  arc  not  uncoiuuion. 

Sji)cn'af  ScnsrSjV^Vvonhlt'.i  in  vision  nuiy  be  the  first  symptom  of  the 
disease.  It  is  renuirkable  in  how  many  cases  of  interstitial  nephritis  the 
coudilion  is  diagnosed  Iirst  by  tlu;  ophthalmi(^  surgeon.  The  (lame=.shaiH'd 
li,iMuorrhages  are  the  most  conunon.  Less  fre(iuent  is  dili'use  retinitis  ur 
papillitis.  Suddeii  blindness  may  su[)ervene  without  retinal  changes — 
lu'a'inic  amaurosis.  Auditory  troubles  are  by  lu)  means  infrvVjuent  in  chroiiii^ 
Mright's  disease,  liinging  in  the  ears,  with  dizziness,  is  not  uiu'ommon. 
Various  forms  of  (U'afness  may  occur. 

Skill. — (Edema  is  not  common  in  interstitial  neph^iMtis.  Slight  pulli- 
lu'ss  of  the  aiTkles'may  bo  present,  but  in  a  majority  of  the  cases  dropsy 
iJiHs  not  su[)ervene.  When  extensive,  it  is  almost  idways  Ww  result  of 
jrriidiial  failure  of  the  hypertropbied  heart.  The  skin  is  often  dry  and 
]iuk',  and  sweats  are  not  common.  In  some  instances  the  sweat  may  de- 
jiiisit  a  white  frost  of  urea  on  the  surface  of  the  skiiu  Ec^^enui  is  a  com- 
iimu  accompaniment  of  chroni(3  interstitial  m^phritis.  Tingling  of  the 
tiiigers  or  numbness  aiul  pallor — the  dead  fingers — are  not,  as  some  sup- 
pose, in  any  way  pet'iiliar  to  Bright's  disease.  Intolerable  itching  of  the 
skin  may  bo  present,  and  cramps  in  the  muscles  are  by  no  means  rare. 

ILenmrrhages  arc  not  infri'^uent ;  thus,  epistaxis  may  occur  and  prove 
spi'ioiis.  Purimra_may^  develop.  Broncho-jjulmonary  luvmorrhagcs  are 
said,  by  some  French  writers,  to  be  common,  but  no  instance  of  it  has 
01)1110  under  my  observation.  Ascites  is  rare  except  in  association  with 
cirrhosis  of  the  liver. 

Diagnosis. — The  autopsy  often  discloses  the  true  nature  of  the  dis- 
ease, one  of  the  many  intercurrent  aifections  of  which  may  have  j)roved 
fatal.  The  early  stages  of  interstitial  nephritis  are  not  recognizable.  In 
11  patient  with  increased  pulse  tension  (particularly  if  the  vessel  wall 
is  silerotic),  with  the  apex  beat  of  the  heart  dislocated  to  the  left,  the 
■•^(■'•ond  aortic  sound  ringing  and  accentuated,  the  urine  abundant  and  of 
luw  specific  gravity,  with  a  trace  of  albumin  and  an  occasional  hyaline  or 


/ 


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■;;',■■■  i;i 


796 


DISEASES  OF  THE   KIDNEYS. 


gmiuiliir  cast,  the  (li!ij,Mi()sis  of  interstitial  lU'iiliiitis  tuny  lie  safely  iii;i(ic. 
Of  all  the  iiulieutions,  that  olTered  l)y  the  i>ulse  is  the  most  iDijiortMnt. 
Persistent  hi^'h  tension  with  thickening  of  the  arterial  wall  in  a  man  uii- 
der  lifty  means  that  serious  mischief  has  already  taken  place,  that  cardio- 
vasenlar  (diaiiges  are  certainly,  and  I'eiial  most  |ir(d)alily,  present.  It  is 
important  in  the  diiignosis  of  this  condition  not  to  rest  content  \nlli  u 
single  examination  of  the  urine.  l'>oth  the  evcnin;:  and  the  morning  seoro- 
tion  slioidd  l)e  studied.  'I'he  sediment  should  he  collected  in  a  cotijial 
glass,  and  in  looking  for  tuhe-casts  a  laige  surface  should  be  examiiHMi 
with  a  tolerably  low  power  and  little  light,  '!"he  ai  terio-selcrotic  kidncv 
may  exist  for  a  long  time  without  the  occurrence  of  albumin,  or  the  allui- 
min  may  be  in  very  small  (jnantitics.  In  many  cases  it  is  impossible  to 
dilTerentiate  the  ])rimary  interstitial  nephritis  from  an  arteiio-scleidiic 
kidney,  nor  clinically  is  it  of  any  special  value  so  to  do.  In  jiersons  iiii(|er 
forty,  witii  very  high  tension,  great  thickening  of  the  superlicial  arteries, 
and  marked  hypertrophy  of  the  heart,  the  renal  are  more  likely  to  hi'  sec- 
ondary to  the  arterial  changes. 

Prognosis. — t'hronicr  I'right's  disease  is  an  incurable  afTection,  aini 
the  anatomical  conditions  on  which  it  de])ends  are  rpiite  as  much  bevotnl 
the  reach  of  medicines  as  wrinkled  skin  or  gray  hair.  Iiitef.-titi;il 
nephritis,  however,  is  compatible  with  the  enjoyment  of  life  for  mniiy 
years,  tind  it  is  m)W  universally  recognized  that  increased  tension,  thick- 
ening of  the  arterial  walls,  and  jiolyuriti  with  a  snudl  fpiantity  of  albiiniiii. 
neither  doom  a  man  to  death  within  a  short  time  nor  necessarily  interfere 
with  the  })ursnits  of  an  active  life  so  long  as  proper  care  be  taken.  I 
know  patients  who  have  had  high  tension  and  a  little  albumin  in  the 
urine  with  hyaline  casts  for  ten,  twelve,  and,  in  one  instance,  lifteen  years. 
Serious  iiulications  are  the  development  of  urannic  .symptoms,  dilatation  of 
the  heart,  the  onset  of  serous  etfiisions,  the  development  of  Cheyiio- 
Stokos  breiitliing,  persistent  vomiting,  and  diarrhoea. 

Treatment. — Patients  without  locid  indications  or  in  whom  the  con- 
dition has  been  accidentally  di.st^overcd  should  so  regulate  their  lives  tis  to 
throw  the  least  possible  strain  upon  heart,  arteries,  and  kidneys.  A  <|ui(t 
life  without  mental  worry,  with  g(-ntle  but  iu)t  excessive  exercise,  ami  r.'si- 
dence  in  aii  e(|uable  climate,  should  be  recommeiuled.  In  addition  they 
should  be  told  to  keep  the  bowels  regular,  the  skin  active  by  a  daily  tepid 
bath  with  friction,  aiul  the  urinary  secretion  free  by  drinking  daily  a 
definite  anionnt  of  either  distilled  water  or  some  pleasant  mineral  Avater. 
Alcohol  should  be  strictly  prohibited.     Tea  and  coffee  are  allowable. 

Tlie  diet  should  bo  light  and  nourishing,  and  the  jiatient  should  be 
warned  not  to  eat  excessivcdy,  and  not  to  take  meat  more  than  once  a  day. 
Care  in  food  and  drink  is  probably  the  most  important  element  in  the 
treatment  of  these  early  cases. 

A  patient  in  good  circumstances  may  be  urged  to  go  away  during  the 
winter  months,  or,  if  necessary,  to  move  altogether  to  a  warm  equable  eli- 


CIIIiONlC   HllUJIirs   DISKASK. 


797 


iiiuti',  like*  tliiit  of  soiitlicrii  ("aliforiiia.  Tlicn'  U  no  doubt  of  the  value  in 
ihfsr  casi'S  of  removal  from  llic  cliaii^t'aljlc,  irrci^ular  wcalliur  whicli  pre- 
viiil>  ill  tlio  teniporuk!  r(\i,Moiis  from  N'ovcmhcr  until  Ajiril. 

At  tliin  ]u'rio(l  inudicint's  arc  not  rciiuii'cd  utdcss  for  certain  special 
sviii|itoms.  Patients  derive  miicli  licndit  from  an  annual  visit  to  certain 
minii'al  siirin;,fs,  such  as  I'oland,  Bedford,  Saratoga,  in  this  counlrv,  and 
Vichy  and  others  in  Kuropi-.  Mineral  waters  have  no  ciiratise  iidhience 
upon  elironic  Hrij^ht's  disease;  thev  simply  help  the  interstitial  <'ir<;ulali(»n 
and  keep  the  drains  flushed.  In  this  I'arly  sta<,'e,  when  the  patient's  con- 
ilitioM  is  ^^ood,  till'  tension  not  hi,L;h,  and  the  (|iiantily  (d'  albumin  small, 
iiKMlicines  uvv  not  indicated,  since  no  remedies  arc  known  to  have  the  slight- 
est inlhiencc  upon  the  proiifress  of  the  disease.  Sooner  or  later  symptoms 
ari~r  which  dcnuind  treatment.  Of  these  the  followin^f  are  the  most  im- 
|;i)rt;iiit : 

((/)  (iirii/Iij  /iirrcatt:d  Arlcvial  Toisimi. — It  is  to  Ik;  lemembered  that 
a  certain  increase  of  tension  is  not  only  necessary  but  unavoidable  in 
ciiroiiic  Urii^dit's  disease,  and  probably  the  most  serious  danijer  is  too 
triviil  lowering  (d"  the  blood  tension.  The  ha]»py  nu'dinm  must  be  souj^ht 
lictwcen  such  lieii,ditciu'd  tension  as  throws  a  serious  strain  upon  the  heart 
and  risks  rupture  of  the  vessids  and  the  low  tension  which,  under  these 
rirciiiMstances,  is  specially  liable  to  bo  associated  with  serous  elTusions.  In 
ciiscs  with  persistent  hi;,di  tension  the  diet  shoidd  be  liyht,  an  oecasional 
saline  pur<;e  should  be  i,dven,  ami  sweat injf  promoteil  by  means  of  hot  air 
or  tlie  hot  bath.  If  these  measures  do  not  sullice,  n i t ro^rl vc(;rin  may  be 
tried,  iM'jfinnini^  with  one  mitum  of  the  one  per  cent,  soluiion  three 
times  a  day,  and  j^radually  incroasinjj:  the  dose  if  lu'cessary.  I'atients 
vary  so  mu(di  in  siiscei)til)ility  to  this  drii<j  that  in  eacdi  case  it  must  be  tested, 
the  limit  of  dosai,'((  bein<f  that  at  which  the  patient  e.\|)eriences  the  ])hysio- 
lojfical  effect.  As  much  as  ten  minims  of  the  one  ])er  cent,  solution  nuiy 
he  jxiveii  three  times  a  day.  In  many  eases  I  have  ^ivvn  it  in  much  larger 
(liiscs  for  weeks  at  a  time.  I  have  never  seen  any  ill  etVects  from  it.  If 
the  dose  is  excessive  tlie  pati.Mits  complain  at  om-e  of  ilushinj;  or  headache. 
Its  use  may  be  kept  \\\)  for  six  or  seven  weeks,  then  stopped  for  a  week 
and  resumed.  Its  valm;  is  seen  not  oidy  in  the  reduction  of  the  tension, 
hut  also  in  the  striking;  manner  in  which  it  relieves  the  headache,  dizzi- 
ness, and  dyspna'u. 

{//)  More  or  less  anwrnin  is  present  in  advanced  cases,  which  is  best 
iiu't  by  the  nse  of  iron.  Weir  Miti'hell,  who  has  had  a  uni(|ue  exp<!rienco 
in  certain  forms  of  cliroinc  l^right's  disease,  j,nves  the  tincture  of  the  per- 
cliloride  of  iron  in  large  doses — from  lialf  a  drachm  to  a  dnudim  three 
times  a  day.  lie  thinks  that  it  not  only  benefits  the  anamiia,  but  that  it 
iil.-'o  is  an  important  means  of  reducing  the  arterial  tension. 

('•)  Mi'Tiy  patients  with  Briglit's  disease  present  themselves  for  treat- 
ment with  signs  of  cardiac  dilatation ;  there  is  a  gallop  rliythm  or  the  heart 
sounds  have  a  footal  character,  the  breath  is  short,  the  urine  scanty  and 


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'j- (^'iV»»' »*-     ' 


'■*-  >vA. 


798 


nisii:ASKs  OP  tiik  kmdnkys. 


VII.   AMYLOID  DISEASE. 


Amyloid  (liirdaoeons  or  waxy)  (k\i,'<-'iH'i'ati()ii  of  the  kidneys  is  siiii|ily  in\ 
event  ill  the  in'ocess  of  flironic  Brifflit's  disoasc,  most  commonly  in  the 
(ihronic  paivncliymutous  nephritis  following  fevers  or  of  cacliectic  states. 
It  has  no  claim  to  he  regarded  as  one  of  the  varieties  of  Bright's  disease. 
The  alfcetion  of  the  kidneys  is  generally  a  part  of  a  wide-spread  ainyldiil 
degeneration  oeciirring  in  i)rolonged  snpi)nration,as  in  disease  of  tlielxme. 
in  syphilis,  tnhercnlosis,  and  occasionally  lenkiemia,  lead  poisoning,  and 
gout.     It  varies  curiously  in  frequency  in  different  localities. 

Anatomically  the  amyloid  kidney  is  large  and  pale,  the  surface  stnodth, 
and  the  venne  stellatje  well  marked.  On  section  the  cortex  is  large  and 
may  show  a  peculiar  glisteJiing,  infiltrated  appearance,  and  the  gloniciiili 
are  very  distinct.  The  pyramids,  in  striking  contrast  to  the  cortex,  arc  ef 
a  deep  red  color.  A  section  soaked  in  dilute  tincture  of  iodine  shows  spots 
of  a  walnut  or  mahogany  brown  color.  The  Afalpighian  tufts  and  tlic 
straight  vessels  may  be  most  affected.  In  lardaceous  disease  of  tlie  kid- 
neys the  organs  are  not  always  enlarged.     'J'hey  may  be  normal  in  size  or 


I'VHIilTIS. 


09 


muaW,  piilc,  iiiid  jjriimiliir.  'I'lic  umylciid  diiinj,'!'  is  (Irsl  seen  in  tlic  Miil- 
|ii-iiiiiii  tufts,  mid  tlit'ii  iiivdlvt's  the  alTcri'iit  mid  clTtrctit  vessels  aiid  the 
stniijrlit  vessels.  It  limy  l)e  ciniliiied  eiilirelv  to  tliciii.  In  later  stii;,'es  of 
ihcdiscase  the  tiil)iiles  arc  uiTected,  ehielly  the  iiieiiil)iaiie.  raiely,  if  ever, 
till'  cells  themselves.  1  ii  ailditinii,  t he  kidneys  always  show  siiriis  (d"  dilViise 
iu'|ihriti.s.  The  Howmaii's  eapsules  an:  thiekeiied,  there  may  he  ;,domi'ni- 
litis,  and  the  tuhul  (M)iMK'liiini  is  sw(»llen,  <franular,  and  fatty. 

Symptoms. — The  renal  features  alone  may  not  indicate  llie  preseiici^ 
(;1"  this  dej^eneration.  L'siially  the  associated  eondition  j,dves  a  hint  of  the 
iiiitnre  of  the  process.  The  uriiu-,  as  a  rule,  shows  imjiortant  chan;,'es; 
the  iiiiantit,v  is  increased,  and  it  is  pale,  clear,  and  of  low  speeilic  irravity. 
Till'  alhuiniii  is  usually  ainindant,  i)UL  it  may  he  scanty,  and  in  I'arc  iii- 
.•tiuc.'i's  ahseiit.  I'o.ssihiy  the  variations  in  the  situation  id'  the  amyloid 
cluiiiifes  may  account  for  this,  since  all)umin  is  less  likely  to  lie  pi'oent 
wlii'ii  thu  change  is  eoiiiined  to  the  vasa'  recUv.  In  addition  to  ordinary 
iilliinnin  jrloi)nlin  nniy  be  present.  'J'he  tube-easts  are  variable,  usually 
iivahne,  often  fatly  or  linely  j^ranular.  Oeoasionally  the  amyloid  leaciioii 
run  he  detected  in  the  hyaline  casts.  Dropsy  is  present  in  many  instaiuH'S, 
piu'ticularly  when  tlu're  is  mncli  amernia  or  jtrofound  cachexia.  It  is  not, 
liiiucver,  an  invariable  symiitoin,  and  there  are  cases  in  which  it  does  not 
(Itvelop.     Diarrluj'u  is  a  eominon  aceompaniment. 

Increased  arterial  tension  and  cardiac  hypertropliy  are  not  usually 
pn'sriit,  except  in  those  case.-,  in  which  amyloid  degeneration  occurs  in  the 
scciiiidary  contracted  kidiu'y;  under  which  circiinistances  there  may  beura;- 
iiiiii  and  retinal  changes,  which,  as  a  rule,  are  not  met  with  in  other  forms. 

Diagnosis. — My  the  condition  of  the  urine  alone  it  is  not  possible  to 
ividgnizo  amyloid  (diangcs  in  the  kidney,  r.sually,  however,  there  is  no 
ililliciilty,  siiu-e  the  Hi'ight's  disease  comes  on  in  assoeiaticn  with  syphilis, 
in'iilnnged  suppuration,  disease  of  the  bone,  or  tuberculosis,  and  there  is 
I'videuce  of  enlargement  of  the  liver  and  spleen.  A  suspicions  cireiiin- 
slaiice  is  the  existence  of  iiolynria  with  a  large  amount  of  allmmin  in  the 
mine,  or  when,  in  these  constitutional  alTcctions,  a  large  <|uantity  of  ch-ar, 
imle  urine  is  jia.ssed,  even  without  the  presence  of  albumin. 

The  prognosis  depemls  rather  on  the  eondition  with  which  the  nephri- 
tis is  associated.     As  a  rule  it  is  grave. 

The  treatment  of  the  coiulition  is  that  of  chronic  Brijiht's  disease. 


VIII.    PYELITIS 

(Consecutine  Xephriiis  ;  Pyelonf/ihriti.s  ;  1'ijonephrosi.s), 

Definition. — Inllamnuition  of  the  pelvis  of  the  kidney  and  the  eou- 
iliiidus  which  result  from  it. 

Etiology. — Pyelitis  is  induced  by  many  causes,  among  which  tlie 
fullowing  Mie  most  important:   (a)  The  irritation  of  calculi — a  very 


i' 


!.•: 


800 


DISEASES  OF  THE  KIDNEYS. 


1:^1 


i!       i 

m\ 

mM 

frequont  cause.  (/>)  Tubercle,  (r)  The  infectious  pyelitis  which  develops 
in  fcvons,  in  which  nn  acute  inllaintuation  of  the  pelvis  of  the  kidney  riuiv 
occur,  sornctinies  ha'inorrha^i^ic  in  character,  nujre  frequently  diiththeiiiic. 
(ij)  'I'he  })rcscnce  of  tlccoiuposing  urine,  follow  ing  jtressure  upon  the  iinter 
by  tumors  or  bladder-disease.  By  far  the  most  frequent  form  of  pyelitis  is 
that  which  is  conpecutive  to  cystitis,  from  whatever  cause.  In  these  eases 
the  iullatumation  may  not  lie  confined  to  the  pelvis,  but  pass  to  ilie 
kidney,  inducing  piyclonephritis.  (c)  Occasional  causes  are  cancer,  livila- 
tids,  the  ova  of  certain  jiarasites,  and,  according  to  some,  the  irritation  of 
the  saccharine  urine  of  diabetes,  and  the  irritation  of  turpentine  or  cidiebs. 
(/)  A  primary  pyelitis  or  pyeU. nephritis  has  been  described  as  coniiii;,'  on 
after  cold  or  overexertion,  but  su(di  cases  are  extremely  rare.  The  eondj- 
tion  is  met  with  in  children  (Holt),  and  in  one  case  which  1  saw  witli 
Ilohne.-.  of  Chatham,  the  pus  and  the  chills,  after  recurring  at  intervals 
for  many  months,  disappeared  after  circumcising  the  boy,  who  had  a  very 
narrow  jirepuce. 

Morbid  Anatomy.  —  In  the  early  stages  of  pyelitis  tlu  nuiemis 
membrane  is  turbid,  somewhat  swollen,  and  may  show  ecchymoses  or  a 
grayish  pseudo-membrane,  'i'iie  urine  in  the  jielvis  is  cloudy,  and,  on 
examination,  numbers  of  e])ithelial  cells  are  f^vvu. 

In  the  calculous  pyelitis  there  may  be  ordy  Si:ght  turbidity  (»f  the 
membrane,  wliich  has  been  called  by  scinie  catarriial  })yelitis.  ^lore  com- 
monly the  mucosa  is  roughened,  grayish  in  color,  and  thick,  ruder 
these  circumstances  there  is  almost  always  more  or  less  dilatatio;i  of 
the  calyces  and  llatteniug  of  the  papilhe.  i-'oUowing  this  condition 
there  may  l)e  (a)  extension  of  the  srpjjurative  process  to  the  kicbiey  it- 
self, forming  a  ])Vclonephritis ;  (h)  a  gradual  dilatation  of  the  calyces 
with  atroi»hy  of  the  kidiu'y  substance,  and  linally  ht>  production  of  ihi' 
condition  of  pyonei)hrosis,  in  which  the  entire  tirgan  is  rei)resent,'d  \>y  a 
sac  of  pus  with  or  without  a  thin  sludl  o  renal  tissue,  (c)  After  the  kid- 
ney structure  has  been  destroyed  by  si  ppuration,  and  the  oI)structinn  at 
the  orifice  of  the  pelvis  persists,  the  fluid  portions  may  be  ab.-.rbed.  the 
}»us  l)e<'omc-.  inspissated,  so  that  the  organ  is  represented  liy  a  serie>  nf 
sa(;culi  containing  grayish,  putty-like  masses,  which  nuiy  bcciwnc  impreg- 
nated with  lime  salts. 

Tubcri'uhais  j)yelitis,  as  already  described,  usually  starvs  upon  the  apiees 
of  the  pyramids,  and  may  at  first  '.)e  limited  in  extciii.  ritimately  the 
condition  jiroduccd  may  be  similar  to  that  of  calculous  pyelitis.  I'vdiie- 
phrosis  is  ((uite  as  frccpu'ut  a  se<|Uence,  while  the  final  traiisformatinii  of 
the  jnis  into  a  putty-like  material  impregnated  with  salts,  forming  the 
so-called  scrofulous  kidney,  is  even  commoner. 

The  pyelitis  consecutive  t(  cystitis  is  usually  I»ilateral,  and  the  kidney 
is  apt  to  b(^  involved,  forming  iho  so-called  siin/i''(i(  kidnrji — acute  sup- 
purative luqdiritis.  'I'here  are  lijies  of  S(ipi)uration  extending  alom:  llie 
pyramids,  or  small  abscesses,  in  the  cortex,  i)ften  just  beneath  the  caiisnh'; 


hicli  (U'vclops 
le  kidney  iniiy 
y  dipliilicritir. 
jioii  tlic  untiT 
11  of  pvclitis  is 
In  tlu'.sc  cases 
it  pass  to  tlio 
cancer,  livda- 
e  irritiitioii  df 
tine  or  culicl)s. 
[  as  coniiiij,'  on 
;.  The  condi- 
di  I  saw  with 
[<r  at  intervals 
vho  had  a  very 

s  tlio  nmeoiis 
diynioscs  or  a 
oudy,  and,  on 

rbidity  of  tlio 

s.     ^lorc  eii;ii- 

tliick.       Tinier 

s  dilatatio  '  of 

litis  condiiidii 

d'c  kidney  it- 

f  the  calyees 

notion  of  ilie 

)rescnt.Ml  liy  a 

\ftcr  the  kid- 

)l)struction  at 

ali.-wrlied.  the 

IV  a  scries  nf 

•onic  inipri'ir- 

lon  tlic  aiiiees 
Itiniately  the 
ditis.  Pyoiie- 
isforinatinii  of 
!,  fonninu''  'he 

id  til''  kitlney 
y_acute  >np- 
litiji  alonu  ihc 
h  the  capsule; 


PYELITIS. 


801 


or  there  may  be  vvedge-sliapcd  abscesses.  The  jiiis  organisms  either  juiss 
up  the  tubules  or,  as  Steven  lias  shown,  pass  by  the  lymphatics. 

Symptoms. — The  forms  associated  with  the  fevers  rarely  cause  any 
symptoms,  even  when  tiie  pnxK'ss  is  extensive.  In  mild  grades  there  is 
pain  in  the  back  or  there  may  be  tenderness  on  deep  pressure  on  the  af- 
feeted  side.  Tho  urine  is  turbid,  contains  a  few  mucous  and  jius  cells,  and 
oeeasioiially  blood-corpuscles.  The  urine  is  acid,  and  there  may  be  a  trace 
of  ali)umin. 

Before  the  condition  of  jiyuria  h:  established  there  may  be  attacks  of 
pain  on  the  atfectctl  side  (not  amounting  to  the  severe  agony  of  n-nal  colic), 
I'ijfors,  high  fever,  and  sweats.  L'nder  these  (drcumstances  the  urine, 
\vhi(di  may  have  been  clear,  becomes  turbid  or  smoky  from  the  presence  of 
lilood,  and  may  contain  large  numbers  of  mucus  C(dls  and  transitional  epi- 
thelium. These  cases  are  not  coninion,  l)ut  1  have  twice  had  opi)ortunity 
of  studying  such  attacks  for  a  prolonged  ])eriod.  In  one  patient  the  oc- 
(•lUTcnce  of  the  rigor  and  fever  could  somctnncs  be  predicted  from  tho 
rhangc  in  the  condition  of  the  urine.  Such  cases  occur,  I  believe,  in  as- 
sociation with  calculi  in  the  [xdvis. 

The  statement  is  not  infre(piently  made  that  the  cpitludiiim  in  the 
urine  in  ])yclitis  is  distinctive  and  (diara(dci'istic.  This  is  erroneous, 
as  may  be  readily  demonstrated  by  comparing  scrapings  of  the  mucosa  of 
the  renal  pelvis  and  of  the  blailder.  In  both  the  epithelium  btdongs  to 
what  is  called  the  transitional  variety,  and  in  both  regions  the  same  coni- 
cal, fusiform  and  irregular  cells  with  long  tails  are  found. 

When  the  pyelitis,  diether  calculous  or  tuberculous,  has  become 
chronic  and  suppurative,  the  symptoms  are  : 

(1)  Pt/iiriif. — The  ])us  is  in  variable  amount,  and  may  be  intermittent. 
Thus,  as  is  (d'teii  the  case  when  only  one  kidney  is  involved,  the  ureter 
luay  be  temporarily  bloid\cd,  normal  urine  is  passed  for  a  time,  and  then 
there  is  a  .sudden  outflow  of  the  pi'iit-up  [nis  and  the  mine  becomes  puru- 
lent. Coincident  with  this  retention,  a  tumor  mass  may  l)e  felt  on  the 
side  alTccted.  The  pus  has  the  ordinary  (diaracters,  but  the  transitional 
epithelium  is  not  so  abundant  at  this  stage  and  conies  fiuni  the  bladder  or 
fnuii  the  [Kdvis  of  the  healthy  side.  Occasionally  in  rapidly  ailvancing 
pyelonephritis  portions  of  the  kiiliu'y  tissue,  particnhirly  of  the  apices  of 
the  pyramids,  nuiy  slough  away  and  appeal'  in  the  urine;  or,  as  in  a  re- 
markable s)  ■eimen  shown  to  me  by  Tyson,  s(did  (dieesy  moulds  of  the 
I'lilyces  are  passed.  Casts  from  the  kidney  tubules  are  sometimes  present. 
The  reaction  of  the  urine  is  at  llrst  acid,  and  may  remain  so  even  when 
the  pus  is  passed  in  large  (piantities.  If  it  remains  any  time  in  the  blad- 
der or  if  cystit's  exists  it  becomes  '.mmoniacal.  Micturition  may  be  V(  ry 
fivipient  and  irritability  of  the  biadder  may  be  present. 

( .')  Intermittent  fever  a.ssociated  with  rigors  is  usually  iirescnt  in  cases 
"f  sujipiirative  pyelitis.  The  (diills  may  recur  at  regular  intervals,  and 
the  eases  are  often  mistaken  for  malaria.     Owen-Hees  calhMl  attention  to 


■J. 


f 


<,  M 


I    i' 


§1 


'\i- 


ip 


,..« 


802 


DISEASES  OF  THE  KIDNEYS. 


tlio  freqnont  ofvuiTonoo  of  tlioso  rijj^ors,  which  form  a  oharacti  ristic 
fuature  of  l)()tli  caltiilous  and  tiihcrciilous  pvoh'tis.  ritimati'ly  the  t\vcr 
assumes  a  liectio  typu  aii<l  the  rigors  may  ct-asc. 

(;{)  The  general  condition  of  the  ])atient  nsually  indicates  prcloiiL' 


:.'( 


sni)])iiration.  There  is  mort'  or  less  wasting  with  ana-inia  and  a  i>rogiv>>i\|. 
failure  of  health.  Secondary  abscesses  iiuiy  develoj)  aiul  the  clinical  pict- 
ure ))econics  that  of  ))yu'Miia.  In  some  instancies,  particularly  of  in'HTcu. 
lous  pyelitis,  the  <dinical  course  may  resemble  that  of  typhoid  fever.  'I'lun. 
are  instances  of  ])yuria  recurring,  at  intervals,  for  many  years  without 


impan'inen 


t  of  tl 


le  bodnv  vi^^or 


(4)  I'hysieal  examiiuition   in  chronic  pyelitis  usually  reveals  tei 
u'ss  nn  the  affected  side  or  a  delinite  swelliu'r,  wliich  mav  vary  mi 


Klcr- 


icli    111 


size  and  ultimately  attain  large  dimensions  if  the  kidney  becomes  i  iKir- 
niously  <listended,  as  in  pyoiiej)hrosis. 

(.*»)  Occasionally  nervous  symptoms,  which  may  be  associated  with 
dyspiuva,  supervene,  or  the  termination  may  he  by  coma,  not  uidiki>  tliat 
of  diabetes.  'I'hese  liave  Iteen  attributed  to  the  absorpti«m  of  the  deeoni- 
posiiig  materials  in  the  urine,  and  has  been  call(Ml  ammoniannia.  A  f 
of  ))ara[ilegia  has  l)ei. 


(iVIll 


n  described  in  connection  with  some  cases  of 


alisi't'ss 


of  the  kidney,  but  whether  due  to  a  myelitis  or  to  a  ]>eripheral  iiciiiiiis 
has  not  yet.  been  determined. 

In  suiipiirative  nephritis  or  surgical  kidne;  following  cystitis,  tlie  pii- 
tieiit,  complains  of  pain  in  the  ba(d<,  the  fever  Itecomes  high,  irregular.  Mini 
ass(tciatt'(]  with  chills,  and  in  acute  eases  a  typhoid  state  develops  in 
death  occurs. 


Whlrli 


Diag^nosis. — between  the  tub.'rcnious  and  the  cahudous  forms  if 
pyelitis  it  may  be  dillicult  or  impossible  to  distinguish,  exce|)t  l)y  the  de- 
tection  of  tubercle  bacilli  in  the  pus.  The  examination  for  bacilli  should 
be  made  systenuitically  in  all  susj)iei()us  cases.  I-'rom  perinephric  abseos,- 
])yoncphrosis  is  distinguished  by  the  nmro  definite  character  of  the  tmnni, 
the  absence  of  (edematous  swelling  in  the  lumbar  region,  and,  most  impnr- 
tant  of  all,  the  history  of  the  ease.  'I'he  urine,  too,  in  ])erinephric  alis('C!:.s 
may  be  free  from  jiiis.  There  are  cases,  however,  in  which  it  is  dillliult 
indeed  to  make  a  satisfactory  diagnosis.  A  patient  whom  I  saw  with 
Fiissell  liad  had  cystitis  through  her  jiregnancy,  subsequently  i)us  in  tin' 
urine  for  several  months,  and  then  a  large  lluctuating  abscess  devchiiinl 
in  the  right  lumbar  region.  It  did  not  seem  ])o.ssible,  either  before  er 
during  the  operation,  to  determine  whether  the  ease  was  a  simple  pyo- 
ne]>lirosis  or  whether  there  had  been  a  perinephric  abscess  caused  by  the 
in'elitis. 

Suppurative  |)yelitis  and  cystitis  are  frequently  confounded.  I  have 
known  three  instances  of  the  former  in  whicdi  perineal  section  was 
]ierformed  (ui  the  .supposition  of  tlie  existence  of  an  intractable  cystitis. 
The  two  conditions  may,  of  course,  coexist  and  prove  puzzling,  but  tin' 
liistory,  the  acid  character  of  the  pus  in  many  instances,  the  less  freipuiit 


^1:: 


nVDRONEPHROSIS. 


;  charar'tt'ristic 
atcly  the  I'l'Vrr 

uites  prclfiiit:,.,! 
111  a  in'oLM'cs-.i\(. 
II'  clinical  |iiit- 

irlv  of  tu'ilTiMl- 

(1  IVvcf.  'I'linv 
'  Y('a^^^  willnuit 


reveals  ti'iidfr- 
V  vary  imich  in 
■  becomes  ciinr- 


[issociiited  with 
not  unlike  that 

I  of   tlie   (lr(<]||l- 

iinnia.  A  t'ovm 
oases  oi"  alisi't'ss 
'ipheral  iicuriiis 

cystitis,  the  pa- 
li,  irreirnlar.  ami 
■velops  ill  wh.irh 

nlous   forms  (f 

ee|)t  1>y  the  lic- 

•  haeilli  should 

icphric  altsei's.> 

r  of  tlu'  tiiiiiiir, 

1(1,  most  impor- 

iiephric  al)M'i'.>:s 

1   it  is  ilitlii'uh 

Ml   I  saw  with 

itly  pus  in  the 

eess  (levchipuil 

ithor  before  or 

ii  sirnj)!!'  pVK- 

s  caiisetl  hy  tlio 

iindetl.  I  have 
'al  section  was 
at'table  cystitis. 
izzliii.Lr,  liiit  till' 
le  less  frei|iient 


808 


occurrence  of  ammoniacal  deconiposition,  tbo  local  signs  in  one  lumbar 
rpoioti,  and  the  absence  of  pain  in  the  bladder  should  be  sulTicient  to  dif- 
ferentiate the  atfections.  In  women,  by  catlieterization  of  the  ureters,  it 
niav  he  definitely  determined  wliether  the  pus  comes  from  the  kidneys  or 
from  the  bladder.     The  cystoscope  may  be  used  for  this  purpose. 

Prognosis. — Cases  coming  on  during  the  fevers  usually  recover. 
Tulieiciilous  pyelitis  may  terminate  favorably  by  inspissatioii  of  the  pus 
and  conversion  into  a  putty -like  substance  witb  deposition  of  lime 
.silts.  When  pyoneplirosis  develo})s  tlie  dangers  are  inc'reased.  Perfora- 
tii.u  may  occur,  the  patient  may  be  worn  out  by  the  hectic  fever,  or  amy- 
Idivl  disease  may  develop. 

Treatment. — In  mild  cases  fluids  should  be  taken  freely,  particularly 
the  alkaline  mineral  waters,  to  which  the  citrate  of  potash  may  be  added. 

The  treatment  of  the  calculous  form  will  be  c(jnsidered  later.  Practi- 
eully  there  are  no  remedies  which  have  much  influence  upon  the  jiyuria. 
Astringents  in  no  way  control  the  discharge,  nor  liave  I  seen  the  slightest 
heiielit  from  buchii,  copaiba,  sandal-wood  oil,  or  uva  ursi.  Tonics  should 
be  given,  a  nourishing  diet,  and  milk  and  butter-milk  maybe  taken  freely. 
W  lien  the  tumor,  has  formed  or  even  before  it  is  perceptible,  if  the  symp- 
toms are  serious  and  severe,  the  kidney  should  be  c.xi)lored,  and,  if  necta- 
sury,  nephrotomy  should  be  })erformed. 


IX.    HYDRONEPHROSIS. 

Definition. — Dilatation  of  the  ju'lvis  and  calyces  of  the  kidney  with 
atiojiliy  of  its  substance,  caused  by  the  accumulation  of  non-purulent 
lliiids  the  result  of  obstruction. 

Etiology. — The  condition  may  be  congenital,  owing  to  some  ab- 
normality in  the  ureter  or  urethra.  The  tumor  produc^ed  may  be  large 
enough  to  retard  labor.  Sotnetimes  it  is  associated  with  other  nialfornia- 
tioiis.  There  is  a  conditioJi  of  moderate  dilatation,  api)arently  congenital, 
which  is  not  connected  with  any  obstruction  in  the  ducts.  A  case  of  the 
kiml  was  shown  at  the  Philadeljihia  Pat1i<iIogical  Society  by  Dalaiid. 

In  some  instances  there  has  been  contraction  or  twisting  of  the  ureter, 
or  it  has  been  inserted  into  the  kidiu'y  at  an  acute  angle  or  at  a  high  level. 
In  adult  life  the  condition  may  be  due  to  lodgement  of  a  calcidus,  or  to 
a  eieatrieial  stricture  following  ulcer. 

.New  growths,  su(di  as  tubercle  or  cancer,  occasionally  induce  hydro- 
iiephnisis.  More  commonly,  jiressure  u))0!i  the  ureter  from  without,  jiar- 
ticiilarly  tumors  of  the  ovaries  and  uterus.  Occasionally  cicatricial  bunds 
compress  the  ureter.  Obstruction  within  the  l)ladder  may  result  from 
cancer,  from  hypertrophy  of  the  prostate  with  I'ystitis,  and  in  the  urefhra 
from  stricture.  It  is  stated  that  slight  grades  of  hydroiu>phrosis  have 
been  iovnd  in  patients  with  excessive  polvuria. 
61 


■I  I- 5..  I ;-: 


:  ;  f  i 


1    I. 


■i-;!);:;, 


i       <  H 


t'  '^F'l 


804 


DISEASES  OP  THE  KIDNEYS. 


it!  i  :i 


In  whatever  way  prodneod,  when  the  ureter  is  blocked  the  secretion  ac- 
cumulates in  the  pelvis  and  infnndihiila.  Sometimes  acute  inflanmiiiliKU 
follows,  l)ut  more  oommonly  the  slow,  gradmil  pressure  causes  atropliv  of 
the  papilla)  with  gradual  distention  and  wasting  of  the  organ.  In  acijiiiiiHl 
cases  from  pressure,  even  when  dilatation  is  extreme,  there  nuiy  usuallv  \m 
seen  a  thin  layer  of  renal  structure.  In  the  most  extreme  stages  the  kid- 
ney is  represented  by  a  large  cyst,  whitih  may  perhaps  sliow  on  its  inner 
surface  imperfect  septa.  Tlie  lluid  is  tliin  and  yellowish  in  color,  ainl 
contains  traces  of  urinary  salts,  urea,  uric  acid,  aiul  sotnelimes  alljiunin. 
The  secretion  may  be  turbid  from  admixture  with  small  quantities  of  pus. 

Total  occlusion  does  not  always  lead  to  a  hydronephrosis,  but  may  W. 
followed  by  atrojdiy  of  the  ki(hiey.  It  appears  tliat  when  the  obstnutinii 
is  intermittent  or  not  complete  tlie  greatest  dilatation  is  apt  to  follow. 
The  sac  may  be  enormous,  and  cause  an  abdominal  tumor  of  the  largest 
size.  The  condition  has  even  been  mistaken  for  ascites.  Enlargenuiit  of 
the  other  kidney  nuiy  compensate  for  the  defect.  Ilyiiertrophy  of  the  left 
side  of  the  heart  usually  f(dlows. 

Symptoms. — AVheii  snudl,  it  miiy  not  be  notic(!d.  The  congenital 
cases  when  bilateral  usually  prove  fatal  within  a  few  days ;  when  unilateral, 
the  tumor  may  not  be  notiix-d  for  some  time.  It  iiu'reases  progressively 
and  has  all  the  characters  of  a  tumor  in  the  renal  region.  In  adult  life 
many  of  the  cases,  due  to  pressure  by  tumors,  as  in  cancer  of  the  utirus 
and  oidargement  of  the  ])rostate,  etc.,  give  rise  to  no  symptoms. 

There  are  renuirkable  instances  of  interniiftoit  hydroneiihrosis  in 
whi(;h  the  tumor  suddenly  disappears  with  the  dis(diarge  of  a  large  ([uan- 
tity  of  (dear  fluid.  The  sac  gradually  refills,  and  the  ])rocess  may  be 
repeated  for  years.  In  these  cases  the  obstruction  is  unilateral  ;  a  (dcatri- 
cial  stricture  exists,  or  a  valve  is  present  in  the  un  ter,  or  the  ureter  (titers 
the  upper  part  of  the  jxdvis.  Many  of  the  cases  are  in  women  and  a^.■^lt- 
ciated  with  movable  kidney. 

The  examination  of  the  abdomen  shows,  in  unilateral  hydroneiihrosis, 
a  tumor  occupying  the  renal  region.  When  of  moderate  size  it  is  readily 
recognized,  but  \\\w\\  large  it  may  be  confouiuled  Mith  ovarian  or  other 
tumors.  In  young  (diildrcn  it  may  l)e  mistaken  for  sarcoma  of  tiic  kiilney 
or  of  the  n'troperitoneal  glands,  the  comnKUi  causes  of  abdonunal  tuttior 
in  early  life.  Aspiration  aloiu>  wonid  eiia1)le  ns  to  difFerenfiatc  ln'- 
twoen  hydronephrosis  and  tumor.  The  large  hydronephrotic  sac  is  fic- 
qm^itly  mistaken  for  ovarian  tumor.  The  latter  is,  as  a  rule,  nutre  nioiiile, 
and  rarely  tills  the  deeper  portion  of  the  liind)ar  region  .so  tlioronuMy. 
The  ascending  colon  can  often  be  detected  passing  over  the  reind  tumor, 
and  examination  per  vaginam,  particularly  under  ether,  will  give  impor- 
tant indicatioi\s  as  to  the  condition  of  the  ovaries.  In  doubtful  cas(  s  tiic 
sac  should  be  aspirated.  Tlii'  fluid  of  the  retuil  cyst  is  clear,  or  turlml 
from  the  presence  of  cell  elenu'uts,  rarely  colloid  in  (duiracter;  the  s|i('(itio 
gravity  is  low ;  albumin  and  traces  of  urea  and  uric  acid  are  usually  pri><ut; 


HYDRONEPHROSIS. 


805 


and  tlie  opitholial  olemonts  in  it  may  be  similar  to  those  found  in  the  pel- 
vis of  tlie  kidney.  In  old  sacs,  however,  the  lluid  may  not  be  charaeteristic, 
siiii  t'  the  urinary  salts  disappear,  bnt  in  one  case  of  several  years'  duration 
oxiilute  of  lime  and  urea  were  found. 

IV'rhaps  the  greatest  ditticulty  is  olTerod  l)y  the  condition  of  hydro- 
i)t')ilirosis  in  a  movable  kidney.  Here,  the  history  of  sudden  disap|tear- 
aiico  of  the  tumor  with  the  passage  of  a  large  quantity  of  clear  fluid  would 
be  a  point  of  great  importance  in  the  diagnosis.  In  those  rare  instances 
of  an  enormous  sac  filling  the  entire  ab(h)JU{'U,  and  sometimes  mistaken 
foriiscites,  the  character  of  the  iluid  might  be  the  only  })oint  of  dilTerence. 
Tilt'  tumor  of  jjyoimphrosis  may  l)e  prat'tically  the  same  in  physical  char- 
acteristics. Fever  is  usually  preserv,  and  ])ns  is  often  found  in  the  urine. 
Ill  these  eases,  when  in  doubt,  exidoratory  puncture  should  he  made. 

The  outlook  in  hydronephrosis  depends  much  upon  the  cause.  When 
single,  the  condition  may  never  produce  serious  trouble,  and  the  inter- 
mittent cases  may  persist  for  years  and  finally  disappear.  Occasionally 
tlio  cyst  ruptures  into  the  peritonamm,  more  rarely  through  the  dia- 
phragm into  the  lung.  A  remarkable  case  of  this  kind  was  under  the 
care  of  my  colleague,  Ilalsted.  A  man,  aged  twenty-one,  had,  from  his 
second  year,  attacks  of  abdominal  pain  in  which  a  swelling  would  apjiear 
between  the  hip  and  costal  margin  and  subside  with  the  passage  of  a 
liuge  amount  of  urine.  In  January,  1888,  the  sac  discharged  through 
tiie  right  lung.*  Heaccumulations  have  occurred  on  several  occasions 
since,  and  on  June  9,  1891,  the  sac  was  opened  and  drained.  He  re- 
mains well  (May,  1895),  though  there  is  still  a  sinus  through  which  a 
clear,  jirobably  urinous,  fiuid  is  discharged. 

The  sac  may  discharge  si)ontaneously  through  the  ureter  and  the  fluid 
never  reaccumiilate.  In  bilateral  hydronephrosis  there  is  a  danger  that 
ur.einia  may  sujiervene.  There  are  instances,  too,  in  which  blocking  of 
the  ureter  on  the  sound  side  by  calculus  has  been  followed  by  ura-miu. 
Ami,  lastly,  the  sac  may  suppurate,  and  the  condition  change  to  one  of 
pyonephrosis. 

Treatment. — Cases  of  intermittent  hydronephrosis  which  do  not 
oause  serious  symptoms  should  be  let  alone.  It  is  stated  that,  in  sacs  of 
iiioderate  size,  the  obstruction  has  been  overcome  by  shampooing.  If 
practised,  it  should  be  done  with  great  care.  When  the  sac  reaches  a  largo 
size  aspiration  may  be  performed  and  rcju-atcd  if  neccs.sary.  I'uncture 
slionid  he  made  in  the  Hank,  midway  between  the  ilium  and  the  last  rib. 
If  the  fluid  reaccumulates  and  the  siic  becomes  large,  it  may  be  incised 
and  iliained,  or,  as  a  last  resort,  the  kidney  may  be  removed.  In  women  a 
carefully  adapted  ita<l  and  bandage  will  sometimes  prevent  the  recurrence 
of  iiii  intermittent  hydronephrosis. f 

*  Sowers,  Now  York  Jlcdiciil  Roconl,  18K8. 

t  Si'e  ilhistralive  casus  in  my  Lectures  on  Abdominal  Tumors,  185)4. 


,  I 


fM' 


I  I^Jtiiiit 


806 


DISEASES  OF  TIIK  KIDNEYS. 


X.   NEPHROLITHIASIS  (Ii<'nal  Calculus). 


DefiLnition. — Tlio  fdrnuition  in  tlio  kidiu'V  or  in  its  pelvis  of  rnn- 
crotions,  by  tlio  (loposition  of  ('crtaiii  of  the  solid  constituonts  of  the  uriiH', 

Etiology  and  Pathology. — In  liic  kidney  substance  itself  the 
eepanition  of  the  urinary  salts  produces  a  condition  to  which,  unfoi in- 
nately, the  term  infarct  lias  l)een  applied.  Three  varieties  may  be  rccu;;. 
nizcd  :  (1)  The  uric-acid  infarct,  usually  met  with  at  the  apices  of  tiic 
pyramids  in  now-boiri  children  and  during  the  first  weeks  of  life,  li  is 
readily  recognized  as  a  yellowish  linear  streak  in  the  pyramids  and  is  of 
no  signillcance ;  ("-2)  tln!  urate  of  soda  infarct,  sometimes  associated  wjili 
urate  of  ammonia,  which  forms  whitish  lines  at  tlu^  apices  of  the  pyramids 
and  is  met  with  chiefly,  but  not  always,  in  gouty  jjcrsons;  and  (;>)  tlu' 
lime  infarcts,  forming  very  opaque  white  liiu^s  in  the  j)yraniids,  usually  in 
old  people. 

In  the  pelvis  and  calices  concretions  of  the  following  forms  occur:  (a) 
Small  gritty  particles,  renal  sand,  ranging  in  size  from  the  indiviiluiil 
grains  of  the  uric-acid  sediment  to  bodies  one  or  two  niillinu^tres  in  diaiiic- 
ter.  These  may  bo  passed  in  the  urine  for  long  periods  without  producing 
any  symptoms,  since  they  are  too  fine  to  be  arrested  in  their  downuaiil 
passag(>. 

{/))  Larger  concretions,  ranging  in  size  fi'om  a  small  pea  to  a  bean,  iuul 
either  solitary  or  multii)le  in  the  calyces  and  pelvis.  It  is  the  smaller  cf 
these  calcuili  whi(>h,  in  their  passage,  produce  the  attacks  of  renal  colic, 
They  nuiy  be  rounded  aiul  smooth,  or  present  numerous  irregular  projec- 
tions. 

{(•)  The  dendritic  form  of  calculus.  The  orifice  of  the  ureter  miiy  be 
blocked  by  a  Y-shaped  stone.  The  pelvis  itself  may  be  occupied  by  ilie 
concretion,  which  forms  a  tnore  or  less  distinct  mould.  These  are  the  re- 
markable coral  caloili.,  which  form  in  the  pelvis  complete  moulds  of  iii- 
fundibula  and  calices,  the  latter  even  presenting  cu})-like  depressions  cor- 
responding to  the  apices  of  the  papilla*.  Some  of  these  casts  in  stone  of 
the  renal  pelvis  are  as  beautifully  moulded  as  Ilyrtl's  corrosion  prepani- 
tions. 

('hemi(,'ally  the  varieties  of  calculi  are:  (1)  Fric  acid,  by  far  the  nio4 
important,  which  nuiy  form  the  renal  sand,  the  small  solitary,  or  the  liU'^e 
dendritic  stones.  They  are  very  hard,  the  surface  is  smooth,  and  the  color 
reddish.  Thi^  larger  stones  are  usually  stratified  ami  very  dense.  Usually 
the  uric  acid  and  the  urates  are  mixed,  but  in  children  stones  composed  of 
urates  alone  may  occur. 

(2)  Oxalate  of  lime,  whicdi  forms  mulberry-shaped  calculi,  studded  « ith 
points  and  spines.  They  are  often  very  dark  in  color,  intensely  hard,  ami 
are  a  mixture  of  oxalate  of  lime  and  uric  acid. 

(3)  IMiosphatic  calculi  are  composed  of  the  phosi)hate  of  lime  ainI  tlio 
amnionio-magnesiuni  phosphate,  sometimes  mixed  with  a  small  amoimi  of 


rogular  prujcc- 


rosioii  i)reiiiini- 


NEPHROLITIIIASIS. 


807 


c'arl)Oiiato  of  lime.  Tliev  are  not  coinnion,  since  tlio  phospliiitic!  salts  uro 
ol'toiior  deposited  about  the  uric  aoid  or  the  oxalate  of  lime  stones. 

(4)  IJare  forms  of  calculi  are  maile  up  of  cystine,  xanthine,  carbonate 
of  lime,  indigo,  and  urostealitli. 

The  mode  of  formation  of  calculi  has  been  much  discussed.  They  may 
lie  produced  i)y  an  excess  of  a  sparingly  soluble  abnornuil  iugredient,  sucli 
as  (■v.sliue  or  xanthine ;  more  f  r(^(|uently  by  the  presence  of  uric  acid  in  a 
very  acid  urine  vhich  favors  its  (h"j)osition.  Sir  William  IJobcrts  thus 
brictly  states  the  coiulitions  which  lead  to  the  formation  of  ihe  uric-acid 
concretions:  high  acidity,  poverty  in  sidines,  low  pignu'iitation,  and  high 
jicrcentage  of  uri(!  acicL  The  presence  of  albumin  and  mucus  nuiy  deter- 
iiiinc,  as  Ord  suggests,  the  deposition  of  the  uric  acid  and  thus  form  the 
starting  ))oint  of  a  stone.  Ova  of  ]iarasites,  blood-clot,  casts,  and  shreds  of 
(■|iilheliiim  uniy  form  the  nuclei  of  stones. 

licnal  calculi  are  most  common  in  the  early  and  later  periods  of  life. 
Tluy  are  moderately  fre(]Uent  in  this  country,  but  there  do  not  appear 
til  he  special  districts,  corresponding  to  the  "stone  counties"  in  Kngland. 
.\b'ii  are  im^re  often  affected  than  women.  Sedentary  occupations  seem 
to  ])redispose  to  stone. 

The  effects  of  the  calctdi  are  varied.  It  is  by  no  means  uiu-ommon  to 
thul  a  dozen  or  more  stones  of  various  sizes  in  the  calyces  without  any 
(iestnietion  of  the  mucous  nu-mbrane  or  dilatation  of  the  pelvis.  A  tur- 
bid urine  fills  the  i)elvis  in  which  there  are  numerous  cells  from  the 
epithelial  lining.  There  are  cases  of  this  sort  in  which,  apparently,  the 
stones  nuiy  go  on  forming  and  are  ])assed  for  years  without  seriously  im- 
pairing the  health  and  without  inconvenience,  excejjt  the  attacks  of  renal 
ciilie.  Still  more  remarkable  are  the  cases  of  coral-like  calculi,  which 
may  occupy  the  entire  pelvis  and  calyces  without  causing  pyelitis,  but 
which  gradually  lead  to  more  or  less  induration  of  the  kidney.  The  most 
serious  elfects  are  when  the  stone  excites  a  su])purative  pyelitis  and  i)yo- 
ne]ihrosis. 

Symptoms. — Patients  nuiy  pass  gravel  for  years  without  having  an 
attack  of  renal  colic,  and  a  stone  may  never  lodge  in  the  ureter.  In 
other  instances,  the  formation  of  calculi  goes  on  year  by  year  aiul  the  pa- 
tient has  recurring  attacks  such  as  have  been  so  graphically  described  by 
Mniilaigne  in  his  own  case.  A  jjatient  may  j)ass  an  enornH)ns  numl)er  of 
oalculi.  Some  years  ago  I  was  consulted  by  a  commercial  traveller,  an 
extremely  vigorous  man,  who  for  many  years  had  repeated  attacks  of  renal 
I'lilie.  and  had  passed  several  hundred  calcrdi  of  vai'ious  sizes.  His  col- 
lection tilled  an  ounce  bottle.  A  patient  may  pass  a  single  calciUus,  and 
never  be  troubled  a<rain.     The  larire  coral  calcul 


'ly 


syi 


toins.  In  a  remarkable  specimen  of  the  kind,  presented  to  the  McCiill 
Medical  Museum  by  J.  A.  Macdonald,  the  patient,  a  middle-aged  woman, 
ilied  suddenly  with  unvmic  symptoms.  There  was  no  pyelitis,  but  the 
kiihu'ys  were  sclerotic. 


hi- 


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808 


DISEASKS  OF  THE   KIDNEYS. 


Renal  colic  ensnos  whon  ti  stone  enters  the  ureter.  An  attack  iiiny 
Bct  in  abruptly  without  ajtparent  cause,  or  may  folh>\v  a  strain  in  lift- 
ing. It  is  characterizi'd  by  a{^onizin<f  j)ain,  which  starts  in  the  llaiik  nf 
the  affected  si(k',  passes  (h)wn  the  ureter,  and  is  felt  in  tlie  testicle  ami 
along  the  inner  side  of  the  thigh.  The  pain  nuiy  also  radiate  tlnoii;:!! 
the  abdomen  and  chest,  and  be  very  intense  in  the  back.  In  severe  at- 
tacks there  are  nausea  and  vomiting  ami  the  patient  is  collapsed,  'i'lic 
j)erspiration  breaks  out  upon  the  face  and  the  ])ulse  is  feeble  and  (niick. 
A  chill  may  prei-ede  the  outbreak,  and  the  temperature  may  rise  as  \\v^\\ 
KKJ'.  No  one  has  more  graphically  described  an  attack  of  "the  stone"  tliau 
!^^ontaigne,*  who  was  a  suflVrer  for  numy  years:  "Thou  art  seen  fd 
sweat  with  pain,  to  look  pale  and  red,  to  tremble,  to  vomit  well-ni;:li  to 
blood,  to  siilt'er  strange  contortions  and  convulsions,  by  starts  to  let  tears 
drop  from  thine  eyes,  to  urine  thick,  black,  and  frightful  water,  or  to  have  it 
8iii)pressed  by  some  sharp  and  craggy  stone,  that  cruelly  i)ricks  aiul  tears 
thee."  The  symptoms  persist  for  u  variable  period.  In  short  attacks 
they  do  not  last  longer  than  an  hour  ;  in  other  instaiu'cs  they  eonliuin! 
for  a  day  or  more,  with  temporary  relief.  Micturition  is  frecjuent,  occa- 
sionally painful,  and  the  urine,  as  a  ruk',  is  bloody.  There  are  instances 
in  whicdi  a  large  amount  of  clear  urine  is  passed,  probably  from  tlie  otlu  r 
kidney.  In  ran;  eases  the  secretion  of  urine  is  comi»letely  sui^pres.-cij, 
even  when  the  kidiu'y  on  the  opposite  side  is  normal,  and  dcatli  may 
occur  from  ura'iuia.  This  most  frequently  hapi)ens  when  the  second  kiil- 
iiey  is  extensively  diseased,  or  when  only  a  single  kidney  exists.  A  inuiilier 
of  eases  of  this  kind  have  been  recorded.  The  condition  has  been  teriiKd, 
by  Sir  William  Roberts,  ol)structive  suppression.  It  is  met  with  also  when 
can(!er  compresses  both  ureters  or  involves  their  orifices  in  the  bladder.  Tlio 
patient  may  not  appear  to  be  seriously  ill  at  first,  and  ura-mic  symjitoiiis 
may  not  develop  for  a  week,  when  twitching  of  the  muscles,  great  rest- 
lessness, and  sometinu's  drowsiness  supervene,  but,  strange  to  say,  neither 
convulsions  nor  coma.  Death  takes  place  usually  within  twelve  tlays 
from  the  onset  of  the  obstruction. 

After  the  attatjk  of  colic  has  passed  there  is  more  or  less  aching  on  tlic 
affected  side,  and  the  patient  can  usually  tell  from  which  kidney  the  stdiio 
has  come.  Examination  during  the  attack  is  usually  negative.  Very 
rarely  the  kidney  becomes  palpable.  Teiuleriu'ss  on  the  affected  side  is 
common.  In  very  thin  persmis  it  may  be  possible,  on  examination  of  the 
abdomen,  to  feel  the  stone  in  the  ureter;  or  the  patient  may  complain  nf 
u  grating  sensation. 

When  the  cahndi  remain  in  the  kidney  they  may  produce  very  deflnito 
and  characteristic  symptoms,  of  which  the  following  are  the  most  im- 
portant : 

(1)  Pain,,  usually  in  the  hack,  which  is  often  no  more  than  adullsore- 

•  Essays,  Book  HI,  18. 


m 


!•  iBiJ 


hnn  adullsore- 


NKIMIROLITIIIASIS. 


809 


noss,  but  wliicli  may  be  sovoro  and  come  on  in  paroxysms.  It  is  usually  on 
tlu'  siile  alTected,  but  may  be  referri;il  to  tlie  ojjpojite  kidney,  and  there  aro 
iiistiiiiees  in  whieli  the  pain  has  been  contined  to  tlie  sound  side.  Pains 
iif  a -sitnilar  nature  may  oeeur  in  movable  kidneys,  and  there  are  several 
iiistunces  on  record  in  which  surj^eons  have  incised  the  kidney  lor  stone 
iiiiJ  found  none.  In  an  instance  in  which  j)ain  was  j)resent  for  a  couplo 
of  ytars  the  exploration  rcivealed  oidy  a  contracted  kidney. 

(v')  lJ(r;nuitin'iff.—A]\h()U<f:,h  this  (tccur.s  most  frequently  when  the 
stdiie  l)e<'ojiies  en|^agcd  in  the  ureter,  it  nuiy  also  come  on  when  the  stoiuM 
art'  ill  the  jx'lvis.  The  bleed iui;  is  seldom  profuse,  as  in  cancer,  l)ut  in 
siiiiic  instances  may  pei'sjvt  for  a  loii^f  timi'.  It  is  ii<,'<:fravated  by  exertion 
aihl  lessened  by  rest.  Krcijuently  it  oidy  j^ives  to  tiie  urine  a  smoky  bue. 
The  u"'ne  juay  be  fi'cc  for  diiys,  ;iiid  tlu'U  a  sudden  exertion  or  a  proloii<j;ed 
ride  may  caus(^  smokiucss, or  blood  luay  be  passed  in  considerable  (juantities. 

(:{)  J^i/rli/i.s. — [ff)  There  nuiy  l)e  attacks  of  severe  jtain  in  the  back, 
net  aMiountin<i;  to  actual  colic,  which  are  initiated  l>yalieavy  chill  f(tllowed 
li_v  fever,  in  which  the  temperature  nuiy  reach  104°  or  ]()o°,  followed  by 
jirofiise  sweating.  The  urine,  which  has  been  clear,  may  become  turltid 
1111(1  .-luoky  and  contain  lilood  and  abundant  epitlu'lium  from  the  pelvis. 
Attacks  of  this  description  may  recur  at  intervals  for  montlis  or  even 
ytars,  and  are  generally  mistaken  for  malaria,  unless  special  attention  is 
paid  to  the  urine  and  to  the  existt'iice  of  the  jiaiu  in  the  back.  'Phis  rcmd 
iiitcrniittent  fever,  i\\w  to  the  presence  of  calculi,  is  identical  with  the 
lit'patic  intermittent  fever,  due  to  gall-stones,  and  in  both  it  is  imi)ortant 
t(i  remember  that  the  most  intense  paroxysms  may  occur  without  any  evi- 
tlciire  of  suppuration. 

(//)  More  freipiently  the  symptoms  of  purulent  pyelitis,  which  have 
already  been  descril)cd,  are  ])rcsent  ;  pain  in  the  renal  region,  recurring 
(.hills,  and  pus  in  the  urin*>,  with  or  without  indications  of  pyonephrosis. 

(1)  Pyuria. — There  .ire  instances  of  stone  in  the  kidney  in  which  juus 
occurs  continuously  i^r  intermittently  in  the  uriiic  for  many  years.  On 
many  occasions  between  ISJ,")  and  188-t  I  examined  the  urine  of  a  jdiy- 
sii'ian  who  had  passed  calculi  when  a  student  in  184.'),  and  has  had  pu.s  in 
till'  urine  at  intervals  to  18'.)1,  when  I  last  heard  fnun  him.  In  spite  of 
the  prolonged  suppuration  he  has  had  remarkable  mental  and  bodily  vigor. 

Patients  with  stone  in  the  '  -'Iney  are  often  robust,  high  livers,  and 
gouty.  Attacks  of  dyspepsia  are  not  uncommon,  or  they  may  have  severe 
lioadachos. 

Diagnosis. — TJenal  nuiy  be  mistaken  for  intestinal  colic,  particularly 
if  the  distention  of  the  bowels  is  marked,  or  for  iiiliary  colic.  'I'he  situa- 
tion and  direction  of  the  pain,  the  retraction  and  tenderness  of  the  testicle, 
tlie  occurrence  of  htematuria,  and  the  altered  character  of  tbe  urine  are 
liistinctive  features.  Attention  may  again  be  called  to  tlie  fact  that  at- 
tacks simulating  renal  colic  are  associated  with  movable  kidiiey,  or  even, 
it  has  been  supposed,  without  mobility  of  the  kidney,  with  the  accumu- 


M»  ■  ■■ 


I'V 


•i 


\  , 


( -1 


■     - 3r 


810 


DISEASES  OF  THE   KIDNEYS. 


lution  of  tlu!  oxaliitcK  or  iirif  ac-id  in  tlio  pelvis  of  tlic  l\i(liioy.  Tlio  diaj;. 
nosis  ln'twi't'ii  u  .stone  in  the  kidney  and  stone  in  tlie  hitidder  is  not  alwiivs 
eawy,  tliou^ii  in  tlie  latter  tlie  pain  is  particidai-ly  al)ont  the  neck  of  the 
bladder,  and  not  limited  to  one  side.  Important  points  are  tlu'  nintidn 
of  the  urine,  which  in  stone  in  the  hladder  is  alnwtst  invuriahly  alkuliiic, 
and  till'  ahnndance  id"  mucus  with  tlii^  [tiis.  it  is  >tatiM|  that  certjiin  diiTcr- 
enees  occur  in  the  syn4)tonis  produced  hy  dilTerent  sorts  of  calculi.  Ttn' 
hirj^o  urie-aeid  calculi  less  freipiently  j)roduee  severe  symj)toms.  On  tlu. 
other  hand,  as  the  oxalate  of  lime  is  a  rouji;her  cakailns,  it  is  apt  to  ino- 
duce  more  pain  (often  of  a  nidiatiiiff  (diaraeter)  than  the  lithjc-acid  t'urni, 
and  to  cause  ha-morrhaf^e.  In  both  these  forms  tlaMirine  is  acid.  T!)i' 
pliosphatie  calculi  are  stated  to  produce  the  most  intense  jtain,  and  tliu 
urine  is  commonly  alkaline. 

Treatment. — In  the  attacks  of  ronal  colic  great  relief  is  ex])erieii(((l 
by  the  hot  bath,  whi(di  is  sometimes  siinieient  to  relax  the  spasm.  Wliiii 
the  jiaiii  is  very  intense  morphia  should  be  given  hypudermically,  ami  iii- 
halation.s  of  eliloroform  may  be  necessary  until  the  elfeets  of  the  aiiudyiic 
are  manifest.  Local  applications  are  sometimes  grateful — hot  jioiiltiiis, 
or  (doths  wrung  out  of  hot  water.  The  patient  may  diink  freely  nf  hot 
lemonade,  soda  water,  or  barley  water.  Occasionally  change  in  po-tiiic 
will  give  great  relief,  and  inversion  of  the  jjatieiit  is  said  to  be  followed  by 
immediate  cessation  of  t'     pain. 

In  the  intervals  the  patient  should,  as  far  as  possible,  live  a  (juiet  life, 
avoiding  sudden  exertion  of  all  sorts.  The  essential  feature  in  the  trc.it- 
ment  is  to  keep  the  urine  abundant  and,  in  a  majority  of  the  cases,  alka- 
line. The  patient  should  drink  daily  a  large  but  dctinite  (|uantity  of 
mineral  waters*  or  distilled  water,  wliitdi  is  just  as  satisfactory.  The 
citrate  or  bicarbonate  of  potasii  may  be  added.  The  aidiing  pains  in  tlu' 
back  are  often  greatly  relieved  by  this  treatment.  Many  patients  liinl 
benefit  from  a  stay  at  Saratoga,  Bedford,  I'oland,  or  other  mineral  sprint:' 
in  this  councry,  or  at  Vichy  or  Ems  in  Europe. 

Tlu-  diet  should  be  carefully  regulated,  and  similar  to  that  indicated  in 
the  early  stages  of  gout.  Sir  William  Roberts  reeonnnends  what  is  kimwii 
as  the  Sidvent  treatment  for  urir  acid  calculi.  The  citrate  of  potash  is 
given  in  large  doses  >.f  half  a  dratdim  toadraidim  every  three  hours  in  a  tiiiii- 
blerful  of  water.  This  should  bo  kept  up  for  several  months.  1  liavi  had 
no  success  with  this  treatment,  nor,  when  one  considers  the  character  of  tho 
uric-a(dd  stones  usually  met  with  in  the  kidney,  does  it  seem  likely  that 
any  scdvent  action  could  bo  exendsed  u])on  them  by  changes  in  the  urine. 
This  treatment  should  be  altandoned  if  tlie  urine  becomes  animoniacal. 

The  value  of  piperazino  as  a  solvent  of  uric-acid  gravel  or  of  uric  aoid 
stones  has  been  much  discussed  of  late.     While  outside  the  body  a  watery 


*  Some  of  these,  if  we  judge  by  the  laudatory  reports,  are  as  potent  as  the  wiilirs 
of  Corsena,  declared  by  Montaigne  to  be  "  powerful  enough  to  break  stones." 


TUMORS  OF   TflE   KIDNKY. 


811 


t 


ley.  The  (li;ii». 
er  in  not  ahvavs 
tlic  neck  (if  till' 
fc  flic  n'lictidii 
irialtly  alkiiliiic, 
it  certain  ililTcr- 
f  fak'uli.    Til,. 

])tlMllS.       «hi  tlic 

t  is  a[)t  Id  |ini- 
ithic-aciil  t'nnii, 
ic  is  a<i(l.  T'li' 
e  pain,  and  ihc 

'f  is  ('X|it'ri('ii('iMl 
•  spasm.  W  lull 
niicaily,  anil  iii- 
ol"  tiu'  annil\iu' 
— hot  jiitiiltiii's, 
ik  freely  nf  Ik  it 
iiific  in  |in>tiirr 
J  bu  followed  liy 

live  a  (juii't  liff. 

WW  in  the  irc.ii- 
tlic  cases,  alk;i- 
ite  (piantity  of 
isfaetory.  Tin' 
u<:  pains  in  the 
y  })aticnts  tiiul 
Miincral  sprinj^'s 

lat  iiiilii-iteil  in 
;  what  is  kiidwu 
ate  of  jiotasli  is 

hours  in  a  timi- 
hs.  I  have  had 
(diaracter  of  tlio 
eeni  likcdy  lluit 
Xcs  in  the  urine. 
aninioniacal. 

or  of  uric  ai'id 
0  body  ii  watory 

tent  as  the  wators 
stones." 


solution  of  the  drug  lias  this  power  in  a  marked  (lc;.'rco,  the  amount  ex- 
creted in  tht!  urino  iw  ju'ivcii  in  tho  ordimiry  doses  of  fifteen  graiius  daily 
srcrns  to  have  very  little  influence.  Several  observers  have  shown  that  tho 
piT'cntago  of  pi])erazine  excreted  in  tho  urine,  when  taken  in  doses  of 
troiii  one  to  two  orammes,  has,  when  tested  outsidu  of  thu  body,  little  or 
110  inlluunco  as  a  solvent  (Fuwcett,  Gordon). 

XI.  TUMORS  OF  THE   KIDNEY. 

These  are  l)eni<in  and  mali,i,niant.  Of  the  beniifii  tumors,  the  most 
idiiiiiion  are  the  small  nodular  JihrDiiKtht  which  occur  fre<pu'ntlv  in  tho 
jiyraniids,  tluw//>*'/vv//(/ ^^^//7'//«/.s' wlii(di  (irawitz  has  (lescril)c(l,  and  occa- 
siiinally  lijminii,  int(/ioi/iff,  or  hjinpli(i<l(>iiiinm.  'V\u'  ailnmnuiht  may  ho 
niui^vnital.  In  one  of  my  cases  the  kidneys  wt-re  j^reafly  iiilar<red,  con- 
tained sniull  cysts,  and  numerous  adenomatous  structures  throughout 
lidtli  iir<jans. 

Malignant  ^Yi)\\i\\^~c(t nrcr  i.r  sarrotiia — may  he  either  primary  or 
stcdiidary.  The  sarcomata  are  the  most  common,  either  alve(dar  sarcoma 
111'  the  lemarkable  form  containing  striped  muscular  fibres — rhabdo-niyonm. 
Cairinoina  is  less  frequent,  and  is  of  the  encephaloid  variety. 

I'rimnnj  my/;rr— meaning  by  this,  malignant  disease — is  not  nncom- 
iiioii.  .111(1  the  statistics  given  by  some  wrili'r,-  do  not  represent  the  fre- 
(liieiuy  with  whudi  if  is  met  with,  at  any  rate,  in  this  country.  Virchow 
giv's  the  ratio  to  canc'r  in  other  parts  as  one  half  of  one  per  cent. 

The  tumors  attain  a  very  large  size,  fn  one  of  my  cases  flu-  left  kidney 
wciulied  twidvo  ]ioniids  Mid  almost  filled  the  alxlonien.  In  children  they 
may  reach  an  enormous  size.  Morris  states  that  in  a  lioy  at  the  .Middlesex 
lliispital  the  tumor  weighed  thirty-one  ])ounds.  Tiny  g'^w  rapidly,  are 
often  soft,  and  Inemorrhage  frequently  takes  places  into  llieni.  In  the 
saivdinata  invasion  of  the  pelvis  or  of  the  renal  vein  is  common.  The 
I'lialido-myomas  rarely  form  very  large  tumors,  and  death  occurs  shortly 
alter  birth.  In  one  of  my  cas.'s  the  child  lived  to  the  age  of  three  years 
ami  a  half.  The  tumor  grew  into  the  renal  vein  and  inferior  cava.  A 
(ictaehed  fragment  passed  as  an  embolus  into  the  j)iilmoiiary  artery,  and  a 
portion  of  it  Idockeil  the  tricuspid  orilice. 

Symptoms. — The  following  are  the  most  important:  (1)  Ihema- 
tiiria.  This  may  be  the  first  indication.  The  idood  is  fluid  or  (dotted, 
aud  there  may  be  very  charactcristie  moulds  of  the  pelvis  of  the  kidney  and 
iif  the  ureter.  It  would  no  doubt  be  ])ossible  for  su(di  to  form  in  the  Inema- 
turia  from  ealcidus,  hut  I  have  never  met  with  a  case  of  blood-casts  of  tho 
IH'Ivis  and  of  the  ureter,  either  alone  or  together,  ex(;e))t  in  cancer.  It  is 
!'aro  indeed  that  cancer  elements  may  be  recognized  as  in  the  nrine. 
'^f  the  numerous  specimens  which  I  have  examined,  in  not  one  have  I 
fiHitid  elements  vvhi(di  could  be  clearly  distinguished  from  the  multiform 
transitional  epithelium  constantly  present  in  these  cases. 


1-f 


'%     ' 


.i;i' 


I  imm 


812 


DISKASKS  OP  THK   KIDNKYS. 


.  f 
I  i 


If  *  nip 


(2)  Piiiii  U  fill  tnu'ortain  xyniptom.  Tn  Hovoral  of  tho  liirgost  tuiiHirs 
wliicli  luivc  ('OHIO  iiiidcr  my  olwrviitioii  tlwrc  lias  been  no  discoriifoit  fnun 
l)('j;iiiiiiii;X  to  close.  Wlifii  present,  it  is  of  ji  (Ira<,';,Miij:,  tliiU  eliaraetcr.  >.it- 
iiateil  ill  the  lluiil<  and  radialin},'  down  tlie  tidgli.  The  pussnye  of  ilie 
eiots  nKiy  eanse  <!:r('ut  pain 

(;i)  Pri)j:;n'Hsivo  emaciation.  The  loss  of  llesli  is  nsiially  marked 
aTid  advancts  rapidly.  There  may,  however,  he  a  very  hirge  tumor  with- 
out emariatinii. 

Physical  Signs.— Tn  almost  all  instances  tumor  is  present.  W  lim 
small  and  on  tlie  rij^ht  side,  it  may  be  very  movaliI(> ;  in  some  iiistuiices, 
occupyinjx  a  position  in  the  iliac  fossa,  it  has  been  mistaken  for  ovinMiiu 
tumor.  The  lar;,'e  "growths  till  the  flank  and  j^radually  extend  toward  the 
middh'  line,  oecnpyinfi;  the  rij^ht  or  left  half  oi'  the  abdomen.  Inspeciidn 
rmiy  show  two  or  three  hemispherical  j)rojeetioiis  corresponding  to  (hs- 
tonded  sectimis  of  the  orj^an.  In  (diildren  the  abdomen  may  reach  ;iii 
imonnous  size  and  the  veins  are  prominent  and  distended.  On  bitiiiiiiiial 
palpatio!!  the  tumor  is  felt  to  occupy  the  lumbar  region  and  can  usimlly 
bo  lifted  slightly  from  its  bed;  in  some  eases  it  is  very  movable,  even  wIhh 
large;  in  others  it  is  lixed,  firm,  and  solid.  The  respiratory  moveuiciits 
have  but  slight  influence  upon  it.  Hai)idly  growing  remil  tumors  mv 
soft,  and  on  palpation  may  give  a  sense  of  iluctmition.  A  ])oint  of  ciiii- 
siderable  importance  is  the  fact  that  the  colon  crosses  the  tumor,  and  can 
usually  be  detected  without  dillicnlty. 

Diagnosis.  —  In  (duldren  very  largo  abdominal  tumors  are  either 
renal  or  retro[)critoneal.  The  retroperitoneal  sarcoma  (ijobsteiirs  can- 
cor)  is  nn)re  central,  but  may  attain  as  large  a  size.  If  the  case  is  seen  only 
toward  the  end,  a  differential  diagnosis  may  be  impossil)le  ;  but  as  a  rule  Uie 
sarcoma  is  less  movable.  It  is  to  be  remembered  that  those  tumors  may 
invade  tho  kidney.  On  the  left  side  an  enlarged  spleen  is  readily  distin- 
guished, as  the  edge  is  very  distinct  and  the  notch  or  notidies  well  maikcil ; 
it  descends  during  res[)iration,  and  ilie  colon  lies  behind,  not  in  front  (if 
it.  On  tho  right  side  growths  of  tho  liver  aro  occasionally  confouiuhtl 
with  renal  tumors;  but  such  instances  are  rare,  and  there  can  usually  U' 
detected  a  zone  of  resonance  between  the  upper  margin  of  the  renal  tinnur 
and  the  ribs.  Late  in  the  disease,  however,  this  is  not  possible,  for  the 
renal  tumor  is  in  close  union  with  the  liver. 

A  malignant  growth  in  a  movable  kidney  may  bo  very  dcco))tivc  ami 
may  simulate  cancer  of  the  ovary  or  fibroid  of  the  uterus.  The  grci'.t 
mol)ility  upward  of  tho  renal  growth  and  the  negative  result  of  examina- 
tion of  tho  pelvic  viscera  are  tho  reliable  points. 

Medicinal  treatment  is  of  no  avail.  When  tho  growth  is  small  anr.  tlio 
patient  in  good  condition  removal  of  the  organ  may  be  undertaken,  but 
the  percentage  of  cases  of  recovery  is  very  small. 


}  liirpc'st.  tiimnrs 
tliscotiifort  from 
11  cliiinictfr.  sit- 
('  pussajjc  (if  ilif. 

usiiiilly  iiiarkcil 
ii'gc  timinr  willi- 

prcsciit.     When 

some  iiistiiiurs, 
iikcii  fur  (iv;iri;iii 
;tfiHl  toward  the 
lU'H.  Iiisju'ctidii 
«pnii(liii;jj  t(»  (lis- 
n  may  ivacli  an 
1.     Oil  liiiiiaiiual 

and  can  usually 
val)li',  cvi'ii  wlirii 
itory  niovciiiciits 
TMul  tumors  arc 

A  i)oint  of  I'dii- 
e  tumor,  anil  can 

imors  arc  citlicr 

(Lobstein's  can- 

case  is  seen  oiily 

but  as  a  rule  tlic 

lese  tumors  may 

is  rcatlily  distin- 

u'H  well  marked; 

,  not  in  front  of 

lally  confoiiiidfil 

•e  can  usually  t"' 

the  renal  tiimur 

possible,  for  IIr' 

ry  (loce))tivc  ami 
'rua.  The  ;irf;'.t 
.'suit  of  exaiuiiia- 

is  small  am'  the 
uudertakeu,  but 


rVSTir   DISEASR  OF'^  TIIK   KIDXKY.  813 


XII.    CYSTIC    DISEASE    OF   THE    KIDNEY. 

Tlie  foUowinj;  varieties  of  cysts  are  met  with  : 

(1)  The  HMiall  cysts,  already  descrilifd  in  connection  with  the  (  hroiiic 
nephritis,  which  result  from  dilatation  of  obstructed  tubules  or  of  Mow- 
iiiaii's  capsulus.  There  are  casi-s  very  dillicult  to  classify,  in  which  the 
kidneys  are  greatly  enlarged,  and  very  cystic  in  middle-aged  or  ehlcrly 
]i  iMiii^,  and  yel  not  so  large  as  the  congenital  form. 

(I')  Solitary  cysts,  ranging  in  si/e  from  a  mari)le  to  an  orange,  or  even 
larger,  are  occasionally  found  in  kidneys  which  present  no  other  changes. 
They  never  give  rise  to  symptoms,  though,  in  exceptioiuil  cases,  they  nniy 
Iniiii  tumors  of  considerable  size.  'I'hey,  too,  in  all  probability,  result 
fiuiu  ol)struetion. 

{:])  The  congenital  cystic  kidneys.  In  this  renuirkable  condition  the 
kidneys  are  represented  by  a  conglomerution  of  cysts,  varying  in  size  from 
a  jiea  to  a  nuirble.  'I"he  organs  are  greatly  enlarged,  and  together  may 
tttii:h  six  or  more  pounds.  In  the  fietus  thev  mav  attain  a  size  sullieient 
til  impede  labor.  Little  or  no  renal  tissue  nuiy  be  notieealile,  although  in 
iiiicroseopieal  sections  it  is  seen  that  u  considerable  amount  remains  in 
ilie  intersjiaces.  'I'he  cysts  contain  u  clear  or  turbid  fluid,  sometimes 
ri'dtlisli  brown  or  even  blackish  in  color,  and  maybe  of  a  colloidal  consiKt- 
riiie.  All)umin,  blood  crystals,  cholesterin,  with  triple  phosphates  and 
tat  drops  are  found  in  the  contents.  Urea  and  uric  acid  are  rarely  jtres- 
iiit.  The  cysta  are  lined  by  a  flattened  epithelium.  It  is  luit  yet  accu- 
rately known  how  these  cysts  originate.  That  it  is  n  defect  in  develoj)- 
iiiiiit  rather  than  a  pathological  change  is  suggested  by  'he  fact  that  it  is 
often  in  the  embryo  associated  with  other  anomalies,  particularly  iinper- 
funite  anus.  lioth  Shattock  and  Hlaiul  Sutton,  who  have  studied  the 
qiKstiun  carefully,  bcdieve  that  the  anonuily  of  development  is  in  the  fail- 
ure of  comidete  dilTerentiation  of  the  Wolllian  bodies,  which  are,  as  it 
wtMv,  mixed  with  the  kidneys  aiul  give  rise  to  the  cysts.  Though  the  con- 
diiiiui  is  congenital,  yet  from  the  history  of  certain  cases  it  is  evident  that 
till.' organs  must  increase  enormously  in  size.  In  a  patient  of  Dr.  .Mfred 
King's,  of  I'ortland,  Me.,  a  man  age(l  (iftv-fouV,  the  abdonu'ti  presented 
nothing  abiH)rnnd  on  careful  examimition  three  years  before  his  death,  but 
three  niojiths  prior  to  this  date  there  were  largo  bilateral  tumors  in  the 
renal  regions,  which  were  readily  diagnosed  as  cystic  kidneys.  The  organs 
weii:lied  four  pounds  each. 

In  a  large  majority  of  the  cases  death  occurs,  either  /'//  u/cro  or  shortly 
after  iiirth  ;  but  instances  are  met  with  at  all  ages  up  to  fifty  or  sixty,  and 
I  see  no  reason  to  suppose  that  these  are  not  instances  of  j)ersistence  of 
the  congenital  form. 

In  the  adult  the  tumors  may  be  felt  in  the  lumbar  region  as  large 
rounded  masses. 


li- 


ft    \ 


if 


Hj 


ir 


;it' 


4}} 


814 


DISEASES  OP  THE  KIDNEYS. 


The  si/»ip/i»ns  uro  those  of  cliroiiic!  intorstitial  ii('i)liritis.  Many  of  the 
casos  liiive  prorifiitcd  no  iiidit-atioiis  wliatovcr  until  u  suddun  attuck  of 
ur.Miiia  ;  otlicrs  have  died  of  lieart-faihire.  A  rare  termination  in  a  caso 
at  the  University  Ilosiiital,  J'iiiladelpliia,  was  the  rupture  of  one  ut  tln' 
cysts  and  the  production  of  a  perinepiiritic  abseess.  The  card io- vascular 
chan<j(\s  induced  are  similar  to  those  of  interstitial  nephritis.  The  left 
ventricle  is  hypertrctphied  and  the  arterial  tension  is  greatly  iMcicaM. 
The  condition  i^  compatible  with  excellent  health.  The  dangers  are 
those  associated  with  chronic  liright's  disease.  It  is  important  td  iv- 
nu'iid)er  that  the  •  uigiomeratc  cystic  kidney  is  almost  invarir  hilat- 
eral.  One  kidney  may  be  somewhat  larger  and  more  ejstic  than  ihc 
other. 

The  diagnosis  can  sometimes  be  made.  Great  enlargement  of  lidth 
organs,  with  hypertrophy  of  the  left  heart  and  increased  arterial  teiision, 
would  suggest  the  condition. 

()p(M'ativc  interference  is  not  justiliable.  I  know  of  an  instance  in 
which  one  kidjiey  was  removed  and  the  patient  died  within  twenty-four 
hours. 

(4)  Occasionally  the  kidneys  and  liver  ])resent  nunu'rous  small  (•\st,s 
scattered  through  the  substance.  The  spleen  n]<o  nuiy  be  involved.  'I'lir 
cysts  in  the  kidney  are  small,  and  neither  so  nunu'rous  nor  so  thickly  sd 
as  in  the  conglomerate  form,  though  in  these  cases  the  condition  is  pioh- 
ably  the  result  of  some  congcintal  defect.  'I'here  are  cases,  however,  iii 
which  the  kidneys  ai'c  very  large.  It  is  more  common  in  t.lic  lower  ani- 
mals than  in  num.  I  have  si-en  several  instances  of  ic  in  the  hog;  in  cue 
case  the  liver  weighed  forty  pounds,  and  was  convert 'd  into  a  mass  of  miu- 
pie  cysts.  Tlic  kidneys  were  less  invohnl.  Charles  Kiwincdy  *  states  tinii 
he  has  found  references  to  twelve  cases  of  cond)ined  cystic  disea.se  c  f  the 
liver  and  kidneys. 

The  echinoeo>.cus  cysts  will  be  sjioken  of  under  the  section  on  para- 
sites. 

XIII.    PERINEPHRIC    ABSCESS. 

Suppuration  in  the  cbnnective  i'M^i'iw  about  the  kidney  may  follow 
(I)  l)lo\vs  and  injuries;  (y)  tlie  e.xtensicm  of  inilamnuitiou  fiom  tiic  privis 
of  the  kidney,  the  kidiu'y  itself,  or  tl-.e  ureters;  {',))  perforation  ol'  the 
bowel,  most  commonly  the  ajipemlix,  in  some  instances  the  colon;  {•!) 
extension  of  suppuration  from  the  spine,  as  in  caries,  or  from  the  pleura, 
as  in  empyema;  (r»)  as  a  seipu'l  of  the  fevers,  particularly  in  chihhvn. 

In  tlu'  post-nujftem  examination  of  a  case  of  jierinephric  abscess  the 
kidney  is  found  surrounded  by  j»us,  particularly  at  the  posterior  part, 
though  the  pus  n.ny  lie  altogether  in  front,  between  the  kidni'y  u.'id  ihc 


*  Laboratory  Reports  of  the  Royul  Collige  of  Physicians,  Edinliurgh,  vol.  iii. 


Lis.  Many  of  the 
-iid.liMi  attiuk  of 
liiiiitioii  ill  a  laso 
re  of  one  nf  the 
10  card  io- vascular 
[»lirilis.  'I'll,.  l,ft 
^[rc'atly  iiicKascil. 
'I'lie  (laii<,'i'r.s  im 
inijiortant  to  re- 
in vari;'  hihit- 
c'}.stic   than   tlic 

irgciiieiit  of  lidtli 
1  urtcrial  tonsion, 

f  an   iiislaiici^  in 
itliin  twenty -fuiir 

crous  small  cNsts 

)o  involved.     The 

nor  so  tliirkl\  sil 

L'ondition  is  pmli- 

cases,  liowcvn-.  in 

in  llio  lower  uiii- 

1  the  lioj:;  in  eiio 

to  a  mass  of  siiii- 

led y  *  states  thai 

tic  disease  (  f  tlio 

auction  on  pane 


Iney  may  f<illu\v 

II  from  the  |ielvis 

rf(»ration  nf  the 

s  the  colon ;  (-1) 

from  the  pleiini, 

in  eliildivii. 

|ihrie  abstess  the 

e   posterior  [.n't. 

kidiu'V  and  the 


PERINEPIIRTC   ARSCESS. 


815 


jieritninvnm.  Usually  the  abscess  cavity  is  larff(>  and  extensive.  The  pu.g 
is  often  otTen.sive  and  may  liavo  u  distinctly  fa'cal  odor  from  contact  with 
the  lar<,'e  bowel.  It  may  burrow  in  various  directions  and  may  burst  into 
tlie  pleura  and  be  (liscl\ar<fed  through  the  lungs,  A  more  frequent  direc- 
tion is  down  tlie  ])soas  mustde,  wlien  it  appears  in  the  groin,  or  it  mtiy 
|i;\ss  along  the  iliacus  fascia  and  appear  at  IVnipart's  ligament.  It  may 
perforate  th(>  bowel  or  rupture  into  the  peritoiueum,  an  i  in-^nme  instances 
it  has  penetrated  the  l)ladder  or  vagina. 

I'ost  mortem  we  occasionally  find  a  condition  of  chronic  perinephritis 
ill  which  tho  fatty  capsule  of  the  kidney  is  extremely  firm,  with  numer- 
ous liands  of  fibrous  tissue,  and  is  stripped  off  from  the  proi>er  caj).sule 
with  llu!  greatest  ditticulty.  Sucli  a  condition  probably  produces  no  symp- 
toms. 

Symptoms. — There  n;;/  be  intense  pain,  aggravated  by  pressure,  in 
the  lumbar  region.  In  otluM'  instances,  the  onset  is  insidious;  there  is  no 
]);iin  in  the  renal  region,  ])ut  on  the  first  examination  signs  of  di'ep-seated 
sii|ipiiratioii  may  be  detectecl.  On  the  alfeeted  side  there  is  usually  pain, 
which  may  be  rid'crred  to  the  neigtiborhooil  of  the  bip-joint  or  radiate 
down  the  thigh  and  be  a.ssociated  with  retraction  of  the  testis.  Sometimes 
the  pain  is  refcrreil  even  to  the  knee-joint,  as  in  liip-disea~e.  The  patient 
lies  with  the  thigh  flexed,  so  as  to  rehix  the  psoas  muscle,  and  in  walking 
throws,  as  far  as  possible,  the  weight  on  the  ojiposite  l«'g.  According  to 
(iihiiey,  the  jiatient  kcvpa  the  spine  immobile,  assumes  a  stooping  posture 
ill  walking,  and  lias  great  difVicnlty  in  voluntarily  aiidiicting  the  thigh. 

There  maybe  jius  in  tlie  urine  if  the  disease  has  extender  I  from  the 
]ie]vis  or  the  kidney,  Itnt  in  other  forms  the  urine  is  clear.  \\  len  piis  has 
formed  there  are  usually  chills  with  irregular  fever  ands\V(ats.  On  ex- 
iiiiiination,  dee])-seated  induration  is  felt  between  tliela-t  riband  the  crest 
of  the  i'inm.  Himanual  palpation  may  reveal  a  distinct  tumor  mass. 
U'Menia  or  ]»uniness  of  the  skin  is  frccpiently  present. 

The  diagnosis  of  ]>erinepliric  ab.sct'ss  is  usually  easy,  and  in  any  case 
when  doubt  I'xists  the  asjfirator  needle  .should  be  used.  WC  cannot  always 
ilillVrentiate  the  primary  forms  from  those  due  to  j)erforatioii  of  the  kid- 
ney or  of  the  bowel.  This,  however,  uiakes  but  little  diircrcnce,  for  the 
tre;itnient  is  identical.  It  is  usually  jiossilde  i)y  the  history  ami  examina- 
tion to  exclude  disease  of  tht"  vertebra.  In  children  the  condition  is  ofti'ii 
llli^taken  for  disease  of  the  hip-joint,  but  the  pain  is  higher,  and  there  is 
an  entire  aiiseiice  of  fulness  and  tenderness  over  the  hiji-joint  itself. 

I'rom  whatever  cause  ))roduced,  the  indications  for  treatment  .irc  ideii- 
tieiil— early,  free,  and  permanent  draimige. 


|l    1 


iliurgh,  vol.  iii. 


f  tm 


SECTION    VIII. 


DISEASES   OF   TUE  NERVOUS   SYSTEM. 


I.    (^ENEEAL    INTRODrCTIOX. 


In  disoasos  of  tlio  nervous  s\-stom  it  is  of  the  greatest  irniiortiirire  tn 
know  aconrately  the  ixjsition  of  the  morbid  process,  mid  liere,  even  nidiv 
tliati  in  tlie  other  de|*rtniejits  of  medicine,  a  thoroutrh  knowlcdtrc  of 
anatomy  and  j»hy*i()l<';ry  is  essential.  For  full  details  tlte  stinlfiit  is  n- 
fcrred  to  the  te.\t-l)ooks  on  the  subject,  as  it  is  ])0ssible  to  only  touch  nn 
the  subject  in  this  place. 

'i'lie  n-'cnt  studies  of  (Joljri,  Ramon  y  C'ajal,  "Waldeyer,  f'"rkeley,  \'iiii 
Cicliuchten,  and  others  have  modilied  our  conceptions  of  the  fundanieiitul 
structure  of  the  nervous  system.  At  jvrcsent  we  think  r>f  it  as  a  eouilmia- 
tion  of  an  inunen.se  inunl)er  of  units,  called  iffiiroti/f,  all  !iaviii<j;  e.-s('iiii;i!ly 
the  same  structure.  P^uch  neuron  is  eom2)osed  of  a  cell  body,  the  |in>i.i- 
pliismie  processes  or  f/f'«^//v/;^^•,  and  the  axis-cylinder  process.  The  iintii- 
tion  of  till' neuron  depends  upon  the  condition  of  the  cell  body.  If  tin' 
cell  is  injuretl  in  any  manner  the  i>roeesses  detrenerate,  or  if  the  proic-st- 
are  separated  from  t!ie  t'ell  they  degenerate.  No  neuron  has  an  ii(tii;il 
connection  with  any  other — that  is,  there  is  no  continuity  of  their  I'ldtn- 
])la8m.  Nervous  ini])idse8  are  transmitted  from  one  neuron  to  !ino(lirr  In 
the  close  [troximity  or  contact  of  their  parts.  The  protoplasmic  |>nMi--i- 
conduct  impul.ses  to  the  cell,  and  the  axis-cylinder  process  conducts  tliciii 
away  from  the  cell.  The  axis-i-ylindcr  process  after  leaving  the  cell  jrivtv 
off  at  varying  intervals  lateral  branches  calh'd  collaterals,  which  nm  iii 
right  angles  to  the  process.  The  collaterals  and  finally  the  axis-cyliiiiicf 
])rocess  itself  at  their  terminations  split  up  into  many  tine  libres,  foiiniii^' 
the  end-brushes.  'J'liese,  known  as  arborizations,  surround  the  heiiy  nf 
another  I'cll,  or  interlace  with  its  protoplasmi<'  ]»roee.sses.  The  cell  lieilif.- 
of  the  neurons  are  collected  more  or  less  closely  together  in  the  gray  iir.it 
ter  of  the  brain  and  spinal  cord  and  in  the  ganglia  of  the  iierijilirml 
nerves.  Their  processes,  especially  the  axis-cylinder  ))rocesses,  run  tor  tlu 
most  part  in  the  white  tracts  of  the  braiu  and  spinal  cord  and  in  the  pe- 


GENERAL   TNTUOnUCTION. 


817 


YSTE^r. 


I'l 


pst  impnrtaiifo  to 

licro,  even  u\i\\v 

rh    knowlcil;.'!'  (if 

I  he  stiuU'iit  is  re- 

to  only   to\l('h  nil 

:•!•,  f'Tkolcv,  Van 

the  fuiidaiiH'iitiil 

it  !is  a  comljiiui- 

aviii^  essciilially 

liody,  tlio  in'iitii- 

css.     'riic  luiti'i- 

l)otly.     If  the 

if  tlu^  |>riic('Sso.s 

II  lla^<  an  nitiial 

y  of  tlifir  [iriitii- 

m  to  another  liy 

thisniic  priMi--  - 

s  conducts  tiuiii 

i)«r  thi'  cfll  ,i:ivt'^ 

s,  wliich  run  at 

tho  axiH-cyhtnlfV 

,'  tilirt's.  fdiiiiiiii: 

Tid   th<>  IhmIv  iif 

'I'llC  (I'll  IkmHis 

in  the  gray  inat- 
f  the  jicrii'licral 
sscs,  rnn  for  I  hi' 
1  and  in  tlic  pc- 


riphi  ral  nerves.  In  tliis  way  tlie  diiTerent  parts  of  the  centnil  nervous  sys- 
tem are  brought  into  relation  with  ca<di  other  and  with  the  rest  of  the 
1mm1\.  In  many  cases  the  connections  are  extremely  (;om])lieated  and  have 
(iiiiv  just  begun  to  be  nnravcUed,  hut,  fortunately  for  the  clinician,  the 
iur\"us  mechanism  upon  which  motion  depends  is  the  best  iind(.!rst,ood 
iiiid  i.>  the  simplest. 

A  motor  impulse  starting  from  the  brain  cortex  must  jtass  through  at 
ItaM  two  neurons  before  it  can  reach  the  muscles,  and  we  therefore  .speak 
(jftlic  motor  tract  as  being  composed  of  two  segments — an  upper  and  a 
Idttcr  segment.  The  neurons  of  the  lower  segment  liave  the  cell  bodies 
and  their  protoplasmic  pro(!esses  in  the  diiTerent  levels  of  the  anterior 
hdriis  of  the  sj)inal  cord  and  in  the  motor  inudei  of  tlu!  cranial  nerves. 
The  axis-cylinder  ])roccsses  of  the  lower  motor  neurons  leave  the  spinal 
(■(iiil  in  the  iinterior  roots  and  run  in  the  ])eripheral  lu-rves,  to  be  di.strih- 
iiteil  to  all  the  muscles  of  the  body,  where  they  end  in  arborizations  in  the 
iiKii-i  end  plates,  'i'hese  neurons  arc  direct — tliat  is.  tlicir  cell  liodies, 
their  processes,  and  tlie  nmscles  in  which  they  end  are  all  on  the  same  side 
(if  the  bo<ly. 

The  neurons  of  the  upper  motor  si'g- 
ineiil  have  their  cell  bodies  and  protojjlas- 
niie  proces.ses  in  the  cortex  of  the  brain 
almnt  the  fissure  of  Rolando.  Their  axis- 
(vliiidcr  ])rocesses  run  in  the  white  matter 
(if  the  l)rain  through  the  internal  capside 
ai"l  ihc  peduncles  into  the  pons,  medulla, 
ami  eord,  ending  in  arborization;:  around 
tie  protoplasmic  processes  and  cell  bodies 
(if  the  l(»wer  motor  neurons.  'ITie  upiier 
sciinient  is  a  crossed  tract — that  is  to  .say, 
the  iKMirons  which  compose*  it  have  their 
|ii'(it(iplasmic  processes  and  cell  bodies  ou 
one  side  (jf  the  body,  whereas  their  a.vis- 
eyliiider  process's  cro.>is  the  middle  line^ 
t.i  end  aliout  cell  bodies  of  the  lower  mo- 
t'lr  neurons  on   the  opposite  side  of  the 

hni'|\  , 

Motor  imimlses  starting  in  the  left  side 
ef  the  brain  cause  contractions  of  muscles 
ell  the  right  side  of  the  body,  and  those 
from  the  right  side  of  the  brain  in  muo^'les 
of  the  left  side  of  the  body.  The  motor 
jiuth  is  crossed,  and  the  crossing  takes 
jihui  in  the  upper  segment  (Figs.  1  and  2). 
even  the  simplest,  requires  the  activity  of  numy  neurons.  In  the  ])roduc- 
tion  (jf  each  movement  special  neurons  are  brought  into  play  in  a  definite 


Fui.   1. — T>iHKniiii  of  nidtvir  patiu 

slldWillf;  llie  I  |•^>^sll)Jf  of  the 
path,  wliieli  taker;  place  in 
the  upper  wfjmeiit.  (\'ua  (ie- 
huellten.  eolored.) 

Everv  muscular  movement, 


Ji  1 


i;  V'S 


T^ 


818 


DISKASKS  OP  TIIK  NERVOUS  SYSTKM. 
\.  K  0 


Fid.  3. — Diiiffniin  of  ttiotor  pafl<  froin  riulit  liraiii.  Tho  upper  sof^im-nt  is  liluck.  llic 
lowir  red.  'I'lu'  iiuflci  of  tlu'  iiiolor  rniiiial  lu'i'vt's  tin'  sImiwii  dii  llio  left  Nidi  ;  "ii 
tlio  rijilit  side  the  eniiiial  nerves  <)•"  that  side  are  iiidientud.  A  lesiou  ai  '.  '  .i'l 
cause  ii[iper  seirmciii,  paralysis  in  the  arm  uf  the  opposite  side — ecrel'ra!  iin -.'i- 
plejcii" ;  fit'  ~,  upper  sei,'iuenl  paralysis  of  the  whole  o|)posito  sid  ol'  the  lioily- 
hemiplegia;  at ;{.  upper  se^mutit  {)araiysis  of  tiie  oji|iosite  face,  arm  tie  I  leiC.  ■  ' 
lower  sej^uu'iil   paralysis  of  (he  eye  muscles  oti  the  same;  side — cr  |<..r:ri> 

at  4.  upp'M"  s(-gmeul  paralysis  of  opposite  arm  and  leg,  and  lowei  cieiit  I'.aaly- 

sih!  of  the  face  and  the  external  reetu\  on  the?  sairie  side— crossei'.  fiaralyi^is;  n\'>, 
upfier  segment  paralysis  of  all  muscles  helow  lesion,  ai:d  lower  segment  p;ii  ly^'i- 
of  muscles  represented  at  level  of  lesion — spinal  jiaraplegia  ;  at  (i,  lower  s  r.r'M 
paralysis  of  muscles  localized  at  seat  of  le^ioIl — anterior  poliomyelitiii,  (^':>ii  '"i'- 
huchlen,  modified.) 


GRNERAL   INTRODUCTION. 


819 


iiciit   is  lilui'lv 

llii' 

1  Ihe  left  sulr 

;  I'M 

Ii'sicii  (i>;  '.  ^ 

■•M 

!— ciTcItii'   !:i 

il      of   till!   Imi 

ly- 

aim   (!'•  1  icc 

,     1 

cr           |i..iMi 

1         iiii'iit.  ]'" 

.■iily- 

I'l'.  jiiiriiljhi-: 

at  .'), 

st'fjiiietil  pill 

lysi" 

(!.  lower  f' 

iii'iit 

yclilirf.     (Viii 

(ie- 

comliination,  and  whoncvor  those  nourous  act  in  tins  oonibiniition  that 
sppcitio  movcinojit  is  tlie  result.  In  otlier  words,  all  the  niovetiients  of 
the  hiidy  are  represented  in  the  central  nervous  system  liy  eonihinations 
of  lu'iirons — that  is,  they  are  loealized.  Museuhir  movements  are  loeal- 
izfcl  in  every  part  of  the  motor  ])ath,  and  in  cases  of  disease  of  the  nerv- 
ous system  a  study  of  the  motor  defeet  often  enables  one  to  fix  npon  the 
Hto  of  the  process,  and  it  wonld  ])c  hard  to  overestimate  the  importance 
of  a  tliorongh  knowledjj^e  of  such  localization. 

Tiie  axis-cylinder  jirocesses  of  the  lower  motor  neurons  run  in  the  pe- 
ri|ilnral  nerves.  Kacii  nerve  contains  processes  which  are  supplied  to  deli- 
iiitc  muscles,  anil  we  have  in  this  way  a  peripheral  localization.  (See  sec- 
tions on  Diseases  of  the  Cranial  and  Spiiial  Nerves.) 

Tlie  axis-cylinder  ])rocesses  which  run  in  tiie  pi'iipheral  nerves  K'ave  the 
pentval  nervous  system  from  its  anterior  as])ect.  Tlu'  anterior  roots  of  the 
.spinal  cord  are  from  above  dowji,  collected  into  small  jrrcups.  which,  afUT 
joiiiiui,'  with  the  posterior  roots  of  the  same  level  of  the  cord,  leave  the 
spinal  canal  between  the  vertebra'  as  the  spinal  nerves,  'i'liat  j)art  of  the 
cord  from  whiidi  the  roots  formiiifr  a  singh'  spinal  nerve  arise  is  called  a 
segment,  and  corresponds  to  the  nerve  which  arises  from  it  and  not  to  the 
vpi'ti'bra  to  which  it  may  be  opposite.  Tlie  axis-cylinder  j)rocesses  which 
po  to  make  up  any  one  peripheral  nerve  do  not  necessarily  arise  from  the 
same  segment  of  the  spinal  cord  ;  in  fact,  most  })eri[)lieral  nerves  I'on- 
taii!  |irocesses  from  several  often  cpiite  widely  separated  sejrments,  and  so 
it  happens  that  the  movements  are  re[U'eseiite(l  in  the  spinal  cord  in  a 
(lilTcii'iit  manner — that  is,  there  is  spinal  localization,  or,  better,  lower 
livcl  localization,  since  it  also  includes  the  motor  nuch'i  of  the  cranial 

lU'l'Vt'S. 

Our  knowledL'e  of  tho  localization  of  the  muscular  movenients  in  the 
L'lay  matter  of  tl;e  lower  motor  sej;ment  is  far  from  com[»leti',  liiit  enough 
i"  known  to  aid  materialiy  in  determining  the  site  of  a  spinal  lesion.  A 
iiuniiier  of  tables  have  been  preparet]  hy  dilTercut,  (li)servers  to  represent 
ijiir  present  knowledge  of  this  subject.  Tliey  dilTcr  from  each  other  in 
minor  details,  but  agree  in  the  main.  The  fdllnwing  is  the  table  prepared 
by  Starr,  in  which  th(>  names  of  the  muscles  are  given  whose  movement.s 
arc  represented  in  each  of  the  spinal  .segments.  Movements,  not  muscles, 
arc  localized  in  tiie  central  nervous  system,  a  point  carefully  lo  be  borne 
ill  mind  by  the  student. 

Lni'itVudtio)!  of  thr  Finti't'onA  of  the  !>ff)rncnfn  of  Ihe  Sfiinal  Coiil. 
Srumknt.  Mi'sc'i.kk.  Hkfi.kx.  Sks-atidn. 


II  ami    j  Storno-miistoid. 

III  •',      'i'raiM'/iiH. 

;  Sciilciii  and  iicek. 
I  Diiiphragiii. 


Sudden  iiis|iir.ilioii  pro- 
(hiccil  liy  sudiicn  [ircss- 
iirc  helical ti  the  lowor 
border  of  riljs. 


Hiiek  of  head  to  ver- 
tex. 
Neck. 


if' 


;■       , 


Yi 


820 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


Hbument. 

MuDCLRg.                                                   KBrLKX. 

HBNMATIMN. 

IV  C. 

[>ia|iiira.i,'in. 

Pupil.     -Ith    to    Ttli   cer- 

\ock. 

hi'hoid.' 

vical. 

I'ppor  shoulder. 

Miccps. 

Dilatation    of    tlic    i)Ui)il 

Outer  arm. 

('onico-lii'iicliiiilis. 

produced  liy  irritation 

Sii|iiiialiir  Idiij^us. 

of  neck. 

Ulioiiilidiil. 

Supra  1111(1  iiil'ra  spinatiis. 

V  C. 

D.Itoid. 

Scapular. 

Hack  of  shoulder  and 

Miccps. 

.")lli  cervical  to  1st  dorsal. 

arm. 

('iiracii-l>racliialis. 

Iri'itation  of  skih  over  the 

Outer    side    of    luiii 

UrK'iiialis  niiticiis. 

scapula    produc<'s   con- 

and forearm,  front 

Siipiiiatdi'  lniij^iis. 

traction  ol  the  scapular 

and  Imck. 

Siipiiiahir  lii'cvis. 

muxles. 

Ivli<iiiil)i>iil. 

Supinator  loiij;us. 

'i'crcs  iiiiiiiir. 

Tappin;^    its    tendon    in 

I'cci  oral  JMclaviciilar  part). 

wrist    produces   llcxion 

Scrratus  iim;;ims. 

of  forearm. 

VI  C. 

Iliccps. 

Tricep-. 

Outer    side    of    f,,iv- 

iiraiiiialis  aiiliciis. 

51  h  to  (ith  cervical. 

urm.      front      ami 

l'ccliiialiM,rla\  iciilarparl). 

Tappini;     cUn'W     tendon 

liack. 

Scrral  us  iuaj;iius 

proihues    extension    of 

Outer  half  of  haiiil. 

Triceps. 

forearm. 

IvxlcMsiirs   of    wribL    ami 

Posterior  wrist. 

liii;;('rs. 

(ith  to  sih  cervical. 

rrdiiiitors. 

Tiippinj;    tendons   causes 

e.Ktensioit  of  liaiid, 

i\ntcrior  wrist. 

VIl  V. 

Ti'iccps  {loiiL.'  head). 

. 

Inner  side  and  Link 

llxicM.-iii's    III'    wrist   Hiul 

7th  to  8th  cervical. 

of  arm  and    len- 

iin.u'ci's. 

Tappiiij,'  anterior  tendons 

arm. 

Prdiialiirs  of  wrist. 

causes  flexion  of  wrist. 

Hadial    half    ut    tlic 

l''lc\ors  oj'  wrist. 

Palmar.     7lh  cervical   to 

iiand. 

Su')ScapM|:ir. 

1st  dorsal. 

I'cctoralis  (costal  part). 

Stroking      palm      causes 

I.at  i.>inuis  liursi. 

closure  of  lingers. 

Teres  major. 

VIII  V. 

Flexors  ol'  wrist  and  liu- 

Forearm   and   hand, 

Kcrs. 

inner  half. 

Iiitruisic  iiuisclesof  iiaiid. 
Extensors  of  tluirul'. 

I  n. 

Forearm,  imier  hiilf. 

Intrinsic  hand  muscles. 

rinar  distrii)UtinM  tn 

Thenar   and    hypothenar 

hand. 

emii\ence-i. 

H  to 

Muscles  of  liack  aiidabdo- 

Epi;rastric.     4th    to    7th 

Skin    of    chest    and 

XII   I). 

nuMi. 

dor>al. 

ai'domen  in  hands 

Ereclores  spina". 

Tickling     manunary     re- 

running      anunid 

gions  causes  retraction 

anddownwai-il.rer- 

of  epigastrium. 

responding  t"  sjii- 

Aiiilominal.     7th  to  lltli 

nal  lu'ives. 

dorsal. 

rpl)er  gluteal  re;,'itin. 

Strokin;f  side  of  ali(lomen 

causi's     retraction      of 
belly. 

CnMntusterio,      1st    to  ad 

IL. 

Ilio-psotts. 

.Skin  nvr-r  groin  and 

Sarlorius. 

1iind)ar. 

front  of  scrotum. 

Muscles  of  abdomen. 

Stroking      inner      thigh 
causes     retraction     of 
scrotum. 

Sknmatidv 

ipi'i'  sliiMildrr. 
Iter  arm. 


U'k  of  slioiilili'niMd 

arm. 

ilcr    siilr    iif    iinii 

and  foi'canii.  friim 

aii<l  Itauk. 


Iter   side   i>[  fore- 
arm,    fnmt     ami 

\r.uk. 

iiUT  lialf  of  liiiiiil. 


iiiiT  side  and  i'lick 
of  arm  and  Ion- 
arm. 

dial    lialf    ot    iIh 
hand. 


ircarm    and    luiml, 
nncr  lialt'. 

rearm,  inner  liiilf. 
liar  di!*trilmti"ii  lo 
Hand. 


II)  iif  elie>l  iiinl 
idnru'ii  in  liiinil> 
minin;,'  itnmiMl 
ml  ddwnwaiil.ciir- 
■-|i(iiidin,!;  t'>  spi- 
lal  nerves. 
K'r  gluteal  ivgieii, 


1  over  groin  «i"l 
[ront  of  serotimi. 


r.KNKIlAL   INTKOnrcTlOX. 


S21 


II  ',. 


Mi'Hri.KM. 

Ilio-psoas.     Siirtorlns. 
l'"lexors  of  knee  (IJemak). 
(^iiiidriee|is  femoris. 

(^nailrieeps  femoris. 
Inner  rolalors  of  tlii),di. 
Alidnelors  of  tliiudi. 

Alpdnetors  of  tliigli. 
,\dilnetorsof  tliiirli. 
i'-lexors  of  knee  ( l''ei'rier). 
Tiliiali^  jintieiis. 


Outward  rotators  of  lliifih. 
[■'lexors  of  knee  ( l''erri(.'r). 
i-'lexors  of  ankle. 
Kxt  elisors  of  loes. 


Hkki.kx.  I 

I'alella  tendon. 
.Slrokiiifj:     leiidiin    eaiisus  I 
cxteiisiun  of  leji. 


SKNKATION. 


Older  side  of  lliigli. 


Front,  and  inner  side 
of  tlii;;li. 


itn   II 


111   In 
V    ,S. 


{•'lexors  of  ankle. 

l/i.nu;  llexor  nf  loes. 

Ceroiia-i. 

Inirinsii'  miisides  of  foot. 

i'l'lilleal  nill>eles. 


(■luteal,     -till  lo  ."Mil  liiiii- 

liar. 
Slriikiii;:    l)iilto(d\    eanses 

(iim|iliii>;     in     fold    (d' 

Imttnek. 


iiiiuT  .si(l(^  of  thi^li 

and  leg  to  aiikli>. 
iniiei'  si(le  (if  fcioi. 


liack  of  tliigh.  Iiiu'k 
of  leg.  and  oilier 
pari  of  fo<it. 


IMantar. 

Tiekling  sole  of  fodi 
causes  lleximi  of  Ides 
and  rel  laetion  of  lej;. 

Foot      rofle.N.       Aeliilles 

tenddii. 
Overexleiisidll       of       foot 

causes    rajiid     flexion  ; 

ankle-cldiiir-. 
IJladdeiand  rectal  ct'iitri's. 


l5aok  of  tliitrh. 
Leg  ami    fool,  oilier 
side. 


.Skill  over  ."-uoniin. 

Anns. 

I'diiiii'iim.    (ienitals. 


Tlic  above  t:il)le  ivfoi\s  only  to  localization  in  tlio  spinal  cofd.  'IMio 
niamicr  in  wliicli  inovi'inont.s  ai'o  ivpiT.sontcd  in  tlio  jhuls  and  incdiilla  is 
iilioiit  as  follow.s.  This  tabic  is  conslnictrd  from  above  downward  in  ft-f- 
creiiec  to  tlii'  motor  nuclei  of  the  I'ranial  nerves: 


Xl  riKI 


in. 


.Sol 


pllincler.      '.  lllMIV  lllll>cle; 


Levator  palpalira'  siiperidiis.     fiei'liis  inlernns  (in  cdnvcrgoncc), 
lic'lns  siiperinr.     Uectiis  inferior. 
( >l)li(|iiiis  inferior 


\'.  I  Ol)li(|iiiis  superior. 
l_     (Upper  facial  group.) 


(  Keetiis  exierniis.     Reeliis 
^'l.•       inter,   of  opposite    >ide 


y  (  (.Associated  nidvenient  of  levator  |)al|ial»ni'.) 


Mi; 


ill  lateral  movenienl- 


VIl.-Facial 


^11   1  (Lower  facial  grnnp), 


L\.  I  Miis( 


d  Idwer  jaw 


iscles. 

f  iiliarvnx. 


i 


Muscles  of  tongue. 


x.Si 

XI.  (  Muscles  of  larynx 


iiscles  ol  d'sdpliagus, 


CHrebral  Motor  Localization.— T he  eell  Ijodies  of  the  upper  motor 

MciinniH  are  found  in  the  brain  c-ortex  about  the  tis.siire  of  liolando,  and 
it  is  in  this  refjioii  that  we  find  the  movements  of  thi;  body  a^ain  rei)re- 
sontcd.  'riuj  (dinieal  studies  of  Ilti^'hlinjjs  .lac^kson,  and  the  exjieriments 
"f  Iliizig  aiid  Fritsch,  and  of  Ferriur,  laid  the  foundation  for  lh((  grout 
63 


*/,i*    ' 


--  -    h 


I  ~IM 


\'4i.l/:; 


8'22 


DISK  ASKS  OK  TIIK   XKIIVOUS  SYSTKM. 


muss  of  most  oxcclliMit  work  wliich  1ms  been  dono  upon  this  siihjoct.  \\\> 
owo  much  to  N'ictor  Ilorsloy  and  his  assnciatcs  for  their  ('arcfiil  wniL  in 
this  dirt'C'tion,  and  liio  following  desuriplion  is  lm.st'(l  laryoly  ujinn  iiuir 


papers,  and  espeoiiilly  njxm  the  paper  of  Beevor  and  TTorsley,  in  wloli 
Ihey  give  the  results  of  their  experimental  work  on  tlui  orang-niil:  :!'_'. 
Clinical  observation  and  eleetrical  stimulation  of  the  brain  cortex  iIiuiml; 


S  811 

hjoct. 

We 

cure 

fill    Wu 

K  ill 

?«'y 

Upnll 

llrir 

ti    1/ 

_ 

>    JZ 

r^ 

sS    « 

^ 

-a  ^ 

.L 

u  - 

"* 

2      ' 

^ 

=   c 

T     " 

i.' 

te  -^ 

1 

c  ^ 

" 

GKNKUAL   I NTIIODUCTION. 


S23 


n|M  iiitioiia  on  human  beings  have  conlirrncd   the  results  of  experinients 
iijini)  iinnnals. 

The  motor  area  coiniiriscH  the  aseeiidiii^'  frontal  convolution,  and  to  a 
li^>  1  xtent  the  ascending'  parietal  convolution,  the  hinder  part  of  the  three 
inmial  oonvolulions  and  the  paracentral  lohuh;.  In  tlie  oranj^-outan^' and 
iiiiiii  not  every  part  of  this  region  is  excital)le  hy  electrical  stimulation. 
Till  movements  are  quite  sharply  localized,  and  there  are  inext.-itable 
iinas  between  the  areas  of  representation  of  the  larfj^er  divisions  of  the 
liody,  'I'lie  diajjram  (I'ij;.  ^5)  shows  the  centres  as  {jfivi-n  by  lieevor  and 
||nr<ley.  Certain  landmarks  are  important.  The  genu  of  the  fissure  of 
li'iil.iiido,  which  when  present  in  nuin  i.s  fouml  at  ai)oint  about  midway  or 
I'vcii  higher  between  the  upper  nnirgin  of  the  liennsphere  and  the  fissure 
(if  Sylvius,  n\arks  the  boundary  l)etween  the  area  of  representation  of  the 
uriii  from  that  of  the  face.  The  level  of  the  superior  frontal  sulcus  iiidi- 
cutis  the  division  of  the  leg  from  the  arm  area.  From  above  down  the 
Ulcus  of  representation  occur  in  this  order:  leg,  arm,  face.  'ITiose  of  the 
1( ;:  iind  arm  occupy  the  upper  half  of  the  eonvoliilinii,  and  that  for  the 
fiHf  is  spread  out  over  the  lowt-r  half. 
Tilt  diagram  indicates  the  localization  of 
till'  movements  of  the  difTereut  parts  of 
the  <'\tremities. 

The  centres  for  the  trunk  are,  ac(!ord- 
iiij;  to  Schiifer,  situated  in  the  nuirginal 
<ryriis  ju.st  within  the  longitudinal  lissure 
ill  the  jiaracentral  lobule.  In  num  the 
iiintur  s|)eech  centre  is  localized  in  the 
posterior  part  of  the  left  third  frontal 
coiivoluticm. 

The  axis -cylinder  processes  of  the 
iipiicr  motor  neurons  after  leaving  tho 
irriiy  inattor  of  the  motor  cortex  pass  into 
the  white  matter  of  the  brain  and  form 
piirt  of  the  corona  radiata.  They  con- 
vi'iiTc  and  pass  between  the  basal  gan- 
irlia  in  the  internal  capsule.  Here  the 
iimtor-axis  cylinders  are  collected  into  a 
coiiiliact  bundle — the  pyramidal  tract —  Fro.  4.— Diagram  of  motor  and  son- 
oirupying  the  knee  and  anterior  two  sory  roprosentation  in  the  int.T- 
tliinls  of  the  posterior  lindj  of  the  inter- 
nal capsule.  The  order  in  which  the 
in(i\cinents  of  the  opposite  side  of  the 
biidy  are  represented  here  is  given  in 
Fi,-.  \. 

After  passing  through  the  internal  capsule  tho  fibres  of  the  pyramidal 
tnici  leave  the  hemisphere  by  the  cms,  in  which  they  occupy  a  lower  and 


OPTIC 


iial  capsule.  NL.,  licnticuiiir 
iiiicleiis.  N(\,  Caudiito  iiiicleiis. 
TIIO..  Optic  tlialaiiHis.  The  mo- 
tor paths  are  red  and  black,  tho 
sensory  are  l)lue. 


if 


"h   '■ 


824 


DISKASKS  OF  TIIK   NKIIVOIS  SVSTKM. 


Flo.  T). —  Diiiprain  of  inntnr  and  sonsory  jiatlis  in  Cnira. 


iiUMlian  position   (Fij;.  A).     The  inovoiiicntH  of  the  toiijjfiic  and  lip    nrf 
ri'|in'.s(*iiU'(l  nearest  the  middle  line. 

As  soon  us  the  tract  enters  tlie  erns,  some  of  its  axis-eylin(U;r  pi'invvMs 
louvo  it  and  erusH  tiie  middle  line  tu  end  in  urborizationH  ahont  the  iran- 

glion  cells  in  tin  im. 
cleiisof  the  tliinl  wryw 
on  the  o|)|»()site  .-idi  ; 
ami  in  this  way,  as  tjic 
pyramidal  tract  passes 
down,  it  ^fives  olT  at 
dilTerent  levels  liltns 
which  end  in  the  nu- 
clei of  all  the  iiidtor 
cranial  nerves  on  \\u- 
opposite  side  of  ijn' 
body.  From  tlu'  iiiis. 
th(^  pyramidal  tiad 
runs  thron<,'li  the  pdiis 
and  forms  in  the  mc- 
dnlla  ol)lon;;ata  the  anterior  pyranud,  which  <i;ives  its  name  to  the  tract. 
At  the  lowi'r  part  of  the  medulla,  after  the  fibres  .yoing"  to  the  cranial 
nerves  have  crossed  the  middle  line,  a  large  i)roportion  of  the  fibres  which 
are  left  cross,  decussat- 
ing with  those  from  the 
opposite  pyramid,  and 
pass  ii\to  the  ojjposite 
side  of  the  spimd  cord, 
forminj^  the  cro.ised  py- 
ramidal tract  of  the  lat- 
eral column  (Fi<f.  (!,  1). 
The  snuiller  number  of 
fibres  which  do  not  at 
this  tinu'  cross,  descend 
in  the  anterior  column 
of  the  same  side,  form- 
ing the  direct  pyramidal 
tract,  or  Tiirck's  column 
(Fig.  0,2). 

At  every  level  of  the 
spinal  cord  axis  -  cylin- 
der processes  leave  the 
crossed  pyrami(hil  tract 
to  enter  the  anterior  horns  and  end  about  the  cell  bodies  of  the  Inwrv 
motor  neurons.  The  tract  diminishes  in  size  from  above  downward.  Tin' 
fibres  of  the  direct  i)yranudal  tract  cross  at  different  levels  in  the  ant«  ii"i' 


Fio.  (». —  Diafjrarn  of  cross-section  of  spinal  conl.  >liii«- 
ing  motor,  red.  and  sonsory.  bine  patlis.  1,  I.aiiiiil 
pyramidal  tract.  2.  Anterior  pyramidal  Iracl.  ■'. 
Posterior  coluiiuis.  4,  Direct  cerel)eliar  trad.  "i. 
Anturo-lateral  ground  l)undles.  (!,  .Antero-lairi.il 
ascending  trad  of  (iowers.  (N'aii  (ieiiui'iitcii,  r^l- 
ored.) 


'  5 


liiidtT  processes 

altollt  tllc  <.';i|i. 

L'Us  ill  the  nil- 
tho  tliini  iicivc 

OpjIOsitf    siilc; 

til  is  \v:iy,  as  the 
(lal  tract  passes 
it  fjivcs  (ilT  at 
It  levels  lilirts 
.'lul   ill   llif  nii- 

ail    tlie   iiikIiii' 

nerves  (ui  the 
e    wide    ol'    ihc 

From  the  iTii«. 
.•ramiilal  iiad 
nm^'li  tile  [iniis 
•ins  in  tile  iiic- 
ne  t(j  tlie   Iract. 

to  the  eraiiiiil 
he  llbros  wiiiili 


liiial  eonl,  ^hl'W- 
■atlis.  1.  \.-A\rn\ 
aiiiiilai   trad.    '■'>. 

)i'llar    trai'i.     ■'). 

II,     AllttTO-l.-llrlill 
(Jfllllelltrli,  rtil- 


of  the  h'WvV 
wnward.  1 1"' 
iu  the  aiiu  lior 


(IKNKUAli    INTItoDl'cnoN. 


825 


will''  enminissiire,  aiwl  also  end  a 


hoiit 


cells  in  tlie  antefhir  liurns  on  llie 


(iiip 


te  side  of  the  cord.     'I'his  tract  iisuallv  ri\t\^  almiit  the  iiiiddle  of  tl 


10 


ilm-al  re-'ioii  nf  the  cord. 


T 


le  pa 


th  f( 


)r  seiisorv  condiictum  is  iiiorc  coiniilieiiteil  than   the  iinttor 


paili,  l»nt  in  its  simplest  form  it  is  also  composed  of  two  neurons,  oi 


le 


iliiiM'  the  other — an  upper  and  lower  seiisorv  neuron.     'The  eel!  liodies  (»f 
:li('  lower  neurons  are  in  the  posterior  spinal  f,Mii;;lia  and   the  L;an,udia  of 


tli(   seiisorv  cranial   nerve 


liese   fraiiLrlioii   cells   have  a  special   form, 


liaviii';  apparently  lint  a  single  process,  which,  soon  after  leaviiiir  the  cell, 
(livides  in  a  T-shaped  manner,  one  portion  riinniiig  into  the  central  nerv- 
(iiis  system  and  the  other  to  tlii'  jteriphery  of  the  body.  Knihryoio;:ieal 
;inii  comparative  anatomical  studies  have  made  it  prohahle  that  these  cells 
really  have  two  processes,  which  run  together  for  a  short  time  and  then 
>e|iiirate  to  go  in  opposite  directions.  'The  process  which  conducts  towaixl 
the  cell  represents  the  jirotoplasinic  processes,  while  that  which  conducts 
away  from  the  cell  is  the  axis-cylinder  jtrocess.  In  the  peripheral  sensory 
iier\es  we  have,  then,  the  protoplasmic  process  of  the  lower  seiisorv  neu- 
ron-. Tlu'se  start  in  the  periphery  id"  the  hotly  from  their  various  spccial- 
i;;ei|  end  organs.  The  axis-cylinder  proces.ses  leave  the  ganglia  and  enter 
the  spinal  cord  by  its  posterior  roots.  After  entering  the  cord  each  axis- 
ryliiider  process  divides  into  an  ascending  and  a  descending  branch,  which 
run  in  tlie  posterior  columns.  'I'he  descending  bramdi  runs  but  a  short 
ilistaiice,  and  ends  in  the  gray  matter  of  the  same  side  of  the  cord,  it 
L'ives  olT  a  number  of  collaterals,  which  also  end  in  the  gray  matter.  The 
;is(  riiiliiig  branch  may  end  in  the  gray  matter  soon  after  entering,  or  it 
iiiiiv  run  in  the  pcsterior  columns  to  the  inediilla,  and  end  in  the  nuclei 
III'  these  columns.  In  any  ca.se  it  does  not  cro.ss  the  middle  line.  The 
liiwei' sensitive  neuron  is  direct.  T'he  cells  about  which  the  axis-cylinder 
jii'iieesses  and  their  collaterals  of  the  lower  sensitive  neuron  end  are  (tf 
varidiis  kinds.     In  the  lirst  idaoe,  some  of  tlu-m  end  about  the  cell  bodies 


1 

of  the  lower  motor  neurons,  forming  the  path  for  rellexes.     They  also  end 

aliiMii  cells  whose  axis-cylinder  processes  cro.ss  the  middle  line  and  imiii  to 
the  iipposite  side  of  the  brain.  In  the  spinal  cord  these  cells  are  found  in 
ilic  ilitTerent  parts  of  the  gray  matter,  and  their  axi.s-cylinder  processt's  run 
ill  the  opposite  antenj-lateral  asceiuling  tract  (Fig.  (i,  (i). 

Ill  the  medulla  the  nuclei  of  the  [losterior  columns  eontain  for  the 
>l  part  cells  of  this  <'liaracter.  Their  axis-cylinder  proces.ses,  after  cro.ss- 
iiiir.  run  toward  the  brain  in  the  bumlle  (d"  the  fillet,  wlii(di  is  also  joined 
I'v  ilie  fibres  of  the  antero-lateral  ascending  tract.  This  is  probably  the 
'inportant  ])atli  of  sensory  conduction,  and  nuiy  be  looked  upon  as 


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826 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


VIII 


Pio.  7. — Diagram  of  skin  areas  correspon(lip<j  to  the  dilforent  spinal  segincuU 
((.'oinbiued  from  Head's  diagrams.) 


GENERAL   INTRODUCTION. 


827 


Fid.  8. — Diugrum  of  skin  areas  corrcispoiuliiig  to  tho  difTLTeiit,  siiiiuil  segments. 
(Combined  from  Head's  dingrams.) 


I    '>i 


I:' 

i 


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,  /I   :,'  1. 
■  1- 

1                               ■?■"' 

WTTff 


828 


DISEASES  OP  THE   NERVOUS  SYSTEM. 


5  1!  ■'" 


i'i  ' 


eyliiulers  of  wliicli  run  in  the  diivot  oorobpllur  tnict  of  the  sanv  -idi. 
(Fig.  (i),  iiiul  tlioso  wliieh  end  about  cells  wliosc!  axis-eyliiider  prdii  >«(■< 
rnn  hut  a  .short  distanee  in  the  cord,  to  end  in  the  gray  matter  of  a  dilTcr. 
ent  level.  The  2)o.sriil)le  paths  of  sensory  conduction  are  many,  ami  liiciv 
is  much  doubt  and  dispute  about  the  question,  ami  for  this  reason  (li>. 
turbances  of  sensation  do  not  give  us  as  nuudi  heli)  in  making  ;i  lucul 
diagnosis  as  do  those  of  motion.  Certain  facts  are  important  to  kd'H  in 
mind.  'I'hc  dilTerent  peri])heral  nerves  contain  sensory  fibres  from  ijiti- 
nite  areas  of  the  skin,  and  upon  this  depends  the  peripheral  sensory  iv|i- 
resentatioii.     (See  section  on  J^iseases  of  the  Spituil  Xerves.) 

The  sensory  areas  of  the  skin  are  represented  in  the  spinal  cord  in  ;in 
entirely  ditferetit  manner  from  the  peripheral  representation,  just  as  is 
the  case  in  regard  to  motion.  The  surface  of  the  body  has  been  niiipiici] 
out  into  areas  -which  are  meant  to  correspond  to  the  dilTerent  [xisicrinr 
roots  or  spinal  segments.  In  Starr's  table  the  third  column  indicates  his 
belief.  His  nu:re  recent  division  of  the  sensory  areas  on  tlu;  limbs  is  |iic- 
tured  in  the  American  Journal  of  the  Medical  Sciences,  June,  isiiri. 
Figs.  T  and  8  embody  the  result  of  Head's  work.  Tliey  are  also  the 
areas  in  which  the  referred  pain  and  cutaneous  tenderness  in  visccial 
diseases  make  their  appearaiu'e.  The  cutaneous  sensory  impressions  are 
in  man  conducted  toward  the  brain,  probably  on  the  op])osite  side  of 
the  cord — that  is,  the  path  crosses  to  the  oppo.site  side  soon  after  enter- 
ing the  cord.  Muscular  sense,  on  the  other  haiul,  is  conducted  (»n  the 
same  side  of  the  cord  in  tho~  columns  of  (ioll,  to  cross  abov<!  in  the 
medulla. 

The  localization  of  sensory  impressions  in  the  cortex  of  the  l)riiin  is 
not  delinitely  determined,  but  it  seems  probable  that  the  so-calle(l  moinr 
cortex  has  also  to  do  with  seh.sation,  and  should  perhaps  be  called  the 
sensori-inotor  region. 

The  paths  for  the  conduction  of  the  stimuli  which  underlie  the  sincinl 
senses  are  given  in  the  section  upon  the  cranial  luirves,  and  it  is  only 
necessary  here  to  refer  to  what  is  known  of  the  cortical  representatio,  of 
these  senses. 

Visual  impressions  are  localized  in  the  occipital  lob(!S.  The  primary 
visual  centre  is  on  the  mesial  surface  in  the  cuneus,  and  here  arc  icjuv- 
sented  the  op})osite  half-visual  fields.  Some  authors  believe  tiuit  there  is 
another  higher  centre  on  the  outer  surface  of  the  occipital  loljc,  in  u  hii  h 
the  vision  of  the  opposite  eye  is  chiefly  represented.  However  tlii.-  may 
be,  it  seems  certain  that  the  angular  gyrus  of  the  left  hennsphciv  i-  ;i 
part  of  the  brain  in  which  are  stored  the  memories  of  the  meaninLf  "f 
letters,  words,  figures,  and  indeed  of  all  seen  objects.  This  is  designated 
in  the  visual  speech  ceuLre  on  the  diagram  (Fig.  3). 

Auditory  impressions  are  localized  for  the  most  part  in  the  first  imi- 
poral  convolution,  and  it  is  in  this  region  in  the  left  hemisphere  that  the 
memories  of  the  meaninji;s  of  heard  words  and  sounds  are  stored.    M  u-i'  ;il 


I  it'S 


GENERAL  INTRODUCTION. 


821) 


3). 


memories  arc  lopulized  somewhat  in  front  of  tliose  for  word.s  (Fi 
Tiistt^  and  smell  are  localized  in  the  uncinate  f(yrus. 

Topical  Diagnosis. — The  successful  diagnosis  of  the  position  of 
u  IcsiDii  in  the  nervous  system  depends  u])on  a  careful  and  oxliaustive 
fxaiiiiiuition  into  all  the  syniptoms  that  are  i)resent,  and  then  endeav- 
oring' with  the  help  of  anatomy  ajid  physiology  to  determine  the  place, 
fulistiirhance  of  wliicli  might  produce  these  syniptoms. 

The  ahnormalities  of  iiKition  are  usually  the  most  important  localizing 
svniptoins,  both  on  account  of  the  case  with  which  tliey  can  be  demon- 
strated, u.id  also  because  of  the  comparative  accuracy  of  our  knowledge  of 
the  motor  path. 

Lesions  in  any  part  of  the  motor  path  cause  disturbances  of  motion.  If 
ilestnictive,  the  fun  m  of  the  part  is  abolished,  and  as  the  result  there 
Uparali/si.s.  If,  on  the  oMier  haiul,  the  lesion  is  an  irritative  one,  the 
strnetures  are  thrown  into  abnornud  activity,  which  produces  abnortnal 
miisriihtr  C'l/itrfiiiion.  Tlic  character  of  tlie  paralysis  or  of  the  abnormal 
Diiiseiilar  conti'action  varies  with  lesions  of  tlie  upper  and  lower  motor 
st'guient,  the  variations  dejsending,  lirst,  upon  tlie  anatomical  jjosition  of 
the  two  segments  ;  and,  secondly,  upon  the  symptoms  which  are  tlie  result 
(if  secondary  degeneration  in  each  of  the  segments. 

{11}  Lesions  of  the  Lower  or  Spino-muscular  Segment.— Dcsfrnctive 
Lesions. — It  has  been  stated  above  that  the  nutrition  of  all  parts  of  a 
ni'uron  depends  u2)on  their  conucctiou  with  its  healthy  cell  body;  and  if 
tlio  cell  body  he  injured,  its  processes  undergo  degeneration,  or  if  a  por- 
tidu  of  a  process  be  separated  from  the  cell  body,  that  jtart  degenerates 
along  its  whole  length.  This  so-called  secondary  degeneration  plays  a 
very  important  role  in  the  symptonuitology. 

hi  tlie  lower  motor  segment  the  degenerati(m  not  oidy  alTects  the  axis- 
cvHinler  {irocesses  which  run  in  the  peripheral  nerves,  but  also  the  muscle 
libres  in  which  the  axis-cylinder  process  end.  The  degeneration  of  the 
nerve;;  and  muscles  is  made  evident,  first,  by  the  muscles  becoming  smaller 
and  llidiby,  and,  secondly,  by  change  in  their  normal  reaction  to  electrical 
stinudation^  The  degenerated  nerve  gives  no  res{)onse  to  either  the  gal- 
viuiie  or  the  faradic  current,  and  the  muscle  does  not  respond  to  faradic 
stinuilation,  hut  reacts  in  a  characteristic  manner  to  the  galvanic  current. 
The  contraction,  instead  of  being  sharp,  qaick,  lightniug-iike,  as  in  that 
of  11  normal  must'le,  is  slow  and  lazy,  and  is  often  produced  by  a  weaker 
I'urreiit,  and  the  anode-closing  contraction  may  be  greater  than  the  cathode- 
dosing  contraction.  This  is  the  reaction  of  degeneration,  but  it  is  not 
alwiiys  present  in  tuo  classical  form.  The  essential  feature  is  the  slow, 
l:i/.y  contraction  of  the  muscle  to  the  galvanic  current,  and  when  this  is 
lireseiit  the  muscle  is  degenerated. 

The  myotatic  irritability,  or  muscle  reflex,  and  the  muscle  tonus  de- 
pond  upon  the  integrity  of  the  reflex  arc,  of  which  the  lower  motor  seg- 
ment is  the  efferent  limb,  and  in  a  paralysis  due  to  lesion  of  this  segment 
5a 


^^ 


t.Tl 


830 


DISEASES  OF  THE  NERVOUS  SVSTE3I. 


HI 

III 


) 


the  muscle  reflexes  (teiitlon  reflexes)  iiro  abolished  unci  there  is  a  (limin- 
ished  muscular  tension. 

Lower  sefjmont  ])araly80s  have  for  their  eharacteristics  defrencnitivo 
atropliy  with  tiie  reaction  of  dej,'eneratioJi  in  tlie  ulTectcd  nui.sclts,  Itiss  df 
their  reflex  excitability,  and  a  (Utninislicd  mus(;ular  tension.  Thc-c  niv 
the  general  characteristics,  but  tlie  anatomical  relations  of  this  scj^fnicnt. 
also  give  certain  ]»eculiarities  in  the  distribution  of  the  ])aralyses  whiih 
hel{)  to  distinguish  them  from  those  which  follow  lesions  of  the  ii|i|ici'si';;. 
ment,  and  wiiich  also  aid  in  determining  the  site  of  the  lesion  in  the  Idwcr 
segment  itself.  The  cell  bodies  of  this  segment  are  distriDuted  in  giiuips, 
from  the  level  of  the  peduncles  of  the  brain  throughout  the  wliolc  txtciit 
of  the  spinal  cord  to  its  termination  opposite  liie  secoml  lumbar  verU'lini, 
and  their  axis-cylitider  processes  run  in  the  peri})heral  nerves  to  cvtiy 
muscle  in  the  body  ;  so  that  tlie  component  parts  are  more  or  less  wiiloly 
separated  from  each  other,  and  a  local  lesion  causes  paralysis  of  only  ii  few 
muscles  or  groups  of  muscles,  and  not  of  a  whole  section  of  the  body,  jis 
is  the  case  where  lesions  affect  the  upjier  segment.  The  muscdes  which 
are  paralyzed  indicate  -whether  the  disease  is  in  the  peripheral  ner\('s  (ir 
spinal  cord  ;  for,  as  we  have  seen  above,  the  muscles  are  represented  ditTtr- 
ently  in  the  peripheral  nerves  and  in  the  S2)inal  cord.  Sensory  sympldins 
which  may  accompany  the  paralysis,  are  often  of  great  assistance  in  inakiiii; 
a  local  diagnosis.  Thus,  in  a  paralysis  Avith  the  charactcristii-s  of  a  Icsicm 
of  the  lower  motor  segment,  if  the  paralyzed  muscles  are  all  supplied  liy 
orie  nerve,  and  the  anaesthetic  area  of  the  skin  is  supplied  by  that  nc  rve, 
it  is  evident  that  the  lesion  nnist  be  in  the  nerve  itself.  On  the  otlicr 
hand,  if  the  muscles  paralyzed  are  not  supplied  by  a  single  nerve,  but  are 
represented  close  together  in  the  spinal  cord,  and  the  aiuesthetic  area  cor- 
resjKmds  to  that  section  of  the  cord  (see  table),  it  is  equally  clear  that  the 
lesion  must  be  of  the  cord  itself  or  of  its  nerve  roots. 

Irritative  Lesions  of  the  Lower  Motor  Segment.— Le -ions  of  this  seg- 
ment cause  comparatively  tew  symptoms  of  irritation,  and  our  knowleijoe 
on  the  point  is  neither  extensive  nor  accurate.  The  fibrillary  contraetidiis 
which  are  so  common  in  muscles  undergoing  degejieration  are  })rolialily 
due  to  stimulation  of  the  cell  bodies  in  their  slow  degeneration,  jis  in  pro- 
gressive muscular  atrophy,  or  of  irritation  of  the  axis-cylinder  processes 
in  the  peripheral  nerves,  as  in  neuritis.  Lesions  which  affect  the  motor 
roots  as  they  leave  the  central  nervous  system  may  cause  spasmodic  coii- 
tractions  in  the  muscles  supplied  by  them.  Certain  convulsive  paroxysms, 
of  which  laryngismus  stridulus  is  a  type,  and  to  which  the  sjiasiiis  of 
tetany  also  belong,  are  believed  to  be  due  to  abnormal  activity  in  the 
lower  motor  centres.  These  are  the  "lowest  level  fits"  of  llughlinirs 
Jackson.  Certain  poisons,  as  strychnia  and  that  of  tetanus,  act  particu- 
larly upon  these  centres. 

The  principal  diseases  in  which  the  lower  motor  segment  may  lie  in- 
volved are:  all  diseases  involving  the  perijdieral  nerves,  cerebral  and  spinal 


;  'M 


GENER.>  L   INTIlOOrCTION. 


831 


icrc  is  a  diitiin. 
ics  (l(>gcM(T;itivo 

IIIIIHCIOS,  loss  (if 

ion.  'riic-c  !in3 
of  tliis  sfi:;iiciit 
})!ii'alys('.s  wliieh 

>f  tho  U]l|lCl'S(>(r. 

:ioii  in  tiic  IdWiT 
iiiitcil  in  ,i,'r(iii|is, 
lie  whole  exH'iit 
lumbar  vortelirii, 

iicrvos  to  cviTy 
ii'e  or  loss  widely 
sis  of  only  a  few 
1  of  tlio  hody,  as 
L'  muscles  which 
)liei'al  noi'\cs  or 
[ii'csented  dilTcr- 
nsory  symiiloiiis, 
stance  in  making 
•istics  of  a  lesion 
p  all  supplied  liy 
1  by  that  nerve, 
On  the  other 

e  nerve,  but  are 
sthetic  area  eor- 

y  clear  that  tlic 

ions  of  this  scff- 

our  knowledge 

ary  eontraetions 

)n  are  ])rohahly 

ition,  as  in  pro- 

limlcr  prooesses 

ilTeet  the  motor 

spasmodic  eori- 

dvo  paroxysms, 

the  spasms  of 

activity  in  the 

of  llu^'hlings 

us,  act  partieii- 

lont  may  he  in- 
;brul  and  spinal 


mfilngitis,  injuries,  hivjnorrhagcs  and  tumors  of  the  medulla  and  cord  or 
their  membranes,  lesions  of  the  gray  matter  of  the  segment,  anterior  jxilio- 
Miyi  litis,  progressive  muscular  atrophy,  bulbar  paralysis,  ophthalmoplegia, 
svringo-myelia,  etc. 

(//)  Lesions  of  the  Upper  Cerebro-Spinal  Motor  Segment— A'.v//v^'/;>(! 
k'tiiiiis  cause,  as  in  the  lower  motor  segment,  i)aralysis,  and  here  again  the 
secondary  degeneration  which  follows  the  lesion  gives  to  the  }iaralysis  its 
distinctive  characteristics.  In  this  case  the  paralysis  is  accom])anied  by 
a  spastic  cotidition,  shown  in  an  exaggeration  of  muscle  reflex  antl  an  in- 
crease in  the  tension  of  the  muscle.  It  is  not  accurately  known  how  the 
degeneration  of  the  pyramidal  iibres  causes  this  excess  of  the  muscle 
nUex.  The  usual  explanation  is,  that  under  normal  circumstances  the 
upper  motor  centres  are  constantly  exerting  a  restraining  inlhience  upon 
the  at^tivity  of  the  lower  centres,  and  that  when  the  influence  ceases  to 
act,  on  account  of  disease  of  the  i)yramidal  fibres,  the  latter  take  on  in- 
creased activity,  which  is  made  manifest  by  an  exaggeration  of  the  muscle 
reflex. 

\\'e  have  seen  that  the  neurons  composing  each  segment  of  the  motor 
path  are  to  be  considered  as  nutritional  units,  and  therefore  the  secondary 
(i.  "lu'ration  in  the  upper  segment  stops  at  the  beginning  of  the  lower. 
Fei  'his  reason  the  muscles  paralyzed  by  lesions  in  the  upper  segment  do 
not  undergo  degenerative  atrophy,  nor  do  they  show  any  marked  change 
iu  their  electrical  reactions. 

The  separate  parts  of  the  upper  motor  segment  lie  much  more  closely 
together  thtkii  do  those  of  the  lower  segment,  and  therefore  ii  small  lesion 
may  cause  paralysis  in  many  muscles.  This  is  more  particularly  true  iu 
the  internal  capsule,  where  all  the  axis-cylinder  processes  of  this  segtnent 
are  collected  into  a  compact  bundle — the  pyramidal  tract.  A  lesioii  in 
this  region  usually  causes  paralysis  of  all  the  muscles  on  the  opposite  side 
of  the  body — that  is,  hemiplegia.  The  pyramidal  tract  continues  in  a 
compact  bundle,  giving  off  fibres  to  the  motor  nuclei  at  different  levels;  a 
lesion  anywhere  in  its  course  is  followed  by  paralysis  of  all  the  muscU's 
whose  nuclei  are  situated  below  the  lesion.  When  theilisease  is  above  the 
decussation,  the  paralysis  is  on  the  opposite  side  of  the  body ;  when  below, 
the  paralyzed  muscles  are  on  the  same  side  as  the  lesion.  Al)ove  the  in- 
tcrmd  capsule  the  path  is  somewhat  more  separated,  and  iu  the  cortex  the 
centres  for  the  movements  of  the  diirerent  sections  of  the  body  are  com- 
paratively far  a])art,  aiul  a  sharply  localized  lesion  iu  this  region  nuiy  cause 
ii  nnire  limited  paralysis,  afTecting  a  limb  or  a  segment  of  a  limb — the  cere- 
bral nuuioplegias ;  but  even  here  the  paralysis  is  not  confined  to  an  indi- 
vidual muscle  or  group  of  muscles,  as  is  commonly  the  case  in  lower  seg- 
ment paralysis  (see  Fig.  2  and  explanation). 

To  sum  up,  the  paralyses  due  to  lesions  of  the  cerebro-spinal  motor 
segment;  are  wide-spread,  often  hemiplegic  ;  the  jiaralyzed  muscles  are  spas- 
tic (the  tendon  reflexes  exaggerated),  they  do  not  undergo  degenerative 


f  ■ 

fi  '  <  t  1    ■ 

:  i-!i 

'■( 

1, 

-1 

>     I! 


•'   -  ■ ' ;  vii 


832 


DISEASES  OF  THE   NEUVOUS  SYSTEM. 


atropliy,  and  tliov  ilo  not  pro.sont  tlio  dogonorativo  ivartinii  to  oloctricnl 
stirniihifioii. 

Tlicrt!  is  an  cxcoption  to  the  above  statomcnt — that  is,  in  tlio  tianihscs 
wliii'li  follow  a  .'oin2)lotc  transvorso  lesion  of  tlio  spinal  oonl.  lli  ic  \\\,. 
limbs  are  of  course  oonipletoly  paralyzinl,  but  in.-tead  of  being  spastii'  tluy 
are  ilaoeid  and  tb.e  doop  reflexes  are  al)sent.  Tliore  is,  liowever,  no  inarknl 
atrojdiy  in  the  muscles,  and  they  react  normally  to  electricity.  Tiiere  is 
no  satisfactory  explanation  of  why  the  reflexes  should  be  abolished  uii.lcr 
th(\se  conditions. 

Irritative  Lesions  of  the  Upper  Motor  Segment.— Our  knowlcdp^  (,t 
such  lesions  is  confined  for  the  most  jiart  to  those  acting  on  the  nuitor 
cortex.  The  abnormal  muscular  contractions  resulting  from  lesion.*  .<o 
situated  have  as  their  type  the  localized  convulsive  seizures  classed  mulcr 
Jacksonian  oi-  cortical  epilepsy,  which  are  characterized  by  the  conviilsidii 
beginning  in  a  single  muscle  or  grouj)  of  muscles  and  involving  otlicr 
muscles  in  a  diilinite  order,  depending  upon  the  j)Osition  of  their  reiirescii- 
tation  in  the  cortex.  For  instance,  such  a  convulsion,  beginning  in  the 
muscles  of  the  face,  next  involves  those  of  the  arm  and  hand,  and  tluii 
the  leg.  The  convulsion  is  usually  accomjianied  by  sensory  phenunn'im 
and  followed  by  a  weakness  of  the  muscles  involved. 

A  majority  of  lesions  of  the  motor  cortex  are  both  destructive  and  iiii- 
tative — i.  e.,  they  destroy  the  nerve  cells  of  a  certain  centre,  and  eitlur  in 
their  growth  or  by  their  presence  throw  into  abnormal  activity  tlio.-e  nf 
the  surrounding  centres. 

The  upper  motor  segment  is  involved  in  nearly  all  the  diseases  of  the 
brain  and  spinal  cord,  especially  in  injuries,  tumors,  abscesses,  Jind  lui'iii- 
orrhages ;  transverse  lesions  of  the  cord ;  syringo-myelia,  progressive 
miiscidar  atro})hy,  bulbar  })andysis,  etc.  One  lesion  often  involves  lidth 
the  upper  and  tiie  lower  motor  segments,  and  we  have  paralysis  in  the 
ditTerent  parts  of  the  body,  with  the  characteristics  of  each.  Such  a  <oni- 
bination  enables  us  in  many  cases  to  make  an  accurate  local  diagnosis. 

Lesions  in  the  oi)tic  2)ath  and  in  the  ditTerent  speech  centres  also  give 
localizing  symptoms,  which  should  be  always  looked  for. 


¥'< 


'4 


!!•■ 


^% 


nil  to  oloctricnl 

ill  tlic  nar;i!\s('s 
Koi'd.  Here  the 
■iiifT  sjKistic  tlicv 
•ever,  no  niiirkcd 
rieity.  Tlicrc  is 
iibolisliotl  un.ler 

111"  knowlodfre  of 

iig  on  the  iiKitiii' 

from  lesions  sn 

■es  clii.s.sod  uiiiliT 

y  the  conviilsidii 

involvinj;  otluT 

f  their  roprescn- 

bcgiiuiini,''  in  the 

hand,  and  then 

isory  phenoiiiciiu 

tructivc  and  irii- 
re,  and  either  in 
activity  these  of 

e  disease.^  of  tlie 

esses,  and  liu'iii- 

lia,    progressive 

en  involves  liodi 

aralysis  in  tlie 

Sueli  a  ciiiii- 

1  diagnosis. 

entres  also  give 


II.   DISEASES   OF  THE   NERVES. 

I.   NEURITIS  {Inflammation  of  the  Xcr'r.  Fihre.s). 

Neuritis  may  be  localized  in  a  single  nerve,  or  (jencral,  involving  a 
large  number  of  nerves,  in  which  case  it  is  usually  kjiown  as  midtiple 
lU'iiritis  ov  jwJjineuritis.  > 

Etiology. — LoniUzed  itenritis  arises  from  (a)  cold,  which  is  a  very 
frecjuent  cause,  as,  for  exami)le,  in  the  facial  nerve.  This  is  sometimes 
known  as  rheumatic  neuritis,  {b)  Traumatisjn — wounds,  blows,  direct 
pressure  on  the  nerves,  the  tearing  and  stretching  wliich  follow  a  disloca- 
tion or  a  fracture,  and  the  hypodermic  injection  of  ether.  Under  tliis 
section  come  also  the  professional  palsies,  due  to  pressure  in  the  exercise 
of  certain  occupations,  (r)  Extension  of  inflammation  from  neighboring 
inu'ts,  as  in  a  neuritis  of  the  facial  nerve  due  to  caries  in  the  temjjoral  bone, 
or  in  that  met  with  in  syphilitic  disease  of  the  bones,  disease  of  the  joints, 
!iii(l  occasionally  in  tumors. 

Multiple  neiiriiin  has  a  very  complex  etiology,  the  causes  of  which 
niiiy  1)0  classified  as  follows  :  (a)  The  jjoisons  of  infectious  diseases,  as  in 
leprosy,  diphtheria,  typhoid  fever,  small-pox,  scarlet  fever,  and  occasion- 
ally in  other  forms;  (/»)  the  organic  poisons,  comprising  the  ditfusible 
stimulants,  such  as  alcohol  and  ether,  bisulphide  of  carbon,  and  naphtha, 
and  the  metallic  bodies,  such  as  lead,  arsenic,  and  mercury ;  (r)  cachectic 
conditions,  such  as  occur  iu  anaemia,  cancer,  tuberculosis,  or  marasmus 
from  any  cause ;  (d)  the  endemic  neuritis  or  beri-beri ;  and  (e)  lastly, 
there  are  cases  in  which  none  of  theue  factors  prevail,  but  the  disease  sets 
in  suddenly  after  ovei'exertion  or  exposure  to  cold. 

Morbid  Anatomy. — In  neuritis  due  to  the  extension  of  inflamma- 
tion the  nerve  is  usually  swollen,  infiltrated,  and  red  in  color.  The  in- 
llanimation  may  be  chiefly  perineural  or  it  may  pass  into  the  deei)er 
portion — interstitial  neuritis — in  which  form  there  is  an  accumulation  of 
lynij)lioid  elements  between  the  nerve  bundles.  The  nerve  fibres  them- 
selves may  not  appear  involved,  but  there  is  an  increase  in  the  nuclei  of 


,,^  |. 


..,( 


;     ! 


iiill#i-i.;.. 

§:■<„ 


wm^ 


T"' 


rn 


834: 


DTSEASrS  OF  THE  NKir  OUS  SYSTEM. 


tlic  sliciitli  of  Scliwaiin.  'I'lic  niycrm  is  fn  ^rnu-ntiMl,  the  miclci  nf  the  in. 
tcnindiil  (••■lis  lire  swollen,  aiid  tiic  axis  'yliinli'i's  juvscnt  variccwitic;.  or 
iiiidcrj^fo  <:r!imiiiir  (Ifirciicration.  ritiina'.'ly  tlu'  ihtvc  (ihrcs  may  lie  idin. 
])lt't('ly  dcstfoycil  ami  r('[)la('('(l  by  a  fi  irons  coiim-ctivo  tissue  in  \\lii(li 
iniK'li  fat  is  soiiietiiiies  deposited — tli'  lijtouuihiKs  vntritis  of  licydeii. 

In  other  instanees  the  (-onditi'  a  is  termed  /)(iniirhi/ni((/ut/s  ueiiiiiiN  in 
■\vliieli  tile  eliaii>;i-.'i  ...^  '.'!.u  iiioso  met  with  in  the  seeondary  or  Wallrriaii 
deireneration,  whieh  follows  when  the  nt-rvc^  is  cut  olT  from  its  (ciiin'. 
Tile  medullary  substance  and  the  axis  cyliiidiM's  are  ehielly  Involveil,  llir 
interstitial  tissue  heiny  but  little  altered  or  only  affected  seeondarily.  Tlir 
myelin  becomes  soi,niienti'd  and  divides  into  small  globules  ami  ;:i'aiiuli  -, 
and  the  axis  cylinders  become  <ii'anular,  broken,  subdivided,  and  iilii- 
niately  disapjiear.  'J'ho  nuclei  of  the  sheath  of  Schwann  proliferate  iuid 
nltimately  the  fibres  are  reduced  to  ii  state  of  atrojihie  tubes  willinut  ;i 
trace  of  the  normal  structure.  The  muscles  connected  with  the  dej^encratcil 
nerves  usually  show  marked  atrojjliic  changes,  ami  in  some  instances  tlic 
change  in  the  nerve  sheath  ajtpears  to  extend  directly  to  the  interstitial 
tissue  of  the  muscU's — the  iiriin'/is /(i.scians  of  Kichh(»rst. 

Syjnptoms.  (c)  Localized  Neuritis. — Asa  rule  the  constitutidiial 
disturbances  are  slight.  'IMie  most  important  symptom  is  jiain  of  a  Imh- 
ing  or  stal)l)itig  cluiracter,  usually  felt  in  the  course  of  the  nerve  and  in 
the  })arts  to  which  it  is  distributed.  The  nerve  itself  is  sensitive  to  pns-- 
ure,  probably, as  Weir  Mitchell  suggests,  owing  to  the  irritation  of  its  iiervi 
nervorum.  The  skin  nuiy  be  slightly  reddened  or  even  tedomatous  ovit 
the  seat  of  the  inflammation.  ^litchell  has  described  increase  iu  the  tem- 
perature and  sweating  in  tliealTected  region,  and  such  trophic  dislurltancrs 
as  effusion  into  the  joints  and  herpes.  The  function  of  the  muscle  to 
which  the  nerve  fibres  arc  distributed  is  imj)aired,  motion  is  painful, 
and  there  may  be  twitdiings  or  contractions.  The  tactile  sensation  ol 
the  part  may  be  somewhat  deadened,  even  when  the  pain  is  greatly  in- 
creased. In  the  more  chroinc  cases  of  local  neuritis,  such,  for  instance,  a.s 
follow  the  dislocation  of  the  humerus,  the  localized  i)ain,  which  at  first  nniy 
be  severe,  gradually  disappears,  though  some  sensitiveness  of  the  hraihiiil 
plexus  may  persist  for  a  long  time,  and  the  nerve  cords  may  be  felt  to  liu 
swollen  and  firm.  The  pain  is  variable — sometimes  intense  and  distress- 
ing; at  others  not  causing  much  inconvenience.  Xumbness  and  forniiia- 
tion  may  be  present  and  the  tactile  sensation  may  be  greatly  impaired. 
The  motor  disturbances  arc  marked.  Ultinnitely  there  is  extreme  atrojihy 
of  the  muscles.  Contractures  may  occur  in  the  fingers.  The  skin  may  be 
reddened  or  glossy,  the  subcutaneous  tissue  oedematous, and  the  nutiition 
of  the  nails  may  be  defective. 

A  neuritis  limited  at  first  to  a  peripheral  nerve  may  extend  upward— 
the  so-called  ascending  or  migratory  neuritis — and  involve  the  laru'er 
nerve  trunks,  or  even  reach  the  spinal  cord,  causing  subacute  myelitis 
(Gowers),     The  condition  is  rarely  seen  in  the  neuritis  from  cold,  or  iu 


Ni:nuTis. 


836 


tliiit  which  follows  fovors  ;  but  it  occurs  most  frci^iuMitly  in  tnummtic 
lu'tiritis.  .1.  K.  Mitclicll  in  his  recent  nioiiognipii  On  Injuries  of 
Ncrvis  (1S!»5),  ooneludes  that  the  hiij^er  nerve  trunks  ure  most  suseop- 
tibli',  i'.nd  that  tin*  neuritis  may  spread  either  up  or  down,  tiie  fortner 
kill,:,'  tlio  most  i-ominoii.  'riie  paralysis  secondary  to  visceral  disease,  as 
(if  llio  bladder,  may  he  due  loan  ascetuliin,'  neuritis.  The  inllammation 
iiiiiy  extend  to  the  nerves  of  the  other  side,  either  throu^di  the  s])iiuil 
rord  or  its  membranes,  or  without  any  involveinent  of  ihe  nerve  centrea, 
the  ,--o-called  sym[)athetic  neuritis.  The  electrical  changes  in  localized 
iii'iiritis  vary  a  jrreat  di'al,  dejiending  upon  the  extent  to  which  the  nerve 
is  injured.  The  lesi((ii  may  bo  so  sli;;ht  that  the  nerve  and  the  niiisck'S 
to  which  it  is  distril)uted  may  react  normally  to  both  currents;  or  it  nuiy 
Ik' SI)  severe  that  the  tyiiical  reaction  of  de^^eneration  dev(dops  within  ji 
tVw  (lavs — i.  e.,  the  nerve  does  not  resiioiul  t(j  stimuUilion  bv  idtlier  cur- 
iviit,  while  the  muscle  reacts  only  to  the  galvanic  cunvni,  and  in  a  peculiar 
iiiiiiiiu'r.  The  contraction  caused  is  slow  and  lazy,  instead  of  siiarp  and 
(|ui(k  as  in  the  normal  muscle,  and  the  AnC  (.'ontraction  is  usually  stronger 
than  the  CC  contraction.  Uetweeii  the.sc  two  extremes  there  are  many 
ilitTerent  grules,  ami  a  careful  electrical  examination  is  most  important  as 
an  aid  to  diagnosis  and  prognosis.* 

The  duration  varies  from  a  few  days  to  weeks  or  months.  A  slight 
tnuiiiKitie  neuritis  m.iy  i)ass  olT  in  a  day  or  two,  while  the  .severer  cases. 
niiL'li  as  follow  iinreiluced  dislocation  of  the  humerus,  may  ])crsist  for 
months  or  never  be  completely  relieved. 

(//)  iVlultiple  Netiritis.— This  presents  a  complex  symptomatology.  The 
fi)ll(j\ving  are  the  most  im[»ortant  groups  of  cases  : 

(l)  Acute  Febnlv  Puli/zteiirifis. — The  attack  follows  exposure  to  cold 
or  overexertion,  or,  in  some  instances,  comes  on  spontaneously.  The  on- 
.*t  resembles  that  of  an  acute  infccl-,ioti3  disease.  There  may  be  a  dermito 
chill,  pains  in  the  back  and  limbs  or  joints,  so  that  the  case  may  be  thought 
to  he  acute  rheumatism.  The  temperature  rises  rapidly  and  may  reach 
lUIj"  or  l()-i°.  There  are  headache,  loss  of  apjietite,  and  the  general  symp- 
toms of  acute  infection.  The  liml>s  and  back  ache.  Intense  pain  in  the 
nerves,  however,  is  by  no  means  constant.  I'ingling  aiul  formication  are 
Mt  in  the  fingers  and  toes,  and  there  is  increased  sensitiveness  of  the  nerve 
trunks  or  of  the  entire  limb.  Loss  of  muscular  ])ower,  first  marked,  ])er- 
hajjs,  in  the  legs,  gradually  comes  on  and  extends  with  the  features  of  an 
ascending  paralysis.  In  other  cases  the  paralysis  begins  in  the  arms.  The 
extensors  of  the  wrists  and  the  flexors  of  the  ankles  are  early  affected,  so 
that  there  is  foot  and  wrist  drop.  In  severe  cases  there  is  general  loss  of 
iiuii^cular  power,  producing  a  flabby  paralysis,  which  may  extend  to  the 
nuiselos  of  the  face  and  to  the  intercostals,  and  respiration  may  be  carried 
on  by  the  diaphragm  alone.    Thu  muscles  soften  and  waste  rapidly.    There 


See  under  facial  pamlysis. 


m:. 


;^;c: 


If 


KM 


83»1 


DISEASES   OF  TUK   NRUVorS  SYSTF<:M. 


may  be  only  liyjx'i'a'stliosiii  with  .sorciums  luid  stiffness  of  the  limbs;  in  some 
cases,  inereiised  sensitiveness  with  nnii'sthesiii ;  in  other  instiinces  the  sen- 
sory (listnr})iUH'('S  iire  sjii^ht.  Tiie  ciiniciil  pii'tiirc  is  not  to  he  lii^tin. 
guislied,  in  niiiny  cases,  I'roui  iiiindry's  |iiiralysis;  in  otlicrs,  rrotu  tlic  miIi- 
acute  myelitis  ol"  Dnchenne.  .latnes  [{oss  eoncliides  from  an  r.nalv.-is  df 
all  the  reported  eases  oF  tlu'  t'oi'mc  r  disease  that  it  coincides  wiih  iiiiihi|ili> 
nenritis  in  f:jeneral  etiolo<ry,  syni|)tonis,  and  eonrse.  On  the  otiier  h;iiii|, 
linn,  in  a  very  thoro  i^di  stmly  oi"  a  recent  case  of  Landry's  paralysis,  ('(111. 
eludes  that  it  is  a  «"|)arate  and  distinctive  disease. 

The  course  is  variable.  In  the  most  intense  t'ortns  the  jiatieiil  iniivilic 
in  a  week  or  ten  days,  with  inv(»lvement  of  the  respiratory  muscles  or  frniii 
paralysis  of  the  heart.  As  a  rule  in  cases  of  moderate  si>verity,  afti  r  )i(r- 
sisting  for  five  or  six  tveeks,  the  conditi(»n  remains  stationary  and  tlu'ii  slow 
improvement  beffins.  The  paralysis  in  some  muscles  may  i)ersist  for  iiiiiny 
months  and  contraetures  may  occur  frcin  shortetnn^j  of  the  muscles,  Inn 
even  when  this  occurs  the  outlook  is,  as  a  rule,  good,  allhoii;,di  the  [m- 
ralysis  may  have  lasted  for  a  year  or  more. 

{'-I)  liiritrriiKi  Mnltiph  Xrnn'/is. — I'lider  the  term  /)nli/)iriiri/is  ir- 
currens  Mary  .Sherwood  has  described  from  l-'ichhorst's  clinic  two  eiises  in 
adults — in  one  v\u\  ,,ivolvin,i:f  the  nerves  of  the  ri,u;ht  arm,  in  the  otlur 
both  legs.  In  ono  ))atient  there  were  three  attacks,  in  the  other  two,  the 
distribution  in  the;  various  attacks  beinj,'  identical.  There  has  recently 
been  at  my  elinie  a  somewhat  similar  ease — a  man,  aged  thirty-one.  wlie 
had,  two  and  a  half  years  ago,  widespread  paralysis,  and  who  now  has  a 
second  attack. 

(;5)  AIniliolif  NriirHi.'i. — This,  perhaps  the  most  important  form  of 
multi'>le  neuritis,  was  described  in  lS'^»'i  by  .lames  Jackson,  Sr.,  of  Bos. 
ton,  whose  acc^ount  of  it  is  veVy  graphic.  W'ilks  recognized  it  as  alcdlMiJic 
paraplegia,  l)ut  the  starting  point  of  the  recent  researches  on  the  disease 
dates  from  the  observation  of  Dumeiul,  of  IJouen.  Of  late  years  (niv 
knowledge  of  the  disease  lias  ext'Mided  rapidly,  owing  to  the  researches  of 
Huss,  Leyden,  James  l^)ss,  liuzzard,  and  Henry  Hun.  It  oeeurs  laost 
frequently  in  women,  particularly  steady,  quiet  tipj)lers.  Its  appoinami' 
may  be  tlio  tirst  revelation  to  the  physician  or  to  the  family  of  haliits  nf 
secret  driid<ing.  The  onset  is  usually  gradual,  and  may  be  jirecedid  for 
weeks  or  numths  by  neuralgic  pains  and  tingling  in  the  feet  and  lianil>. 
Convulsions  are  not  uncommon.  Fever  is  rare.  The  paralysis  gradually  sets 
in,  at  first  in  the  feet  and  legs,  and  then  in  the  hands  and  forearms.  The 
extensors  arc  alfectcd  more  than  the  flexors,  so  that  there  is  wrist-drup  anil 
foot-drop.  The  paralysis  may  be  tbus  limited  and  not  extend  higher  in 
the  lindjs.  In  other  inst:uiccs  there  is  paraplegia  alone,  while  in  the  most 
extreme  cases  all  the  extremities  are  involved.  In  rare  instances  the  facial 
muscles  and  the  sphincters  are  also  affected.  A  case  witli  tliis  distribution 
recovered  in  my  wards  last  year.  The  sensory  symptoms  are  very  varialik'. 
There  are  cases  in  which  there  are  numbness  and  tingling  only,  ^vitlumt 


ic  limits;  in  snino 
isliiticcs  the  sen- 
lot  to  lie  (listin- 
'I's,  from  tlic  siili. 
>m  !in  i.iKilvHs  (if 
ics  with  iiiiiliipl,. 
till'  otlici'  liainl, 
v"s  |)iirii!_vsjs,  ('(111- 

('  ))iiti('nt  iiiiiyilic 
*■  iiiusclcs  or  t'nuii 
'Verily,  iil'ti  r  pcr- 
iiry  iiiul  tlicii  sldw 
>■  persist  for  niMiiy 
tlic  iiiuscles,  liin 
iiitlioiigh  the  pii- 

p(iJi/)ir)n'ifis  vf- 
lii)ic  two  eusc.i  ill 
iirm,  ill  the  othiT 
lie  other  two,  the 
loi'o  has  recently 
thirty-one,  wlm 
who  now  liiis  11 


NKUUITIS. 


8;i; 


ifrciil  pain,  fii  other  fiisos  there  iii'<>  severe  hiiriiitii;  or  horiii^  luiiiis,  the 
nerve  truiilis  art- sensitive,  and  tln^  muscles  mv  sore  when  ^M'asped.  'j'lie 
|i;ini|>  ami  feet  are  frtM|uently  swollen  ami  eonjrested,  particularly  when 
iirlij  ilown  for  a  few  moments.  The  iMitaiieitus  rellexes  as  a  rule  are  pre- 
served.    The  deep  reflexes  are  usually  lost. 

Tlie  eoMi'se  of  these  alcoholic  cases  is,  as  a  rule,  favorable,  and  after 
|icrsi>tin<j;  for  weeks  or  months  improvement  ;,'radually  Ik'^mus,  tin-  mu.s- 
ili's  re;,'ain  their  power,  and  even  in  the  most  desperate  eases  recovery  may 
t'lillow.  The  extensors  of  the  fivt  m;iy  remain  paraly/.eil  for  some  time, 
mill  iiive  to  the  paiieiit  u  distinctive  walk,  the  so-called  s/rppai/c  irait, 
rlime'teristic  of  peripheral  neuritis.  It  is  sometimes  known  as  the  [tscudo- 
liiltrlic  j,Mit,  althou,i,di  in  reality  it  could  m»t  well  he  mistaken  for  the  ,<:ait 
iif  ataxia.  The  fnot  is  iIiimwii  forcihly  forward,  the  toe  lifted  hij^rli  in  ili(> 
air  SI)  a.s  not  to  trip  upon  it.  The  lu'cl  is  hroiiirht  down  lirst  and  then  the 
entire  foot.  It  is  an  awkwai'd,  clumsy  L-ait,  and  i^ives  tlu^  jiatieiit  tlu  ap- 
[leiirance  of  constantly  steppiiiu,-  over  obstacles.  Vmonj,'  the  most  strikiiij^ 
features  of  alcoludic  neuritis  are  the  mental  synijiloms.  Delirium  is  coin- 
iiiiiii,  and  hallucinations  with  cxtrava^'aiit  ideas,  resemblinj;  somewhat 
tliiKc  of  general  paralysis.  In  some  cases  ill"  picture  is  that  of  oi'dinary 
delirium  tremens,  l)iit  tlu'  most  peculiar  and  almost  cliaracteri.-lic  menial 
diMii'iier  is  that  so  well  described  by  Wilks,  in  which  the  ))atieiit  loses  all 
;i|ilii'eeiatioii  of  time  and  [ilace,  and  describes  w  itli  circum.-tanlial  details 
jiin;:  journeys  which  he  has  recently  taken,  or  tells  of  [lersons  whom  li(>  has 
just  seen. 

(4)  Miillipio  Xrini'lis  in  fj/r  fiifWfioKs  />i.<irnsrs. — This  has  been  al- 
ready referred  to,  partiiMilarly  in  dijihtheria,  in  wliicdi  it  is  most  common. 
The  peripheral  nature  of  the  lesion  in  these  instances  has  lieeii  shown  by 
pnst-iiiortem  examination.  'i"he  outlook  is  usually  favorable  and,  except 
in  iliplitlieria,  fatal  cases  are  uncommon.  Multijile  neuritis  in  tubereii- 
losis,  diabetes,  and  ^vpliilis  is  of  the  same  nature,  pnjbably  duo  to  toxic 
materials  absorbed  into  the  blood. 

('))  Arsenical  and  Satnrnine  Xenritia. — The  arsenical  neuritis  is  not 
(oiiuiion  ;  only  a  .siiiirle  instance  of  it  has  come  under  my  observation. 
<hily  one  case  to  my  knowledjjfe  has  followed  the  use  of  Fowler's  sidiition 
ill  my  ward  or  dispensary  practice,  althoufrh  I  am  in  the  habit  of  giving 
in  chorea  and  ana'inia  doses  which  might  be  regarded  as  excessive.  The 
most  common  cau.ses  arc  accidental  poisoning,  as  in  the  cases  reported  by 
Mills.  In  a  case  of  K.  G.  Cutler  the  patient  got  the  ar.senic-  from  green- 
paper  tags,  which  he  was  in  the  habit  of  putting  in  his  mouth.  The  gen- 
eral symptoms  are  not  unlike  those  of  alcoholic  paralysis;  the  weakness  of 
the  extensors  is  marked  and  the  stepparje  gait  characteristic.  The  neuritis 
due  to  lead  will  be  discussed  in  the  consideration  of  lead  poisoning.  The 
special  involvement  of  the  motor  nerves  and  the  great  fre(piency  of  the 
occurrence  of  wrist-drop  are  the  peculiarities  of  this  form, 

A  similar  form  of  neuritis  is  caused  by  the  bisulphide  of  carbon. 


II 


/'« 


ifU 


•m 


li 


838 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


'™iHB 


(G)  Eudctnic  Xauritis  ;  lieri-hcri. — Tliis  is  a  widely  spread  disease  in 
parts  of  India,  and  in  China  and  Japan.  To  Shenbe  ana  I?aelz  are  duo 
the  credit  of  determining  its  true  nature.  Great  difference  of  opinion 
sti'i  prevails  concerning  the  cause  of  the  disease.  It  is  i)robably  (hie  to  h 
micro-organism.  Food  ajijjcars  also  to  have  a  large  share  in  its  causatidii, 
and  it  has  been  attributed  to  a  fish  diet.  Overcrowding  is  a  very  iiiipoitant 
factor,  particularly  on  ships.  Some  have  thought  it  might  be  due  to  the 
presence  of  parasites  in  the  intestines,  but  there  are  no  grounds  for  this 
belief.  There  are  several  types  of  cases.  In  the  acute  pernicious  form 
the  nervous  phenomena  arc  not  so  marked.  There  are  fever,  iuueiiiia, 
and  general  anasarca.  In  another  group  of  cases  there  are  nunil)iie>.s 
loss  of  tendon  reflexes,  areas  of  ana'sthesia,  and  mnscidar  atro])]iy  and 
anasarca.  In  other  cases  the  paralysis  and  atrophy  are  the  most  promi- 
nent symptoms,  and  the  clinical  picture  is  that  of  a  rajjidly  progressing 
multiple  neuritis  with  sensory  and  motor  diL^turbances.  The  nioitalilv 
varies  from  three  or  four  to  fifty  per  cent.  It  occurs  in  epidemic!  form, 
and  has,  as  prominent  symi)tonis,  general  rcdenia,  shortness  of  l)reatli. 
and  sensory  disturbances  with  paralysis.  In  other  instances  the  paralysis 
is  more  extensive  and  proves  fatal.  In  this  country  the  ilisease  has  beiii 
met  with  in  the  fishermen  on  the  Xewfoundland  banks  (J.  J.  Putnam). 
In  1881  and  1889  there  were  epidemics  among  the  crews  of  vessels  fisliin<,' 


in  this  region. 


Birge  describes  eleven  cases  which  occuri'cd  on  one  vessel 


in  a  crew  of  thirteen,  two  of  whom  died.  It  is  not  infrequently  brought 
here  in  the  crews  from  the  West  Indies  and  the  East. 

In  Great  Britain  an  outbreak  occurred  last  year  (1894)  in  the  Kich- 
mond  Asylum,  Dublin,  in  which  149  inmates  were  attacked,  of  whom  K 
died. 

Diagnosis. — The  electrical  condition  in  multiple  neuritis  is  thus 
described  by  Allen  Starr  :  "  The  excitability  is  very  rapidly  and  niarkeilly 
changed;  bnt  the  conditions  which  have  been  observed  are  quite  variims. 
Sometimes  there  is  a  simple  dimimition  of  excitability,  and  then  a  very 
strong  faradic  or  galvanic  cnrrcnt  is  needed  to  produce  contractions. 
Frequently  all  faradic  excitability  is  lost  and  then  the  muscles  contract  to 
a  galvanic  cnrrent  only.  In  this  condition  it  may  require  a  veryslnmg 
galvanic  current  to  produce  conti'action,  and  thus  far  it  is  quite  patlio!,'- 
nomonic  of  neuritis.  For  in  anterior  i)olio-myelitis,  where  the  muscles  re- 
spond to  galvanism  only,  it  does  not  require  a  strong  current  to  cause  u 
motion  until  some  months  after  the  invasion. 

"  The  action  of  the  different  poles  is  not  uniform.  In  many  cases 
the  contraction  of  the  muscle  when  stimulated  with  the  positive  pole 
is  greater  than  when  stimulated  with  the  negative  pole,  and  tlie  eou- 
tractions  may  be  sluggish.  Then  the  reaction  of  degeneration  i.s  pres- 
ent. But  in  some  cases  the  normal  eonditiou  is  found  and  the  nega- 
tive pole  produces  stronger  contractions  than  the  positive  pole.  A  loss 
of  faradic  irritability  and  a  marked  decrease  in  the  galvanic  irritability  o. 


MrMii 


NEUROMATA. 


839 


1}     !i 


spread  disease  in 
a  Biielz  nw  duo 
rence  of  (ii)iiii(jii 
H'obiibly  due  to  .t 
!  in  its  caiisjition, 
a  very  itiipdrtant 
;ht  1)0  due  to  tlio 
grounds  for  thi.s 
pernicious  furm 
e  fever,  iuueniia, 
•e  are  iuiinlitie>!i, 
dar  atro])liy  and 
the  most  pronu- 
l)idly  progrost-ing 
,  Tlie  niditality 
,  epidemic  form, 
rtness  of  breatli, 
ces  the  paralysis 
disease  lias  bein 
i  (J.  J.  rutiiani). 
of  vessels  lisliiiiij 
■red  on  one  vesstl 
?quently  brought 

^94)  in  the  Kicli- 
ked,  of  whom  K 

neuritis  is  thus 
ly  and  niarkcdly 
re  (juite  various. 

lud  then  a  very 
ce  contractious, 
sclos  contract  to 
re  a  very  strong 

is  quite  nathog- 
Q  the  muscles  rc- 
urrent  to  cause  a 

In  many  cases 
le  positive  pi'lc 
0,  and  the  cou- 
leration  is  pres- 
l  and  the  iiega- 
e  pole.  A  loss 
iiic  irritability  of 


the  lauscle  and   nerve  are   therefore   important  symptoms  of   multiple 
iiouritis. 

Tlierc  is  rarely  any  difficulty  in  distinguishing  the  alcoliol  eases.  The 
emubination  of  wrist  and  foot  dro})  with  congestion  of  the  hands  and  feet, 
and  tlie  peculiar  ddii'ium  already  referred  to,  is  quite  characteristic.  Tlio 
rapidly  advancing  eases  with  paralysis  of  all  extremities,  often  reaching 
to  the  face  and  involving  the  sphincters,  are  more  conunoidy  regarded  as 
of  sjiinal  origin,  but  the  general  opinion  seems  to  point  strongly  to  the 
fact  tbat  all  such  cases  are  peripheral.  1'he  less  acute  cases,  in  which  the 
paralysis  gradually  involves  the  legs  and  arms  with  rapid  wasting,  siniu- 
latu  closely  and  are  usually  confounded  with  the  subacute  atrophic  spinal 
paralysis  of  Diu'henne.  I'he  diagnosis  from  locomotor  ataxia  is  rarely 
difficult.  The  xtcpjxicje  gait  is  entirely  ditferent  from  that  of  tabes.  There 
is  rarely  positive  incoordination.  The  patient  can  usually  stand  well  with 
the  eyes  closed.  Foot-drop  is  not  common  in  locomotor  ataxia.  The 
hghtiiing  pains  are  absent  and  there  are  no  pupillary  symptoms.  The  eti- 
ology, too,  is  of  moment.  The  patient  is  recovering  from  a  ])aralysis  which 
has  bt'cn  more  extensive,  or  from  arsenical  poisoidng  or  has  diabetes. 

Treatment. — Kest  in  bed  is  essential.  In  the  acute  cases  with  fever, 
the  salicylates  and  antii)yrin  are  recommended.  To  allay  the  intense 
pain  mf'phia  or  the  hot  apidications  of  lead  water  and  laudanum  are 
oftuu  required.  CJreat  care  must  be  exercised  in  treating  the  alcoholic 
foiin,  and  the  physician  must  not  allow  himself  to  be  deceived  by  the 
statements  of  the  relatives.  It  is  sometimes  exceedingly  ditlicult  to  get  a 
history  of  sj)irit-driidYing.  In  the  alcoholic  form  it  is  well  to  reduce  the 
stimulants  gradually.  If  there  is  any  tendency  to  bed-sore  an  air-l)ed 
should  be  used  or  the  patient  placed  in  a  continuous  Ijatli.  (lientlc  fric- 
tion of  the  nuisclcs  may  be  applied  from  the  outset,  and  in  the  later  stages, 
wlmi  the  atrophy  is  marked  and  the  pains  have  lessened,  massage  is  prob- 
acy the  most  reliable  means  at  our  comnumd.  Contractures  m;iy  be 
gradually  overcome  by  j^assive  movements  and  extension.  Often,  with 
the  nu)st  extreme  deformity  from  contracture,  recovery  is,  in  time,  still 
possible.  The  interru2)ted  current  is  useful  when  the  acute  stage  is 
•  passed. 

Of  internal  remedies,  strycdmia  is  of  ,alue  and  may  be  given  in  in- 
creasing doses.  Arsenic  also  may  be  employed,  and  if  there  is  a  history 
of  syphilis  the  iodide  of  potassium  and  mercury  may  be  given. 


II.  NEUROMATA. 

Tumors  situated  on  nerve  fdn'cs  may  consist  of  nerve  pubstaiicc  proper, 
the  iruo  neuronutta,  or  of  fibrous  tissue,  the  false  neuromata.      The  truo 

•  Lectures  on  Neuritis,  Medical  Record,  New  York,  1887. 


840 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


n    r 


neuroma  usually  contains  nerve  fibres  only,  or  in  rare  instances  gauflion 
cells.  Cases  of  ganglionic  or  medullary  neuroma  are  extremely  run." 
some  of  them,  as  Lancereaux  suggests,  are  undoubtedly  instances  of  mal- 
formation of  the  brain  substance.  In  other  instances,  as  in  the  case  wliich 
I  reported,*  the  tumor  is,  in  all  probability,  a  glioma  with  cells  closclv  re- 
sembling  those  of  the  central  nervous  system.  The  true  fasciculav  in'u- 
roma  occurs  in  the  form  of  the  small  subcutaneous  painful  tumor — /nbcr- 
cilia  dolorosa — which  is  situated  on  the  nerves  of  the-  skin  about  the 
joiuts,  sometimes  on  the  face  or  on  the  breast.  It  is  not  always  miide  up 
of  nerve  fibics,  but  may  be,  as  shown  by  lloggan,  an  adenomatous  growth 
of  the  sweat  glands. 

The  true  neuromata,  as  a  rule,  are  not  painful,  and  occasionally  aro 
found  associated  with  the  nerve  fibres  in  various  regions.  Those  wliich 
develop  at  the  ends  and  along  the  course  of  the  nerves  of  the  stump  iit'ter 
am})utation  consist  of  connective  tissue  and  of  medullated  and  non-iiu'ili.l- 
lated  nerve  fibres.  The  most  remarkable  form  is  the  ple.ct'fonn  ncnnuiKi, 
in  which  the  various  nerve  cords  aro  occuj)ie(l  by  many  hundreds  of 
tumors.  The  cases  are  usually  congenital.  The  tumors  occur  in  nil  tlu' 
nerves  of  the  body.  One  of  the  nuist  remarkaljle  is  that  descrilird  hv 
Prudden,  the  specimens  of  which  are  in  the  medical  museum  of  Cdlunibia 
College,  Xew  York.  There  were  over  1,182  distinct  tumors  distributi'd  m 
the  nerves  of  the  body.  Prudden  f  has  collected  forty-one  cases  from  the 
literature,  in  a  majority  of  which  the  peripheral  nerves  were  alfected. 

A'euromata  rarely  cause  symptoms,  except  the  subcutaneous  ])imifiil 
tumor  or  those  in  the  amputation  stump.  Here  they  may  be  very  paiii- 
fid  and  cause  great  distress.  Motor  symptoms  are  sometimes  present. 
particularly  a  constant  twiteliing.  Epilepsy  has  sometimes  beeu  asso- 
ciated, and  relief  has  followed  removal  of  the  growths. 

The  only  available  treatment  is  excision.  The  subcutaneous  jiainful 
tunmr  does  not  return,  aiul  excision  completely  relieves  the  symptoiiis. 
On  the  other  lumd,  the  amputation  neuronuita  may  recur. 


ii--'^ii 

').  ■' ' ' 

]  i.  • .  ,J.j| 

jiM 

III.    DISEASES  OF  THE  CRANIAL  NERVES. 

Olfactory  Xerve. 

The  functions  of  this  nerve  may  be  disturbed  at  its  peripheral  ending. 
at  the  bulb,  in  the  course  of  the  nerve,  or  at  the  central  origin  in  the  Inain. 
The  disturbances  may  be  manifested  in  subjective  sensations  of  snull. 
complete  loss  of  the  sense,  and  occasionally  in  hyperit>sthesia. 

{a)  Suhjective  Sensations ;  Parosmia. — Hallucinations  of  this  kind  arc 
found  in  the  insane  and  in  epilepsy.    The  aura  nuiy  be  represented  by  au 

*  Journal  of  Anatomy  and  Physiology,  vol.  xv, 

f  American  Journal  of  the  Medical  Sciences,  vol.  Ixxx. 


DISEASES  OF  THE  CRANIAL  NERVES. 


811 


unpK'iii^tint  odor,  described  as  resembling  cldoride  of  lime,  burning  rags^ 
or  fciitliers.  In  a  few  eases  with  these  subjective  setisations  tumors  have 
been  found  in  the  hippocampal  lobules.  In  rare  instances,  after  injury  of 
the  head  the  sense  is  perverted — odors  of  the  most  different  character  may 
be  alike,  or  the  odor  may  be  changed,  as  in  a  patient  noted  by  ^lorell 
Miickcnzie,  who  for  some  time  could  not  touch  cooked  meat,  as  it  smelt 
t(i  her  exactly  like  stinking  fish. 

(//)  TncvcnHcd  senftitimness,  or  hi/pei'osmia,  occurs  chiefly  in  nervous, 
livsterioal  women,  in  whom  it  may  sometimes  be  developed  so  greatly  that, 
like  a  dog,  they  can  recognize  the  difference  between  iiulividmds  by  the 
odor  alone. 

(r)  Amsmio  ;  Losff  of  the  Senile  of  Smell. — This  nuiy  be  produced  by: 
(1)  Affections  of  the  termination  of  the  nerve  in  the  mucous  membrane, 
ffhicli  is  perhaps  the  most  frequent  cause.  It  is  by  no  means  uiu'ommon 
in  iissociation  with  chronic  nasal  catarrA  and  polypi.  In  paralysis  of  the 
fifth  nerve,  the  sense  of  smell  may  be  lost  on  the  alTet^ted  side,  owing  to 
interference  with  the  secretion. 

It  is  doubtfid  whether  the  ca.ses  of  loss  of  snudl  following  the  inhala- 
tions of  very  foul  or  strong  odors  should  come  under  this  or  under  the 
wiitnil  divisicui. 

(■2)  The  lesions  of  the  bulb  or  of  the  nerves.  In  falls  or  blow/;,  in 
{\irios  of  the  bones,  and  in  meningitis  (H'  tumor,  the  l^dbs  or  tlu'  iierve 
t'lmks  may  be  involved.  After  an  injury  to  the  lu'a<l  the  loss  of  hi;<ell 
m;iy  1)0  the  only  sym[)tom.  Mackenzie  lujfes  a  case  of  a  surgeon  who  Mas 
tlirown  from  his  gig  aiul  liglited  on  his  bead.  The  injury  was  slight,  but 
t!io  anosmia  which  followed  was  persistent.  In  locomotor  ataxia  the  sense 
of  :^lnell  may  be  lost,  due  possibly  to  atroj)iiy  of  the  nei'ves. 

(3)  Lesions  of  the  olfactory  centre.  Tiiere  are  congenital  cases  in 
which  fhe  nerve  structures  h.ive  not  l)een  developed.  Cases  have  been  re- 
ported by  Beevor,  Ilughlings  . Jackson,  and  others,  in  Avhich  this  symp- 
tom has  been  associated  with  disease  in  the  heniis])here.  The  centre  for 
tlif  t:enso  of  smell  is  placed  by  Ferrier  in  the  uncinate  gyrus. 

To  test  the  sense  of  smell  the  pungent  bodies,  such  as  ammonia,  which 
act  upon  the  fifth  nerve,  should  not  be  used,  but  su(di  substances  as  cloves, 
pe|)[iermint,  and  musk.  This  .sense  is  readily  tested  as  a  routine  matter  in 
liniiu  cases  by  having  two  or  three  bottles  containing  the  essential  oils. 
Ill  till  instances  a  rhinoscopical  examination  should  Ite  made,  as  the  con- 
ihtion  may  be  due  to  local,  not  central  causes.  The  ircahnvnt  is  unsatis- 
factory even  in  the  cases  due  to  local  lesions  in  the  nostrils. 

Optic  Nkrve  axo  Tract. 

(1)  Lesions  of  the  Retina. 

These  are  of  importance  to  the  physician,  and  information  of  the 
greatest  value  nuiy  be  obtained  by  a  systematic  examination  of  the  eye- 


til 


''iti 


m\ 


842 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


I  fW 


grounds.  Only  a  brief  reference  can  here  be  made  to  the  more  iinpor- 
tant  of  the  appearances. 

{(i)  Retinitis. — Tliis  occurs  in  certain  general  aiTections,  more  inn  .'un- 
larly  in  Briglit's  disease,  syphilis,  leuka?nua,  and  an:emia.  Tiie  coiiiuKm 
feature  in  all  these  states  is  the  oceurreiuie  of  lia-morrlia^'c  and  tlic  dc- 
velopnient  of  opacities.  There  may  also  be  a  dill'use  cloudiness  diii' to 
elfusion  of  serum.  The  luemorrhages  are  in  the  layer  of  nerve  iibrcs. 
Tbey  vary  greatly  in  size  and  form,  bat  often  follow  tlie  course  of  vessels. 
Wben  recent  the  color  is  bright  red,  bivt  tbey  gradually  .duiiige  iind  (,]i| 
hamorrhages  are  almost  black.  Tbe  white  si)ots  are  iUw  either  to  librin- 
ous  exudate  or  to  fatty  degeneration  of  the  retinal  elements,  and  occasiim- 
ally  to  accumulation  of  leucocytes  or  to  a  localized  sclerosis  of  tin  ivtiim' 
elements.  The  more  importaTit  of  the  forms  of  retinitis  to  be  reco^nizod 
are: 

Albuminuric  retinitis,  which  'occurs  in  chronic  nejdiritis,  particulailv 
in  the  interstitial  or  contracted  form.  The  ])erceiitage  of  cases  aUVftnl 
is  from  fifteen  to  twenty-five.  There  are  instances  in  which  these  retinal 
changes  are  associated  with  the  granular  kidney  at  a  stages  when  the 
amount  of  albumen  may  be  slight  or  transient;  but  in  all  such  instances 
it  will  be  found  that  tliei'e  is  a  nuirked  arterio-sclerosis.  po^vers  roco}:- 
nizes  a  degenerative  form  (most  common),  in  which,  with  the  retina! 
changes,  there  may  be  scarcely  any  alteration  in  the  disk  ;  a  ha'iiiorrlmjrii' 
form,  with  many  luemorrhages  and  but  slight  signs  of  inflammation  ;  aiiil 
an  inflamnuitory  form,  in  which  there  is  much  swelling  of  the  retina  anil 
obscuration  of  the  disk.  It  is  noteworthy  that  in  some  instances  the  in- 
llammation  of  the  optic  nerve  predominates  over  the  other  retinal  changes 
and  one  may  be  in  doubt  for  a  time  whether  the  condition  is  reallv  asso- 
ciated with  the  renal  changes  or  dependent  ui)on  iiilraeraiiial  disease. 

SiipliHitic  Jh'tinifis. — In  the  acquired  form  this  is  less  common  tlian 
choroiditis.  In  inherited  syphilis  retinitis pif/mentom  in  sometimes  met 
with. 

Retinitis  in  Anceniia. —Jt  has  long  been  known  that  a  patient  may 
become  blind  after  a  large  luvmorrhage,  either  suddenly  or  within  two  nr 
three  days,  and  in  one  or  both  eyes.  Occasionally  the  loss  may  b*'  ]iei"^ia- 
nent  and  comjdete.  In  some  of  these  instances  a  neuro-retinitis  bus  l)oeii 
found,  probably  sufficient  to  account  for  the  symptoms.  In  the  more 
chronic  ana'inias,  particularly  in  the  pernicious  form,  retinitis  is  conunoii, 
as  determined  first  by  Quincke. 

In  tnatdi'ia  retinitis  or  neuro-retinitis  may  be  present,  as  noted  h 
Stephen  >rackenzie.  It  is  seen  only  in  the  chronic  cases  with  atnemia, 
and  in  my  experience  is  not  nearly  so  common  ])roportionately  as  in  por- 
nicious  anaemia.  Of  many  instances  which  have  come  under  my  ohserva- 
tion  of  severe  malarial  anamiia,  particularly  at  the  J*liilau(d])hia  Hospital, 
there  were  only  two  with  retinal  luemorrhages. 

Leukmmic   Retinitis. — In   this  affection  the   retinal  veins  an'  large 


the  more  iinpor- 


liil  veins  aiv  large 


DISEASES  OF  THE  CRANIAL  NERVES. 


843 


anil  illstendc'd  ;  tlioro  is  also  a  pppuliar  rotiiiitin,  as  doseribod  by  Licbivicb. 
It  is  not  VI"  j  fomniou.  Of  the  seventeen  cases  of  luuka'niia  wliicli  have 
cojiic  under  my  observation,  retinitis  existed  in  only  three  of  the  ten  in 
wliich  the  eye-grounds  were  examined.  There  are  numerous  luvmor- 
rlmifcs  and  white  or  yellow  areas,  which  )  lay  Ite  large  and  prominent. 
In  one  of  my  cases  the  retina  [lost  mortem  was  occupied  by  many  small, 
opaqtu',  wliite  spots,  looking  like  little  tumors,  the  larger  of  which  had  a 
diameter  of  nearly  two  niillimeti'cs.  In  Case  13  of  my  series  tlie  leuka'miu 
WHS  iliagnosed  by  Morris  and  De  8eliweinitz,  at  whose  clinic  the  patient 
had  ajiplied  on  account  of  failing  vision,  from  the  condition  of  the  eye- 
gnninds  alone. 

Kctinitis  is  also  found  occasionally  in  diabetes,  in  purpura,  in  chronic 
load  jioisoning,  and  sometimes  as  an  idiijpathic  aifection. 

(h)  Functional  Disturbances  of  the  Retina.  (1)  To.dc  AmauroKis'.— 
This  occurs  in  ura'inia  and  may  f(dlow  convulsions  or  come  on  indeiiend- 
ontly.  Thus,  a  patient  who  had  l)ecome  suddenly  blind  the  previous  ihiy, 
was  led  into  one  of  my  wards  at  the  Montreal  (ieneral  Hospital,  lie  had 
had  no  special  symptoms,  but  examination  showed  extensive  cardio-vas- 
cahir  (dianges.  The  uriiu'  was  alltuniinous.  The  ophthalmoscopic  exam- 
iiiatiim  was  negative.  The  condition,  as  a  rule,  persists  only  for  a  day 
1)1' two.  This  form  of  amaurosis  occurs  in  poisoning  by  lend  and  occa- 
sionally by  quinine.  It  .seems  more  probable  that  the  pt)isons  act  on  the 
centres  and  not  on  the  retina. 

(•.')  Iljisfcrirdl  AnKini'osix. — ^lore  frequently  this  is  loss  of  acutene.ss 
iif  vision — amblyopia — but  the  loss  of  sight  in  one  or  both  eyes  nuiy 
apparently  be  complete.  T'ho  condition  will  l)e  mentioned  subsequently 
under  hysteria. 

(o)  Tubarco  Amhhjnpid. — Tlie  loss  of  sight  is  usually  gradual,  equal  in 
both  eyes,  and  allects  particularly  the  centre  of  the  field  of  vision.  The 
evt'-grounds  may  be  normal,  l)ut  occasionally  there  is  congestion  of  the 
disks.  On  testing  the  color  fields  a  central  scotoma  for  red  and  green  is 
found  in  all  cases.  Ultimately,  if  the  use  of  tobacco  is  continued,  organic 
olianges  may  develop  with  atrophy  of  the  disk. 

(4)  y'Kjhl-bJiiKbirss — injrtaJopia — the  condition  in  wliich  objects  are 
dearly  seen  during  the  day  or  by  strong  artificial  light,  l)ut  become  in- 
visihle  in  the  shade  or  in  twilight,  and  Iicmcralopiii,  in  whiidi  objects 
ciiiiniit  be  clearlv  seen  without  distress  in  davliijbt  or  in  a  strong  artificial 
li,;ht,  liut  are  readily  seen  in  a  deep  shade  or  in  twilight,  are  fuiu>tional 
anomalies  of  the  retina  whi(;h  rarely  come  under  the  notice  of  the 
physician.     It  may  occur  in  epidemic  form. 

('))  Rvfiixd  hiijwriPxIhfisUi  is  sometimes  seen  in  hysterical  women,  but 
i^  not  fouiul  frequently  in  actual  retinitis.  I  have  seen  it  once,  however, 
ill  alltuminuric  retinitis,  ami  once,  in  a  marked  degree,  in  a  i)atient  with 
aortic  insufficiency,  in  whose  retiuaj  there  were  no  signs  other  than  the 
throbbing  arteries. 


■':N 


1~  ! 


I 


'*;' 


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wwm, 


I"! 


'4 


su 


DISKASES  OF  THE  NERVOUS  SYSTEM. 


(2)   Lesions  of  the  Optic  Xerve. 

(rt)  Optic  Neuritis  {PapiUitis  ;  Cholfd  Did-).—\\\  the  first  stajre  thorp 
is  congestion  of  tlu'  disk  iiiul  tlio  edges  are  l)liirred  an<l  striated,  lu  tin- 
80CO7id  stage,  the  eor.gestioii  is  more  marked,  the  swelling  inereases,  the 
striation  also  is  more  visible.  Tlie  i)hysiologieal  eupping  disappears  and 
)ia'morrliages  arc  not  nncommon.  The  arteries  present  little  eliangc,  tlio 
veins  inw  dilated,  and  the  disk  may  swell  greatly.  In  slight  grades  of  in- 
llanunation  the  swelling  gradually  sul)sides  and  oeeasionally  the  nerve 
recovers  completely.  In  instances  in  which  the  swelling  and  exudate  uri' 
very  great,  the  subsidence  is  slow,  and  when  it  fiiudly  disappears  there  i> 
complete  atrophy  of  the  nerve.  The  retina  not  infre(piently  partieiputft: 
in  the  inilanimation,  which  is  then  a  neuro-retinitis. 

This  condition  is  of  the  greatest  im])ortanee  in  diagnosis.  It  mav  exist 
in  its  early  stages  without  any  disturbance  of  vision,  and  even  with  exti'ii- 
sive  pai)illit.is  the  sight  may  for  a  time  be  good. 

Optic  neuritis  is  seen  occasionally  in  aiuemia  and  lead  poisoning,  inere 
commoidy  in  Bright's  disease  as  neuro-retinitis.  It  occnirs  occasionally  as 
a  primary  idio})athic  aU'ection.  The  frequent  connection  with  intracranial 
disease,  particularly  tumor,  mak(!s  its  presence  of  great  value  to  ])ra(ti- 
tioners.  The  nature  of  the  growth  is  without  influence.  In  over  ninety 
2)er  cent  of  siudi  instances  the  i)apillitis  is  bilateral.  It,  is  also  foiind  in 
meningitis,  either  the  tuberculous  or  the  simple  form.  In  nieningitis  it  is 
easy  to  see  how  the  inflammation  may  extend  down  the  nerve  sheaths,  lu 
the  case  of  tumor  it  was  thought  at  first  that  a  choked  disk  resulted  from 
increased  pressure  within  the  skull,  it  is  now  more  commonly  regarded, 
however,  us  a  descjLiu.din<^neiu'i|is. 

(i)  Optic  AtropnyT— This  may  be  :  (1)  A  primary  affection.  Tlicro  is 
an  hereditary  form,  in  which  the  disease  has  developed  in  all  the  males »{ 
a  family  shortly  after  puberty.  A  large  numl)er  of  the  cases  of  primary 
atrojjhy  are  associated  with  spinal  disease,  ])articularly  locomotor  ataxia. 
Other  causes  which  have  been  assigned  for  the  })rimary  atroi)hy  are  cold, 
sexual  excesses,  diabe'^'^'S,  the  specific  fevers,  alcohol,  and  lead. 

{•Z  Secondary  atrophy  results  from  cortical  lesions,  pressure  on  the 
chiasma  or  on  the  nerves,  or,  niost  commonly  of  all,  is  a  sequen(!(!  of  jni- 
pillitis. 

The  ophthalmoscopic  appearances  are  different  in  the  cases  of  priniaiy 
and  secondary  atrophy.  In  the  former,  the  disk  has  a  gray  tint,  thf  edges 
are  well  defined,  and  the  arteries  look  almost  normal ;  whereas  in  the  con- 
secutive atroi)hy  the  disk  has  a  staring  opaque-white  aspect,  with  irregu- 
lar outlines,  and  the  arteries  are  very  small. 

The  symptom  of  optic  atrophy  is  loss  of  sight,  proportionate  to  llie 
damage  in  the  nerve.  The  change  is  in  three  directions:  "(1)  Diminished 
acuity  of  vision  ;  {'i)  alteration  in  the  field  of  vision  ;  and  (.'})  altered  per- 
ception of  color."    (dowers.)     The  outlook  in  jjrimary  atrophy  is  bad. 


.,■)  ,.. 


I ..,, 


DISEASES  OF  THE  CRANIAL   NERVES. 


846 


(;})  A(f'c(:lio7is  of  the  Chinsmn  and  Tract. 

At  tho  chiiisniii  tho  optic  nerves  undergo  partial  decussation.  Each 
(iplic  tnii't,  us  it  joins  the  chiasma,  contains  nerve  tibres  wliicli  supply  half 
III'  tlie  retina  of  eit'cr  eye.  Thus,  of  the  fibres  of  the  right  tract,  part  pass 
thr  iliiiisnia  without  decussating  and  supj)ly  the  teinj)oral  half  of  the  right 
rclinii,  the  other  and  larger  portioti  of  the  fibres  of  the  tract  decussate  in 
the  (  hiasrna  and  join  tho  left  optic  nerve,  su})plying  the  nasal  half  of  the 
rcliiKi  on  the  other  side.  The  fibres  which  cross  are  in  the  middle  j)ortion 
of  tlic  (!hiasma,  while  the  direct  fibres  are  on  each  side.  The  following  are 
the  most  important  changes  which  ensue  in  lesions  of  the  tract  and  of  the 
cliiiismii: 

(it)  Iiiiloteral  Affection  of  Tract. — If  right,  this  produces  loss  of  func- 
tion in  the  temporal  half  of  the  retina  on  the  right  side,  and  on  the  nasal 
liiiir  of  the  retina  on  the  left  side,  so  that  there  is  only  half  vision,  and 
the  patient  is  blind  to  objects  on  the  left  side.  This  is  termed  homony- 
mous hemianojiia  or  lateral  hemianopia.  The  fibres  })assing  to  the  right 
half  (if  each  retina  being  involved,  necessarily  the  left  half  of  each  visual 
Held  is  blind.  The  hemianojiia  may  be  ])artial  and  only  a  portion  of  the 
hiilf  field  may  be  lost.  The  unaffected  visual  fields  may  have  the  normal 
extent,  but  in  .some  instances  there  is  considerable  reduction.  When  the 
left  liulf  of  one  field  and  the  right  half  of  the  other,  or  vice  ve)'m,  are 
blind,  the  condition  is  known  as  heteronymous  hemianopia. 

(//)  Disease  of  the  Chiasma. —  (1)  A  lesion  involves,  as  a  rule,  chiefly 
the  central  portion,  in  which  the  decussating  fibres  pass  which  supply  the 
inner  or  nasal  halves  of  the  retintv,  producing  in  consequence  loss  of  vision 
in  the  outer  half  of  each  field,  or  what  is  known  as  temporal  hemianopia. 

(•■2)  If  the  lesion  is  more  extensive  it  may  involve  not  only  the  central 
portion,  but  also  the  direct  fibres  on  one  side  of  the  commissure,  in  which 
case  tliere  would  be  total  blindness  in  one  eye  and  temporal  hemianopia 
in  tlie  other. 

(.'!)  Still  more  extensive  disease  is  not  infrequent  from  presisure  of  tu- 
mors in  this  region,  the  whole  chiasma  is  involved,  and  total  blindness 
re.snlts.  The  different  stages  in  the  process  may  often  be  traced  in  a  sin- 
jrle  case  from  tem])oral  hemianopia,  then  comjilete  blindness  in  one  eye 
witli  temporal  hemianopia  in  the  other,  and  finally  complete  blindness. 

(1)  A  limited  lesion  of  the  outer  part  of  the  chiasma  involve-^,  only  the 
ilirect  fibres  passing  to  the  temporal  halves  of  the  retina;  and  inducing 
blindness  in  the  nasal  field,  or,  as  it  is  called,  nasal  hemianopia.  'J'his,  of 
conrse,  is  extremely  rare.  Double  nasal  hemianopia  may  occur  as  a  mani- 
festation of  tabes  and  in  tumors  involving  the  outer  fibres  of  each  tract. 

(4)  Affect iotis  of  the  Tract  and  Centres. 

'i'he  optic  tract  crosses  the  crus  to  the  hinder  part  of  the  o])tic  thala- 
mus and  divides  into  two  portions,  one  of  which  goes  to  the  thalamus  and 
external  geniculate  bodies  and  to  the  anterior  quadrigemiual  bodies.    From 


?' 


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it, 


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:n/'  -i.  ■ : 


846 


DISEASES  OF  THE   NERVOUS  SYSTEM. 


CUNEU3 


VlSU^ 


T  E  M  P  0  ^'  A  U 


'SU  A^ 


Fig.  9.— Diagram  ot  visual  paths.  (From  Vialet.  motlificc^ )  OP.  N.,  0|.tic  iRTve, 
OP.  C,  Optic  chiasm.  OP.  T.,  0[)tic  tract.  OP.  R.,  Optic  radial i(.iis.  KXT. 
GEN.,  External  geniculate  body.  TIIO.,  Optic  thalamus.  C.  QU.,  ('(iriiuiii 
qua(lri};;cmina.  ('.  C,  (Corpus  callosum.  V.  S.,  Visual  si)ecch  centre,  A.  S..  .Audi- 
tory speech  centre.  Jf.  S.,  ]\Iotor  speecli  centre.  A  lesion  at  1  causes  blindiKss 
of  that  eye;  at  2,  bi-tcmporal  heinianopia;  at  3,  nasal  heniianopia.  Syriinut- 
rical  lesions  at  ii  and  3'  would  cause  bi-iiasal  heniianopia;  at  4,  homiiinnpin  cif 
both  eyes,  with  hemianopic  pupillary  inaction;  at  5  and  6,  heniianopia  d'  Imlli 
eyes,  pupillary  reflexed  normal;  at  7,  amblyopia,  especially  of  opposite  eye;  at  8, 
on  left  side,  word-blindness. 


DISEASKS  OF  THE  CRANIAL   NHItVHS. 


.S47 


tliosi'  parts  iil)ros  pass  into  tlie  postcridr  jMirt  of  tliu  iiilcnial  oapstilc  ami 
iiiUT  ilio  occipital  lobe,  i'onuing  tlic  lil)rc.s  of  tiic  optic  railialioii,  wliich 
icniiiiiiite  ill  Hiul  about  the  ciincus,  the  region  of  the  visual  perceptive 
(ciitiv.  The  fibres  of  the  other  division  of  tlie  tract  pass  to  the  internal 
geniculate  Ijodies  and  to  the  posterior  cpiadriyenunal  body.  It  is  still 
licM  by  some  piiysiolo^ists  that  the  cortical  visual  centre  is  not  conlined 
ij  till'  occipital  lobe  alone,  but  embraces  the  occipito-an<j;ular  re<,non. 

A  lesion  of  the  fibres  of  the  optic  tract  anywhere  l)et\veen  tlie  cortical 
(TUtiv  and  the  chiasimi  will  ])r()(hice  lateral  hemianopia.  Tiu'  lesion  may 
hi' situated  :  {(i)  In  the  tract  itself.  {/>)  In  tiie  region  of  tiie  tiialanius  and 
till.' corpora  (|uadrigcmina,  into  wiiicli  the  larger  part  of  each  tract  enters. 
((■)  A  lesion  of  the  fibres  passing  from  the  corjxtra  (piadrigemina  to  ilie  oc- 
cipital lol)e.  This  nuiy  be  either  in  the  hinder  part  of  the  internal  capsule 
or  the  white  fibres  of  the  optic  radiation.  ((/)  liCsiou  of  the  cuneus.  Hi- 
liitcral  di.sease  of  the  cuneus  nuiy  result  in  total  blindness,  (r)  There  is 
cjiiiical  evidence  to  show  that  lesion  of  the  angular  gyrus  may  be  asso<'i- 
;itf(l  with  visual  defect,  not  so  often  hemianopia  as  cros.sed  amblyoj)ia, 
iliiiimss  of  vision  in  the  opposite  eye,  and  great  contraction  in  the 
tifltl  of  vision.  Lesimis  in  this  region  are  associated  with  mind  blind- 
mss,  a  condition  in  which  there  is  failure  to  recognize  the  nature  of  ob- 

jl'lLS. 

Tlie  effects  of  lesions  in  the  optic  nerve  in  difTerent  situations  from  the 
ivtiuiil  expansion  to  the  brain  cortex  are  as  follows :  (1)  Of  tiie  optic  nerve 
— tdtal  blindness  of  the  corresponding  eye;  {'I)  of  the  optic  chiasma, 
citlier  temporal  hemianopia,  if  the  central  part  alone  is  involved,  or 
iiasiil  hemianopia,  if  the  lateral  region  of  each  chiasma  is  involved  ;  (3) 
k'sidii  of  the  optic  tract  between  the  chiasma  and  the  geniculate  bod- 
its,  produces  lateral  hemianopia;  (4)  lesion  of  the  central  fdires  of  the 
iKTve  between  the  geniculate  bodies  and  the  cerebral  cortex  produces 
lateral  heniianoiiia ;  (5)  lesion  of  the  cuneus  causes  lat(!ral  hemianopia ; 
ami  (li)  lesion  of  the  angular  gyrus  may  be  associated  with  hemianopia, 
MiiiU'tiiues  crossed  amhlyopia,  and  the  condition  known  as  mind  blind- 
ness.   (See  Fig.  9,  with  accompanying  explanation.) 

Diagnosis. — The  student  or  practitioner  must  have  a  clear  idea  of 
tlio  physiology  of  the  nerve  centres  before  he  can  appreciate  the  symptoms 
or  undertake  the  diagnosis  of  lesions  of  the  optic  nerve.  Having  detor- 
mineil  the  presence  of  hemiano])ia,  the  question  arises  as  to  the  situation 
of  the  lesion,  whether  in  the  tract  between  the  chiasma  and  the  genicnlatu 
bodies  or  in  the  central  portion  of  the  fibres  between  these  bodies  and  the 
visual  centres.  This  can  be  determined  in  some  cases  by  the  test  known 
as  Wernicke's  hemiopic  pupiUary  iiiac/ion.  The  pupil  reflex  depends  on 
the  integrity  of  the  retina  or  receiving  membrane,  on  the  fibres  of  the  op- 
tie  lurve  and  tract  which  transmit  the  impulse,  and  the  nerve  centre  in 
the  geniculate  bodies  which  receives  the  impression  and  transmits  it  to  the 
third  nerve  along  which  the  motor  impulses  pass  to  the  iris.  If  a  bright 
54 


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DISKASRS  OP  THE   NKIIVOUS  SYSTK.\r. 


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i  ■ 


li^jht  is  tlirowii  into  tli(>  eye  and  tin-  pupil  rciict.s  tlu'  iii(c<:rity  (.1  ihisiv- 
Hex  iU'c  is  (Iciiioiistriitcd.  It  is  [lossihlc  in  cases  of  lateral  lieniiMiKMiin  v,, 
to  throw  the  lii,'lit  inti>  llie  eye  tlmt  it  fails  upon  tlie  l)linM  lialf  (if  tli,. 
retina.  If  when  tliis  is  done  tiie  pupil  contracts,  the  indicatinn  |>  tlmi 
the  rellex  an;  ahove  referred  to  is  perfect,  hy  wliicii  we  nieaii  iliat  tl,,. 
optic  nerve  fibres  from  the  retinal  expansion  to  the  centre,  the  ivntiv 
itself,  and  the  third  nerve  are  uninvolved.  In  such  a  case  thf  niiiclii- 
sion   would   he  justifii'd    that  the  cause  of  tlu    heniiauopia   was  rciitml; 

that  is,  situiited  behind  the  f,'eniculate  bodies,  either  in  the  fibres  of  \\ 

tic  radiation  or  in  the  visual  c(»rtical  centres.  11',  on  the  other  hand.  uIkh 
the  li<i:ht  is  carefully  thrown  on  the  henuopie  half  of  the  retina,  thr  |iii|iil 
remains  inactive,  the  com'lusi<(n  is  justiliable  that  there  is  interni)iti(iii  in 
the  path  between  the  retina  and  the  <i;eni<'ulate  bodies,  and  that  the  luini. 
anopia  is  not  central,  but  dependent  upon  a  lesion  situated  in  the  iiait. 
This  test  of  Wernicke's  is  sometimes  didicult  to  obtain.  It  is  hi^t  |i(.|'. 
formed  as  follows:  "The  patient  beiiij;  in  a  dark  or  nearly  dark  nimn 
with  the  lamp  or  jras-li<,dit  behiiul  his  head  in  the  usual  position,  I  iiid  him 
look  O'er  to  the  other  side  of  the  room,  so  as  to  exclude  accouniUMlativc 
iris  moveineuts  (which  are  not  necessarily  associated  with  the  rclltx). 
Then  I  throw  a  faint  li^Mit  from  a  plane  mirror  or  from  a  larj^e  idiicavc 
mirror  held  well  out  of  focus  upon  the  eye  and  note  the  size  of  the  |iu|iil. 
With  my  other  hand  I  now  throw  a  In-am  of  lij,dit,  focussed  from  the  laiii|< 
by  an  o])hthalmoscopi(!  mirror,  directly  into  the  optical  centre  of  tln'  eve; 
then  laterally  in  various  i)ositioiis,  and  also  from  above  and  below  the 
equator  of  the  eye,  noting  the  reaction  at  all  angles  of  incidence  of  ihr 
ray  of  light."    (Seguin.) 

The  siguifieance  of  hemianopia  varies.  There  is  a  functional  hctni- 
anopia  associated  with  migraine  and  hysteria.  In  a  considerable  pM- 
])ortion  of  all  cases  there  are  signs  of  organic  brain-disease.  lleiiii|ilc,i:i;i 
is  common  and  the  loss  of  ])ower  and  blindness  are  on  the  same  >ulv. 
Thus,  a  lesion  in  the  left  hemisphere  involving  the  motor  tract  priMlmrs 
right  hemi[)legia,  and  when  the  fibres  of  the  optic  radiation  are  involved 
in  the  internal  capsule,  there  is  also  left  lateral  hemiano])ia,  so  that  ohjtHts 
in  the  field  of  vision  to  the  right  are  not  perceived.  lIemiana\stliosi;t  is 
not  nncommon,  owing  to  the  close  as.sociation  of  the  sensory  and  visii;il 
tracts  at  the  ])osterior  ])art  of  the  internal  capsule.  Certain  fni'iiis  d 
aphasia  also  occur  in  many  of  the  cases, 

Motor  Ni:rvi:s  oi'  thk  Eyeball. 

Third  Nerve. — Arising  from  th.e  floor  of  the  aqueduct  of  Sylvius,  the 
nerve  passes  through  tlie  cms  at  the  side  of  which  it  emerges.  I'assini; 
along  the  wall  of  the  cavernous  sinus,  it  enters  the  orbit  thron'.;li  the 
sphenoidal  fissure  and  supplies,  by  its  superior  branch,  the  levator  ]»aliit'- 
brae  superioris  and  the  superior  rectus,  and  by  its  inferior  branch  i  lie  in- 


I  ;5 


tc;,'nty  of  this  n- 
ill  licniiiiiinnia  mi 
l)liii.I  lialr  lit'  the 
luliciitidii  i>  tluii 
('  niciiii   iliiii  111,. 

Clltrr,    lllr    (Tllliv 

ciisc  tlir  ciiiii'lu- 
)l)iii  was  cciitriil; 
0  fibres  dI'  lin'  nji. 
otlu'i'  liaml.  ulicii 
'  ivtiiia.  till'  |iii|iil 

is  iiit('rni|ili(iii  in 
III!  tiial  till'  lii'Mii- 

IIUmI    ill    the    tl'ilct. 

II.  It  is  liot  |ici'- 
lu'iirly  (larl\  nimii 
lositidii,  1  liid  Jiiiii 
it'  acr(>iiiiiHiil;ilivi' 

with  till'  irlK'x). 
Ill  ii  hirj^i'  ('(iiiciivc 
'  size  of  till'  iiii|iil. 
sfti  from  the  laiiiii 

centre  of  tlie  eye; 
ve  and  hclnw  tln' 
f  iiR'ideiiee  til'  llif 

fuiu'tioiial   hciiii- 

coiisideralilc  imi- 
H>ase.      Ileiiii|ilt',i.'i;i 

on  the  same  siilc. 

or  tract  pnidiu'i^ 
ition  are  iiivolvcil 
ia,  so  tiiat  ohji'cts 
leiniana'sthcsiii  i> 

sensory  and  visinil 
Certain  fnriiis  I'f 


ict  of  Sylvius,  the 
merges,     riissiiit; 

3rbit  throiii-di  the 
the  levator  ]rd\\w- 

lor  branch  the  i"- 


DISRASKS  OF  TllK  CUAXIAL  XKliVES. 


h49 


tornai  and  inferior  recti  nuis(des  and  tlio  inferior  obliciuo.  I^raiudies 
piis.-i  lo  tile  ciliary  nuisclo  and  the  constrictor  of  the  iris,  [.esioiis  may 
alTfct  tlie  centre  or  tlie  nerve  in  its  course  and  cause  citlier  jiaralysis  or 
•|i;isin. 

I'liniJi/sis. — A  nucdear  lesion  is  usually  associated  with  the  disease 
of  thi'  (H'litres  for  the  otiier  eyt*  mus(dcs,  producing  a  condiiioti  of  gen- 
I'mi  (iiditlialnioplegia.  More  commonly  tiie  nerve  itstdf  is  involved 
ill  its  course,  either  liy  meningitis,  giimiiiata,  or  aneurism,  or  is  at- 
tiiikcd  by  neuritis,  as  in  (iii)htlieria  and  locomotor  ataxia.  Coniidete 
imralysis  of  the  third  nerve  is  accompani'Hl  by  tiie  following  syinp- 
tiiiii-  : 

Paralysis  of  all  the  nniscles,  except  the  superior  oI)Iique  and  external 
rcrtiis,  by  which  the  eye  can  bo  moved  outward  and  a  little  downward  and 
inward.  There  is  divergent  strabismus.  'J'herc  is  ptosis  or  drooping  of 
the  .upper  eyelid,  owing  to  paralysis  of  the  levator  paljx'bra'.  '['he  pupil  is 
usually  dilated.  It  does  not  contract  to  light,  and  the  jiower  of  accom- 
iiiiidation  is  lost.  The  most  striking  features  of  this  jiaralysis  are  the  ex- 
ternal strabismus,  with  diplo])ia  or  (loul)le  vision,  and  the  ptosis.  In  very 
iniiiiy  cases  the  alTection  of  the  third  nerve  is  jiartial.  Thus  the  levator 
|ialp('l)ra' and  the  superior  rectus  may  ])e  involved  togetliei-,  or  the  ciliary 
iiuiscles  and  the  iris  may  be  all'ected  and  the  external  muscles  may 
escape. 

There  is  a  remarkable  form  of  recurring  oculo-motor  jiaralysis  alfect- 
iiijr  iliieily  women,  and  involving  all  the  l)rajudu's  of  the  nerve.  Jn  some 
(■;i;;(s  the  attacks  have  come  on  at  intervals  of  a  month  ;  in  others  a  miudi 
Imiger  period  has  elai)sed.  The  attacks  may  iiersist  throughout  life. 
TlifV  are  sometimes  associated  with  pain  in  the  head  and  sometimes  with 
iiiiirraiue.  !Mary  Sherwood  has  collected  from  the  literature  twenty-three 
rases. 

y/as/.v  is  a  common  and  imjiortant  .symptom  in  nervous  alfections. 
Wr  may  here  briefly  refer  to  the  conditions  under  which  it  may  occur: 
{i()  A  congenital,  incurable  form,  whi(di  is  frequently  seen  ;  (/v)  the  form 
associated  with  definite  lesion  of  the  third  nerve,  either  in  its  course  or 
at  its  iiiudeus.  This  may  come  on  with  ])aralysis  of  the  superior  rectus 
ajiiiie  or  with  paralysis  of  the  internal  and  inferior  recti  as  well.  ('■) 
There  are  instances  of  complete  or  jiartial  ])tosis  as.sociated  with  cere- 
bral lesions  without  any  other  bran(di  of  the  third  nerve  being  j>ar- 
alyzed.  The  positir)n  of  the  cortical  centre  is  as  yet  unknown.  (d) 
ilysterioal  ptosis,  which  is  double  and  occurs  with  other  hysterical  .symp- 
toms, [p)  Pseudo-ptosis,  due  to  affection  of  the  sympathetic  nerve,  is 
associated  with  syniptoms  of  vaso-motor  palsy,  such  as  elevation  of  the 
it'iiipcrature  on  the  affected  side  with  redness  and  u'denia  of  the  skin. 
Coiitractiou  of  the  pupil  exists  on  the  same  side  and  the  eyeball  appears 
rather  to  have  shrunk  into  the  orbit,  (/)  In  idiopathic  muscular  atrophy, 
when  the  face  muscles  are  involved,  there  may  be  marked  bilateral  ptosis. 


IPPI 


W^'' 


L.1  .^-■. 


,  i-ri 


<?..  f,;, 
-,j.. 


m  mf 


.(  !■ 


850 


DISKASES  OF  THE   NEIIVOI'S  SYSTE.M. 


And,  lastly,  in  weak,  dclicato  wonu'ii  tlii'i't-  is  ofU'ii  to  lu!  st'cii  u  Iran-iciii 
ptosis,  iiarticiilarly  in  tlu;  iiiorninf;. 

Anioiif,'  the  most  important  of  the  symptoms  of  the  tliii'd-ncrsc  |,ai:il- 
ysis  arc  those  wliiidi  relate  to  tlie  ciliary  muscle  and  iris. 

('l/r/(iji2ri/ia,  paralysis  of  tlie  ciliary  muscle,  causes  loss  of  tlie  |Hi\V(r 
of  accommodation.  Distant  vision  is  (dear,  hut  near  ohjects  caiiimt  lie 
properly  seen.  In  conse(|Uence  the  vision  is  indistinct,  hut  ciin  he  n- 
stored  hy  the  use  of  convex  j,dasses.  This  nuiy  occur  in  out'oi'  in  hoih  i\(.<; 
in  the  latter  case  it  is  usually  associated  with  disease  in  the  iniclci  df  the 
lu'rve.  Cyclople^da  is  an  early  and  frc(|uent  symptom  in  diphlli'rilic 
paralysis  and  occurs  also  in  tahes. 

Irii/(i/ih'f/ifi,  or  paralysis  of  the  iris,  occjirs  in  three  forms  (dowers). 

{(i)  ArrotintiiHldlii'r  iridajili'ijid,  in  which  the  pupil  docs  not  dimiiiisji 
in  .size  dnrinif  the  act  of  accommodation.  'I'o  tt'st  for  this  the  piiticiit 
Hliould  look  first  ut  a  distant  unil  then  at  a  near  ohject  in  the  same  liiienf 
vision. 

(/>)  lii'tli'x  Iridoph'tjin. — The  path  for  the  iris  reflex  is  ah)n<;  the  (i|itir 
nerve  and  tract  to  the  <ienicnlate  Ixtdies,  then  to  the  inicleus  of  the  ihinl 
nerve,  and  alon^f  the  trunk  of  this  nt'rve  to  the  ciliary  <ran^dion,  .iik;  «m 
through  the  ciliary  nerve.s  to  the  eyes.  Ka(di  eye  should  he  tested  .<(|ia- 
rately,  the  other  one  heing  covered.  'J'he  patient  should  look  at  a  disliini 
ohject  in  a  dark  part  of  the  room  ;  then  a  light  is  hronglit  suddenly  in 
front  of  the  eye  at  a  distance  of  threes  or  four  feet,  so  as  to  avoid  the  ellVrt 
of  accommodation.  Loss  of  this  iris  reflex  with  retention  of  the  aciom. 
modation  contraetion  is  known  as  the  Argyll- HoV)ertson  ])ni)il. 

(<•)  Loss  of  the  Skhi  Jt''flr.r. — If  the  skin  of  the  neck  is  pinched  or 
pricked  the  jiupil  dilates  reflexly,  the  afferent  impulses  heing  convcvnl 
Hh)ng  the  cervical  sympathetic.  Erh  ])ointed  out  that  this  skin  rcllcx  is 
k)st  usually  in  association  with  the  reflex  contraction,  hut  the  two  ;ii.'  imt 
neces.sarily  conjoined.  In  iridoplegia  the  pupils  are  often  small,  \y  itiiii- 
larly  in  sjjinal  disease,  as  in  the  characteristic  small  pu]iils  of  tahes — ,-|iiiial 
myosis.     Iridojilegia  may  coexist  with  a  ])upil  of  medium  size. 

Inequality  of  the  pupils — aniguauria — is  not  infrequent  in  ])r(igivssiv(' 
paresis  and  in  tahes.     It  may  also  occur  in  j)erfectly  healthy  individual. 

Spasm. — Occasionally  in  meningitis  and  in  hysteria  there  is  spasm  of 
the  nuuseles  sui)plied  hy  the  third  nerve,  particularly  the  internal  nctiis 
and  the  levator  })alpel)nv.  The  clonic  rhythmical  spasm  of  the  eye  iiiiiv 
des  is  known  as  ni/sfaffintts,  in  which  there  is  usually  ahilateral,  rli\iliiiii- 
eal,  involuntary  movement  of  the  eyehalls.  The  condition  is  met  with  in 
many  congenital  and  acquired  hrain  lesions,  in  albinism,  and  soiiiitiiias 
in  coal-miners. 

Fourth  Nerve. — This  su])plies  the  superior  oblique  muscle.  h\  h 
course  around  the  outer  surface  of  the  crus  and  in  its  passage  into  the 


^HMl 


DISHASKS  OF   TIIK  (IIAXIAI.   XKIIVKS. 


.S51 


iiird-iii'rvc  |i;ir;il- 

)SS    of    tile    \'<<\\vy 
Itjl'ctS    Cllllliiit    iir 

,  l»ut  can   lir  rt'- 
(•  (If  ill  lidlli  I'Vfs; 

tllC     mil'Icl    nf  till' 

I    in    ili|ililli"i'ilir 

rnis  (dowel). 
(Iocs  nut  iliniini-li 
•   this    the   |i;ilirlil 
n  tlif  same  line  nf 

is   alt»n<;    tlie  e|itir 

cleiis  (•!'  the  tliinl 
,'  fran^'li()i\,  and  sd 
lid  111"  tested  si'ini- 
l  look  at  a  (lisliiiit 
•ou}fht  siuldeiily  in 
to  avoitl  ttie  etlVri 
[ion  <»f  the  arcimi- 
piiliil. 

leelv  is  ])inetie(l  or 
s  beinj,'  coiivevt'il 
this  skin  rellex  is 
lit  the  two  ar,'  imt 
en  small,  p'  I'ti'-n- 
Is  of  tubes— .-^pii ml 
n  size. 

eiit  in  proiri'eHsivi' 
dtliy  iiulividiiak 

tliere  is  siia-m  of 
the  internal  intus 
[11  of  the  eye  niiiv 
l)ilateral,  riivilnni- 
tion  is  met  \vil!i  i" 
kn,  and  sonieiiin<-'^ 


muscle.      l!>  i'^ 
Its  passage  into  tli'" 


orliit  it  is  lial)le  to  he  eonipressed  hy  timiors,  hy  aiiiMirism  or  in  the  exii- 
ihiiinii  of  i)a>ilai'  meiiin;:itis.  Its  nucleus  in  the  upper  part  of  the  fonrth 
vciiirieje  niay  he  involved  hy  tumors  or  iinder^xo  deifcncratioii  with  the 
(iilicr  ocular  nuclei.  Tlio  superior  oiilicpie  muscle  acts  in  such  a  way  as 
til  dii'ect  the  eyehall  downward  and  rotates  it  sli<;litly.  The  paralysis 
ciiiises  defective  ilownward  and  inward  inovemeiit,  (d'teii  too  sli;,dit  to  he 
iiiitieed.  'I'he  head  is  imdined  somewhat  forward  and  toward  the  sound 
.-iile,  aiid  there  is  double  vision  when  the  patient  looks  down. 

Sixth  Nerve. — 'i'his  nervi*  enierires  at  the  junction  of  the  ])ons  and 
imdiilla,  then,  passiiii,'  forward,  it  enters  the  orbit  and  supplies  the  externa! 
rn  tns  muscle,  it  is  alfccte(l  by  meningitis  at  tlu*  base  or  by  «,'umimitii  or 
(idler  tumors,  and  sometimes  hy  c(dd.  'I'liere  is  internal  straliismiis,  and 
tliie\('  cannot  \)v  turned  taitward.  Dijdopia  occurs  on  lookin^r  toward 
the  |i;irulyzeil  side. 

'•When  the  nucleus  is  affected  there  is,  in  addition  to  jiaralysis  of  the 
t'Xlciiial  rectus,  inability  cd' the  internal  rei-tiisof  the  opposite  eye  to  turn  that 
I  ye  inwards.     As  ji  conse((uence  (»f  this  the  axes  of  the  eyes  ai'e  kept  parallel 
;iiiil  both  are  conju;,Mtely  deviated  to  tlie  opposite  side,  away  from  the  side 
iif  IcsioJi.     The  reason  of  this  is  that  the  nu(deiis  of  the  sixth  nerve  sends 
lilire>  up  in  the  pons  to  that  [lart  of  the  nucleus  of  tlu'  o])i»osite  third 
ihive  which  supplies  the  internal  rectus.      W'c  thus  have  paralysis  of  the 
iiitiTiial  rectus  without  the   mudeiis  of  the   third   nerve  beinjf  involved, 
"iviijH- to  its  reeeivin;,'  its  nervous  impulses  for  paralhl  mo\cnieiit  fi'om 
ilir  >ixth  nucleus  of  the   op])osite  side.     .\s  the  sixth  nii(deus  is  in  siudi     * 
|irn\iiiiity  to  the  facial  nerve  in  the  substunee^of  the  pons,  it  is  fre(|iiently  i 
fiMiiid  that  the  whole  (d'  the  face  u.u_the  same  side  is  ])aralyzed,  and  ^ives  \[ 
liu'  ek'ctrical  reaction  of  deireneration,  so  that  with  a  lesion  of  the  Itf/   ^ 
MXtli  mudeus  there  is  conjujfate  deviation  of  both  eyes  to  the  ri(.//i/ — i.  e., 
[iiiriilysis  of  tbe  feft  external  and  tlio^rii^ht  internal  rectus,  ajid  soinetimcs 
('iiiii|)k't.e  paralysis  of  tlio  h'ff  Md<i.iiJLUiiiiiico."     (Meevor.)  — >-—  . 

"Hjeneral  Features  of  Paralysis  of  the  Motor  Nerves  of  the  Eye.— rJowers 
liiviiles  them  into  five  i^roups  : 

((')  LimihdttDi  of  Morcinciit. — Thus,  in  paralysis  of  the  external  rec- 
tus, the  cyebidl  cannot  be  moved  outward.  ^Vhen  the  paralysis  is  iiicom- 
I'lttr  tiie  movement  is  deficient  in  proportion  to  the  de<,'ree  of  the  palsy. 

[b)  S/nffiismns. — The  axes  of  the  eyes  do  not  correspon>l.  Thus,  ))a- 
nilysis  of  the  internal  rectus  causes  a  diverjirent  s(piint ;  ot  the  external 
rwtiis,  a  convergent  squint.  At  first  this  is  only  evident  when  the  eyes  are 
iinivcd  in  the  direction  of  the  action  of  the  weak  muscle,  but  may  Ijccome 
"instant  by  the  contraction  of  the  opposing  muscde.  The  deviation  of  the 
wis  of  the  affected  eye  from  inirallelism  with  the  other  is  called  the  pri- 
iiiiiry  deviation. 

('■)  Secondary  Devinfinii. — If,  while  the  jiatient  is  looking  at  an  ob- 
ji'ft,  the  sound  eye  is  covered,  so  that  lie  fixes  the  o1)ject  looked  at  with 
lilt' ii fleeted  eye  only,  the  sound  eye  is  moved  still  further  in  the  same  di- 


I 


t   I' 


Hi 


M' 


852 


DISEASES  OP  THE  NERVOUS  SYSTEM, 


rt'ction — e.  g.,  outward — witli  panilysis  of  the  oj)i)osite  iute  nal  icct,;;,. 
This  is  known  us  secondary  deviation.  ]t  depends  upon  the  I'ad  iLat,  if 
two  musck'S  are  acting  togetlier,  when  one  is  weak  and  an  ell'ort  i>  made 
to  contract  it,  the  increased  effort — innervation — acts  ])owerfully  u|)(iii  iiu. 
other  muscle,  causing  an  increased  contraction. 

(r/)  EvruncoHH  Projection. — "  We  judge  of  the  relation  of  cMiinal 
objects  to  each  other  ])y  the  relation  of  their  inuiges  on  the  retina ;  hut 
we  judge  of  their  relation  to  our  own  body  by  the  position  of  the  cvclnill 
as  indicated  to  us  by  the  innervation  we  give  to  tiie  ocular  nuisclc-  ' 
((iowers).  With  the  eyes  at  rest  in  tlie  mid-position,  an  object  at  whiil! 
we  are  looking  is  directly  opjjosite  our  face.  'I'uriung  the  eyes  to  dUc 
side,  we  recognize  that  object  in  the  middle  of  the  lield  or  to  the  sidr  of 
this  former  ])osition.  We  estimate  the  degree  by  the  amount  of  niovu- 
ment  of  the  eyes,  and  when  the  object  moves  and  we  follow  it  we  jiidire 
of  its  position  by  the  amount  of  movement  of  the  eyeballs.  When  oiie 
o(!uIar  muscle  is  weak,  the  increased  innervation  gives  the  impressiiui  nf 
a  greater  movement  of  the  eye  than  has  really  taken  place.  The  niind,  at 
the  same  time,  receives  the  idea  that  the  object  is  further  on  one  .-<i(lo 
than  it  really  is,  and  in  an  attempt  to  touch  it  the  finger  may  go  bcvdiid 
it.  As  the  ecpiilibrium  of  the  body  is  in  a  largo  part  nuuntaiiicd  In  a 
knowledge  of  the  relation  of  external  objects  to  it  obtained  by  the  art  ion 
of  the  eye  nnistdes,  this  ernmeous  ])rojection  resulting  from  i)aralysis  dis- 
turbs the  harmony  of  these  visual  impressions  and  may  lead  to  giddiness 
— ocuhir  vertigo. 

{e)  Donbh  Virion. — This  is  one  of  the  most  disturbing  features  nf 
paralysis  of  the  eye  muscles.  The  visual  axes  do  not  corres])ond,  so  llmt 
there  is  a  double  image — diplopia.  That  seen  l)y  the  sound  eye  is  ttTiiied 
the  true  image  ;  that  by  the  paralyzed  eye,  the  false.  In  sim])le  or  honion- 
ymous  di])lopia  the  false  image  is  "  on  the  same  side  of  the  other  as  the  eve 
by  wliich  it  is  seen."  In  crossed  diplopia  it  is  on  the  other  side.  In  nin- 
vergent  squint  the  diiilopia  is  sim[)le;  in  divergent  it  is  crossed. 

Ophthalmopleg'ia. — I'nder  this  term  is  described  a  chronic  progrcs>i\(' 
paralysis  of  the  ocidar  muscles.  Two  forms  are  recognized — ophthiilino- 
plegia  o.rfcrnn  and  ophthalmoplegia  iiiterna.  The  conditions  may  oivur 
separately  or  together  and  are  described  by  Cowers  under  nuclear  ociihir 
palsy. 

Oj)I//IinhnnpJrr/ia  r.iicnin. — Tlio  condition  is  one  of  more  or  less  luin- 
plete  palsy  of  the  external  nuiscles  of  the  eyeball,  due  usually  to  a  flow 
degeneration  in  the  nuclei  of  the  nerves,  but  sometimes  to  pressure  nf 
tumors  or  to  basilar  meni'igitis.  It  is  often  but  not  necessarily  associated 
with  ophthalmoplegia  interna.  Sicnu'rling,  in  the  recent  nu)no!';'.\i[  'i  in 
which  lie  lias  analyzed  the  material  (eight  cases)  left  by  the  late  I'.nr. 
Westphal,  states  that  sixty-two  cases  are  on  record.  In  only  eleven  <if 
these  could  sy])Iiilis  lie  jxisitively  determined.  The  levator  muscdes  of  tlii' 
eyelids  and  the  superior  recti  are  tlrst  involved,  and  gradually  the  itliiT 


II: ! 


Mi, 


DISEASES  OP  THE  CRANIAL  NERVES. 


I  tho  fad  that,  if 
nil  effort  i>  iikuIl' 
vcrfuUy  upuu  the 

ition   of  cxirnial 
n  tho  retina  ;  Imt 
on  of  the  cvcliall 
ociihir  nius(l('>  ' 
1  object  at  wliicli 
;  the  eyes  to  nm 
or  to  the  siilf  of 
amount  of  iiuivc- 
illow  it  we  juiliTf 
■bails.     AViieii  inic 
tlie  impressiiui  uf 
ce.     The  mind,  at 
rther  on  oiu'  sidu 
er  may  go  bcvdiiil 
:  nuiintaiiied  by  a 
ined  by  tlie  action 
from  i)aralysi^  ilis- 
•  lead  to  giildiiiL'js 

irbing  features  (if 
orres])ond,  so  lluit 
und  eye  is  teriiird 
simple  or  lionion- 
le  other  as  the  v\v 
ler  side.  In  cini- 
crossed. 

hronic  pro,trre<>ivi' 
lized — ophthahiKi- 
ditions  may  orcnr 
(ler  nuclear  oiiilar 

more  or  less  o  un- 
usually to  a  .-low 
lies  to  ])ressnrt'  uf 
ccssarily  associatcil 
ent  mt)no»':rai  'i  in 
by  the  late  I'.of. 
In  only  eleven  uf 
itor  muscles  of  thi' 
nidually  the  >tlit't 


853 


muscles,  so  that  the  eyeballs  are  fixed  and  tho  eyelids  droop.  There  is 
jiiiiu'iimes  slight  protrusion  of  tho  eyeballs.  The  disease  is  essentially 
ihnmic  and  may  last  for  many  years.  It  is  found  particularly  in  association 
with  general  paralysis,  locomotor  ataxia,  and  in  })rogressivo  muscular 
;itr(i|iliv.  .Mental  disorders  were  ])resent  in  eleven  of  the  sixty-tvvo  cases. 
Willi  it  may  be  associated  atro{)hy  of  the  optic  nerve  and  affections  of 
(itlit  r  iranial  nerves.  Occasionally,  as  noted  by  liristowe,  it  may  bo  func- 
tiidial. 

0 l!h thai inophy ill  i)iterna. — Jonathan  Hutchinson  applied  this  term  to 

II  jirogressive  paralysis  of  the  internal  ocular  muscles,  causing  loss  of  j)upil- 
hirv  action  and  tho  power  of  accommodation.  When  the  internal  and 
ixterual  muscles  are  involved  tho  affection  is  known  as  total  ophthalmo- 
|il('gi;i,  and  in  a  majority  of  the  cases  tho  two  conditions  are  associated. 

III  sDiiie  instances  the  internal  form  may  depend  upon  disease  of  the 
liliary  ganglion. 

While,  as  a  rule,  ophthalmoplegia  is  a  chronic  process,  there  is  an  acute 
form  associated  with  Inx'morrhagic  softening  of  the  nuclei  of  the  ocular 
iimsclcs.  There  is  usually  nmrked  ecebral  disturbance.  It  was  to  this 
fiii'iii  that  Wernicke  gave  the  name  polio-encephalitis  superior. 

Treatment  of  Ocular  Palsies. — It  is  important  to  ascertain,  if 
|iiissihle,  the  cause.  The  forms  swsociate'l  with  locomotor  ataxia  are 
(ilistinato,  and  resist  treatment.  Occasionally,  however,  a  palsy,  com|)lete 
or  partial,  may  jjass  away  spontaneously.  The  grou[)  of  cases  associated 
with  chronic  degenerative  changes,  as  in  progressive  i)aresis  and  bulbar 
|iiiralysis,  is  little  affected  by  treatment.  On  the  other  hand,  in  syphilitic 
rasis,  mercury  and  iodide  of  potassium  are  indicated  and  are  often  bene- 
tiiial.  Arsenic  and  strychnia,  the  latter  hypodermically,  may  be  employed. 
Ill  iiiiy  case  in  which  the  onset  is  acute,  with  ])ain,  hot  fomentations  iind 
(iiuiitcr-irritation  or  leeches  applied  to  the  temple  give  relief.  The  direct 
tr  utiiiciit  by  electricity  has  been  extensively  employed,  but  probably  with- 
iiiitany  special  effect.  The  di[)lopia  may  be  relieved  by  the  use  of  prisms, 
or  it  may  be  necessary  to  cover  the  affecteil  eye  with  an  o})a(pie  glass. 

Fifth  Xerve. 

Piinili/sis  may  result  from:  (n)  Disease  of  the  pons,  ))articularly  hivm- 
orrhage  or  patches  of  sclerosis.  (//)  Injury  or  disi'ase  at  the  base  of  tiie 
briMi,  Fractitro  rarely  involves  the  nerve;  on  the  other  hand,  menin- 
gitis, acute  or  chronic,  and  caries  of  tho  bone  arc  not  uncommon  causes. 
(')  The  branches  may  be  affected  as  they  2)ass  out — the  first  division  by 
liiiiiiiis  pressing  on  the  cavernous  siiuis  or  by  aneurism ;  the  second  and 
tliinl  divisions  by  growtii.s  which  invade  the  spheno-niaxillary  fossa, 
('/)  I'riniary  neuritis,  which  is  rare. 

Symptoms. — (a)  Scn^ori/  Portion. — Paralysis  of  tho  fifth  nerve 
•"iiisos  luss  of  sensation  in  the  i)arts  supplied,  iiududiiig  the  half  of  tlie 


-I  r  1 

:  '    I 


i 

^  •'    ''■ 

i  . 
t 

maM  \ 

mPmI! 

iU 


.1  ! 


854 


DISEASES  OP  THE   NERVOUS  SYSTEM. 


face,  tho  corresponding  side  of  tlio  head,  the  conjunctiva,  the  niiKd^imf 
the  lips,  tongue,  hard  and  soft  pahite,  and  of  tlie  nose  of  tho  saiuc  siilc. 
The  anaesthesia  may  be  preceded  by  tingling  or  pain.  The  muscles  (if  the 
face  are  also  insensible  and  the  movements  may  be  slower.  The  s(>iise  (if 
smell  is  interfered  with.  There  is  disturbance  of  the  sense  of  t^n-tc. 
Tiiere  are,  in  addition,  trophic  changes;  the  salivary,  lachrymal,  aiul  biic. 
cal  secretions  may  be  lessened,  abrasions  of  the  mucous  membraiK  s  IkuI 
slowly,  and  the  teetli  may  become  loose.  The  eye  inflames,  tlie  cunica' 
become  cloudy  and  may  ulcerate.  It  was  formerly  held  that  these  sviiip. 
toms  only  occurred  when  the  Gasserian  ganglion  was  affected,  but  ol'  late 
years  this  has  been  completely  removed  for  obstinate  neuralgia  withoiu  jnn- 
ducing  any  trophic  disturbance.  Herpes  may  develoj)  in  the  region  snpiiliiM] 
by  the  nerve,  usually  the  upjjcr  branch,  and  is  associated  with  much  pain, 
which  may  be  peculiarly  enduring,  lasting  for  months  or  years  ((ioweis). 

{b)  Motor  Portion. — 'I'he  inability  to  use  the  muscles  of  iiiastiia- 
tion  on  the  atYected  side  is  the  distinguishing  feature  of  paralysis  (if  this 
])ortion  of  the  nerve.  It  is  recognized  by  ])lacing  the  linger  on  the  iiias- 
seter  and  temporal  muscles,  and,  when  the  patient  closes  the  jau-,  thu 
feebleness  of  their  contraction  is  noted.  If  paralyzed,  tho  external  jiterv- 
goid  cannot  move  the  jaw  toward  the  uiuitfected  side  ;  and  when  depresscil, 
the  jaw  deviates  to  the  ])aralyze(l  side.  The  motor  paralysis  of  the  tiflh 
nerve  is  almost  invarialdy  a  result  of  involvement  of  the  nerve  after  it  has 
left  the  nucleus.  Cases,  however,  have  been  associated  with  (•((vticul 
lesions,  ilirt  concludes,  from  his  case,  that  the  motor  centre  f(ir  the 
trigeminus  is  in  the  neighborhood  of  tlie  lower  third  of  the  aseeiidiiiir 
frontal  convolution. 

Spaion  of  tho  Miniclca  of  }fatitirntion. — Trismus,  the  masticatorv  spasm 
of  Romberg,  may  be  tonic  or  clonic,  and  is  either  an  associated  pheinniie- 
non  in  general  convulsions  or,  more  rarely,  an  independent  atfectioii.  In 
the  tonic  form  the  jaws  are  kept  close  together — lock-jaw — or  can  liv 
separated  only  for  a  short  space.  The  muscles  of  mastication  can  he  scvn 
in  contraction  and  felt  to  be  hard  and  the  spasm  is  often  ])ainful.  This 
tonic  contraction  is  an  early  symiitom  in  tetanus,  and  is  sometimes  -irn  in 
tetany.  A  form  of  this  tonic  spasm  occurs  in  hysteria.  Occasioiiallv  tris- 
mus follows  exposure  to  cold,  and  is  said  to  be  due  to  reflex  irritatidii  I'nm] 
the  teeth,  the  mouth,  or  caries  of  the  jaw.  It  may  also  be  a  syinptnin  nf 
organic  disease  due  to  irritation  near  the  motor  nucleus  of  the  fifth  lu'ive. 

67o;«V;  spasm  of  the  muscles  siip])lied  by  the  fifth  occurs  in  the  Uwm  ef 
rapidly  repeated  contractions,  as  in  "  chattering  teetli."  'I'liis  is  rare  apart 
from  general  conditions,  though  cases  are  on  record,  usually  in  woiiie.i  late 
in  life,  in  whom  this  isolated  clonic  s[)asm  of  the  muscles  of  the  j  iw  has 
been  found.  In  anotlier  form  of  clonic  spasm  sometimes  seen  in  i  hnica. 
there  arc  forcible  single  contractions.  (Jowers  mentions  an  instance  of  lis 
occurrence  as  an  isolated  alfection. 

(r)  (runtafori/. —  Ijoss  of  the  sense  of  taste  in  the  anterior  two  tiiiidsnt 


DISEASES  OP  THE  CUANIAL  NEHVES. 


855 


rior  two  tliiiii^' 


tlu>  tongue,  as  a  rule,  follows  ])anily.sis  of  the  tiftli  nerve.  'I'lio  trustutory 
libns  pass  from  the  chorda  tyjiijmni  to  the  lingual  bnincli  of  the  fil'tli. 
ni-iaso  of  the  fifth  nerve  is,  however,  not  always  associated  with  loss  of 
tiistc  in  tlie  anterior  jtart  of  the  tongue,  in  which  case  eitiu'r  the  taste 
tihivs  escape,  or  the  disease  is  within  the  jjons  whcK-  these  lihres  are 
lii'pnrate  from  those  of  sensation. 

'i'he  dinrjnosis  of  disease  of  the  trifacial  nerve  is  rarely  dithcult.  It 
iiiiist  be  remembered  tliat  the  preliminary  jiain  aiul  liypera'sthesia  are 
siiiiiitinies  mistaken  for  neuralgia.  The  loss  of  sensation  and  the  palsy  of 
the  iiniscles  of  mastication  are  readily  determimul. 

Treatment. — Wlien  tlie  jiain  is  severe  morj)hia  may  be  required  and 
liH'iil  applications  are  useful.  If  there  is  a  suspicion  of  syphilis,  appropri- 
ate treatnuMit  should  be  given.     Faradization  is  sometimes  beneficial. 

Facial  "N'ervk. 

Paralysis  {Bcirs  Falsi/). — 'J'he  facial  or  seventh  may  be  paralyzed  by 
(1)  lesions  of  the  cortex — supranuclear  palsy;  {'i)  lesions  of  the  nucleus 
itjiclf ;  or  (;))  involvement  of  the  iterve  trunk  in  its  tortuous  course  within 
the  pons  and  through  the  wall  of  the  skull. 

I.  Siipnoiuclcnr  J^imli/six,  duo  to  lesion  of  the  cortex  or  of  the  facial 
fibres  in  the  corona  radiata  or  internal  capsule,  is,  as  a  rule,  associated 
with  hemiplegia.  It  nniy  be  caused  by  tumors,  abscess,  chronic  iidlamma- 
tion,or  softening  in  the  region  of  the  internal  caiisule.  It  is  distinguished 
from  the  peripheral  form  by  two  well-marked  characters — the  persistence 
of  the  normal  electrical  excitability  of  both  nerves  and  muscles  and  the 
absence  of  involvement  of  the  uj)per  branches  of  the  nerve,  so  that  the  or- 
bicularis palpebrarum  aiul  frontalis  muscle  are  spared.  In  rare  instances 
ihoH'  muscles  are  paralyzed.  A  third  dilU'reiice  is  that  in  this  form  the 
viilmitary  movements  are  more  impaired  than  the  emotional.  There  are 
instimces  of  cortical  facial  paralysis — monoplegiii  facialis — associated  with 
k'siiius  in  the  centre  for  the  face  muscles  in  the  lower  Kolandic  region. 
Isiiiiited  paralysis,  duo  to  involvement  of  the  nerve  fibres  in  their  ])ath  to 
the  nucleus,  is  uncommon.  In  the  great  majority  of  cases  supraniu'lcar 
fa(i;il  paralysis  is  part  of  a  hemiplegia.  Paralysis  is  on  the  same  side  as 
thiit  I  if  the  arm  and  leg  because  the  facial  muscles  bear  precisely  the  same 
relaiidii  to  the  cortex  as  the  spinal  muscles.  The  nuclei  of  origin  on 
fithcr  side  of  the  middle  line  in  the  medidla  are  united  by  decussating 
fibres  with  the  cortical  centre  on  the  oi)posite  side  (see  Fig.  9). 

II.  The  nurUar  jmrnhjKis  caused  by  lesions  of  the  nerve  centre  in  the 
nieihiUa  is  not  common  alone;  but  is  seen  occasionally  in  tumors,  chronic 
siiftiiiing,  and  luvmorrhage.  In  rare  instances  of  anterior  polio-myelitis 
the  facial  nucleus  is  alfected.  In  diphtheria  this  centre  may  also  be 
iiiv(.l\ed.  The  symptoms  are  practically  similar  to  those  of  an  alTectiou 
I'f  the  nerve  fibre  itself — infranuclear  paralysis. 


¥ 


t| 


'1i  >: 


K 


i 

11 


856 


DISEASKS  OF  TIIH   NKRVOUS  SYSTEM. 


liili^ 


' '  fl 

w 

III.  Involvement  of  the  Xcrve  Trunk. — ranilysis  may  result  froti)  : 

{(()  Involvement  of  the  nerve  as  it  passes  tlirouyli  tlie  pons — ihati?! 
between  its  nucleus  in  the  iloor  of  the  fourth  ventricle  and  the  jH.int  of 
enier<,fence  in  the  postero-lateral  aspect  of  tiie  jtons.  'i'he  sj)eeially  iiitcr- 
cstinjx  feature  in  connection  with  involvement  of  this  jtart  is  the  prudii  ■ii(jii 
of  what  is  called  alternating  or  cross pnrah/sis,  the  face  being  inv()lv((l  du 
the  same  side  as  the  lesion,  and  the  arm  and  leg  on  the  op])osite  side,  siiuio 
the  motor  path  is  involved  above  the  point  of  <lecussation  in  the  nuihillu 
(Fig.  9).  This  occurs  only  when  the  lesion  is  in  the  lower  section  of  the 
pons.  A  lesion  in  the  upper  division  involves  the  fibres  not  of  the  (uit- 
going  nerve  on  the  same  side,  but  of  the  fibres  from  tliehemisj)her(s  licfdii' 
they  have  crossed  to  the  nucleus  of  the  opposite  side.  In  tliis  case  then' 
would  of  course  be,  as  in  hemi])legia,  paralysis  of  the  face  and  lind)s  on  the 
side  opjiosite  to  the  lesion.  The  palsy,  too,  would  resemble  the  ecrebral 
form,  involving  only  the  lower  fibres  of  the  facial  nerve. 

{//)  The  nerve  may  be  involved  at  its  point  of  emergence  by  tumors, 
gummata,  meningitis,  or  occasionally  may  be  injured  in  fracture  of  the 
base. 

(c)  In  passing  through  the  Fallopian  canal  the  nerve  may  be  involved 
in  disease  of  the  ear,  particularly  by  caries  of  the  bone  in  otitis  media, 
This  is  a  common  cause  in  children. 

{(I)  As  the  nerve  emerges  from  the  styloid  foramen  it  is  exposed  to 
injuries  and  blows  which  not  infrequently  cause  paralysis.  The  lihres 
may  be  cut  in  the  removal  of  tumors  in  this  region,  or  the  paralysis  may 
be  caused  by  pressure  of  the  forcei)s  in  an  instrumental  delivery. 

{(')  Exposure  to  cold  is  the  most  common  cause  of  facial  paralysi>-, 
inducing  a  neuritis  of  the  nerve  within  the  Fallopian  canal. 

(/)  i^yphilis  is  not  an  infivqucnt  cause,  and  the  paralysis  may  develop 
early  with  the  secondary  symptoms. 

Facial  ttipleff id  \s  ii  rare  coiulition  occasionally  found  in  affections  at 
the  base  of  the  brain,  lesions  in  tiie  pons,  sinudtaneous  involvement  of  the 
nerves  in  ear  disease  and  in  dijditheritic  paralysis.  Disease  of  tiie  luielei 
or  symmetrical  in'  olvement  of  the  cortex  might  also  produce  it. 

Symptoms. — In  the  peripheral  facial  i)aralysis  all  tiie  brantdu':^  of 
the  nerve  are  involved.  The  face  on  the  affected  si(k'  is  immobile  anil  can 
neither  be  moved  at  will  nor  ])artici[)ate  in  any  emotional  movements. 
The  skin  is  smooth,  and  the  wrinkles  are  effaced,  a  imint  particiihiiiy 
noticeable  on  the  forehead  of  elderly  persons.  The  eye  cannot  he  <  hwih 
the  lower  lid  droops,  and  the  eyewaters.  On  the  affected  side  the  iiiiL'le 
of  the  mouth  is  lowered,  and  in  drinking  the  lips  uw  not  kept  in  rlose 
ap])()sition  to  the  glass,  so  that  the  licpiid  is  a[)t  to  run  out.  In  sinilinir  or 
laughing  the  contrast  is  most  striking,  as  the  affected  side  does  not  innvc, 
which  gives  a  curious  unequal  appearance  to  the  two  sides  of  the  Iiki'. 
Tlie  eye  cainiot  be  closed  and  the  forehead  cannot  be  wrinkleil.  On  n-kiii;' 
a  patient  to  show  his  u})i)er  teeth,  the  angle  of  the  mouth  is  not  raised.    In 


iii 


I    :>:: 


result  fi'otn : 
i  pons— that  is, 
lid  tin-  i^iiiit  of 

specially  intcr- 
s  the  pi'udiiriiou 
'in*,'  involved  on 
)o.sit(;  side,  i^iiice 

in  the  nudiilla 
er  seelion  of  tliu 

not  of  tiic  <ait- 
tnisphercs  licfore 
1  this  ease  there 
md  linihs  on  tlio 
ble  the  cfrcbnil 

;once  hy  tuniors, 
fraetiire  of  the 

may  be  iiivcjlvod 
ill  otitis  media. 

it  is  exposed  to 
,sis.      The  iihi'es 
he  pai'alysis  iiiiiy 
divery. 

facial  paralysis, 
d. 
ysis  may  develop 

1  in  afTeetions  at 
t'olvi'inent  of  tlie 
ISC  of  tlie  nuclei 
luce  it. 
thi'  hrancdies  of 


DISEASES  OF  THE  CRANIAL  NERVES. 


'>o^ 


all  these  movements  the  face  is  drawn  to  the  sound  side  hy  the  action  of 
the  muscles.  Si)eakin,<f  may  be  sli<,ditly  interfered  with,  owing  to  the  ini- 
iicrfectioii  in  the  formation  of  the  labial  sounds.  Whistling  cannot  be 
jiurformed.  In  chewing  the  food,  owing  to  the  paralysis  of  the  buccinator, 
iiartielea  collect  on  the  atfected  si(h'.  The  jiaralysis  of  the  nasal  niuscdes 
is  seen  on  asking  the  patient  to  snitf.  Owing  to  tlie  fact  tiiat  the  lips  are 
(hawu  to  the  sound  side,  tlie  tongue,  when  })rotruded,  looks  as  if  it  were 
pushed  to  the  jiaraiyzed  side;  but  on  taking  its  jiosition  from  the  incisor 
Urtli,  it  will  be  found  to  be  in  the  middle  line.  T'lie  rellex  movements 
are  h'st  in  this  peripheral  form.  It  is  usually  stated  that  the  palate  is 
paralvzed  on  the  same  side  and  that  the  uvula  deviates.  Hotli  (iowers 
and  lliighlings  .lackson  d.'ny  the  existence  of  this  involvement  in  the 
iireat  majority  of  cases,  and  llorsley  and  Beevor  have  shown  that  these 
parts  are  innervated  by  tlu;  accessory  nerve  to  the  vagus. 

When    the  nerve  is  involved  within  the  canal  between  the  genu  and 
the  origin  of  the  chorda  tympani,  the  sense  of  taste  may  be  lost  in  the  : 
anterior  part  of  the  tongue  on  the  affected  side.      AVhen  the  iierve   is 
damaged  outside  the  skull  the  sense  of  taste  is  unaffected.     Hearing  is  i 
(iftei.  impaired  in  facial  paraly-sis,  most  commonly  by  preceding  car  dis- j 
ease.     The  paralysis  of  the  stapedius  muscle  may  lead  to  increased  sen-  | 
sitiveness  to  musical  notes.     neri)es  is  sometimes  associated  with  fii'  ial  ' 
paralysis.    Pain  is  not  common,  but  there  may  be  neuralgia  about  the  ear. 
The  face  on  the  affected  side  may  be  swollen. 

The  elcetricdl  reactions,  which  are  those  of  a  ])eriphei-al  ])alsy,  havo 
considerable  iuqiortance  from  a  2>rognostic  standpoint.  Krb's  rules  are  as 
fiillows :  If  there  is  no  change,  either  faradie  or  galvanic,  the  prognosis 
is  good  and  recovery  takes  place  in  from  fourteen  to  twenty  days.  If  the 
farad ii^  and  galvanic  excitabilitv  of  the  nerve  is  onlv  lessened  and  that  of 
the  mu.scle  increased  to  the  galvanic;  current  and  the  contraction  foi'mula 
altercil  (the  contraction  sluggish  An('>C'("),  the  outlook  is  relatively 
j:oi)d  and  recovery  will  jirobably  take  jdace  in  from  four  to  six  weeks  ;  oc- 
easionally  in  from  eight  to  ten.  AVheii  the  reaction  of  degeneration  is 
present — that  is,  if  the  faradie  and  galvanic  excitability  of  the  nerves  and 
tile  faradie  excitability  of  the  muscdes  are  lost  and  the  galvanic  ex(dta- 
liility  of  the  mu.scde  is  (piantitatively  increased  and  qualitatively  changed, 
and  if  the  mechanical  ex(dtability  is  altered — the  prognosis  is  relatively 
unfavorable  and  the  recovery  may  not  occur  for  two,  .six,  eight,  or  even  lif- 
teeu  months. 

The  course  of  facial  paralysis  is  usually  favorable.  The  onset  in  tho 
f'lrm  following  cold  is  very  rajiid,  developing  perhaps  within  twenty-four 
liours,  ])ut  rarely  is  the  ])aralysis  permanent.  On  the  other  hand,  in  tho 
paralysis  from  injury,  as  by  a  blow  on  the  mastoid  jirocess,  the  paralysis 
may  remain.  When  })ermanent  the  musides  are  entirely  toncdess.  In  some 
instances  contracture  develops  as  the  voluntary  power  returns,  and  the  natu- 
ral folds  and  the  wrinkles  on  the  affected  side  may  be  deepened,  so  that  on 


,u    ? 


ri-r 


^4.  >  ',   , 

III    ,    I,     i      • 


ii  'i 


1  n  <  r! 
1     (■  ■ 


'  ■; 


858 


DISEASES  OP  THE  XKRVOrS  SYSTEM. 


i§^>. 


Hooking  at  the  fiice  one  at  first  may  liave  tlio  imj)R>s.sion  that  tlio  anVc  t((l 
side  is  the  soinul  one.  'I'liis  is  corrected  at  once  on  asking  the  patiint  tu 
smile,  when  it  is  seen  which  side  of  the  face  has  tlie  most  acli\t'  hkivc 
nieiit, 

Tlio  dinf/iiosis  of  facial  paralysis  is  usually  easy.  The  distiuciinn  1)^.. 
tween  perii)heral  and  central  is  hased  on  facts  already  mentioned. 

Treatment. — In  the  cases  which  result  from  cold  and  are  judliahlv 
due  to  neuritis  within  the  hony  caiud,  hot  appHcations  first  sliuuld  l,,. 
made;  subsequently  tiie  thcrmo-cautery  may  lie  used  lightly  at  inicrvuis 
of  a  day  or  two  over  the  mastoid  jirocess,  or  snudl  blisters  npplicd. 
If  the  ear  is  diseased,  free  discharge  for  the  secretion  should  lie  oli- 
tained.  The  continuous  current  may  be  employed  to  kei'[)  up  the  mi- 
trition  of  the  muscles.  The  })ositive  jiole  should  be  placed  beliiii(!  the 
ear,  the  negative  one  along  the  zygomatic  aiul  other  muscles.  'I'Ih'  a|p- 
plication  can  be  made  daily  for  a  quarter  of  an  hour  and  the  patient  caii 
readily  l)e  taught  to  make  it  himself  before  the  looking-glass,  ^lassauc  of 
the  muscles  of  the  face  is  also  useful. 

A  course  of  iodide  of  ])otassiuni  may  be  given  even  wlien  there  is  iio 
imlicatioii  of  syphilis. 

Spasm. — The  spasm  may  be  limited  to  a  few  or  involve  all  the  niiisrlcs 
innervated  by  the  facial  nerve  and  may  be  unilateral  or  bilateral. 

It  is  known  also  by  the  name  of  mimic  spasm  or  of  couvulsivc  tii'. 
Several  diiferent  ajfectious  are  usually  considered  under  the  name  of  facia' 
or  mimic  si)asm,  but  we  shall  here  speak  only  of  the  simj)le  spasm  of  the 
facial  muscles,  either  ])rimary  or  following  paralysis,  and  shall  ii<it  iii- 
eludo  the  cases  of  habit  spasm  in  children,  or  tiio  tic  concuhif  of  the 
French. 

Ciowers  recognizes  two  classes — one  in  which  there  is  an  oi-ganii'  lr>inii. 
and  an  idiopathic  form.  It  is  thought  to  be  due  also  to  refiex  causes,  suck 
as  the  irritation  from  carious  teeth  or  the  preseiu^e  of  intestinal  worms. 
The  disease  usually  occurs  in  adults,  whereas  the  habit  spasm  and  the  //'•: 
cnxnilsif  {)i  the  French,  often  confounded  Avith  it,  are  most  coiiuiKiii  in 
children.  True  mimi(!  spasm  occasionally  comes  on  in  childhooil  ami  |icr 
sists.  In  the  case  of  a  school-mate,  the  atfection  Avas  marked  as  earl\  as 
the  eleventh  or  twelfth  year  and  still  continues.  When  the  result  <ifm" 
ganic  disease  there  has  usually  been  a  lesion  of  the  centre  in  the  corlex.  a.i 
in  the  case  reported  by  Berkeley,  or  pressure  on  the  nerve  at  the  base  ef 
the  brain  by  aneurism  or  tunu)r. 

Symptoms. — The  spasm  may  involve  oidy  the  muscles  arotinil  ilio 
eye — blepharospasm — in  which*  case  there  is  constant,  rapid,  quick  actiim 
of  the  orbicularis  palpebrarum,  -which,  in  association  with  photoplmliiM. 
may  be  tonic  in  character.  ^lore  commonly  the  spasm  affects  the  latenii 
facial  muscles  with  those  of  the  eye  and  there  is  constant  twitchinu'  if  tlin 
side  of  the  face  with  partial  closure  of  the  eye.     The  frontalis  is  ruivly  iti' 


I  that  tlio  iiiiV(t!(l 

Ig    tlu'    ]IUtirlit    tn 

lost  iicti\c  iiiiiV(.'- 

10  (lisfiiictiiMi  lif- 
.■ntioiu'il. 
and  arc  judliaMv 
IS  first  slidiihl  Ik. 
Iflitly  at  iiitcrviiis 
blisters  ;i|i|)lic(|. 
m  sliould  lie  iili- 
kc'C'p  up  till'  iiu- 
)la('0(l  iR'Iiiiiil  the 
imsclt'S,  The  ii|)- 
1(1  tlie  }iatit'Mt  Clin 
'lass.     ^rassaj:'c  of 

1  wliou  tlicrc  is  1111 


vc  all  the  iiiu.>ili'> 
bilateral, 
of  couvulsivc  tie. 
the  name  of  faciit' 
iiple  spasm  of  tin 
iiiitl  shall  lint  iii- 
concuhif  (if  tliu 

in  organic  Ir^inu. 
rellex  causes,  siirli 
intestinal  wni'ins. 
pasiu  and  the  //■: 
most  coiiinioii  in 

ildhood  ami  per 
arked  as  eai'l)  as 
1  the  result  cf  cr 
e  in  the  cortex,  as 

ve  at  the  hiise  ef 

iscles  arouiul  tlii3 
ipid,  cpiick  ai'tiim 
k'ith  photu|ihiiliiii. 
affects  the  liiterin 
;  twitehiii.ir  if  tlin 
iitalis  is  raivlv  iii' 


DLSKA.SES  OF   TlIK  CllAXlAIi   NERVES. 

volwd.  In  a<;f!;ravatcd  eases  the  depressors  of  the  angle  of  tlie  mouth,  tlio 
Irvatnr  menti,  and  tiie  platysma  myoides  are  alTected.  'J'iiis  spasm  is  eon- 
liiieil  to  one  side  of  the  face  in  a  majority  of  cases,  tiiough  it  may  extend 
mill  hccome  bilateral.  It  is  increasetl  by  emotional  causes  and  involunta'y 
iiiiiveiiieiits  of  the  face.  As  a  rule,  it  is  })aiiiless,  but  tiiere  may  be  tender 
piiiiiis  on  tlie  course  of  the  liftli  nerve,  iiarticiilarly  the  supraorbital 
Imiiiili.  Tonic  spasm  of  tiie  facial  muscle  may  follow  ])aralysis,  and  is 
siiid  to  result  occasionally  from  cold. 

The  outlook  in  facial  spasm  is  always  (lul)ious.  A  majority  of  tho 
rases  persist  for  years  and  are  incurable. 

Treatment. — Sources  of  irritation  should  be  looked  for  .jid  re- 
iiioveii.  When  a  painful  s])ot  is  present  over  the  fifth  nerve,  blistering 
or  the  application  of  the  thermo-eautery  may  relieve  it.  llypotleriiiio 
iiijoetions  of  strychnia  may  be  tried,  but  are  of  doubtful  benetit.  Weir 
Mitchell  recommends  tho  freezing  of  the  cheek  for  a  few  minutes  daily 
or  every  second  day  with  the  spray,  and  this,  in  some  instances,  is  bene- 
tirial.  Often  the  relief  is  transient;  the  cases  return,  and  at  every 
clinic  may  be  seen  half  a  dozen  or  more  of  such  })atients  who  have  run 
till'  gamut  of  all  measures  without  material  improvement.  Operative 
iiiteiferenee  may  be  resorted  to  in  sevei'o  cases,  although  not  much  can 
be  expected  of  it. 

AuDiTOuv  Nervk. 

The  eighth,  known  also  as  portio  mollis  of  the  seventh  pair,  enters  the 
internal  auditory  meatus,  and  divides  into  the  cochlear  and  vestibular 
liiaiiehes.  The  cortical  centre  for  hearing  is  in  the  temporo-sphenoidal 
liilie.  Primary  disease  of  the  auditory  nerve  in  its  centre  or  intracranial 
nmrsc  is  uncommon.  More  frequently  the  tei'ininal  branches  are  alfected 
within  the  labyrinth. 

{(i)  Affection  of  the  Cortical  Centre. — In  the  monkey,  experiments 
inilieate  that  the  first  temporal  gyri  re])resent  the  centre  for  hearing.  In 
man  the  cases  of  disease  indicate  that  it  has  the  same  .situation,  as  de- 
struetion  of  this  gyrus  on  the  left  side  results  in  word-deafness,  which 
may  he  defined  as  an  inability  to  understand  the  meaning  of  words,  though 
they  may  still  be  heard  as  sounds.  The  central  fibres  of  the  auditory  nerve 
between  the  cortical  centre  and  the  nuclens  in  the  fourth  ventricle  may  be 
iiiviilvcd  and  produce  deafness.  This  has  resulted  from  the  jiresence  of  a 
tuniiir  in  the  corpora  quadrigemina,  and  maybe  associated  with  a  lesion  of 
the  internal  capsule. 

(//)  Le.^ions  of  the  nerve  at  t/ie  base  of  the  brain  may  result  from  the 
pressure  of  tumors,  meningitis  (particularly  the  cerebro-spinal  form),  luem- 
oriliage,  or  traumatism.  A  primary  degeneration  of  the  nerve  may  occur 
in  liieomotor  ataxia.  Xuclear  disease  is  rare.  By  far  the  most  interest- 
ing form  results  from  epidemic  cerobro-spiuul  meningitis,  iu  which  the 


It" 


T 

t'r'T 

'  ilr^H 

i 

i 

lil 

f! 

1 

SdO 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


lUMTO   is   froquontly  involvoil,  ciiusint^    jH'riimiu'nt   dfiifiicss.      In    Vdiinr 
chiklroii  the  ('oiiditioii  rosults  iti  (U'iir-mutism. 

(r)  In  ii  luiijdrity  of  the  cases  associati'd  witli  auditorv-norvc  sviii|itniiis 
tlic!  lesion  is  in  tiie  Iti/ii/rin/fi,  either  in-iniary  or  tlie  resnlt  of  I'XtciHidii  (,f 
disease  of  the  middle  ear.  Three  <jrouits  of  symptoms  may  bo  proihiicd— 
hy|)era'sthesia  and  irritation,  diminislied  funetion  or  nervous  deafm  >-.  ami 


verti^'o. 


(1)  Ifi//)rr<i'sf/ir.<<i(i  laid  Irritatian. — Tliis  may  he  due  to  altered  I'mic 
tiou  of  tlie  centre  as  well  as  of  tiie  lU'rve  ending.  True  hypera'sthcsiu— 
hyperacusis — is  a  condition  in  Avliicli  sounds,  sometimes  oven  those  iniiinli- 
ble  to  other  })ersons,  aro  hoard  witli  great  intensity.  It  occurs  in  li\.-t(ii;i 
and  occasionally  in  cerebral  disease.  As  already  mentioned,  in  jiiiralvsis 
of  tho  stapedius  low  notes  may  ho  heard  with  intensity.  In  dysa'sllicsi;!. 
or  dysacusis,  ordinary  sounds  cause  an  unpleasant  sensation,  as  coiiiiikhiIv 
hapix'us  in  connection  with  headache,  when  ordinary  noises  are  Imdlv 
boriu'. 

Tiiiiiihtii  aiiriiiin  is  a  term  employed  to  designate  certain  siilijcdiv,* 
sensations  of  ringing,  roaring,  ticking,  and  whirring  noises  in  the  ear.  It  is 
a  very  common  and  often  a  distressing  sym})tom.  It  is  a.ssociated  with  iiiaiiv 
forms  of  oar  disease  and  may  result  from  pressure  of  wax  on  the  dniiii.  li 
is  rare  in  organic  disease  of  the  central  connections  of  the  nerve.  Siiddi  n 
intense  stimulation  of  the  nerve  may  cause  it.  A  form  not  uncoiniiKnilv 
met  with  in  medical  ])ractice  is  that  in  which  the  patient  hears  a  continual 
hntit  in  the  ear,  and  the  noise  has  a  systoli(!  intensification,  usually  mi 
QUO  side.  I  have  twice  been  consulted  by  physicians  for  this  conditioii 
under  the  belief  that  they  had  au  internal  aneurism.  It  occurs  in  cniidi- 
tions  of  ana'mia  and  neurasthenia.  ^Subjective  uoises  in  the  ear  may  \\w- 
cede  an  epileptic  seizure  and  are  sometimes  present  in  migraine.  In 
whatever  form  tinnitus  exists,  though  slight  and  often  regarded  as  trivial. 
it  occasions  great  annoyance  and  often  mental  distress,  and  has  even  driven 
patients  to  suicide. 

The  liidr/iiosis  is  readily  made;  but  it  is  often  extremely  dillicult  in  de- 
termine u])on  Avhat  condition  the  tinnitus  depends.  The  relief  (d'  enn- 
stitutional  states,  such  as  auiiimia,  neurasthenia,  or  gout,  nuiy  re>idt 
in  cure.  A  cari'ful  local  examination  of  the  ear  should  always  be  nuide. 
One  of  the  most  worrying  forms  is  the  constant  clicking,  sometimes  audi- 
ble many  feet  away  from  tho  patient,  and  due  probably  to  clonic  spasin 
of  the  muscles  connected  with  the  Eustachian  tube  or  of  the  levator  pahiti. 
The  condition  may  persist  for  years  unchanged,  and  then  disajipear  sml- 
denly.  The  pul.sating  forms  of  tinnitus,  in  which  the  sound  is  like  tli:it 
of  a  systolic  bruit,  are  almost  invariably  subjective,  ami  iu)thing  is  aiidiMe 
with  the  stethoscope.  It  is  to  be  remembered  that  in  children  tlu'ie  is  a 
systolic  brain  murmur,  best  heard  over  the  ear,  and  in  some  instiinees'H 
heard  in  the  adult. 

(2)  Diminished  Function  or  Nervous  Deafness. — lu  testing  for  nervous 


m'y 


loss.         Ill     ynUl|;_t 

-iicrvc  s\  iii|ii,iiii< 
:,  of  cxtcii-iiiii  of 
[ly  1)1'  |»r(i(lii(Ti|— 
oils  llciiriii  s>,  ;iiiil 

to    illtlTCll     I'lllic 

3  liy])i'rii'stlicsiii— 
'Von  those  iiiamli- 
H'ctirs  in  li\.-ti'i'i;i 
oned,  in  ]i;ii'iilvsis 
In  (lysii'stlifsiii. 
ion,  as  foimiiiiiilv 
iioisos   are  liudly 

certain  sulijccliv,* 

s  in  the  ear.     Ills 

ociated  with  iiuiiiy 

on  the  driMii.     h 

le  nerve.     Sinlilcn 

not  luicoiiniKnily 

hears  a  coiitiiuuil 

cation,  usuiilly  mi 

or  this  (•(iiulitiiiii 

occurs  ill  cdiKli- 

the  ear  inii\  \n'v- 

n  niiiiraiiic.     In 

jranU'd  as  trivial. 

i  lias  even  driven 

Oy  (linicult  todc- 
'he  rcli'd'  (d'  cnii- 
^out,  may  rt'>ult 

always  be  iiiudt'. 

sonietiiiu's  amli- 

to  clonic  spasm 
the  levatoi'  palati. 
en  disaiipcar  sud- 
niind  is  like  tliat 
lothing  is  audililc 
lildren  there  is  :i 

some  instiiiKt'S!!! 


esting  for  nervous 


DISl-USHS  OF  TIIH  CU-VNI-Vfi   NKllVHS. 


8;;  I 


deafness,  if  the  tiinin,i,'-fork  cannot  be  heard  wiieii  |tlaceil  near  the  meatus, 
liut  I  he  vil)rations  are  audil)le  by  jtlai-in;,'  the  foot  of  the  tiiuiii,u-birl\  airainst 
the  temporal  Ixme,  the  conclusion  may  he  drawn  that  the  deafness  is  not 
ihie  to  involvement  of  the  nerve,  'riie  vil)rations  are  conveyed  throujrh 
the  ;eiiii»oral  bone  to  the  coclil  ;i  and  vestibule.  The  \vat(di  may  be  used 
lor  the  same  pur[)ose,  and  if  the  meatus  is  (dosed  and  tlie  wat(di  is  heard 
lietter  in  contact  with  the  mastoid  process  than  when  op])osile  tlie  open 
meatus,  the  deafness  i.s  probably  not  nervous.  I'ractically,  disturbance  of 
tile  function  of  the  auditory  nerve  is  not  a  very  fre(|uent  symiitom  in 
liraiii-diseasi",  but  in  all  cases  the  function  of  the  nerve  should  be  carefully 
tested 

(.i)  Auditory  Vertigo— Meniere's  Disease.— In  isdl  .Meniere,  a  Fremdi 
|ihysi(dan,  described  an  atl'ection  (diaracterized  liy  noises  in  the  ear,  vt'r- 
tiLTii  (\vhi(di  might  be  associated  with  loss  of  consciousness),  vomiting,  and, 
ill  iiiaiiy  cases,  jirogressivt?  loss  of  hearing.  'I'lie  term  is  now  used  to  in- 
chide  all  cases  of  sudden  vertigo  accom[»anie(l  by  noises  in  the  ear  and 
ileafiiess.  The  frequency  of  vertigo  with  ear  symptoms  is  striking. 
'I'lius,  of  10(3  eases  noted  by  (Jowers,  in  whitdi  there  was  dctinite  vertigo, 
in  HI  ear  symptoms  were  ju'esent,  either  tinnitus  or  deafness  or  both. 

Symptoms. — The  attacdc  usually  sets  in  suddenly  with  a  Im/zing 
neise  in  the  ears  and  the  jiatient  feids  as  if  he  was  reeding  or  staggering. 
He  may  feel  himself  to  be  reeling,  or  the  objects  about  him  may  seem  to 
lie  turning,  or  the  phenomena  may  be  coinl)ined.  The  attaid\  is  often  so 
alinipt;  tliat  the  patient  falls,  though,  as  a  rule,  he  has  time  to  steady  liim- 
s(df  liy  grasping  some  neighboring  objet't.  There  may  be  slight  but 
transient  loss  of  consciousness.  In  a  few  minutes,  or  even  less,  the  ver- 
\vj,n  passe.-;  off  and  the  patient  becomes  jiale  and  muuseated,  a  (danimy 
sweat  iireaks  out  on  the  face,  and  vomiting  may  follow. 

The  deafness,  which  is  always  of  a  nervous  character,  may  be  in  only 
nno  ear  and  is  never  complete.  As  a  rule,  the  -patients  have  no  atTec- 
tioii  of  the  middle  ear.  The  tinnitus  is  described  as  either  a  roaring 
nr  ii  throbbing  sound.  Ocular  symptoms  may  be  present ;  thus,  jerk- 
inir  of  the  eyeballs  or  nystagmus  may  develop  during  the  attatdc,  or 
(ii|ili)|iia. 

bahyrintliine  vertigo  is  paroxysmal,  corning  on  at  irregular  intervals. 
Siiiiietimes  weeks  or  months  may  elapse  between  the  atta<d<s  ;  in  other 
eases  there  may  be  several  attacks  in  a  day.  The  disease  rarely  occurs  in 
young  persons,  is  most  fre(pient  after  the  fortieth  year,  and  is  more  com- 
mon in  men  than  in  women. 

Tiic  pathology  of  the  disease  has  been  much  discussed.  There  are 
two  theories  concerning  its  origin — one,  that  it  is  due  to  alTectioii  of  the 
labyrinth  itself,  which  causes  a  disturbance  of  equilibrium,  such  as  is 
proved  by  experiment  to  be  associated  with  lesion  of  the  semicircular 
canals;  the  other  that  it  is  really  a  trouble  involving  the  centres  presiding 
over  hearing  and  e(piilibration. 


|1 


8(i2 


DISKASKS  OV  TIIK  NKHVOUS  SYSTEM. 


J  f  -     vfeiife 


It  has  also  iK't'ii  held  to  he  a  vaso-iiiotor  neurosis  of  the  vessels  nf  tho 
labyrintli.  'I'lie  coiidition  ol"  tlie  lahyrintli  in  these  eases  is  \;iii!ili|,.. 
Acute  disease  with  ha'inori'hajjfe  has  heeu  ih'serihed,  or  slow  |)ro,i,M'cs>i\v 
(h'fjeTioratioii  ol"  tlie  nerves,  (ii(hlia(>ss  and  voniitin;r  inay,  howescr.  l,c. 
jji'ddueed  l)y  irritation  in  other  parts  of  the  ear;  tiuis,  there  are  in>l;iiii(.s 
ill  wiiieh  pressure  on  the  drum  or  irritation  of  tlu-  external  uii'atus  is  In]. 
lowed  hy  an  attack  of  ^nddiuess  and  voniitin<f. 

Diagnosis. — 'i'lie  conil)iiuiti(tn  of  tinnitus  with  ^dddiness,  will:  „r 
vvitliout  j^astric  disturhance,  is  sutlicient  to  estaldish  a  din^niosi.^.  Thnv 
are  other  forms  of  vertiji;o  from  which  it  must  he  distin<,niished.  The 
form  known  as  gastric  vertiifo,  which  is  associated  witii  dyspepsia  ami  dc- 
curs  most  cominonly  in  ])erson.s  of  middle  a<,n',  is,  as  a  rule,  readily  disiin- 
guished  l)y  theahseiice  of  tinnitus  or  evidences  of  disturhance  in  the  i'liiir- 
tion  of  the  auditory  nerve,  'i'his  variety  of  verti<,'o  is  much  less  comhiiou 
than  Trousseau's  description  wt)uld  load  us  to  hclieve. 
•  The  card io- vascular  vertigo,  one  of  tho  most  common  forms,  occurs  in 
cases  of  valvular  disease,  particularly  aortic  insutllcioncy,  and  as  freiiiicuilv 
in  artorio-.sclorosis. 

'J'hore  is  a  remarkable  form  of  vertigo  described  by  Gerlior,  which  i> 
oluiractorizod  by  attacks  of  ])aretic  weakness  of  the  extremities,  falliii,ir  of 
the  eyelids,  remarkable  depression,  but  with  retention  of  consciotisncss. 
It  attacks  only  men,  and  has  occurred  in  e])idemic  form  among  laborers  in 
the  canton  of  (Jeneva. 

Aural  vertigo  must  be  carefully  distinguished  from  attacks  of  pHil 
mal,  or,  indeed,  of  definite  epilepsy.  It  is  rare  in  petti  mal  to  have  iioisfs 
in  the  ear  or  actual  giddiness,  but  in  the  aura  preceding  an  epileptic  nttark 
the  patient  may  feel  giddy,  (iiddiness  and  transient  loss  of  consciousiicss 
may  be  associated  with  organic  disease  of  the  brain,  more  particularly  uiih 
tumor.  Vomiting  also  may  be  present.  A  careful  investigation  nf  \\w 
symptoms  will  usually  lead  to  a  correct  diagnosis. 

The  outlook  in  Meniere's  disease  is  uncertain.  While  many  cases  ro- 
cover  completely,  in  others  deafness  results  aiul  the  attacks  reciu'  nt 
shorter  intervals.  In  aggravated  cases  the  patient  constantly  suifers  liom 
vertigo  and  may  even  be  confined  to  his  bed. 

Treatment. — Bromide  of  potassium,  in  twenty-grain  doses  Ihrtr 
times  a  day,  is  sonu'times  beneficial.  If  there  is  a  history  of  syphilis 
the  iodide  should  bo  administered.  The  salicylates  are  recommended,  luid 
Charcot  advises  quinine  to  cincbonism.  Incases  in  whicb  there  is  iiuivasc 
in  the  arterial  tension  nitroglycerine  may  be  given,  at  first  in  very  siiiiil! 
doses,  but  increasing  gradually.  It  is  not  specially  valuable  in  ^leiiii'rcV 
disease,  but  in  the  cases  of  giddiness  in  middle-aged  men  and  women  asso- 
ciated with  arterio-sfilerosis  it  sometimes  acts  very  satisfactorily. 


DISEASES  OF  THE   CRANIAL   NEIIVES. 


G  Lo.sso-  I'll  A  u  Y  X(  J  i:  A  I,  N  !•:  u  v  k 


sns 


Tills  nervo  contains  both  motor  and  sensory  fibres  ami  is  also  a  nerve 
iif  till'  S2)eeial  sense  of  taste  to  the  tiiiijfue.  It  sii|»|)lies,  by  its  iiKttor 
bnuiilies,  tlie  styio-piiaryiif^'eus  and  the  middle  eonstrii'tor  of  tlu'  pharynx. 
The  sensory  lilires  are  distribnted  to  the  upper  part  of  the  pharynx. 

Symptoms. — <M'  nuclear  distiirbsince  we  know  very  little,  'i'he 
liliaryii^a'al  syni[)tonis  of  bulijar  })aralysis  are  probalily  associated  with  in- 
MilvcMU'iit  of  the  nuclei  of  this  nerve.  Lesion  of  the  nerve  trunk  itself  is 
piir,  but  it  may  be  compressed  by  tumors  or  involved  in  nieiun^itis.  Dis- 
tui'biiiico  of  the  sense  of  taste  may  result  from  loss  of  function  of  this 
iii'i've,  ill  which  case  it  is  chielly  in  the  posterior  part  of  the  ton;,nu'  and 

•lift  luilate.     (towers,  however,  states  that  there  is  no  ease  on   n rd   in 

whicli  loss  of  taste  in  these  re{j;ions  has  lieeii  produeed  by  disease  of  the  roots 
iif  the  {ijlosso-pharynj^eal ;  whereas,  on  the  other  hand,  disease  of  the  root 
of  the  iiftli  nerve  may  cause  loss  of  taste  on  tlic  l)ack  as  well  as  the  fj'oiit 
(if  the  tongue,  aa  if  the  taste  fibres  of  the  glosso-pharyngeal  came  from  the 
lifth. 

The  general  disturbances  of  tlie  .sense  of  taste  may  here  be  brielly  re- 
ftri'cil  to.  Loss  of  the  sen.se  of  taste — (ujeiixid — may  be  caused  by  dis- 
tiu'bance  of  the  periiiheral  end  organs,  as  in  alTections  of  the  mucosa  of 
thu  tongue.  This  is  very  common  in  the  dry  tongue  ui  fever  or  the  furred 
tmigiie  of  dyspepsia,  under  which  circumstances,  as  the  .saying  is,  every- 
tliiiig  tastes  alike.  Strong  irritants  too,  such  as  pepper,  tobacco,  or  vinegar, 
limy  (lull  or  diminish  the  sen.se  of  taste.  Comiilete  loss  may  be  due  to  in- 
volvoiiu'iit  of  the  nerves  either  in  their  course  or  in  the  centres.  Dis- 
turhiiiice  in  the  sense  of  taste  is  most  commonly  seen  in  involvement  of 
t!iL'  lifth  nerve,  and  it  may  be  that  this  nerve  alone  suliserves  the  function. 
IVrversioii  of  the  sense  of  taste — parayeuAis — is  rarely  found,  except  as 
nil  hysterical  manifestation  and  in  the  insane.  Increased  sensitiveness  is 
<till  more  rare.  There  are  occasional  subjective  sensations  of  taste,  occur- 
riiij][  as  an  aura  in  epilei)sy  or  as  jiart  of  the  hallucinations  in  the  insane. 

To  test  the  sense  of  taste  the  patient's  eyes  should  be  closed  and  small 
'|uantities  of  various  substances  applied.  The  sensation  should  be  per- 
'vivt'd  Ijefore  the  tongue  is  withdrawn.  The  following  are  the  most  suit- 
''l)lo  tests  :  For  bitter,  (|uiniiie  ;  for  sweetness,  a  strong  solution  of  sugar  or 
fiiiccliarin  ;  for  acidity,  vinegar;  and  for  the  saline  test,  common  salt.  One 
"f  tlie  most  important  tests  is  the  feeble  galvanic  current,  which  gives  the 
well-known  metallic  taste. 


K 


'W. 


PXKUMOGASTUIC    NEIiVE. 

Tlio  vagns  nerve  has  t.n  important  and  extensive  distribution,  snpply- 
"1?  the  pharynx,  larynx,  lungs,  heart,  (esophagus,  and   stomach.     The 
nerve  may  be  involved  at  its  luicleus  with  tlu^  sjiinal  accessory  and  the 
Hypoglossal,  forming  what  is  known  as  bulbar  paralysis.     It  may  be  corn- 
So 


t 


< '  >. 


Xi 

Iff!  4   ,  )♦  >l 


I"  7]5f| 


804 


DISKASKS  OF  TIIK   NKHVOUS  SVSTEM. 


1 


])ro.sfle(l  by  tuiuorH  or  unourism,  or  in  tlio  exudation  of  iiioniii<;itis,  siiinilc 
or  8y])liilitit'.  In  its  coiirHc  in  the  nccik  tho  trunk  may  bo  iii\(jU((l  |,v 
tumors  or  in  wounds.  It  bas  been  tied  in  li^^'aturc  of  tbc  curotid,  and  Ims 
boon  cut  ill  tbi'  removal  ul'  di'i'i>-sfatud  tunions.  Tin-  ^-.iuk  mav  lie  at- 
tac'ki'd  by  nouritiH. 

'J'bo  uiructions  ol'  tbu  va<j[us  are  best  considered  in  connection  wiih  il^. 
distribution  of  tlie  si'[»arat((  nerves. 

(ii)  Pharyngeal  Braiaches.— In  (■ond)inatioii  witii  tliep;losso-|ibiii'vii;'(;ii 

tlio  brunches  Troni  the  vagus  form  the  pbarynj;cal  [>h'.\us,  fioni  uhirh  tin. 
muscloa  and  mucosa  of  the  }diaryn.\  arc  8U{)[)li('d.  In  jmntli/sis  t\\w{„ 
involvement  of  thi^  either  in  tiie  nuekd,  as  in  bulbar  paralysis,  or  in  the 
fonrso  of  tiie  nerve,  as  in  dipiitheritic  neuritis,  tliere  is  dillicidty  in  swal- 
lo\vin<^  and  the  food  is  lutt  pas,scd  on  into  the  ie.sopha<,'us.  If  thci  nerve  on 
one  side  oidy  is  involved,  the  deglutition  is  not  much  impaired,  in  tliosc 
eases  tlio  particles  of  food  frcciucntly  pass  into  the  larynx,  and,  wIk  n  tln' 
soft  palate  is  involved,  into  the  pf)sterior  nares. 

Spasm  of  tbc  jdiarynx  is  always  a  functioinil  disorder,  usually  tn-cw. 
ring  in  hysterical  and  nervous  people,  (iowers  mentions  a  case  of  a  j,'cii- 
tleman  who  could  not  cat  uidess  alone,  on  account  of  the  inabilitv  in 
swallow  in  the  presence  of  others  from  siiasm  of  the  pharynx.  This  spiisni 
is  a  well-marked  feature  in  hydrophobia,  and  I  have  seen  it  in  a  ciiso  df 
p.seudo-hydr()pbobia. 

{/>)  Laryngeal  Branches— Tlu^  superior  laryngeal  nei-ve  sup])li(s  ihc 
mucous  membrane  of  tbc  larynx  above  the  cords  and  tlit^  crico-thyrniil 
muscle.  The  inferior  or  recurrent  laryngeal  curves  around  the  arch  of  the 
aorta  on  the  left  side  and  the  subclavian  artery  on  the  right,  passes  almi;' 
the  tracdieaand  supplies  tlie  mucosa  below  the  cords  and  all  the  nnisclcs  of 
the  larynx  except  the  crico-thyroid  and  the  ejiiglottidean.  Ex2)eriments  liiivo 
shown  that  these  motor  nerves  of  the  pncumogastric  are  all  derived  from 
the  spinal  accessory.  The  remarkable  course  of  the  recurrent  laiyiiLrtal 
ner\c's  renders  them  liable  to  pressure  by  tumors  within  the  thorax,  imi- 
ticularly  by  aneurism.  T'he  following  arc  the  most  important  forms  uf 
paralysis : 

(1)  liihteral  Pa?\il>jsis  of  the  Ahhidors. — Tn  this  condition,  the  pos- 
terior crico-arytenoids  are  involved  and  tbc  glottis  is  not  opened  diiriiiL; 
inspiration.  The  cords  may  be  close  together  in  the  position  of  jtlionatioii. 
and  during  inspiration  maybe  brought  even  nearer  together  by  the  pressure 
of  air,  so  that  there  is  only  a  narrow  chink  through  which  the  air  wliistk- 
Avith  a  noisy  stridor.  This  dangerous  form  of  laryngeal  paralysis  onurs 
occasionally  as  a  result  of  cold,  or  may  follow  a  laryngeal  catarrh.  Thf 
})Osterior  muscles  have  been  fonnd  degenerated  Avhen  the  others  wciv 
healthy.  The  condition  may  he  produced  by  pressure  upon  both  vagi,  m 
npon  both  recurrent  nerves.  As  a  central  affection  it  occurs  in  tabes  aiul 
bulbar  paralysis,  but  may  occur  also  in  hysteria.  The  characteristic 
symptoms  are  inspiratory  stridor  with  unimpaired  phoniitiou.    Pessibly, 


I 


loninfriti^J,  An\\\V' 
ly  hv  iiiviiKi'tl  liy 
L'  (iiU'otiil,  and  1ms 
^••'.;uk  iiia\  111'  iil- 

niu'ctidii  w  ith  till' 

gl()S>iti-pli:ii'Ui;:i;il 
is,  fi'din  whirh  tln' 

I    IKdudl/sis  dlK'  til 

[larulysis,  (ir  in  thr 
ditliculty  in  swiil- 
<.  ir  tlui  ncrviMiii 
npuiri'il.  In  thrsc 
nx,  tiiul,  wlii-n  the 

[ler,  usually  <»'Our- 
ins  a  ciis((  of  a  \ivn- 
nf  the  inaliility  to 
iryiix.  'riiissiiasiii 
seen  it  in  u  fU:^t-'  of 

llOl'VO  SUllplU'S   lllf 

,1  tlu^  crico-thyrii'M 
ind  the  arch  of  tlu' 
ri<;ht,  passes  nUv^ 
(1  ill!  the  muselcs  of 
Experiments  luivo 
re  all  derived  from 
ecurrent  huyiiL'ial 

II  the  thorax,  par- 
luportant  forius  ut 

eonditioii,  tlio  1"'^- 
not  opened  duriui; 
lition  of  i>hoinitioiu 
[her  l)y  the  pressure 
(ieh  tlie  air  whistles 
}i\\  paralysis  oc<'iii> 
jgeal  catarrh.    'H'^' 

III  the  othei's  were 
lupon  both  vagi,  or 

)ccurs  in  tahes  ami 

iThe   charaeteristif 

ouation.     Possibly, 


DISKASKS  OF  TIIK  CHANIAIi   NKIIVKS. 


SC,') 


iis  (lowers  sujxf^ests,  many  eases  of  so-called  hysterical  spasm  of  the  glottis 
;,re  ill  reality  altdiictor  paralysis. 

(•.')  riiihe/vnil  Alxliiitiir  I'arahjsis. — This  fre(|iiently  results  from  the 
pressure  of  tumors  or  involvement  of  one  recurrent  nerve.  Aneurism  is 
liv  far  the  most  common  cause,  though  on  the  right  side  the  nerve  may 
hi' in\olv(Ml  in  thiekening  of  the  ])leura.  'I'lie  sympioms  are  hoarseness 
ur  reiighness  of  the  voice,  such  as  is  so  common  in  aiieurisju.  I)yspn(i'a 
1.  not  iiften  preseid,.  The  cdi'd  on  the  alTccted  side  dncs  not  mo\c  in  in- 
jliinitioii.  Siihsetnicntly  tlieadihictors  may  also  heeome  involved,  in  whicli 
I'lise  the  phonation  is  still  more  impaired. 

(:i)  Adtltictor  /'(ini/i/sis. — This  results  from  involvement  of  the  lateral 
ri'ieo-arytouoid  and  the  arytenoid  muscle  itself.  It  is  common  in  hysteria, 
imrticularly  of  women,  and  causes  the  hysterical  aphonia,  \vlii(di  may 
(■(ime  on  sinhh'nly.  It  may  result  from  catarrh  of  the  larynx  or  from 
iiveiMise  of  the  voice.  In  laryngoscopie  examination  it  is  seen,  on  attempt 
at  |ili(Hiation,  that  there  is  no  ])ower  to  bring  the  eords  together.  In  this 
Kiiinection  the  following  table  from  (iowers  work  will  be  found  valuable  to 


till'  student: 
Symptoms. 

No  voice; lU) cough  ; 
firidor  only  oudeepin- 
>|iiration. 

Voice  low  iiit(du'd 
ami  hoarse  ;  no  cough  ; 
>triili)r  absent  or  slight 
"11  deep  breathing. 


Vdiee  little  changed ; 
I  High  normal ;  inspira- 
tum  dillicult  and  long, 
«itli  h.ud  stridor. 


Symptoms  iiu'on- 
iliidvo ;  little  affection 
"I  Voice  or  cough. 

No  voice;  perfect 
'■"iigh;    no  stridor  or 

ilyspiuea. 


Skins. 

Both  cords  moder- 
ately abducted  and  nu>- 
tioidess. 

One  cord  moder- 
ately abducted  and  mo- 
tionless, the  other  mov- 
ing freely,  and  even 
beyond  the  nuddle  line 
in  plumation. 

Both  cords  near  to- 
gether, and  during  in- 
spiration not  separated, 
but  even  drawn  nearer 
together. 

One  cord  near  the 
middle  line  not  moving 
during  inspiration,  the 
other  normal. 

Cords  normal  in  po- 
sition and  moving  nor- 
mally in  respiration, 
but  not  brought  to- 
gether on  an  attempt 
at  phonutiun. 


liKSION. 


Total  bilateral  jialsy. 


Total  unilateral  i)alsy 


Total  abductor  palsy. 


Unilateral     abductoi 
palsy. 

Adductor  palsy. 


■Ml 


li 


806 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


IIH 


'it' 


if^pnfim  of  the  Muscles  of  the  Lnrj/n.r. — In  this  tlic  adductor  iniisclis 
are  involved.  It  is  not  an  iiticommoii  atFcction  in  children,  ami  has  al- 
ready been  referred  to  as  laryn<^isinus  strichdus.  Paroxysmal  attacks  df 
hiryngeal  spasm  are  rare  in  the  adult,  but  cases  are  described  in  whiih  ijn. 
])atient,  usually  a  youufj^  fjirl,  wakes  at  nirfht  in  an  iittack  of  intcusr  dysii. 
iKca,  Avhii'h  nuiy  persist  long  enoujifh  to  produce  cyanosis.  Liveiiii,''  states 
that  they  may  replace  attacks  of  mi,<jjraiiie.  They  occur  in  a  chariictfristir 
form  in  locomotor  ataxiii,  forming  the  so-called  laryugcid  crises.  Thciv  is 
a  condition  known  as  spastic  aphonia,  in  which,  when  the  patient  attrmpt-; 
to  speak,  ])hoiiation  is  completely  prevented  by  a  si)asm. 

Disturbance  of  the  sensor^'  nerves  of  the  larynx  is  rare. 

yl//<p.s7/('f'.s'mnuiy  occur  in  bulbar  paralysis  and  in  diphtheritic  neuritis— 
a  serious  condition,  as  portions  of  food  may  enter  the  windpipe.  It  is 
usually  associated  with  dys[)ha<;ia  and  is  sometimes  present  m  hv.-tcria. 
Ilypera'sthesia  of  the  larynx  is  rare. 

(r)  Cardiac  Branches. — The  cardiac  plexus  is  formed  by  the  iimdii  df 
lu-anches  of  the  vagi  and  of  the  sym])athetic  nerves.  The  vagus  librcs  suii- 
serve  nu»tor,  sensory,  and  probably  trophic  functions. 

(1)  J/(V/*r.— The  lil)res  which  inhibit,  control,  and  regulate  the  eanliai 
action  pass  in  the  vagi.  Irritation  may  ])roduce  slowing  of  the  action,  (zn- 
mak  could  slow  or  even  arrest  the  heart's  action  for  a  few  beats  by  ])i'essiii;'  a 
small  tumor  in  his  neck  against  oiu'  pneumogastric  nerve,  and  it  )s  sani 
that  the  same  can  be  produced  l)y  forcible  bilateral  pressure  on  the  ca- 
rotid canal.  There  are  instances  in  which  persons  a [tpear  to  have  luid  vdl- 
untary  control  over  the  action  of  the  heart.  The  most  remarkahlt'  in- 
stance was  that  of  Colonel  Townseiul,  who  could  slow  the  action  ef  tli' 
heart  at  will.  Hetardatiou  of  the  heart's  action  has  also  followed  airi 
dental  ligature  of  one  vagus.  Irritation  at  the  nuclei  may  also  lie  acconi- 
panied  by  extreme  slowness.  The  condition  of  braehycardia  nuiy  l)e  asn 
dated  with  a  neurosis  of  this  nerve.  On  the  other  haiul,  when  then'  i> 
comiilete  paralysis  of  the  Aagi,  the  iuhil)itory  action  may  be  al)(ili<liel 
and  the  acceleratory  influences  have  full  sway.  The  heart's  action  is  tin "i 
greatly  iiu-reased.  This  is  seen  in  some  instances  of  dij)theritic  neiiriii- 
aud  in  involvement  of  the  nerve  by  tumors,  or  its  accidental  reniovah'! 
ligature.  Complete  lo.ss  of  function  of  one  vagus  may,  howeviT.  lu'l  i^ 
followed  l)y  any  symptoms. 

(3)  Sensor  1/  symptoms  on  the  part  of  the  cardiac  1>raiu'hes  are  wry 
varied.  Xormally,  the  heart's  action  proceeds  regularly  without  the  [nir 
ticipati(m  of  consciousness,  but  the  unpleasant  feelings  ami  seiisalieiis  nf 
])alpitation  and  pain  are  conveyed  to  the  brain  through  this  nerve.  H"*^ 
far  the  fibres  of  the  juununogastric  are  involved  in  angina  it  is  inipessiiil'' 
to  say.  The  various  disturbances  of  sensation  are  described  under  tlio 
cardiac  neuroses. 

{(()  Pulmonary  Branches. — Wo  know  very  little  of  the  puliinMiaiy 
branches  of  the  vagi.     The  motor  fibres  arc  stated  to  control  the  aetioni'i 


"il 


'  adductor  iiiusclis 
ildrcii,  iuiil  luis  ul- 
)xysin;il  attack^  nf 
rihc'd  in  whicli  iln^ 
k  of  intciisf  (lys|i- 
is.  Livciiiir  stiitts 
'  in  a  charactrristic 
id  criHc'S.  'riifiv  is 
le  patitnit  altrmpts 
1. 

iro. 

Iithoritio  neuritis— 
u'  \vindpi|H'.  It  i.< 
present  m  liy>tcn;i, 

led  liy  the  unum  nf 
lie  vagus  libre.s  suli- 

'ejjulate  tlie  eanli;!!' 

of  the  action.  Czn- 

V  heat.^hy  ])ressiiiL' ;i 

lervi',  and   it  i>  s:ii4 

pressure  on  the  m- 

ir  to  have  hail  vnl- 

)st  reniarkahlr  n,- 

tlie  aetion  el'  tln' 

dso  f()lh)\ved  iiiv!- 

nay  also  ho  accoiii- 

ardia  may  he  ii>" 

md,  when   theu'  b 

may  he  ahohsln'l 

art's  action  is  tlii'i 

liptheritic  ncariti- 

idental  reninval  it 

IV,  however,  lu'l  I"' 


DISEASES  OF  THE  CRANIAL   NERVES. 


867 


Wn 


m 


1  tranches  are  viTV 
•ly  without  tlie  par 
s  and  sensatiimsof 
h  tliis  nerve.  H"« 
;ina  it  is  iniims-sil'l'' 
escribed  niuli'i"  tln' 

of    the    puhii.miiry 
ontrol  the  ai'lio""^' 


the  hronchial  nmscles,  ajxl  it  has  long  been  held  that  asthma  may  be  a  neu- 
iiisis  itf  tiiese  fibres.  The  various  alterations  in  the  respiratory  rhythm  are 
preliahly  duo  more  to  changes  in  the  centre  than  in  the  nerves  them- 
seh'es. 

(')  Gastric  and  (Esophageal  Branches.— The  nmscidar  movements  of 
these  jiarts  are  ])resided  over  by  the  vagi  and  vomiting  is  induci'd  throngli 
thi'in,  usually  relluxly,  but  also  by  direct  irritation,  as  in  meningitis.  (S})aHni 
(if  the  oesophagus  generally  oc(;urs  with  other  nervous  iiheiujmena.  (ias- 
truluia  may  sometinu's  be  due  to  cram[)  of  the  stomach,  but  is  more  com- 
monly a  .sen.sory  disturbance  of  this  nerve,  due  to  direct  irritation  of  the 
|nri|iheral  ends,  or  is  a  neuralgia  of  the  terminal  fibres.  Hunger  is  said 
t(i  be  a  sen.sation  aroused  by  the  pneumogastric,  and  some  forms  of  ncrv(»us 
livspepsia  jtrobably  depcnid  upon  disturbed  function  of  this  nerve.  The 
severe  gastric  crises  which  occur  ii\  locomotor  ataxia  ari;  due  to  central 
irritation  of  the  nuclei.  Some  describe  exophthalmic  goitre  uiuler  lesions 
of  the  vagi. 

HlMX.VI,    AcrK.SSORY    >rEKVE. 

Paralysis. — Tlie  smaller  or  internal  part  of  this  nerve  joins  the  vagus 
;iml  is  distributed  through  it  to  the  laryngt^al  mu.scles.  The  larger  external 
|i;irt  is  distributed  to  the  sterno-mastoid  and  trapezius  muscles. 

The  luudci  of  the  nerve,  particularly  of  the  accessory  i>art,  may  be  in- 
viilveil  in  bulbar  i)aralysis.  The  nuclei  of  the  external  jiortion,  situated 
as  they  are  in  the  cervical  cord,  may  be  attacked  in  i)i'ogressive  degenera- 
timi  of  the  motor  niudei  of  the  cord.  Tiie  nerve  may  bo  involved  in 
tJK^  exudation  of  meningitis,  or  be  compres.sod  by  tumors,  or  in  caries. 
The  .ojDiplinnn  of  paralysis  of  the  accessory  portion  which  joins  the  vagus 
havt'  already  been  given  in  the  account  of  the  j)alsy  of  the  laryngeal 
hraiielies  of  the  pneumogastric.  Di.seasc  or  comitression  of  the  external 
|iiirtii>n  is  followed  by  i)aralysis  of  the  sterno-mastoid  and  of  the  trapezius 
im  the  same  side.  In  paralysis  of  one  sterno-nuistoid,  the  patient  rotates 
tln'  head  with  difTicidty  to  the  opposite  side,  Itut  there  is  no  torticollis, 
though  in  some  cases  the  head  is  held  obli(|uoly.  As  the  tra))ezius  is 
suiiplied  in  part  from  the  cervical  nerves,  it  is  not  comjilctely  paralyzed, 
l)iit  the  portion  which  passes  from  the  occipital  bone  to  the  acromion  is 
fiiiietionless.  The  paralysis  of  the  muscle  is  well  seen  when  the  patient 
ilraus  a  deep  breath  or  shrugs  the  shoulders.  The  middle  portion  of  the 
ii'apezius  is  also  weakened,  the  shouldcf  droops  a  little,  ami  the  angle  of 
till' scapula  is  rotated  inward  by  the  action  of  the  rhomboids  and  the  levator 
iiii,i,'uli  scapuhe.  Elevation  of  the  arm  is  imj)aircd,  for  the  trapezius  does 
iiiit  ii\  the  scapula  as  a  ])oint  from  which  the  deltoid  can  work. 

Ill  progressive  muscuilar  atrophy  we  sometimes  see  bilateral  ))aralysis 
"f  these  muscles.  Thus,  if  the  sterno-mastoids  are  affected,  the  head 
tfiuis  to  fall  l)ack;  when  the  trapezii  are  involved,  it  fulls  forward  a 
diaraeteristic  attitude  of  the  head  in  many  cases  of  progressive  muscular 


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868 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


atropliy.  Gowers  suggests  tliat  lesions  of  the  iiccessory  in  difficult  lalxir 
may  accoimt  for  those  cases  in  wliich  during  the  first  year  of  life  the 
child  has  great  difficulty  in  holding  up  the  head.  In  children  this  ilrodh- 
ing  of  the  head  is  an  important  symptom  in  cervical  meningitis,  the 
result  of  caries. 

The  treatment  of  the  condition  depends  much  upon  the  cause.  In  the 
central  nuclear  atrophy  hut  little  can  be  done.  In  paralysis  from  |nvssiiic 
the  symi)toms  may  gradually  be  relieved.  The  paralyzed  muscles  slmuM 
be  stimulated  by  electricity  and  massage. 

Accessory  Spasm. — {7urficoUis  ;  Wry ncr^-.)— Tho  forms  of  spusm 
affecting  the  cervical  muscles  are  best  considered  here,  as  the  iiuisiU's 
supplied  by  the  accessory  are  chiefly,  though  not  solely,  responsible  fur  the 
condition.     The  following  foi'ms  may  be  described  in  this  section : 

(a)  Cotif/enital  Torticollis. — This  condition,  also  known  as  fixed  torti- 
collis, depends  upon  the  shortening  and  atrophy  of  the  sterno-nuistoid  m 
one  side.  It  occurs  in  children  and  may  not  ))e  noticed  for  several  vcai- 
on  account  of  the  shortness  of  the  neck,  the  parents  often  alleging  that  it 
has  only  recently  come  on.  It  alfects  the  right  side  ulmos  .  x'  liisiveh. 
A  remarkable  circumstance  in  connection  with  it  is  the  r-!  ;  .  of  farial 
asymmetry  noted  by  Wilks,  which  api)ears  to  be  an  essenli;d  i)art  of  this 
congenital  form.  It  occurred  in  six  cases  reported  by  (lolding-Bird.  In  a 
case  recently  under  my  observation,  the  wryneck  was  not  noticed  until 
her  tenth  year.  The  muscle  was  divided  and  she  seemed  quite  well;  Init 
as  she  developed  the  asymmetry  of  the  face  became  very  striking.  In  cdn- 
genital  wryneck  the  sterno-n)astoid  is  shortened,  hard  aiul  firm,  ainl  in  a 
condition  of  more  or  less  advanced  atro])hy.  This  must  be  distiuguisheil 
from  the  local  thickening  in  the  sterno-mastoid  due  to  rupture,  which  may 
occur  at  the  time  of  birth  and  produce  an  induration  or  muscle  callus. 
Although  the  sterno-mastoid  is  almost  always  affected,  there  are  rare  cases 
in  which  the  fibrous  atrophy  affects  the  trapezius.  This  form  of  wi'vncfk 
in  itself  is  unimportant,  since  it  is  readily  relieved  by  tenotomy,  h' ' 
CJolding-Bird  states  that  the  facial  asymmetry  ])ersists,  or  nuleed  ina' 
shown  by  ])hotogra})hs  in  my  case,  become  more  evident.  With  ref'r 
to  the  pathology  of  the  affection,  Oolding-Bird  concludes  that  the  i;a.  . 
asymmetry  and  the  torticollis  are  integral  pat*s  of  one  atfecti')n  wliiili 
has  a  central  origin  and  is  the  counterpart  in  the  head  and  neck  of  infan- 
tile paralysis  Avith  talipes  in  the  foot. 

{())  SjMsmodic  Wryneck. — Two  varieties  of  this  s})asm  occur,  the  touii 
and  the  clonic,  which  may  alteriuite  in  the  same  case;  or,  as  is  most 
common,  they  are  separate  ami  renuiin  so  from  the  outset.  Tiie  dis- 
ease is  most  frequent  in  adults  and,  according  to  (iowors,  most  couimou  in 
fenuiles.  In  this  country  it  is  certainly  more  frequent  in  nudes.  ■<"  the 
eight  or  ten  cases  which  came  under  my  observation  in  Monf  d  "■'! 
I'hiladelphia,  all  were  males.  In  females  it  may  be  an  hysterical  ii.  -■  - 
tatiou.    There  may  be  a  marked  neurotic  family  history  but  it  is  usually 


i 


m 
m 


DISEASES  OF  THE  CRANIAL  NERVES. 


8G9 


impossible  to  fix  upon  any  definite  etiological  factor.  Some  cases  have 
folidwiid  cold  ;  others  a  blow. 

Tlio  symptoms  are  well  defined.  In  the  tonic  form  the  contracted 
storno-mastoid  draws  the  occiput  toward  the  shoulder  of  the  affected  side ; 
the  chin  is  raised,  and  the  face  rotated  to  the  otlier  shoulder.  The  sterno- 
mastiiid  may  bo  affected  alone  or  in  association  with  the  tni])ezius.  'When 
the  latter  is  inii)licatL'd  the  head  '.o  depressed  still  more  toward  the  same 
side.  In  long-standing  cases  these  muscles  are  prominent  and  very  rigid. 
Tliere  may  l)e  some  curvature  of  the  s])ine,  the  convexity  of  which  is  toward 
the  sound  side.  The  cases  in  which  the  spasm  is  clonic  are  much  more 
distressing  ai'.i  serious.  The  spasm  is  rarely  limited  to  a  single  muscle. 
The  sterno-mastoid  is  almost  always  involved  and  rotates  the  head  so  as  to 
iipproximate  the  mastoid  process  to  the  inner  eiul  of  the  clavicle,  turning 
the  fiice  to  the  opj)osite  side  and  raising  the  chin.  When  with  this  the 
trapezius  is  affected,  the  depression  of  the  head  toward  the  same  side  is 
more  marked.  The  head  is  drawn  somewhat  jjackward  ;  the  shoulder, 
too,  is  raised  by  its  action.  According  to  Ciowers,  the  splenius  is  associated 
with  the  sterno-mastoid  about  half  as  frequently  as  the  trapezius.  Its  ac- 
tion is  to  incline  the  head  and  rotate  it  sliglitly  toward  the  same  side. 
Otlier  muscles  may  be  involved,  siu-h  as  the  scalenus  and  platysma  myoides ; 
and  in  rare  cases  the  head  may  be  rotated  by  the  dec])  cervical  muscles, 
the  rectus  and  oblirpxus.  There  are  cases  in  whicli  the  spasm  is  bilateral, 
causing  a  backward  movement — the  retro-colli(!  spasm.  This  nuiy  be 
lither  tonic  or  clonic,  and  in  extreme  cases  the  face  is  horizontal  and  looks 
upward. 

Those  clonic  contractions  may  come  on  Avithout  warning,  or  be  pre- 
ceded for  a  time  by  irregular  pains  or  stitfness  of  the  neck.  The  jerking 
niovenients  recur  every  few  moments,  and  it  is  impossible  to  keep  the  head 
still  for  more  than  a  minute  or  two.  In  time  the  muscles  undergo  hyper- 
trophy and  may  be  distinctly  larger  on  oiu>  side  than  the  other.  In  some 
cases  the  pain  is  considerable  ;  in  others  there  is  simply  a  feeling  of  fatigue. 
The  spasms  cease  during  sleep.  Emotion,  excitement,  and  fatigue  increase 
them.  Tlie  spasm  may  extend  from  the  muscles  of  the  neck  and  involve 
those  of  the  face  or  of  the  arms. 

The  disease  varies  much  in  its  course.  Cases  occasionally  get  Avell,  but 
the  preat  majority  of  them  persist,  and,  even  if  t('mj)orarily  relieved,  the 
itisease  frecpu'utly  i-ecurs.  The  affection  is  usually  regarded  as  a  functional 
lu,  m,  but  it  is  possibly  due  to  disturbance  of  the  cortical  centres  pre- 
.•'idinff  :)ver  the  muscles. 

Treatment. — T'emporary  relief  is  sometimes  obtained  ;  a  pernui- 
nent  cure  is  exceptioiud.  Various  drugs  have  been  used,  but  rarely 
with  heiu'fit.  Occasionally,  large  doses  of  bromide  ■will  lessen  the  in- 
tensity of  the  spasm.  Morphia,  subcutaneously,  has  been  successful  in 
i^ome  reported  ca.ses,  but  there  is  the  great  danger  of  esta])lisliing  the 
morphia  habit.     Galvanism  may  be  tried.     Counter-irritation  is  probably 


< 


•ffFTpi 


870 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


:|i 


useless.  Fixation  of  the  head  inoclKUiicully  can  rarely  be  borne  In  the 
piitient.  These  obstinate  cases  fall  ultimately  into  tlie  hands  of  tiu!  sur- 
geon, and  the  operations  of  stretchintf,  division,  and  excision  of  the  acces- 
sory nerve  and  division  of  the  muscles  have  been  tried.  The  latter  dues 
not  check  the  spasm,  and  may  aggravate  the  symptoms.  Tciiiiiciarv 
relief  may  follow,  but,  as  a  rule,  the  condition  returns.  In  the  ciir-cs  of 
spasm  of  the  deep-seated  muscles.  Keen  has  devised  an  operation  I'm'  tla.ii 
section. 

(f)  The  nodding  spasm  of  children  may  here  be  mentioned  as  involv- 
ing chiefly  the  muscles  innervated  by  tlie  accessory  nerve.  Itmavhcu 
simple  trick,  a  form  of  habit  spasm,  or  a  ])lienomenon  of  epilepsy  (K.  nu- 
tans), in  which  case  it  is  associated  with  transient  loss  of  consciousiicss. 
A  similar  nodding  spasm  may  occur  in  ohler  children.  l!i  women  it  sonic- 
times  occurs  as  an  hysterical  manifestation,  commonly  us  part  of  the  su- 
called  salaam  convulsion. 

Hypogloss.vl  Nerve. 

This  is  the  motor  nerve  of  the  tongue  and  for  most  of  the  nuisdcs  at- 
tached to  the  hyoid  bone.  Its  cortical  centre  is  probably  the  lower  part  ol' 
the  ascending  frontal  gyrus. 

Paralysis. — (1)  Codnd  Lesion. — The  tongue  is  often  paralyzed  in 
hemiplegia,  and  the  paralysis  may  result  from  a  lesicju  oi  the  cortex  itself, 
or  of  the  fibres  as  they  })ass  to  the  medulla.  It  does  not  occur  alone  and 
will  be  considered  with  hemiplegia.  There  is  this  dilTcrence,  however,  be- 
tween the  cortical  and  other  forms,  that  the  muscles  on  both  sides  of  the 
tongue  nuiy  be  more  or  less  alfected  but  do  not  waste,  nor  are  their  elec- 
trical reactions  disturbed. 

(•^)  yuclcar  and  infra-nurlear  lesions  of  the  hypoglossal  result  frniii 
slow  progressive  degeneration,  as  in  bulbar  paralysis  or  in  locoinutcr 
ataxia,  and  occasionally  there  is  acute  softening  from  obstruction  of  the 
vessels.  Trauma  and  lead  })oisoning  have  also  been  assigned  as  causes. 
The  fibres  may  be  danuiged  I)y  a  tumor,  and  at  the  base  by  menin^ritis; 
or  the  nerve  is  sometimes  involved  in  its  foramen  by  disease  of  the  skull. 
The  nuclei  of  both  nerves  are  usually  alfected  together,  but  may  lit'  at- 
tackctl  separately.  As  a  result,  there  is  hjss  of  funi-tion  in  the  nerve  lilnes 
and  the  tongue  undergoes  atro])hy  on  the  alfected  side.  It  is  protruded 
toward  the  paralyzed  side  and  may  show  fibrillary  twitching. 

The  siimplonis  of  involvement  of  one  hypoglossal,  eitiier  at  its  centre 
or  in  its  course,  are  those  of  unilateral  j)aralysis  and  atrophy  of  the  tongue. 
When  protruded,  it  is  i)ushed  toward  the  alfected  side,  and  there  aii'  li- 
brillary  twitchings.  The  atrophy  is  usually  nuirked  and  the  mucous  nieiii- 
brane  on  the  alfected  side  is  thrown  into  folds.  Articulation  is  not  luueh 
impaired  in  the  unilateral  affection.  When  the  disease  is  bilateral,  the 
tongue  lies  almost  motioules&  in  the  floor  of  the  mouth;  it  is  utroiiliiwl, 


iMi 


DISEASES  OP  THE  SPINAL  NERVES. 


871 


,•  be  bonu'  liy  the 
hands  of  tin:  i;ui'- 
isioii  of  till'  iivAX'i- 
.  Tlio  latter  (loos 
oiiis.  Tciiijxirurv 
111  tin;  ••uses  of 
ijpt'ruti(jii  U>v  tluii 

'ntioned  lus  itivoh- 
LTve.  It  iiiiiy  !h'  u 
»f  epilepsy  (K.  mi- 
i  oi  coiiscioiisiicss. 
Ill  women  it  soiiu'- 
.'  us  part  ol'  tlio  su- 


of  the  niuHclcs  at- 
y  the  lower  part  of 

)ften  panily/eil  in 
)i  the  eortfX  ilsell', 
ot  oceiir  aloiR'  and 
renee,  liowi'ViT,  U'- 
1  both  sides  of  llii' 
nor  are  their  I'ltr- 

rlossal  rcstiH  fnnu 

■;    or  in   loeoiiiutor 

ol)striU'ti()ii  of  tlk' 

issigned  as  cau.-us. 

ISO  by  nieiiin<ritis; 

sease  of  the  >kull. 

r,  but  may  he  at- 

iii  tiie  nerve  tilnvj 

It  is  prolMided 

img. 

■ilher  at  its  (fiitiv 
pby  of  the  tongue. 
■,  and  there  arc  ti- 
the mueoiis  iiK'iii- 
lation  is  not  hiulIi 
so  is  bilatenil,  the 
h;  it  is  atmiihied, 


and  lannot  be  protrnded.  Speech  and  mastication  are  extremely  ililTieult 
and  deglutition  may  be  impaired.  If  the  seat  of  tin-  disease  is  above  the 
miclt'i,  there  may  be  little  or  no  Avasting.  The  condition  is  seen  in  pro- 
ifivssive  bulbar  i)aralysis  and  occasionally  in  jirogressive  muscular  atrophy. 

The  (li(((jno,si.s  is  readily  made  and  the  situation  of  the  lesion  can 
usaally  be  determined,  since  when  supra-nnclear  there  is  associated  hemi- 
plegia and  no  wasting  of  the  muscles  of  the  tongue.  Nuclear  disease  is 
only  occasionally  unilateral;  most  commonly  bilateral  and  i)art  of  a  Inilbar 
paralysis.  It  should  be  borne  in  mind  that  the  fibres  of  the  hypoglossal 
may  1"  involved  within  the  medulla  after  leaving  their  niudei.  In  such 
a  ease  there  may  be  })aralysis  of  the  tongue  on  one  side  and  ])aralysis  of 
the  Hiiibs  on  the  ojiposite  side,  ami  the  tongue,  when  protruded,  is  pushed 
toward  the  sound  side. 

."^jKisin. — This  rare  atTection  may  be  unilateral  t)r  bilateral.  It  is  most 
fre(|ueutly  a  part  of  some  (ither  convnlsive  disorder,  such  as  ei)ilej)sy, 
ehorea,  or  spasm  of  the  facial  muscles.  In  some  cases  of  stuttering,  spasm 
of  the  tongue  precedes  the  explosive  utterance  of  the  words.  It  may  oc- 
cur in  hysteria,  and  is  said  to  follow  reflex  irritation  in  the  fifth  nerve. 
The  most  remarkaltle  cases  are  those  of  paroxysmal  clonic  spasm,  in  wdiich 
the  tougiie  is  rapidly  thrust  in  and  out,  as  many  as  forty  or  fifty  times  a 
minute.  In  the  case  reported  by  (Jowers  the  attacks  occurred  during 
>lcep  and  continued  for  a  year  and  a  half,  The  spasm  is  usually  bilateral. 
Weiult  has  reported  a  case  in  which  it  was  unilateral.  The  prognosis  is 
usually  good. 


IV.    DISEASES  OF  THE  SPINAL  NERVES. 

Ckuvk'al  Plkxls. 

(1)  Occipitocervical  Neuralgia. — This  involves  the  nerve  territory 
supplied  by  the  second,  the  occipitalis  major  and  minor,  and  the  auricu- 
lavis  inagnus  nerves.  The  pains  are  (diielly  in  the  back  of  the  head  and 
ucek  and  in  the  ear.  The  condition  may  follow  cold  and  is  sometimes 
associated  with  stiffness  of  the  neck  or  torticollis.  Unless  connected  with 
disease  of  the  bones  or  due  to  pressure  of  tumors,  the  outlook  is  usually 
giKid.  There  are  tender  points  midway  between  the  mastoid  process  and 
the  spine  and  just  above  the  parietal  eminence,  and  between  the  stenio- 
niastoid  and  the  tra[)ezius.  The  affection  may  be  due  to  direct  pressure,  in 
[icrsdiis  who  carry  very  heavy  loads  on  the  neck. 

(■-')  Affections  of  the  Phrenic  Nerve.— Paralysis  may  follow  a  lesion  in 
ilu'  anterior  horns  at  the  level  of  the  third  and  fourth  cervical  nerves,  or 
iiuiy  l»e  duo  to  compression  of  the  nerve  by  tumors  or  aneurism.  More 
I'lirely  paralysis  results  from  neuritis. 

It  may  be  part  of  a  diphtheritic  or  lead  palsy  and  is  usually  bilateral. 


I 


t. 


:f^ 


wmm 


HI 


8T2 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


When  the  diiii>liraf^ni  is  iMinily/od  ros[)iriiti()i»  is  carried  on  by  the  inter- 
costal and  uccH'Ssory  niiisclcs.  When  the  jjaticnt  is  (|iiict  and  at  iv>! 
little  may  be  notic<'d,  but  tlie  ai)donien  retracts  in  ins|)irati()n  and  is  I'oivid 
out  in  expiration.  On  exertion  or  oven  on  atteiiii)tin<,'  to  move  there  nmv 
be  dys])n(ea.  If  the  ])aralysis  sets  in  siuhh'nly  there  may  be  ilyiuKia 
and  lividity,  whicli  is  usually  tejuporary  (W.  Pasteur).  Intercurrent  at- 
tacks of  bronchitis  seriously  a;j:<^ravate  the  condition.  D'tticulty  in  ('iiiij.'li- 
ing,  owing  to  the  inipossihility  of  drawing  u  full  breath,  adds  greatly  tn 
the  danger  of  this  comidicatioti,  as  the  mucus  uccumulates  in  the  tubes, 

AVhen  the  phrenic  uerve  is  paralyzed  on  one  side  tlie  paralysis  niav  bi' 
scarcely  noticeable,  1)ut  careftd  inspection  shows  that  the  descent  of  the 
diaphragm  is  much  less  on  the  affected  side. 

The  f/i(i(j/i(tsi.s  of  paralysis  is  not  always  easy,  particularly  in  women. 
who  habitually  use  this  muscle  less  than  men,  ami  in  whom  tlie  ilia- 
phragmatic  breathing  is  less  cons[)icuoiis.  Immobility  of  the  diaplirairiii 
is  not  uncommon,  ])articularly  in  <liaitbragmatic  ])leurisy,  in  large  elTti- 
sions,  and  in  extensive  emi)hyseina.  The  nuiscle  itself  may  be  degener- 
ated aiul  its  power  im])aired. 

Owijig  to  the  lessened  action  of  the  diaphragm,  there  is  a  tendency  tn 
accumulation  of  l)lood  at  the  bases  of  the  lungs,  and  there  may  be  im- 
paired resoiuince  and  signs  of  (cdema.  As  a  rule,  however,  the  j)araly>i< 
is  not  confined  to  this  muscle,  but  is  part  of  a  geiuM-al  neuritis  or  an  an- 
terior polio-myelitis,  and  there  arc  other  symptoms  of  value  in  detenniii- 
ing  its  presence.  The  outlook  is  usually  serious.  Pasteur  states  that  of 
fifteen  cases  following  diphtheria,  only  eight  recovered.  The  treatment 
is  that  of  the  neuritis  or  polio-myelitis  with  which  it  is  associated. 

Hiccough. — Here  may,  perhaps,  best  be  considered  this  remarkable 
symptom,  caused  by  intermittent,  sudden  contraction  of  the  diapliraL'iii. 
The  mechanism,  however,  is  complex,  and  while  the  afferent  iinpressinns 
to  the  respiratory  centre  may  be  peripheral  or  central,  the  efferent  are 
distributed  through  the  phrenic  nerve  to  the  diaphragm,  causing  tlie 
intermittent  spasm,  and  through  the  laryngeal  branches  of  the  vagus  to 
the  glottis,  causing  sudden  closure  as  the  air  is  rapidly  inspired. 

Obstinate  hiccough  is  one  of  the  most  distressing  of  all  symptoms,  and 
may  tax  to  the  uttermost  the  resources  of  the  physician.  W.  Langt'onl 
Symes  in  a  recent  study  groups  the  cases  into : 

{(i)  Inflammatory^  seen  particularly  in  affections  of  the  abdominal 
viscera,  gastritis,  peritonitis,  hernia,  internal  strangulation,  ai)peiiiiiiiti.', 
suppurative  pancreatitis,  and  in  the  severe  forms  of  ty])hoid  fever. 

{b)  Irritative^  as  in  the  direct  stimulus  of  the  diaphragm,  in  the  swal- 
lowing of  very  hot  substances,  local  disease  of  the  oesophagus  near  tlio 
diaphragm,  and  in  many  conditions  of  gastric  and  intestinal  disorder,  more 
particularly  those  associated  with  flatus. 

{c)  Specijic,  or,  perhaps  more  properly,  idiopathic,  in  which  no  evident 
causes  are  present.     In  these  cases  there  is  usually  some  constitutional 


DISEASES  OF  THE  SPINA [i   NERVES. 


873 


taint,  as  gout,  diabetos,  or  clinmic  Bri<,'lit'H  diseiiso.  I  liavo  .soon  sovoral 
iiislaiH't's  of  obstinate  liiccoiigb  in  tlio  lator  sUigo-s  of  chroiiio  inter.stilial 
iit'Iiliritis. 

(//)  Xcurotic,  cases  in  which  the  primary  cause  is  in  the  nervous  .sys- 
tem;  hysteria,  eiMJepsy,  sliock,  or  cerebral  tumors.  Of  these  cases  the 
hv.slcTical  are,  perhaps,  the  most  ob.stiiiate. 

The  treatment  i.s  often  very  unsatisfactory.  fSonietimes  in  the  milder 
torins  a  sudden  reflex  irritation  will  check  it  at  once.  Readers  of  Plato's 
Svinposium  will  remember  that  the  physician  Eryximacluis  recommended 
to  Aristophanes,  who  had  hiccougii  from  eatinjj;  too  niu(;h,  cither  to  hold 
his  Itrcath  (which  for  trivial  forms  of  hiccough  is  very  .satisfactory)  or  to 
pirglc  with  a  little  water;  but  if  it  still  continuetl,  "tickle  your  nose  with 
sdiiu'tliing  and  sneeze;  and  if  yon  sneeze  once  or  twice  even  the  most  vio- 
lent hiccough  is  sure  to  go."  The  attack  must  have  been  of  some  severity, 
as  it  is  stated  subsequently  that  the  hiccough  did  JUit  disappear  until 
.\ristophancs  had  applied  the  sneezing. 

Ice,  a  teaspoonf  ui  of  salt  and  lemon-juice,  or  salt  and  vinegar,  or  ;  'ea- 
spoonful  of  raw  spirits  may  be  tried.  When  the  hiccough  is  due  to  gas- 
tric irritation,  lavage  is  sometimes  promptly  curative.  In  obstinate  csise-s 
the  various  antispasmodics  have  been  used  in  .succession.  l'ilocarj)inc  has 
been  recommended.  One  has  sometimes  to  resort  to  hypodermics  of  mor- 
phia, or  to  inhalations  of  chloroform.  The  nitrite  of  amyl  and  nitro- 
irlyccrine  have  been  beneficial  in  some  cases.  (Jalvauism  over  the  jihrenic 
nerve,  or  pressure  on  the  nerves  a])plied  between  the  heads  of  the  sterno- 
clcido-mastoid  muscles  may  be  used.  In  the  very  severe  forms  all  these 
measures  may  prove  futile. 

Brachial  Plexus. 

(1)  Combined  Paralysis. — The  plexus  may  be  involved  in  the  snpra- 
clavicidar  region  by  compression  of  the  nerve  trunks  as  they  leave  the 
spine,  or  by  tumors  and  other  morbid  processes  in  the  neck.  Below  the 
elavicle  lesicms  are  more  common  and  result  from  injuries  follo»ving  dislo- 
catidii  or  fracture,  sometimes  from  mniritis.  The  most  common  cause 
lit' lesion  of  the  Vrachial  ])lexus  is  luxation  of  the  humerus,  particularly 
the  sul)coracoid  form.  If  the  dislocation  is  rpiickly  reduced  the  symj)- 
tnms  are  rpiite  transient,  and  disappear  in  a  few  days.  In  severe  cases  all 
tlie  branches  of  the  jdexus,  or  oidy  one  or  two,  may  be  involved.  The 
most  serious  cases  are  those  in  which  the  dislocation  is  niidetected  or  nnre- 
iluced  for  some  time,  when  the  prolonged  pressure  on  the  nerves  may  cause 
eomplote  and  permanent  paralysis  of  the  arm.  The  muscles  waste,  the 
veaetion  of  degeneration  is  present,  and  trophic  chiinges  in  the  skin  are 
apt  to  occur.  The  medico-legal  bearings  of  these  cases  are  important,  and 
may  be  thus  briefly  summarized  :  Direct  injury,  as  by  a  fall  or  blow  on  the 
shoulder,  resulting  in  great  bruising  of  the  nerves  without  dislocation,  is 


tLl 


WW 


'■ 


ii  1  = : 


>.• 


m 


: '  r  ■  ..?-:-:-jiiL 


874 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


ocoiusioiially  followotl  by  c()inj)k'to  jjiiralysis  (if  tlio  iirni.  A  (lislooatinn  m;,; 
be  si't  iiiiiiR'diiitcly  and  yet  tlu'  lesion  of  the  Iiracbial  jilexiis  may  Im'  siicii 
ad  tu  caiirio  |)eniianeiit  paralysis  (if  the  nerves.  'I'iio  (lishieatidii  mav  li,. 
redueod  and  the  joint  in  subse(|uent  nidvenicnts  slips  out  a^aiii.  it  Im, 
hi'jipened  that  liy  the  time  the  surgeon  sees  the  jiatieut  again,  the  (laiiia;,'i. 
has  become  irreparable. 

Injuries  and  lilows  on  the  neek  may  cause  partial  paralysis  of  ihc  artii, 
involving  the  deltoid,  supraspinatus,  infrasjiinatus,  biceps,  brachialis  aii- 
ticus,  aiul  the  supinator.  The  injury  nuiy  oceur  to  the  child  durinj;  (lo- 
livery. 

A  primary  neuritis  of  the  brachial  plexus  is  rare,  ^^ore  coiimidnlv 
the  j)r(H:ess  is  an  a.sceiuling  neuritis  from  a  lesion  of  a  peripheral  liiamli. 
involving  first  the  radial  or  ulmir  nerves,  and  sjireading  upward  to  tlu' 
plexus,  producing  gradiudly  complete  loss  of  i)ower  in  the  arm. 

{■i)  Lesions  of  Individual  Nerves  of  the  Plexus.— (^0  ^''>'<[/  T/iararir 

^'errc  (Scrra/iiK  I'dlsii). — 'i'his  occurs  chietly  in  men.  The  nerve  is  iiijiuvil 
in  the  posterior  triangle  of  the  neck,  usually  by  direct  pressure  in  tlic 
carrying  of  loads;  cold  may  cause  neuritis.  It  nuiy  be  involved  alxi  in 
])rogressive  nmscular  atrophy  and  in  ])olio-myelitis  anterior.  When  |iiir- 
alyzed  the  scapula  on  the  alfected  side  looks  winged,  which  results  fnun 
the  j)rojecti()n  of  the  angle  and  pcjsterior  border.  This  is  particuhiilv 
noticeable  when  the  arm  is  moved  forward,  when  the  serratus  no  l(iii}.'(r 
holds  the  scapula  against  the  thorax.  It  is  a  well-defined  and  nadil) 
recognized  form  of  paralysis.  The  onset  is  ass(K'iated  with,  sunu'tiiii(.> 
preceded  by,  neuralgic  ^lains.  The  course  is  dubious,  and  numy  nioiitiij 
nuiy  elapse  before  there  is  any  improvenuMit. 

[h)  Circitiiijh'x  Xi'rir. — This  supplies  the  deltoid  and  tlu'  teres  minor. 
The  nerve  is  apt  to  be  involved  in  injuries,  in  dislocations,  bruising  liv  m 
crutch,  or  sonu'times  by  extension  of  inilamnuition  from  the  joint.  Ocra- 
sionally  the  2)aralysis  arises  from  a  })ressure  neuritis  during  an  illness.  As 
a  conscfpicnce  of  loss  of  power  in  the  deltoid,  the  arm  caniuit  bo  raised. 
The  wasting  is  usually  nuirked  and  changes  the  shape  of  the  slioiiMcr. 
Sensation  nuiy  also  be  impaired  in  the  skin  over  the  muscle.  The  joint 
may  be  relaxed  and  there  may  be  a  distinct  space  between  the  head  of  the 
humerus  and  the  acromion.  In  other  instances  the  ligaments  are  thick- 
ened, and  a  condition  not  unlike  ankylosis  may  be  produced,  wliicli  is 
readily  distinguished  on  moving  tlie  arm. 

{(•)  Muxculo-xpiral  Pdralysis  ;  liadial  Pnmh/sis. — This  is  one  of  the 
most  common  of  peripheral  palsies,  and  results  from  the  exposed  jtositioii 
of  the  musciilo-spiral  nerve.  It  is  often  bruised  in  the  use  of  the  cniteh. 
by  injuries  of  the  arm,  blows,  or  fractures.  It  is  frequently  injured  when 
a  person  falls  asleep  with  the  arm  over  the  back  of  a  cliair,  or  by  {iicssure 
of  the  body  upon  the  arm  when  a  person  is  sleeping  on  a  bench  or  oii  tlie 
ground.  It  may  be  paralyzed  by  sudden  violent  contraction  of  the  triceps- 
It  is  sometimes  involved  in  a  neuritis  from  cold,  but  this  is  uncomniuu  in 


A  (liHlooiiticii  iiijiv 
ilcxiis  may  In-  smli 
lislocatioii  iiiav  li|. 
out  iifriiiii.  Ii  luis 
again,  llu'  (laiiKi;'t. 

ralvsis  ol'  the  arm. 
.'}>s,  bradiialis  aii- 
j  child  diiriii^r  ilv- 

More  odiiiiiMiiilv 
[)erii>hcral  Itiamli, 
iig  upwanl  t(.  till' 
lie  arm. 

[a)  Lun(j  77/iiraiir 
he  nervo  is  iiijiuH'il 

L't   prOSStUT   ill   the 

V  iiivolvi'il  alxp  ill 
'I'ior.  When  jiai- 
'hich  rcsiihs  fnun 
iiis  is  particiilaiiy 
serratiis  ii(»  Idiiirir 
'tuR'd  and  rcadil) 
.  with,  soiiictiiiK- 
iiid  many  iii(iiitli,« 

1  tho  tores  minor. 

ons,  brui.-iiiiir  liy  n 

tho  joint.     Occii- 

\\g  an  ilhu'ss.    .\> 

cannot  he  I'aisi'd. 

of  the  shiiuMiM'. 

usclo.     Tlic  jiiiiit 

n  tlie  head  of  tlie 

mionts  arc  thick- 

oduced,  which  i? 

Phis  is  one  of  the 
exposed  position 
i.so  of  tho  crntrli. 
itly  injured  when 
lir,  or  by  pi'cssnre 
I  bench  or  on  the 
on  of  the  triceps. 
I  is  uncomiiiou  in 


DISEASES  OF   THE  SPINAL  NEIiVES. 


87: 


(■oi)i|iarison  with  other  causes.  In  tlie  siibontaneous  inji'ction  of  olhor  tho 
iiiMVi  nuiy  bo  accidentuUy  struck  and  temporarily  |»aralyze(l.  The  paraly- 
sis of  load  poisoning  is  the  result  of  involvement  of  certain  branches  of 
lhi>  nerve. 

.\  lesion  wlu'ii  high  up  invoh'os  tho  triceps,  tho  brachialis  aiiticns,  and 
flic  supinator  longu.s,  as  well  as  the  extensors  of  the  wrist  and  lingers. 
Nalnrally,  in  lesions  just  above  the  elbow  the  arm  muscles  and  the  supiiia- 
tiir  hiiigns  are  spared.  The  most  characteristic  feature  of  the  paralysis  is 
llif  wrist-drop  and  tho  inability  to  extend  the  first  phalanges  of  the  tingors 
mill  thumb.  In  the  pressure  i)alsies  tho  su|)inators  are  usually  involved 
anil  tho  movements  of  su])inati()i)  cannot  be  accomplished.  The  sensa- 
tions may  be  impaired,  or  there  may  be  marked  tingling,  but  the  loss  of 
,<fiisation  is  rarely  so  pronounco(l  as  that  of  motion. 

The  alTcction  is  readily  recognized,  but  it  is  sonu'tinu'S  dilliciilt  to  say 
ii|i(in  what  it  doi)ends.  The  sleei>  '"'*^  jirossure  palsies  are,  as  a  riiU',  uni- 
lattrnl  and  involve  the  sui)inat<)r  loiigus.  The  paralysis  from  lead  is  lu- 
lutoral  aiul  tho  supinators  are  unatl'ectod.  Hilateral  wrist-drop  is  a  very 
conmion  sym])tom  in  tnany  forms  of  multiple  neuritis,  particularly  the 
aliojiulic;  but  the  mode  of  onset  and  the  involvement  of  tho  logs  and 
iirins  lire  features  which  make  the  diagnosis  easy.  The  duration  and 
loinve  of  the  musculo-spiral  paralysis  are  very  variable.  The  pressure  ])al- 
sics  may  disappear  in  a  few  days.  Kecovory  is  the  rule,  oven  when  the 
atlertion  lasts  for  many  weeks.  Tho  electrical  examination  is  of  im]»or- 
tiiiii  r  in  the  jjrognosis,  ami  the  rules  laid  down  under  ])aralysis  of  the  facial 
iiiTvi'  hold  good  liere. 

The  treatment  is  that  of  neuritis. 

('/)  Ulnar  Xcrrr. — Tho  motor  branches  supply  the  ulnar  halves  of  the 
ilccp  flexor  of  the  linger.s,  the  muscles  of  the  little  finger,  tlu-  intero.ssei, 
tlie  mhluctor  and  the  inner  head  of  the  short  flexor  of  the  tlunnb,  and  the 
iilnnr  flexor  of  the  wrist.  The  sensory  branches  supply  tho  ulnar  side  of 
the  liand — two  and  a  half  lingers  on  the  back,  and  one  atid  a  half  fingers 
on  the  front.  Paralysis  nniy  result  from  ])rossuro,  usually  at  the  elbow- 
joint,  although  tho  nerve  is  hero  j>rotocted.  Possibly  tho  neuritis  in  the 
uhiai  nerve  in  some  cases  of  acute  illness  may  be  due  to  this  cause.  (!owers 
nieiit  tins  the  case  of  a  lady  who  twice  had  ulnar  lU'uritis  after  coidinement. 
Owing  to  paralysis  of  the  ulnar  flexor  of  tho  wrist,  tho  hand  moves  towaril 
tlie  radial  side;  adduction  of  the  thumb  is  impo.ssibie ;  tho  first  phalanges 
eimnot  be  flexed,  and  the  otliers  cannot  be  extended.  In  long-staiuling 
eases  the  first  phalanges  are  overextended  and  the  others  strongly  flexed, 
producing  the  claw-hand  ;  but  this  is  not  so  marked  as  in  the  jirogressive 
niusciilar  atrophy.  The  loss  of  sensation  corresponds  to  the  sensory  dis- 
trihiition  just  mentioned. 

(')  Median  Nerve. — TMiis  supplies  the  flexors  of  the  fingers  except  the 
ulnar  half  of  the  deep  flexors,  the  abductor  and  the  flexors  of  the  thund), 
the  two  radial  lumbricales,  the  pronators,  and  the  radial  flexor  of  the  wrist. 


Tmrrw 


876 


DISEASES  OF  THE  NEllVOUS  SYSTEM. 


The  sensory  (ibros  supply  the  riidial  side  of  the  |iiilin  and  tlie  front  uf  tlu' 
thuinl),  tlic  first  two  liiifrcrs  and  hall'  the  third  rni,i,'cr,  and  tlii'  dorsil  sur- 
fac'i's  of  the  same  three  liii^fers. 

This  nerve  is  seldom  involved  alone.  Paralysis  results  from  iiijin'y 
uiid  oe(!asionaliy  from  neuritis.  The  signs  are  inability  to  |  •ouati'  tlir 
forearm  beyond  the  mid-position.  'I'he  wrist  can  only  be  lli'xed  tduaid 
the  ulnar  side;  the  thumb  cannot  be  opposed  to  the  tips  of  tin;,'crs. 
The  second  phalanges  cannot  l)e  Hexed  on  the  tirst;  the  distal  phalati;,^'s  of 
tlio  first  and  secoiul  fingers  cannot  be  flexed;  but  in  the  third  aiul  I'nuith 
fingers  this  acition  can  be  performed  by  the  ulnar  half  of  the  flexor  pid- 
fundus.  'IMie  loss  of  sensation  is  in  the  region  corresponding  to  the  scnxnv 
distribution  already  mentioned.  'I'he  wasting  of  the  thumb  muscles,  which 
is  usually  marked  in  this  ])aralysis,  gives  to  it  a  eharaeteristie  appeaniiici'. 


'I 
i.i 


h  I'  ;■:  i 


LuMitAU  AND  Sacral  Plexlses. 

The  lumbar  plexus  is  sometimes  involved  in  growths  of  the  lyiiiph 
glands,  in  i)soas  abseess,  and  in  disease  of  the  bones  of  the  vertebra'.  Of 
its  branches  the  ohturntor  nerve  is  occasioimlly  injured  during  parturi- 
tion When  paraly/ed  the  power  is  lost  over  the  adductors  of  the  thi^'h 
and  one  leg  ci'iinot  be  crossed  over  the  other.  Outward  rotation  is  also 
disturbed.  The  anterior  crural  nerve  is  sometimes  involved  in  wouiuls 
(,r  in  dislocation  of  ,lie  hii)-joiut,  less  commonly  during  parturition,  ami 
sonictiuies  by  disease  of  the  bones  and  in  psoas  abseess.  The  speiial 
.symptoms  of  affection  of  this  nerve  are  jtaralysis  of  the  extensoi's  of  the 
knee  with  wastiig  of  the  nuiscles,  aniesthe-  ia  of  the  antero-lateral  parts  df 
thigh  and  of  t!ie  inner  side  of  the  leg  to  the  big  toe.  This  nerve  is  soim- 
times  involved  early  in  growths  about  the  spine,  and  there  may  be  pain  in 
its  area  of  distribution.  IjOss  of  the  power  of  abducting  the  thigh  results 
from  paralysis  of  the  (jlateal  nerve,  Avhich  is  distributed  to  the  gluteus, 
medius,  and  minimus  muscles. 

The  sacral  plexus  is  frequently  involved  in  tumors  and  inflammations 
within  the  pelvis  and  may  be  injured  during  parturition.  Neuritis  is 
common,  usually  an  extension  from  the  sciatic  nerve. 

Of  the  branches,  the  sciatic  nerve,  when  injured  at  or  near  the  initrh, 
causes  paralysis  of  the  flexors  of  the  legs  and  the  muscles  below  the  kiuc, 
but  injury  below  the  middle  of  the  thigh  involves  only  the  latt(M'  muscles. 
There  is  also  anaesthesia  of  the  outer  half  of  the  leg,  the  sole,  and  the  greater 
portion  of  the  dorsum  of  the  foot.  Wasting  of  the  muscles  fretiuintly 
follows,  and  there  may  be  trophic  disturbances.  In  paralysis  of  one  seiatie 
the  leg  is  fixed  at  the  knee  by  the  action  of  the  quadricejjs  extensor  ami 
the  patient  is  able  to  walk. 

Paralysis  of  the  small  sciatic  nerve  is  rarely  seen.  Tlie  gluteus  maxinius 
is  involved  and  there  may  be  difficulty  in  rising  from  a  seat.  There  is  a 
strip  of  antesthcsia  along  the  back  of  the  middle  third  of  the  thigh. 


;■ ," 


DISKASHS  OF  THE  SPINAL  NEIIVKS. 


877 


I  tliP  front  (if  ilif 
(1  tlu'  dorsal  siir- 

iilts  from  iujiirv 
y  to  I  •oiiiilr  the 
bo  lU'Xi'd  toward 

tips  of  (iiiifcrs. 
istal  plialaiiu'ts  df 

third  iiiul  fiiui'th 
i)f  the  tU'Xiir  |ir(i- 
inj^  to  tlic  Hciixjrv 
lb  imisck's,  uliich 
istic  appt'araucc. 


lis  of  tlie  lymph 

lie  vt'rt('l)ra'.    Of 

during  parturi- 

tors  of  tiie  tiiiifli 

•(1  rotation  is  al-n 

.'olvi'd  in  wiiuiul.s 

purtnfition,  ami 

ss.     The  s|H'cial 

extensors  of  tln' 

o-liiteriil  parts  uf 

lis  norve  is  soiiic- 

0  may  he  pain  in 

the  til  iff  li  ivstilts 

to  the  glutcas, 

ul  infliininiatioiis 
on.     Xeiu'itis  is 

near  the  notch, 
below  the  knci', 
le  hitter  niusclfs. 
',  and  the  fri'catiT 
iseles  frequently 
.sis  of  one  sciatic 
ps  extensor  ami 

liiteiiH  nia.xinuH 
ieiit.  There  is  a 
;he  thigh. 


/.'ifmidl  /^opli/ra!  AVy/v.— Paralysis  involves  the  pcronu'i,  the  lonj.?  ex- 
tensor of  the  toes,  tibialis  anticns,  an<l  the  extensor  brevis  digitonnn. 
The  ankle  eannot  be  Hexed,  resnltin,ii;  in  a  condition  knowii  as  foot-drop, 
and  as  till' toes  cannot  be  raised  the  whole  leg  must  bi'  lifted,  producing 
the  characteristic  sfrp/tdi/r  gait  seen  in  so  many  forms  of  peripheral  nen- 
ritis.  In  long-standing  eases  the  foot  is  permanently  exteiidi'd  and  there 
is  wasting  of  the  anterior  tibial  and  peroneal  muscles,  'riie  loss  of  seiisi- 
tidii  is  in  the  outer  half  of  the   front  of  the  leg  and  on  the  dorsum  of 

tilC  foot. 

hilvntdl  ]^n])Jitcal  Xm'r. — When  ])aralyzed  jilantar  flexion  of  the  foot 
and  llcxioii  of  the  toes  are  im[)ossible.  'i'he  foot  cannot  be  addudcd,  nor 
can  the  patient  rise  on  tijitoe.  In  long-standing  ca.ses  talijics  cali-anens 
fdllows  and  the  toes  assume  a  (daw-like  position  from  .secondary  contract- 
ure, due  to  overextension  of  the  proximal  and  llexiou  of  the  second  and 
third  phalanges. 

SciATir.v. 

This  is,  as  a  rule,  a  neuritis  either  of  the  sciatic  nerve  or  of  its  cords 
of  origin.     It  may  in  some  instances  be  a  fiinetional  neuntsis  or  neuralgia. 

It  oceurs  most  commonly  in  ailiilt  male.s.  A  history  of  rheumatism  or 
of  jroiit  is  present  in  many  cases.  Kxposure  to  c(dd,  ]>arli('ularly  after 
heavy  muscular  exertion,  or  a  severe  wetting  are  not  uncommon  causes. 
Within  the  jielvis  the  nerves  may  be  com]tressed  by  large  ovarian  or 
uterine  tumors,  by  lymjihadeiiomata,  by  the  betal  head  during  lai»or,  and 
ot'oa.sionally  lesions  of  the  hip-joint  induce  a  secondary  sciatica.  The  con- 
ilitidii  of  the  nerve  has  been  examined  in  a  ft'W  cases,  and  it  has  often 
lieen  seen  in  the  o])eratioii  of  stretching.  It  is,  as  a  rule,  swollen,  red- 
dened, and  in  a  condition  of  interstitial  neuritis.  The  alVection  may  be 
most  intense  at  the  sciatic  notch  or  in  the  nerve  about  the  middle  of  the 
thigh. 

Of  the  sj/ni/)fo})is,  pain  is  the  most  constant  and  troublesome.  The 
onset  may  be  severe,  with  slight  pyrexia,  but,  as  a  rule,  it  is  gradual,  and 
for  a  time  there  is  only  slight  pain  in  the  back  of  the  thigh,  particularly 
in  certain  positions  or  after  exertion.  Soon  the  ])ain  becomes  more 
intense,  and  instead  of  being  limited  to  the  upper  portion  of  the  nerve, 
extends  down  the  thigh,  reaidiing  the  foot  and  radiating  over  the  entire 
'h.stril)iition  of  the  nerve.  The  jiatient  can  often  jioint  t  the  most  sen- 
sitive spots,  n.sually  at  the  iiotidi  or  in  the  middle  of  the  thigh ;  and  on 
pressure  these  are  ex(piisitely  painful.  T'he  pain  is  described  as  gnawing  or 
burning,  and  is  usually  constant,  but  in  some  instances  is  paroxysmal,  and 
often  worse  at  night.  On  walking  it  may  be  very  great;  the  knee  is  bent 
anil  the  patient  treads  on  the  toes,  so  as  to  relieve  the  tension  on  the  nerve. 
hi  protracted  cases  there  is  wasting  of  the  muscles,  but  the  reaction  of 
Ji'gencration  can  seldom  be  obtained.  In  these  chronic  cases  cramp  may 
occur  and  fibrillar  contractions.     Herpes  may  develop,  but  this  is  un- 


:r| 


tr-t  r 


Iliii 


il-: 


878 


DISKASKS  OV  TIIH  N'HIIVOUS  SYSTKM. 


usual.     Ill  niro   instuiircs  tlio  neuritis  iwcTiids  iiiul    iiivolvofi   tlir   >|i;iii,i 
cord. 

Tlic  (liinitiiiii  iiiid  course  arc  extremely  varialilc.  As  a  rule  it  i>  im 
ol)stiiiati'  alVci'tioii,  lusting  for  iiioiitlis.  or  even,  witli  sli;,dit  rciiiis.-idiis,  fnr 
years.  Iicla)»ses  are  not  iiiicoiiitiioii,  and  tiic  disease  may  hi'  relicNcil  jn 
one  tierve  only  to  appear  in  the  otlier.  In  tiie  severer  forms  the  |iatii m  i, 
bedridden,  and  such  cases  prove  aiiioni,'  the  most  distrcssin;^'  and  ti\iii.' 
wiiich  the  physician  is  cailcil  upon  to  treat. 

Tji  the  iliiti/iiosi.s  it  is  important,  in  the  first  ]ilacc,  to  dctci'miiic  ulntlKr 
tlu'  disease  is  primary,  or  secondary  to  some  alTcction  of  the  pch i- dr  df 
tlie  spiiud  cord.  A  <'arei'iu  rectal  examination  should  he  made,  and.  in 
women,  pelvic  tumor  slioidd  he  exchuhMl.  I.undiairo  may  l)e  cont'duiiiliil 
with  it.  .MTcctions  of  the  liip-joint  ai'c  easily  distinj^niishcd  hv  tln' 
ahscnce  of  tenderness  in  tlic  coui'sc  of  the  nerve  ami  the  sense  of  |i;ii!i 
on  movement  of  the  hip-joint  or  on  pros.sure  in  the  reunion  of  the  tn.. 
chanter.  There  are  instances  of  .sacro-iliac  disease  in  whiidi  the  palifiii 
complains  of  ])ain  in  the  upper  part  of  the  thi<fh,  which  may  soni(tiiii(< 
raiiiate;  hut  cand'ul  examination  will  readily  distinjfuish  hetweiu  tlir 
alTcctions.  Pressure  on  the  nci've  truid\s  of  the  cauda  e(juina,  as  a  nilr. 
causes  bilati-ral  ))ain  and  disturhances  of  sensation,  and,  a.s  double  scialicM 
Is  rare,  these  circumstances  always  suir.ircst  lesion  of  the  nerve  roots.  IV- 
tween  the  severe  lightning  ])ains  of  talx's  and  .sciatica  the  ''ll'ereiues  ;iiv 
usually  well  delined. 

Treatment.— The   Richie   organs  .■^lionld  be  careful. _ .1  systeinati- 

(•ally  exanuned.  ("onstitutioiiid  conditions,  sucdi  as  rheumatism  and  Lrniit. 
should  reci'ive  appropriate  treatiiKMit.  In  a  few  ca.ses  with  proiMuniiiil 
rheunialic  history,  \vhi(di  come  on  acutely  with  fever,  the  salicylates  scnii 
to  do  ijood.  In  other  instances  they  are  (juite  useless.  If  there  is  a  siis- 
pi(;ion  of  syjdiili.s  the  iodide  of  i)otassium  should  be  employed,  and  in 
ijouty  eases  salines. 

Rest  in  bed  with  fixation  of  the  lind)  by  means  of  a  loni:  s]iliiit  is  a 
most  valuable  method  of  treatment  in  many  cases,  one  n]K)n  whidi  W'cii 
Miteholl  has  specially  insisted.  I  have  known  it  to  relieve,  and  in  seme 
instances  to  cure,  obstinate  and  iirotracted  cases  which  had  resiste(|  all 
other  treatment.  Hydrotherapy  is  sometimes  .sati.-^factory,  particularly  tlir 
warm  l)aths  or  the  mud  baths.  ]\Iany  ca.sos  are  relieved  by  a  prolonged 
residence  at  one  of  the  thermal  ,s])rings. 

Antipyrin,  a]>tifebrin,  and  quinine,  are  of  doubtful  benefit. 

Local  applications  are  more  beneficial,  'i'he  hot  iron  or  the  tlicriiio- 
cautcry  or  blisters  relieve  the  pain  temporarily.  Deep  injections  into  tli  ■ 
nerves  give  great  relief  and  may  be  neces.sary  for  the  pain.  It  is  he.-t  tn 
use  cocaine  at  first,  in  doses  of  from  an  eighth  to  a  quarter  of  a  grain.  If 
the  pain  is  unbearable  nuirphia  may  be  used,  but  it  is  a  dangerous  rciniily 
in  sciatica  and  should  be  withheld  as  long  as  possible.  The  disease  is  sn 
l)rotracted,  so  liable  to  relapse,  and  the  patient's  murah  so  undermined  by 


DISKASES  OF  TIIK  SPINAL  NKllVKS. 


87l> 


volvea   tile   M 


iiiiii 


::li1  rciiiissidiis.  for 
liny  he  rt'licvcil  in 
iriiis  llic  |i;iticiit  U 
ri'.sf<iii;,f  and  tniii^' 

(Ic'tiTniiiic  ulictlii  r 

of  tilt'  p('l\i>  (ir  i.f 

be  liiiKlc,  iiiul,  ill 

lay  be  coiirdiiiKJcl 

tiii,<,niislic(l    hy  tlic 

the  sense  <i\'  pain 

rei;i(m  i>\'  the  tni- 

wliicli  the  iiiiticiii 

•ll     llKiy    SOIlHlillU- 

rnisli  between  tlir 
a  e(|iiina,  as  a  rule, 
,  as  <l()uble  seintica 
0  niTvo  mots.  lic- 
tbc     ''Il'erenee>  aiv 

ll. .1  systeiiiati- 

uniatisin  and  !.niiit, 
'  witli  ]>ronniiiiriil 
'  .salicyhites  siriii 
If  there  is  a  sns- 
('nij)hm'd,  and  in 

a  loiiti'  spjinl  i-  a 

ii])on  wliich  Weil' 

ievc,  and  in  sonic 

liad  resisted  ;i!l 

ry,  partieiihirly  tin' 

j(l  by  a  }ir(iliiiii.'i'il 

'iiefit. 

)n  or  the  tliennn- 
injections  iiitu  tli' 
•aiii.  It  is  lie>t  tn 
t(M-  of  a  <.n'ain.  if 
ilaiifferous  reint'dy 

The  disease  is  so 
so  underniiiitd  In' 


tlio  eniistaiit  worry  and  the  sh'uph'ss  iii,t,'lits,  that  the  (hii!;,'er  of  conh'uet- 
iinc  the  niorjdiiii  liabit  i.s  very  great.  On  no  eunsi(h'ration  shoiihl  liio 
iialiriit;  1)1!  permitted  to  use  tlu  hyitoderiiiie  netdh'  liiniself.  It  isreina'k- 
aUi'  how  promptly,  in  fsome  ea.se.s,  tlin  injection  of  distilK-d  water  into  thi- 
iiti've  will  ndievt!  till!  pain.  Aeiipunetiire  may  al>o  be  tried;  the  need h's 
sliiiuld  bo  thrust  deejily  into  tiie  most  painful  spot  for  u  distance  of  al»oiit 
twii  inchcM,  and  left  for  from  liftoeii  to  twenty  minutes.  'I'he  injection  of 
ihldroform  into  the  nervo  lia.s  also  been  recommended. 

KKu'tricity  is  an  uiii:ertain  remedy.  Soinetiines  it  gives  prompt  relief; 
in  other  t.'U.ses  it  may  bo  u.sed  for  weid\s  without  the  slightest  bi'iielit.  It 
is  most  soiviooablo  in  tlio  ehronie  cases  in  which  tluuv  is  wasting  of  the 
k'j;s,  and  should  bo  eombineil  with  massage.  The  galvanii'  current  should 
ill' used  ;  a  Hat  olo(;trodo  should  bo  jiiaceil  over  tho  sciatic  notch,  and  a 
>iiia]hr  one  u.sed  along  the  conr.so  of  t\\{\  nerve  and  its  branches.  In  very 
(ibfltinato  eases  norve-streti'hing  may  be  employed.  It  is  sometimes  suc- 
cessful ;  but  ill  othor  instaiiucs  tlio  eonditiuu  recurs  and  is  us  bud  us  over. 


III.    mSE.VSES   OF  THE   SPINAL  COllD. 

I.  TOPICAL  DIAGNOSIS. 

Wo  have  seen  that  a  lesion  involving  a  dofinito  jiart  of  the  gray  matter 
of  the  lower  motor  segment  is  accompanied  by  loss  of  the  power  to  iior- 
fiirin  certain  dotinito  movements.  A  disease,  such  as  anterior  iiolio-mye- 
litis,  which  is  conlined  to  the  gray  matter  gives  as  its  only  symptom  a 
iliiiracteristic  lower-.segment  paralysis.  Tho  mu.scles  paralyze<l  reveal  tiie 
M'iit  of  the  lesion.  In  many  instances  a  transverse  section  of  the  spinal 
curd  is  involved  to  a  greater  or  le.ss  extent;  if  comjilete,  there  is  lower-seg- 
iiii'iil  paralysis  at  the  level  of  the  lesion.  If  the  niu.scles  so  jiaralyzed  are 
till'  same  on  the  two  sides  of  the  body,  the  lesion  is  strictly  transverse,  for, 
obviously,  if  the  cord  is  involved  higher  on  one  side  than  on  tiie  other  the 
]i;ir;ilyzed  nuuscles  will  vary  accordingly.  IJesides  tho  jiaralysis  due  to 
iuvolvenient  of  tho  lower  segment,  the  niu.scles  whose  centres  are  below 
ilie  losioii  may  also  be  paralyzed  by  the  invohement  of  the  upjier  segment 
ill  the  pyramidal  tract,  and  jiresent  all  the  characteristics  of  such  a  paraly- 
sis. The  degree  of  the  jiaralysis  depends  mion  the  intensity  of  the  lesion 
of  the  {lyramidal  tract,  and  varies  from  a  slight  weakness  in  tho  ilexion  of 
tlu' ankle  to  an  absolute  paralysis  of  all  the  nuiscles  behjw  tho  lesion.  The 
sphincter  muscles  of  the  oladder  and  rectum  are  also  often  2>uralyzed. 

Sensory  symptoms  are  usually  not  as  prominent  as  the  motor  symp- 
tom:^, but  when  the  spinal  cord  is  much  di.seasod  there  is  a  dulling  of  scn- 
^iitiuu  all  over  ihe  body  below  the  lesion.  Tho  upper  border  of  disturbed 
si'U.>iiiion  often  indicates  the  level  of  the  di.seaso,  especially  when  this  is  in 
the  dorsal  region,  where  the  corresponding  motor  paralysis  is  not  easy  to 
ili'iuoiistrate.  It  is  to  be  noted  that  the  ana'sthesia  does  not  reach  quite 
50 


: 


i: 


i'fef: 


I  :  ;|  if 


880 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


i::- 


{<#*»;. 


to  the  level  of  the  lesion  ;  tluis  if  the  fifth  dorsal  sef];nio!it  is  involvt'd,  (ho 
antvsthesiii  will  iiirludc  the  area  sdpplied  by  the  sixth  se<,nn('Ht,  hut  luit  ilmt 
supplied  by  the  fifth.  Tliis  is  due  tu  the  overlap])injj;  of  the  areas.  Tlu'iv 
is  often  a  narrow  zone  of  hypera'sthesia  above  the  una'stlietie  rej^ion. 

When  the  transverse  lesion  is  complete  and  the  lower  part  of  the  cdnl  i-; 
cut  off  from  all  inlliienee  from  above,  there  is  complete  sensory  and  inntur 
paralysis,  and  tlie  deep  rdlexes  instead  of  beinj;^  exa<j:gerated  are  lo-t. 

The  dillVrent  rellcxes  are  dependent  U])on  dilTerent  levels  of  the  cdiil 
(see  Starr's  table),  and  their  absence  or  presence  may  he  importatit  lonili/.- 
iiiir  symptoms. 

Unilateral  Lesions.— The  motor  symptoms  which  foil.iw  lesion?!  (Hill- 
fined  to  one  half  of  the  ero.-js-section  of  the  spinal  cord  follow  the  Siiiin! 
rules  as  those  jfiven  for  transverse  lesions,  except  that  they  are  conliiicd  to 
one  side  of  the  body — that  is,  they  are  on  the  same  side  as  tiie  lesion. 

The  sensory  sym|)iomsare  peculiar.  On  the  side  corresi»ondinir  to  the 
disease — the  paralyzed  sidi^ — there  is  anaesthesia  corresponding  to  tlicsig- 
ment  of  the  cord  involved  ;  above  this  there  is  a  narrow  zone  >if  livjicra's- 
thesia,  but  below  this  there  is  no  diminution  in  the  senses  of  toiicii,  puin, 
or  temperature;  indeed,  there  is  often  hypera^sthesia.  The  niuscuhir 
Reuse,  ho\vev(n',  is  impairc(|.  On  the  side  opposite  to  the  lesion  tiicre  niiiv 
be  complete  loss  of  the  sense  of  touch,  pain,  and  temperature,  or  it  may  onlv 
involve  one  or  two  of  these,  pain  and  temperature  usually  being  associati'iL 

The  following  table,  slightly  modified  from  (lowers,  illustrates  tluiii>- 
tribution  of  these  symptoms  in  a  complete  hemi-lesion  of  the  cord : 

(Wd. 


Zoneof  I'litaiu'oiis  liyiicni'stlu'sin. 
Zone  of  ciUaiicous  aiia'sllusi;i.   . 
Lower  segaiont  jiaralysis. 


Upper  sejafmont  paralysis. 

Hy|ti'ra'sth»'.--ia  of  skiti. 
Miisciili'T  st'tisc  impairi'd. 
Kefli'X  iiclioii  Tirst    Ic'sseiu'il  und 

then  iiuTcascd. 
Temperature  raised. 


Lesion. 


Museular  i)o\ver  normal. 
Ijoss  of  seiisiliilily  nf  ^kill. 
Muscular  sense  noiiiial. 
Keflex  action  normal. 
Tempenilure  same  as  that  alwve 
lesion. 


It  is  on.y  in  exceptional  cases  tliat  all  these  features  arc  met  with,  for  tlicy 
vary  with  its  extent  and  intensity. 

This  coniliination  of  symptoms  avjis  first  recognized  by  lirown-Srijimnl, 
after  whom  it  has  l)een  nanu'd.  Tt  may  follow  tumors,  stab-wounds  fr  t- 
ture  and  caries  of  the  s])ine,  and  it  is  not  infrecpiently  associated  *  iili 
syringo-myelia  a;id  ha'uiorrhages  into  the  cord. 

The  explanation  of  the  di.-Jturbance  in  sensation  is  iiot  satisf.ictorv  ;inil 
cannot  be  until  our  knowledge  of  the  paths  of  sensory  conduction  is  iiieiv 
accurate.  These  cases  have  convinced  most  clinicians  that  in  in.in  tl'i' 
paths  for  toue^,  pain,  and  tem])eratiire  cross  the  middle  line  soon  after 
entering  the  spinal  cord,  and  proceed  toward  the  brain  in  the  op[>osite 
side,  while  that  for  nmscular  sense  remains  in  the  posterior  coluniiis  of 


AFFECTIONS  OF  TITK   IMENINGES. 


SSI 


the  s;imo  side.  We  have  seen  (page  825)  that  anatomy  loiuls  some  sup- 
iidit  to  this  view,  aiul  this  is  the  explanation  that  is  usually  given.  The 
oxiH'iinients  on  animals  have  thrown  some  donht  on  this  view.  es])eeially 
ilidse  of  Mott  on  monkeys,  whi"h  seem  to  in(li<'ate  tliat  the  s  'i  ry  paths 
fur  the  most  part  remain  on  the  same  side  of  the  eord. 

Systemic  Degeneration. — 'l'i>e  long  tracts  of  the  cord  «■  u;:'''mes  under- 
(;o  degeneration.  This  is  nearly  always  secondary  to  so;i>''  lesion,  either 
iibovo,  causing  degt?\ei'i'tioii  in  the  jiyramidal  tracts  (deseeiiding  degenera- 
tion), or  hel(»w,  causing  degeneration  in  the  posterior  cdllnnns,  the  direct 
(vi'fl)ellar  and  the  antero-lateral  ascending  tracts  (ascending  degeneration). 
Lesions  ailecting  the  si)inal  ganglia  or  posterior  spinal  rot)ts  cause  ascend- 
ing degeneration  confined  to  the  posterior  columns  of  the  spinal  cord. 

Sfcondarv  dei;(>neration  in  the  pvnimidiil  tracts  is  believed  to  cause,  or 
iitaiiy  rate  to  accompany,  the  symptoms  which  give  to  the  upper-segment 
piinilysis  its  special  characteristics.  These  are  increased  muscular  tension 
ami  txMggcrated  tendon  rellexes  (the  spastic  condition)..  Therefore,  when 
this  sjiastic  condition  is  ])resent  we  assume  that  the  pyramidal  tracts  are 
iligt'iierated,  and  in  certain  cases  in  which  there  are  no  other  symjjtoms 
it  is  iu'lieved  bv  some  observers  that  the  disease  consists  in  a  primarv  de- 
generation  of  the  tracts  (primary  lateral  sclerosis}. 

Ascending  secondary  degeneration  gives  no  symptoms  by  whitli  we  can 
iletciiiiine  its  presence^  but  disease  involving  the  {)Os(erior  columns  is  of  ten 
1  sm'iated  with  ana'sthesia  andlnuscular  inco-ordiiuUion  (ataxia).  We  iiot 
infrei;uently  have  ataxia  combined  with  the  spastic  contlition,  due  to  in- 
volvonient  of  both  the  posterior  and  lateral  columns  (combined  sclerosis). 


fll-1 


met  with,  fur  llic)' 


II.    AFFECTIONS    OF    THE    MENINGES. 

DisKAsEs  or  Tin;  Dlua  Matku. 

Pachymeningitis. — The  dura  mater  of  the  cord  ,s  separated  by  a  loose 
connortive  tissue  from  the  bony  canal  in  which  it  lies,  aiul  an  inllamturt- 
tion  iiiiiy  involve  either  its  outer  or  its  iniu'r  aspect;  hence  the  division 
into  pachymeningitis  externa  and  interna. 

{ii)  Pfi('fii/meniii(/ifis  ILrtcnia. — This  is  iiivaiinbly  a  secondary  inflam- 
niati(»n  ami  is  occnsionally  met  with  in  an  avittc  form  in  caries,  in  syphi- 
litic alTci'tions  of  the  bone,  in  tumors,  or  in  aii'MirisU:.  Abscess  may  [iciie- 
tnite  the  spinal  canal,  or  the  inllammation  n-ay  even  extend  to  the  pcri- 
'lunil  tissue  in  long-stimding  decubitus.  'J'ho  symptoms  are  usiuilly  th(>se 
"f  .1  compression  myelitis. 

Till'  r/iroin'r  form  of  extermd  iiachymeningitis,  also  a  secondfiry  alTcc- 
'i'Mi,  is  much  more  common.  It  is  a  constant  accontpaniment  of  tuber- 
'iilous  disease  of  the  si)im>  and  plays  a  very  important  part  in  the  prodiu'- 
tMii  (if  I  he  symptoms.  The  alTection  may  be  eontined  to  the  part  in 
iiinut'diute  connection  with  the  local  disease,  but  in  sotne  cases  the  sub- 
'liinil  space  over  six  or  eight  vertebra;  is  occui)ied  by  caseous  masses. 


I  i 


if 


I' , 


)\  i 


'f 


f 


882 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


Tlie  cord  at  the  site  of  tlie  curvature  in  Pott's  disease  may  be  com  pressed 
Avith  perliaps  little  or  no  involvement  of  the  pia  mater.  The  internal  sur. 
face  of  the  dura  may  be  perfectly  smooth,  perhaps  a  little  iidhereiu  lo  tlie 
arachnoid,  while  the  external  dura  is  thicL-ened,  rough,  and  covered  uith  a 
cheesy  substance  of  a  variable  degree  of  consistence.  In  some  iii.-iaiiiis 
the  dura  is  completely  surrounded  by  this  nuiterial ;  in  others  it  is  cliicily 
on  the  anterior  surface.  AVe  can  understand  the  recovery  in  cases  of  coin. 
})ression  ])araplegia  if  we  bear  in  mind  that  in  large  jiart  tlu^  actual  ((hh. 
j)ression  is  })roduced  by  this  material  between  the  diseased  vertelii;e  ami 
the  dura  mater.  The  symptoms  are  those  of  myelitis  from  compicj-sinn. 
often  with  signs  of  involvement  of  the  nerve  roots,  such  as  will  he  iiuii- 
tioned  in  the  next  section. 

(/y)  PiirlijiinciiiiKjiliH  iiilcnid,  described  by  Charcot  and  JofTrov.  in- 
volves chit'tly  the  cervical  region  (/'.  (rrriralis  /n//iniroj)/iin/).  Tli.' 
interspace  betwt'eii  the  cord  and  the  dura  is  occai)ied  by  a  firm,  ciuurn- 
trically  arranged,  librinous  growtli,  which  is  seen  to  luive  developed  wiiliin. 
not  outside  of,  the  dura  mater.  It  is  a  condition  anatomically  idiiitical 
with  the  liaMuorrhagie  |)achymeningitis  interna  of  the  brain.  The  ((inl 
is  u.sually  compressed  ;  the  central  canal  may  ho  dilated — hydromveliis— 
and  there  are  secondary  degenerations.  The  nerve  roots  are  invnhcil  i:. 
the  growth  and  are  damaged  and  comi)ressed.  The  extent  is  varialik'. 
It  may  be  limited  to  one  segment,  but  more  commonly  involves  a  cnn- 
si(ieral)k  ])ortion  of  the  cervical  cidargeirtent.  The  disease  is  clirDiiir, 
and  in  s  une  cases  presents  a  characteristic;  group  of  symi)toms.  Tluiv 
arc  intense  neuralgic  pains  in  the  course  of  the  nerves  whose  mots  aiv 
involved.  They  are  chiefly  in  the  arms  and  in  the  cervical  region,  ami 
vary  greatly  in  intensity.  There  may  be  hypera'sthesia  with  numbness  ami 
tingling;,  atro[)hic  changes  may  develop,  and  there  may  be  areas  of  aii;v>- 
tiu'sia.  (iradually  motor  disturbances  appear;  the  arms  become  weak  iniil 
the  muscles  atrophied,  particularly  in  certain  groups,  as  (be  flexors  of  tin 
hand.  'I'he  extensors,  on  the  other  hand,  remain  intact,  so  that  tliecdii- 
dition  of  claw-hand  is  gradually  produced.  The  grade  of  the  ati'(i|iliy 
de])ends  nnich  upon  the  extent  of  hivolvemcnt  of  the  cervical  nerve  routs 
and  in  many  eases  the  atrophy  of  the  muscles  of  the  shoulders  ami  arms 
bjcoiiu^s  extreme.  The  conditioTi  is  one  of  cervical  para[)legia,  with  ((.ii- 
fractures,  llexion  of  the  wrist,  and  ty])ical  iii/ini  nt  f/rijff.  Tsually  lieforo 
the  arms  are  greatly  atrophied  there  are  the  symptoms  of  '  hat  the  Fiviicli 
writers  term  the  second  stage — tiamely,  involvement  of  the  lower  exlictiii- 
ties  and  the  gradual  production  of  a  spastic  parajdegia,  which  may  (Ievt'|ii|i 
several  months  after  the  onset  of  the  disease,  and  is  diu'  to  secondiirv 
changes  in  the  cord. 

The  disease  runs  a  chronic  course,  lasting,  ])erhaps,  two  or  more  years. 
In  a  few  instances,  in  which  symptoms  pointed  definitely  to  thiscoiulitinii, 
recovery  has  taken  place.  The  disease  is  to  be  distinguished  from  amyn- 
trophic  lateral  sclerosis,  syringomyelia,  and  tumors.     From  the  fii>titis 


AFFECTIONS  OF  THE   MENINGES. 


S83 


ity  bo  coniitrossod, 
'I'lic  inlci'iial  <\\\: 
lo  iullic'iviit  III  ihe 
iiid  eovornl  with  a 
[n  Koiiio  iiisiaiici'S 
others  it  is  diit'lly 
ly  ill  cast's  nf  ann. 
I't  the  iu^tiial  ((iiii- 
iiuseil  vertc'l)ra'  and 
"rciin  p()iii|irc,-si(iii. 
■h  as  will  he  iin'ii- 

t  and   .TdfTniy,  in- 
vrtropliini).     '\\\r 
by  a  firm,  cihutii- 
?  (U'Vt']<>[)i'(l  witliin. 
tomically  idi'iiiical 
'  l)raiii.     '{"lie  ((inl 
(1 — liydroiiiychis— 
)ts  are  iiiv<ihi'il  i;: 
extent  is  varialilu. 
ily  involves  a  cnn- 
disease  is  i-jirdiiic 
symptoms.     Tluiv 
s  whose  riMits  aiv 
vieal  reirimi,  anil 
ith  nmiddu'ssaiitl 
he  areas  of  ana>- 
heconu'  weak  ami 
(be  flexors  (if  lli^ 
,  so  that    llic  '•1111- 
e  of  the  atnipliy 
rvieal  nerve  rents. 
loiilders  and  arms 
apU'fiia,  Willi  ci  li- 
(>.     Tsiially  hefin'o 
>  bat  the  Krciidi 
the  lower  extn-tni- 
wbieb  may  (h'Vcl<i|i 
liie  to  st'i'iiiidary 

wo  or  more  yi'iirs. 
to  thiscoiiilili'iii, 
ished  from  aiiiyi- 
'roin  the  tir>t  it  '^ 


jpjianitod  by  tlie  marked  severity  of  the  initial  jtains  in  the  nook  and  arms; 
{rum  the  second  by  the  absence  of  the  sensory  chanj^es  characteristic  of 
svnii,:,''omye]ia.  From  certain  tnm(;rs  it  ia  very  dillieidt  to  distingnish, 
us,  in  fa(!l,  the  lihrinons  layers  form  a  tnmor  aronnd  X\w  cord. 

The  condition  known  as  /iiptiutfofiia  of  the  dnra  mater  may  occnr  at 
iinv  part  of  the  cord,  or,  in  its  slow,  progressive  form — ])achymeningitis 
lia'iiiorrhagica  interna — may  be  limited  to  the  cervical  region  and  prod  nee 
the  .symptoms  jnst  mentioned.  It  is  sometimes  extensive,  and  nniy  coexist 
wiili  a  similar  condition  of  tlie  cerebral  dura.  Cysts  may  occur  filled  with 
liiLinorrhagic  contents. 

Diseases  of  the  Pi.v  Mater. 

(")  Acute  Spinal  Meningitis;  Leptomeningitis. 

Etiology. — spinal  meningitis  occurs:  (1)  In  tuberculosis.  Tliis  ia 
jit'ihaps  the  most  common  form  in  general  practice  and  has  already  been 
niiisidered-  (2)  In  specific  cerefjro-spinal  meningitis,  Avliich  occurs  en- 
ili'irirally  or  epidemically,  and  has  also  been  considered  under  its  ajjpro- 
priate  section.  (;))  As  a  secondary  involvement  in  certaiji  infectious  dis- 
iiiscs  pneumonia,  small-pox,  scarlet  fever,  and  typhoid  fever.  This  form 
i-  very  rare  Even  in  pneumonia,  in  which  tlie  cerebral  meninges  are 
fiv{|iieiitly  involved,  the  spinal  meninges  are  seldom  affected,  except  i)er- 
liaps  in  the  first  two  or  three  inches  of  the  cervical  region.  (4)  From  in- 
jury or  the  extension  of  inflamnuition,  as  after  ojieration  on  spina  bifiiia. 
("i)  There  are  cases  in  which  the  meningitis  ai)i)ears  to  have  followed  e.x- 
posiin  to  cold  and  wet. 

Morbid  Anatomy. — The  affection  may  i)c  diffused  ovit  the  entire 
I'unl  'ir  localized  to  the  cervical  region.  Tn  th(>  early  stage  the  vessels  of 
the  pia  mater   are    inje(;ted.     The   tlni  'In'   ])ia-arachnoid   space    is 

sliirlitly  turbid.  In  some  inten.se  grades,  on  (»peiiing  the  dnra  the  contimt 
iif  the  cord  cannot  be  seen,  as  it  is  (uimpletely  (•nvi!..ped  in  a  sero-fiiirin- 
"us  ()!•  purulent  exudate,  wliicdi  here  and  there  caus.-:  bulging  't'  tho 
iirarlin()i<l.  Owing  to  the  position  of  the  body,  the  exudate  i.s  most 
ahuiiilant  in  the  posterior  jiart,  or  sinks  to  the  lumbar  region.  In 
111  lite  cases  the  pia  itself  does  m)t  look  thickened,  Imt  in  moie  chronic 
furms  the  membrane  may  1)(>  grayish  and  turbid.  In  a  nnij  ;-itv  of  in- 
stances, if  the  inflammation  is  inten.-^e,  the  exudate  is  seen  in  the  anterior 
:i!iil  pdsterior  median  fissures  and  the  cortical  ])ortioti  of  the  ciud  is 
swollen  and  infiltrated,  so  the  condition  can  be  properly  called  mc  uigo- 
niyelitis.  The  affection  may  be  limited  to  the  s})inal  meninges,  ^mt  in  a 
luajdiity  of  instances  it  is  a  cerebro-spinal  lesion. 

Symptoms. — These  have  already  been  referred  to  in  considei'ing  the 
two  cdiiimonest  varieties,  the  tuberculous  and  the  epidemic.  'I'he  disease 
often  sets  in  with  u  chill  and  fever.  Pain  in  the  back,  stiffness  in  the 
iKH'k,  pain  on  pressure  along  the  vertebne,  tremor  or  spasm  of  the  muscles, 
auil  (liriturbauces  of  sensation  are  usually  present.     CJirdlo  sensations  are 


884 


DISEASES  OF  THE   NERVOUS  SYSTEM. 


! 


not  common.     Tlio  roflcx'os  may  be  increased.     Tiater,  p.iralytic  symptoms 
may  develop,  but  they  are  uncommon,  except  in  pure  s])inal  meningitis. 

Tlie  (lidi/iiDsi.s  is  often  dillicult.  In  a  larffe  ])n){Mn'ti()n  of  the  ciiscs 
.supposed  to  be  spinal  menin<!;itis  the  membranes  are  not  inllamed.  I  liave 
already  referred  to  the  identity  of  the  spinal  sympt(»ms  in  certain  of  the 
infectious  di.seases  with  tliose  of  acute  leptomeiungitis.  In  the  ca>i' of  a 
patient  witli  high  fever,  marked  stiffness  of  the  back  and  neck  mnsclos,  or 
o]tisthot(Mius  witli  rigidity  and  tremor  of  the  muscles,  it  is  not  uiiiiiitiiral 
to  make  a  positive  diagnosis  of  spinal  meningitis,  but  every  Kymptimi  of 
the  condition  may  be  present  Avithout  any  inllammatory  exudate.  The 
truth  of  Stoke's  dictum,  already  quoted  (p,  '^0),  has  Ijccn  brought  lionio 
to  me  on  many  occasioiis.  On  the  other  hand,  there  are  instanoos  of 
Avell-marked  leptomeningitis,  more  particidarly  the  cendjro-spinul  form, 
;n  whieli  spinal  symptoms  are  trifling  or  absent.  To  distinguish  hctwoen 
the  different  forms  of  spinal  meningitis  is  sometimes  extremely  dinioiilt. 
A  correct  diagnosis  is  oftencst  made  in  tuberculous  cases,  since  hero  the 
prodronu^s  are  well  defined  and  the  symptoms  indicative  of  involvoiucnt 
of  the  cerebral  meninges  well  marked.  There  are  cases  in  which  the 
si)inal  meninges  bear  the  brunt  of  the  alTection.  I  have  already  refornd 
to  one  case  in  which  the  meningitis  was  thought  to  be  due  to  trauma- 
tism. The  coexistence  of  disease  at  the  apex  of  the  lungs  or  of  local 
tuberculous  lesions  elsewhere,  as  in  a  testis,  is  of  great  value. 

The  diagnosis  of  tlie  epidemic  form  lias  already  been  considered. 

{/))  Chronic  Leptomeningitis. — As  a  prinuiry  lesion  this  is  extrennlv 
rare.  It  sometimes  follows  the  prolonged  us(!  of  alcohol.  It  occiiis  in 
conne('ti<ni  with  syphilis,  trauma,  and  as  a  complication  of  various  silr- 
roses  of  the  spinal  cord,  either  systemic  or  insular. 

Anatomically  the  condition  is  characterized  by  a  thickening  aiu!  tur- 
bidity of  the  pia,  often  Avith  adhesions  to  the  arachnoid  ami  the  ihna. 
The  membranes^;  may  1)0  stained  with  blood-pigment.  Thesn  altenitioii> 
may  occur  in  localized  s[)ots  or  over  extensive  areas.  The  nerve  roots  may 
be  involved  and  thicketu'd.  The  spinal  cord  itself  is  rarely  alTirtril. 
though  strands  of  connective  tissue  may  exteiul  into  the  cortical  zein', 
jiroducing  slight  sclerosis.  The  opaque,  Avhite,  cartilaginous  jilates  w 
occur  so  often  on  i\w  posterior  .surface  of  the  spinal  arachnoid  and  ar 
sometimes  adherent  to  the  pia  cause  no  symptoms  and  are  not  to  he  mi-- 
taken  for  this  chronic  ineningitis. 

The  ni/mpfoms  of  this  form  are  indefinite.  Sini])le  thickening  of  tlio 
meninges  may  jiroduce  no  signs  during  life  unless  the  spinal  nerve  roots 
are  invf)lved.  In  any  case  the  diagnosis  is  somewhat  doubtful.  Tliore 
are  instances  in  whi(di  ])ain  in  the  back,  stitTness  of  the  dorsal  Tinisdos, 
and  i)ains  radiating  in  the  nerves  of  the  trunk  or  in  the  extremities  have 
been  marked.  IIypera\sthesia  and  skin  eniptions  may  be  present.  Wlmi 
the  cord  is  involved  paralytic  sym{>toms  may  develop.  The  reflexis  luv 
increased.     The  course  is  always  ch  ionic,  lasting  for  many  years. 

The  treatment  is  purely  symptomatic.    Recovery  probably  never  occurs. 


ell 
V 


■  V 


m. 


aralytin  symptoms 
idiil  iiii'iiiii^iiis. 

rtioM    of  the   ciin'S 

iiill!tm(.'(l.     I  l;:iv|. 
?  in  oortiiiii  (if  the 

In  tlio  f'a>i'  of  ;i 
1  iK'C'k  iim.xlfs,  or 
t  is  not  uiiii;ituriil 
every  8yni]itipm  of 
)ry  cxiuliitc,  Tho 
.'cn  brouglit  liorno 
!}.  are  instancos  of 
r(;l)ro-s|)inal  ninii, 
istingiiisli  Ix'twccn 
i'xtromcly  (lilVuiiIt. 
,«C'S,  since  licrc  the 
ve  of  involv(MT)ont 
'USOH  in  wliicli  flic 
vv,  already  fcfcnvd 
be  duo  to  triiuMia- 

lungs  or  of  local 
alue. 
1  considered. 

tliis  is  extronioly 
mol.  It  occurs  ill 
HI  of  various  self- 

lickcninp  and  tiir- 
»i(I  and  tlic  iliiia. 
'I'licsc  altcr;itioti> 
c  nerve  nmls  may 
s  rarely  alTccU'il. 
tlie  cortii'al  zone, 
nous  plates  wliicli 
iraelmoid  and  aiv 
are  not  to  be  iiiiv 

tliiekenin^  of  tlie 
spinal  nei'vc  roots 
doubtful.  Tluiv 
le  dorsal  musclis. 
e  extremities  liaw 
)c  present.  Wlicii 
The  reflexes  aiv 
Tiy  years, 
ably  never  occurs. 


AFFECTIONS  OF  THE  MENINGES. 


885 


II.I-MORRIIAOE   INTO  THE    Sl'INAL   ^fEMUK A  XKS  ;    TI.T:M  ATOURIIArillS. 

Ill  meningeal  apoplexy,  as  it  is  called,  the  blood  may  be  between  the 
iluni  mater  and  the  spinal  canal — extra-meningeal  hivniorrhago — or  within 
the  dura  mater — intra-meningeal  luemorrhage. 

(i/)  E.rtra-iiH'iiiiKjvdl  J/(nnorrJi(i(je  occiiv&  usually  as  a  result  of  traunui. 
Tlic  exudation  may  be  extensive  without  compression  of  the  cord.  The 
Mood  comes  from  the  large  plexuses  of  veins  which  surround  the  dura. 
The  rupture  of  an  aneurism  into  the  spinal  canal  may  i)roduce  extensive 
and  rapidly  fatal  luemorrliage. 

(//)  I)ifni-me)iinf/('(il  IliPmorrluKjc  is  rather  more  common,  but  is  rarely 
extcii.-ive  from  causes  acting  directly  on  the  spinal  nu'iiinges  themselves. 
Scattered  hicmorrhages  are  not  unfrecpient  in  the  acute  infectious  fevers, 
and  I  have  twice,  in  malignant  small-pox,  seen  nnudi  elTusion.  Bleeding 
occurs  also  in  death  from  convulsive  disorders,  such  as  ciiilepsy,  tetanus, 
and  strychnia  poisoning.  The  most  extensive  luemoi'rhages  occur  in  cases 
ill  which  the  blood  comes  from  rupture  of  an  aneurism  at  the  base  of  the 
liraiii,  either  of  the  basilar  or  vertebral.  In  scvei'al  cases  of  this  kind  1  have 
found  a  large  amount  of  blood  in  the  spinal  meninges.  In  ventricular 
apoplexy  the  blood  may  pa.ss  from  the  fourth  ventriele  into  the  spinal 
iiu'iiiiiges.  There  is  a  specimen  in  the  nudical  museum  of  .Me(iill  College 
of  the  most  extensive  intraventricular  htemorrhage,  in  wlii(di  the  blood 
passed  into  the  fourth  ventricde,  and  descended  beneath  the  s])inal  arach- 
noid for  a  considerable  distance.  On  the  other  hand,  luemorrliage  into 
the  spinal  meninges  may  possibly  ascend  into  the  brain. 

The  xyiiiptoinH  in  moderate  gradi^  may  be  slight  and  indefinite.  In 
the  non-traumatic  cases  the  luemcjrrhage  may  either  come  on  suddenly  or 
after  a  day  or  two  of  uneasy  sensations  ahtng  the  spine.  As  a  rule,  the 
onset  is  abrupt,  with  sharp  pain  in  the  bacdv  and  sym[»ti»ms  of  irritation  in 
the  eeiirse  of  the  nerves.  There  may  be  muscuhir  spasms,  or  paralysis  may 
lonie  on  suddenly,  either  in  the  legs  alone  or  both  in  the  legs  and  arms. 
In  some  instances  the  paralysis  deveh)ps  more  slowly  and  is  not  comjdete. 
There  is  no  lo.ss  of  consciousness,  and  there  are  no  signs  of  cerebral  dis- 
turbance. The  clinical  picture  naturally  varies  with  the  site  of  the  ha'mor- 
rliag-o.  If  in  the  lumbar  region,  the  legs  alone  arc  iiiv(dved,  the  reflexes  may 
be  abolished,  and  the  action  of  the  bladder  and  rectum  is  iiniiaircd.  If  in 
the  dorsal  region,  there  is  more  or  less  compk'te  paraplegia,  the  reflexes  are 
usually  retained,  and  there  are  signs  of  disturlKince  in  thc'thoracic  nerves, 
?ucli  as  girdle  sensations,  pains,  and  sometimes  eruption  of  herpes.  In  the 
cervical  region  the  arms  as  well  as  the  legs  may  be  involved  ;  there  may 
be  (lifliculty  in  breathing,  stiffness  of  the  muscles  of  the  neck,  and  occa- 
sionally jmpillary  symptoms. 

Tlie  prognosis  depends  much  upon  the  cause  of  the  haemorrhage. 
Recovery  may  take  i)lace  in  the  traumatic  cases,  and  in  those  associated 
«'ith  the  infectious  discuses. 


*. 

.    m 


■\  \ 


m^'i 


'!if 

'fl 

•1 

i 

i 

1 

s 

i 

880  DISEASES  OP  THE  NERVOUS  SVSTEV. 


III.    AFFECTIONS    OF   THE    BLOOD-VESSELS. 


Im 


{(i)  Congestion. — Apart  from  iic'iii.  myelitis,  we  ruroly  sec  \mi:-\  iiKir- 
tem  evidc'iici's  of  (.'oiijfostioii  of  tlic  spinul  ('ord,  aiul  wlioii  wo  do  it  is  usu- 
ally limited  eitlier  to  the  fjray  matter  or  to  a  definite  portion  of  tlic  (ir;r;iu. 
There  is  necessarily,  frojn  the  [xistiire  of  the  hody  ])ost  mortem,  a  urenicr 
de;:;ree  of  vascularity  in  tlu^  jiosterior  portion  of  the  cord.  'J'he  while  mat- 
ter is  rarely  found  congested,  even  when  inflamed  ;  in  fact,  it  is  reuiurka- 
blo  how  uniformly  ])ale  this  portion  of  the  cord  is.  The  j^ray  matter  ofim 
lias  ji  retldish-pink  tint,  hut  rarely  a  deep  reddish  hue,  exce|it  when  invc- 
litis  is  present.  If  we  know  little  anatomically  of  conditions  <jf  coniris. 
tion  of  the  cord,  we  know  less  clinically,  for  there  are  no  features  in  aiiv 
way  characteristic  of  it. 

{/')  Aniemia. — So,  too,  with  thisT,  state.  There  may  be  extreme  L'radts 
of  anu'mia  of  the  cord  without  symptoms.  In  chlorosis  and  jieriiicidus 
una>mia  there  are  rarely  symptoms  pointinii  to  the  cord,  and  there  is  im 
reason  to  suj)pose  that  such  siMisations  as  heaviness  in  the  iimhs  and  tin- 
gling are  especially  associated  with  anamiia. 

There  are,  however,  some  very  interesting  facts  with  reference  to  tlio 
profound  anivmia  of  the  cord  which  follows  ligature  of  the  aorta.  In  ex- 
periments made  in  Wi'lch's  laboratory  by  Ilerter,  it  was  found  that  within 
a  few  moments  after  the  application  of  the  ligature  to  the  aorta  i'ara|ilt'!:iii 
came  on.  Paralysis  of  of  the  sphincters  developed,  but  less  rapidly.  TJiis 
condition  is  of  interest  in  connection  with  the  fact  of  the  rapid  develop- 
ment of  a  i)araplegia  after  profuse  luemorrhage,  nsually  from  the  stoniacli 
or  uterus,  ft  may  come  on  at  once  or  at  the  end  <»f  a  week  or  ten  days, 
and  is  jtrobably  due  to  an  anatomical  change  in  the  nerve  elements  simi- 
lar to  that  produced  in  Ilerter's  experiments. 

In  this  connection  may  be  mentioned  the  interesting  observations  of 
Liehtheim  upon  the  degeneration  of  the  posterior  columns  of  the  ((inl 
in  pernicions  anannia,  of  which  be  has  reported  three  cases.  'J'he  (|iiestiou 
is  one  to  which  much  attention  has  been  paid  recently,  and  the  observations 
of  Minick,  IS'onne,  and  Burr  show  that  the  change  is  very  common  ;  tliusi. 
in  seven  of  the  cases  examined  by  Hurr  the  cord  was  normal  in  oidy  one. 
The  posterior  columns  may  be  affected  alone,  or  with  the  lateral  eoluinns. 
Liehtheim  regards  it  as  a  form  of  toxic  myelitis,  due  to  the  altered  (diuli- 
tion  of  the  blood. 

{(•)  Embolism  and  Thrombosis. — Hlocking  of  the  spinal  arteries  by  em- 
boli rarely  occurs.  It  may  be  j)roduced  experimentally,  and  Moiu'v  foiiml 
that  it  was  associated  with  choreiform  movements.  Thrombosis  of  the 
smaller  vessels  in  lionneetion  with  endarteritis  plays  an  important  part  in 
many  of  the  acute  ami  chronic  changes  in  the  cord. 

{(/)  Endarteritis. — It  is  renuirkable  bow  frequently  in  persons  over  fifty 
the  arteries  of  the  spitud  cord  are  found  sclerotic.  The  following  fonn> 
maybe  met  with  :  (1)  A  nodular  peri-artcritis  or  endarteritis  assutiatiJ 


AFFECTIONS  OF  THE  BLOOO-VESSKLS. 


887 


i! '  .      : 
i    ' 


lSSELS. 

X'ly  sec  pdst  iiKir- 
i  wo  do  it  is  usu- 
tioii  of  till'  (iv^'iiii, 
niortoin,  si  Liiviitir 
'J'lic  wllilr  llliit- 
iict,  it  is  ri'iiiarkii- 
fffay  niiittcr  dt'tin 
C'xc('|it  wiicii  iiiyc- 
ilitioiis  of  coiiiros- 
lo  IVatui'cs  ill  any 

)0  cxtrciiu'  irnulfs 
sis  iuul  iicrnicidus 
I,  iiiul  tlicrr  is  iki 
tlie  liiiilis  ami  tiii- 

:i  rofcrciKc  to  tlio 

tlie  aorta.     In  t\- 

1  found  that  witliiii 

lio  aorta  raraploiriii 

less  rapidly.    This 

the  rajiid  dcvclnji- 

from  tlie  stoiiuiLli 

wi'ok  or  ton  days, 

vo  elements  siiiii- 

iiiX  observations  of 
innns  of  the  ourd 
ses.     The  (jnestion 

d  the  observations 

y  common  ;  thus. 
ormal  in  only  one, 

le  lateral  eohimiis. 

the  altered  eumli- 

nal  arteries  by  om- 
and  Money  fmiml 

riirombosis  of  the 
important  part  in 

II  persons  over  fifty 
le  followiiiir  f'^™^ 
arteritis  assueiutcd 


with  syphilis  and  .'sometimes  with  gnmmatii  of  tlio  meninges;  (2)  an  arter- 
itis oliliterans,  Avith  great  thiekening  of  the  intima  and  narrowing  of  the 
luiiicii  of  the  vessels,  involving  chietly  the  medium  and  larger-sized  arteries. 
Miliaiv  aneurisms  or  aneurisms  of  the  larger  ves.sels  are  rarely  found  in 
the  s|iinal  cord.  Jn  the  cla.ssieal  work  of  Leyden  but  a  single  instance  of 
tliu  latter  is  mentioned. 

(r)  HaBmorrhage  into  the  Spinal  Cord  (//c/'?/<r//o/H//^7m).—'I'he  existence 
of  a  priniary  Invmorrhage  into  the  cord  lias  been  denied  on  the  ground 
that  in  all  instances  it  is  |)rece(led  l)y  a  condition  of  softening.  \  majority 
iif  authors,  h<»wever,  admit  the  existence  of  a  })rini;;''_-  form.  About  forty- 
twii  leases  arc  on  record,  which  are  collected  in  the  U  sis  of  Hayem  *  and 
ill  the  article  of  Herkeley.f  It  is  more  common  in  males  than  in  females, 
iiiid  at  the  middle  jieriod  of  life.  The  eases  have  followed  either  cold  and 
exposure  or  overexertion,  and,  most  frequently  of  all,  traumatism,  it  oc- 
iiirs  also  in  tetamis  and  convulsions,  ila-nuirrliage  may  be  associated  with 
tniiiors,  with  syringo-myelia,  or  with  myelitis;  it  is  often  ditlicnlt  to  de- 
trniiiiie  whetber  the  case  is  one  of  prinmry  luemorrhage  with  myelitis,  or 
myelitis  with  a  secondary  luvmorrhage. 

The  (Uialoinirtd  conditiim  is  very  varied.  The  cord  may  be  enlarged 
;it  the  site  of  the  luvmorrhage,  and  occasionally  the  white  snb.stance  may 
lit'  laeei'ated  and  bhiod  may  escape  beneath  the  meninges.  The  extravasa- 
tion is  chiefly  in  the  gray  nuitter,  ■'.nil  may  be  limited  or  focal,  or  very 
ilitbise,  extending  a  considerable  distance  in  the  cord.  In  a  case  Mliich 
iKciirred  at  the  MontreaHieneral  Hospital  under  W'illans  the  haMiiorrhage 
occupied  a  position  opposite  the  region  of  the  iifth  and  sixth  cervical 
iiorves  and  on  transverse  section  the  cord  was  occupied  by  a  dark-red  clot 
measuring  twelve  by  Hve  millimetres,  aronr.d  which  the  white  substance 
formed  a  thin,  ragged  .\all.  The  clot  could  be  traced  upward  as  far  as  the 
second  cervii^al,  and  downward  as  far  as  the  fourth  dorsal. 

The  sudden  onset  of  the  symptoms  is  the  most  characteristic  feature 
ill  lia'inatomyelia.  The  loss  of  power  necessarily  varies  with  the  locality 
iitfi'cted.  If  in  the  cervical  region,  bo*^'\  'irms  and  legs  may  be  involved  ; 
Init  if  in  the  dorsal  or  lumbar,  there  is  oidy  parajdi  gia.  'I'here  is  usually 
loss  of  sensation,  and  at  first  loss  of  reflexes.  Myelitis  frequently  develops 
mill  lieeomes  extensive,  with  fever  and  trophic  changes.  The  condition 
may  rapidly  prove  fatal ;  in  other  instances  there  is  gradual  recovery,  often 
with  ]iartial  paralysis. 

The  diagnosis  may  be  made  in  sonu>  instances,  particuli.rly  those  in 
which  the  onset  is  sudden  after  injury,  but  there  is  great  ditliculty  in  dif- 
ferentiating haMuorrhagic  myelitis  from  certain  cases  of  ha-morrhage  into 
the  spinal  meninges.  The  question  of  diagnosis  has  been  carefully  consid- 
eied  l)y  Hoeh  \  in  a  recent  re})ort  of  two  cases  from  my  clinic. 

•Paris.  1873. 
\  Uniin.  1889. 
X  Johns  Hopkins  Hospital  lleporta,  vol.  ii,  fasciculus  6. 


■■     Ml 


i 


888 


DISEASES  OF  THE   NEUVOUS  SYSTEM. 


(/)  Caisson  Disease;  Diver's  Paralysis.— This  rtMnurkablo  iiiTr(ti„:i. 
found  ill  (livers  iiiul  in  wurkiTs  in  caissons,  is  charut'torizetl  by  a  ])arii|>li.'"ia 
luoro  rarely  a  fijeiieral  [y.ihy,  wliieli  supervenes  on  returning  from  tlnMom. 
pressed  atnios])liere  to  tlie  surfaeu. 

The  disease  lias  been  carefully  studied  by  the  French  writers,  liv  I.,  v. 
den  and  Schultze  in  (iennaiiy,  and  in  tliis  country  jiarticularly  by  A.  |[. 
Smith.  'J'he  pressure  must  be  more  than  that  of  thret^  atmospiiercv  Tlif 
symptoms  are  esjjecially  ajtt  to  come  on  if  the  chaiiye  from  the  liiuh  to 
the  ordinary  atmospheric  ]»rcssure  is  (piickly  made.  They  may  sujicrvciii 
immediately  on  leaving  the  caisson,  or  tiiey  may  be  delayed  for  several  li(rurs 
In  the  mildest  form  there  are  simply  pains  aljout  the  knees  and  in  tlic 
legs,  often  of  great  severity,  and  occurring  in  ])ar<»xysms.  Ali(liiiiiiiuil 
pain  and  vomiting  are  not  uncommon.  The  legs  may  be  teiuler  to  iln' 
tomdi,  and  the  })atient  may  walk  with  a  stilfgait.  Dizziness  and  heiHlailic 
may  acconii)aiiy  these  neuralgic  syni])toms,  or  may  occur  alone.  Moic 
commonly  in  the  severe  form  there  is  ])aralysis  both  of  motion  and  kmi- 
sation,  usually  a  jniraplegia,  but  it  may  be  general,  involving  the  trunk 
and  arms.  Monojilcgia  and  hemiplegia  are  rare.  In  the  most  extroiiK' 
instances  the  attacks  resemble  a])o])lexy,  and  the  patient  rapidly  Ih'(uiih« 
comatose  and  death  occurs  in  a  few  hours.  In  the  cases  of  jiaraplcgia  tlir 
outhxdc  is  usually  good,  and  the  jiaralysis  may  pass  oiT  in  a  day,  or  may 
continue  for  .several  weeks  or  even  for  months.  Identical  features  aiv 
met  with  in  the  deep-sea  divers. 

The  explanation  of  this  condition  is  by  no  means  satisfactory.  8evtial 
careful  autopsies  have  been  made.  In  Leyden's  case  death  occurred  on 
the  lifteeiith  day,  and  in  the  dorsal  portion  of  the  cord  there  were  nuiiicr- 
ous  foci  o.''  ha-inorrhages  and  signs  of  an  acute  myelitis.  In  SilmlizcV 
case  death  occurred  in  two  and  a  half  months,  and  a  disseminated  iiiyeliti.« 
was  found  in  the  dorsal  region.  In  both  cases  there  were  fissures,  and 
appearances  as  if  tissue  had  been  lacerated.  In  a  case  examined  on  tlio 
third  day  (Ziegler's  Beitriige,  18'.l"-2)  this  condition  of  fissuring  and  lacera- 
tion was  found.  It  has  been  suggested  that  the  symptoms  arc  due  tn  tlu' 
liberation  in  the  spinal  cord  of  bubbles  of  nitrogen  which  have  been  ab- 
sorbed by  the  blood  under  the  high  pressure,  and  the  condition  founil  at 
the  autopsies  just  referred  to  is  held  to  favor  this  view. 

A  large  majority  of  the  cases  recover.  The  severe  neuralgic  \nini 
often  require  morphia.  Inhalations  of  oxygen  and  the  use  of  coniptvssnl 
air  have  been  ladvised.  When  paraplegia  develops  the  treatment  is  siiui- 
lar  to  that  of  other  forms.  In  all  caisson  work  care  should  be  cxeniscd 
that  the  time  in  passing  through  the  lock  from  the  high  to  the  oiilinarv 
jiressure  be  sufficiently  prolonged.  According  to  A.  II.  Smith,  at  Kast 
five  minutes  should  be  allowed  for  each  additional  atmosphere  of  pressiiiT. 


ACUTK  AFFECTIONS  OF  THE  SPINAL  CORD.  §89 


IV.    ACUTE    AFFECTIONS    OF   THE    SPINAL    CORD. 


(1)   At'lTE   MvJiLlTIS. 


*i 


A      :  ' 


Etiology. — Aciito  myelitis  results  from  iiiiuiy  causes,  and  may  aft'ct 
thciiinl  ill  a  limited  or  extended  jiortion — the  uray  matter  eliiellv.  or  the 
;:rav  and  wiiite  matter  to;jfetlier.  Jt  is  met  with:  (u)  As  an  iiKU'pendeiit 
allVctioii  following  exposure  to  cold,  or  exertion,  and  leading  to  rapid 
liiss  (if  power  with  the  symj)tonis  of  an  acute  ascending  paralysis.  (A)  As 
a  sequel  of  the  infectious  diseases,  such  as  snuill-po\,  typhus,  and  measles. 
[(■)  As  a  result  of  traumatism,  either  fracture  of  the  sjiine  (»r  very  severe 
muscular  ell'ort.  (.'oncussion  without  fracture  may  i)r(iduce  it,  but  this  i.s 
rare.  Acute  myelitis,  for  instance,  scarcely  ever  follows  railway  accidents. 
(il)  In  disease  of  the  bones  of  the  spine,  either  caries  or  cancer,  'i'his  is  a 
luiiieeommon  cause  of  localizi-d  ataite  transverse  myelitis  tliau  of  the  ditfuse 
ailVetiou.  ((')  In  disease  of  the  cord  itself,  .><uch  as  tumors  and  syphilis; 
in  the  latter,  either  in  association  with  gummata,  in  which  case  it  is 
usuiilly  a  late  nuinifestation,  or  it  may  follow  within  a  year  or  eighteen 
lUDiilhs  of  the  primary  atTcction.* 

Morbid  Anatomy. — In  localized  acute  myelitis  alTt-cting  white  and 
j;r;iy  matter,  as  met  with  afteraccident  or  an  acute  cctmpression,  the  i'(»rd  is 
judllen,  the  pia  injected,  the  consistence  greatly  reduced,  and  on  inci--ing 
the  nuMubrane  an  almost  diffluent  fluid  may  esca})e.  In  less  inten.se 
irrailes,  on  section  at  the  alfected  area,  all  trace  of  distinction  between  the 
iri'ay  and  white  nuitter  is  lost,  or  extremely  indistinct.  The  tissue  may  be  in- 
jfcted,  or,  as  is  often  the  case,  luemorrhagic.  It  is  particularly  in  these 
li)ria.s,  due  to  extension  of  disease  from  M'ithout  or  to  acute  compression, 
that  we  tind  definite  involvement  of  the  white  matter.  In  other  instances 
the  irray  matter  is  chielly  affected.  There  may  be  localized  areas  through- 
nut  tlio  cord  in  which  the  gray  matter  is  reduced  in  consistence  and 
Iiivaiorrhagic,  the  so-called  red  softening.  There  may  be  detlnite  cavity 
formations  in  these  foci.  In  some  cases  of  disseminated  or  focal  myelitis 
the  meninges  also  are  involved  and  there  is  a  myelo-meningitis.  And, 
lastly,  there  are  instances  in  which,  throughout  a  long  section  of  the  cord, 
sometimes  through  the  lumbar  and  the  greater  part  of  the  dorsal,  or  in  the 
dorsal  and  cervical  regions,  there  is  a  dilTuse  myelitis  of  the  gray  sub- 
staiu'o. 

Histologically  the  nerve  fd)res  are  much  swollen  and  Irregularly  dis- 
torted, the  axis  cylinders  are  beaded,  the  myelin  droplets  are  al)undant, 
and  the  laminated  bodies  known  as  corpora,  amylacea  may  bi;  seen.  The 
giamdar  fatty  cells  are  also  numerous  and  there  may  be  leucocytes  and 
nil  l)lood-corpu.scles.  Changes  in  the  blood-vessels  are  striking;  the 
Bmaller  veins  are  distended  and  may  show  varicosities.     The  i)erivascular 

*  Breteau,  Des  Maladies  Syphilitiques  Precoces,  Paris  Thesis,  1889. 


lit. 


890 


DISEASES  OP   THE   NEKVorS  SYSTEM. 


lymph  spaces  contiiin  iiumcM'ous  loucofytos,  and  tlio  smaller  artciir^  tlnm. 
st'lvt'8  aro  fntfiut'iitly  tlio  scat  of  liyalino  thrombi.  'I'lic  gunfflidii  rclls 
arc  swttllcii  ami  iri'c<;iiliir  in  outline,  the  protoplasm  is  cxtrcmclv  ^'niiiu- 
lar  and  vacuolated,  aiul  the  luudei,  though  usually  invisihle,  lUiiv  slu.w 
signs  of  division,  and  the  jiroccsscs  of  the  cells  are  not  seen. 

Ill  casus  which  juM'.sist  for  some  time  wo  have  an  oj)portuiutv  of  sccinir 
the  latc^r  stages  of  acute  myelitis.  The  acute,  inllaninuitory,  hy|ier;i  nuc  (,r 
rod  softeiung  is  succce<h'd  hy  stages  in  which  the  an'cete(l  ari'a  lncdiiu.s 
more  yellow  from  gradual  alteration*  of  tiic  hlood-pigrnent,  and  liiialh- 
white  in  color  from  tlu;  advancing  fatty  degeneration.  In  cases  of  (■(im. 
l)ro.ssion  myelitis,  a  sclerosis  may  gradiudly  ho  produced  witii  the  anatmii- 
ical  picture  of  a  chronic  dilTuse  myelitis. 

Symptoms.— ('0  .in//,;  Ccii/ral  Mi)cUIIk.—U  is  this  form  wliidi 
comes  on  spontaneously  after  cold,  or  in  connection  with  syphilis  or  diu' 
of  the  infectious  discuses,  or  is  seen  in  a  ty|)i('al  nianner  in  tlie  exttiisidii 
from  injuries  or  from  tumor.  'J'ho  onset,  tluaigh  scarcely  so  al)ru)it  as  m 
luvmorrhage,  may  he  sudden;  a  jjcrson  may  he  attacked  on  the  street  ami 
have  ditliculty  in  getting  home.  In  sonu'  instances,  the  onset  is  prccediil 
by  pains  in  the  legs  or  hack,  or  a  girdle  sensation  is  jjresont.  Jt  iiiav 
bo  marked  by  chills,  occasionally  by  convulsions;  fovor  is  usually  invsciit 
from  the  beginning — at  lirst  slight,  but  subsofpiently  it  may  hecoiin' 
high. 

The  Dwfor  functions  aro  rapidly  lost,  sometimes  as  quickly  as  in  Lan- 
dry's ascoiuling  paralysis.  The  parai)legia  nuiy  be  comi)k'te,  and.  if  [\w 
myelitis  extends  to  the  cervical  region,  there  may  bo  impairment  of  mo- 
tion, and  ultimately  complete  loss  of  i)owor  of  the  up[)cr  cxtrcniilics  a^ 
well.  The  sensation  is  lost,  but  there  m.iy  at  lirst  be  hypcra'sthesia.  The 
reflexes  in  the  initial  stage  are  increased,  but  in  acute  central  myelitis,  un- 
less limited  in  extent  to  the  dorsal  and  cervical  regions,  tluM'cllexes  aio 
usually  abolished.  The  rectum  and  bladder  aro  paralyzed.  Ti'ophie  dis- 
turbances are  marked  ;  the  muscles  waste  rapidly;  the  skin  is  often  roii- 
gcsted,  and  there  nuiy  be  localized  sweating.  The  tomporaturo  of  i 
ullected  limbs  nuiy  be  lowered.  Acute  bed-sores  may  develo[)  over  i 
sacrum  or  on  the  heels,  and  sometimes  a  multiple  arthritis  is  present  \\ 
those  acute  cases  the  general  symptoms  become  greatly  aggravated,  t 
pidse  is  rai)id,  the  tongue  becomes  dry;  there  is  delirium,  the  fever  in- 
creases, and  may  reach  107°  or  l(i8°. 

The  course  of  the  disease  is  variable.  In  very  acute  cases  death  fnllows 
in  from  five  to  ton  days.  'J'he  cases  following  the  infectious  diseases  par- 
ticularly  the  fevers  and  sometimes  sy))hilis,  inay  run  a  mdder  course. 

The  diagnosis  of  this  variety  of  acute  myelitis  is  rarely  dillicult.  In 
common  Avith  the  acute  ascending  paralysis  of  Landry,  and  with  ccitain 
cases  of  multiple  neuritis,  it  presents  a  rajjidand  progressive  motor  jiaialy- 
sis.  From  the  former  it  is  distinguished  by  the  more  nuirked  involvcnunt 
of  seusation,  the  trophic  disturbauces,  the  paralysis  of  bladder  and  rectum, 


V' 


ACUTE  AFFECTIONS  OP  TIIK  SPINAL  COIlI). 


891 


cr  nrtcrirs  tlu'iii- 

0    gllli;:linll   I'clU 

xtri'iiu'ly  ;'i'iiim- 

sil)U',  luiiy  sliuw 

'11. 

rtuiiity  "f  scciii;; 

I'v,  liy|H'rifiiii('  (ir 

led  iuvii  111  rciinw 

u'ut,  iiiul   liuiilly 

111  CilSCS  (if    rnlU- 

ivith  t'lif  uiuitoiii- 

this     fdl'lU    wllirll 

li  syi>hilis  ov  uir' 
■  ill  tiic  I'XtciisidU 
ly  so  ul>i'ii|it  us  111 
on  till'  street  ami 
onset  is  iirocciK'il 
]tri'st'iit.     It  limy 

is    USlUllly  l.'IVSrllC 

it   nmy   lieeuiin' 

iiiickly  as  in  I.aii- 
Hilctc,  and,  il'  llii 
i[)ainiK'nt  oC  iim- 
\)vv  extrciiiitivs  as 
ni'stlu'sia.    'I'lu' 
tral  myelitis,  nil- 
,  the  rellexes  are 
(1.     'I'rophie  dis- 
till is  often  <(iii- 
perature   id'  lliu 
develoi)  over  llie 
tis  is  present     lu 
aixj^'nivated,  tlin 
mil,  the  i'ever  iii- 

ises  death  rollnw.- 
ous  diseases  par- 
ilder  eniirse. 
rely  dillieult.  hi 
and  with  certain 
5ivo  motor  paraly- 
I'ked  involveiiunt 
iddor  and  reetuin, 


II 


till'  laidd  wasting',  the  (dectrical  (dianjijes, and  tlii^  fever.  From  acute  cases 
of  iniilti|do  neuritis  it  may  hi!  more  dilhciilt  to  distiii;,niisii,  as  the  sensory 
|Vat:ires  in  these  ca.sed  nmy  he  marked,  tlioii^di  there  is  rarely,  if  {'wv,  in 
iiiuliiple  neuritis  c()ni[ilete  amesthesia;  tiie  wasting,  moreover,  is  nioro 
rapid  in  myelitis.  The  Idadder  and  rectum  are  rarely  iii\olved—thoti<,'h 
ill  r\ie]»tiiinal  cases  they  nicy  he — and,  most  impin'taiit  id'  all,  the  trnphic 
clianires,  the  development  of  hiilla',  hed-sores,  etc.,  are  not  seen  in  multiple 


Hell  I'll  is. 


\/i)  Anifc  Tntnxvpr.v.  Mijclilis. — 'The  symptoms   naturally  dilVer  with 


till'  -il.uation  of  the  lesion. 

(I)  Acute  tninsverso  myelitis  in   the  i/nrsdl  rri/ia/i,  t 
situation,  produces  a  very  characti'ri:  tic  picture.     Th 


arc  Vi 


le    mo.-t    cnllininn 
'yinptiiiiis  (d'  oii.«et 
iriahle.     There  may  ho  initial  iiains  or  numhne.ss  iind  tiiiiiliii;;'  in  the 


The  paralysis  may  set  in  ipiickly  and  hecuine  com]dctc  witl 


III 


fi'wdays;  hut  more  commonly  it  is  preceded   for  a  day  or  two  hy  s-eiisa- 

IcLTs.     The  paralysis  nf  the 


timis 

liiWlT 


laiii,  heaviness,  and  drairtrinL'  in   tin 


limhs  is  usually  com})lete,  and  if  at  the  level,  say,  of  the  sixth  dorsal 
vcrtclira,  the  ahdoininal  miisides  are  involved.  Sensatinu  may  he  partially 
or  riiiiipletely  lo.st.  At  the  onset  there  may  he  numhiiess,  tin;^lin<.f,  or  even 
liypciM'sthesia  in  the  le<:s.  At  the  level  of  the  lesion  there  is  often  a  zone 
(if  liyporiKsthesia,  which  is  discovered  hy  iiassing  iitest-tuhe  (•(int;dniii,ir  hot 
water  iiloiiji;  llio  spine,  when  the  sen.sation  of  warmth  (dianii'es  to  one  id" 
ii'!  al  jiain.  A  girdle  sensation  may  occur  early,  and  when  the  lesion  i-  in 
this  situation  it  is  usually  felt  hetweeii  the  ensil'iirni  and  umldlical  regions. 
The  reflex  functions  are  variahle.    There  mavat  lirst  he  aholition  of  the  re- 


dly, th 


dnir  throu'di  th 


llrxcs ;  siiDseiiuentiy,  ilie  rellcxes,  passing  tnrougli  riie  segments  idwcr  man 
the  line  alfected,  may  he  exaggerated  and  the  limhs  may  [lass  into  a  con- 
(iitioii  of  spastic  rigidity.  It  does  not  always  happen,  however,  that  the  re- 
Ik'Xi's  are  increased  in  a  total  transverse  lesion  of  the  cord.  They  may  he 
oiitirely  lost,  as  pointed  out  some  years  ago  hy  IJastian.  and  insisted  iipnii  iiy 
liiiu  in  a  recent  memoir.'*  F.  T.  Miles  has  also  called  attention  to  this  fact 
and  reported  live  cases  in  wliiidi  the  ivllexes  were  lost  in  total  transverse 
lesion  of  the  cord.  That  this  is  not  due  to  the  jireliiiuiiary  slioid\  is  shown 
li)  the  fact  that  the  aholition  of  the  reflexes  may  contiiiue  fur  four  or  more 
niniitlis.  The  trophic  changes  .ire  not  marked.  The  miisides  hcciimc  ex- 
tremely flahhy, hut  not  wasted  in  an  extreme  degree;  sui)se(|iieiitly  rigidity 
develops.  If  the  gray  matter  of  the  lunihar  cord  is  involved,  the  llaciddity 
persists  and  the  wasting  may  he  consideraiile.  The  reaction  of  deirenerii- 
tiiiii  IS  Hot  present.  The  temperature  of  the  paralyzed  limhs  is  varialde. 
It  may  at  lirst  rise,  then  fall  and  hecome  suhiiormal.  I.esions  of  the  skin 
are  not  uncommon,  and  hed-sores  are  apt  to  form.  There  is  at  first  re- 
tention of  urine  and  suhsequent  incontinence.  If  the  liimhar  centres  are 
involved,  tliore  are  from  the  outset  vesical  symptoms.     The  urine  is  alka- 


.,4 


*Medico-ChirurgicaI  Transactions,  vol.  Ixxiii. 


;  :  ■;  ■  i 


if} 


893 


niSKASKS  OF  TIIH   NlMIVOrS  SYSTEM. 


lino  in  roiiotion  and  may  rapiflly  Ik'coimc  amnioniaciil.  Tlif  bdwi  U  mv 
constipated  and  tiu-ro  in  usually  iiiroiitiiifnt'c  oT  tlic  fares.  Sonic  uiitciH 
attriliufc  tilt'  <'ystitis  ussociatcd  with  transverse  myelitis  to  di.>tiirli(  •!  tn,. 
jdiic  inllnenee. 

The  course  of  comiilete  transverse  myelitis  depends  a  jyood  deal  ;:>><iii 
its  eause.  I)eatli  may  result  from  <'xteiisioii.  Se;,nnents  of  tiie  ci  n]  iii;,\ 
1)0  eoni|)letely  and  |)er?naiieiitly  destroyed,  in  which  case  there  is  ]uT,«i,-,;(.|it 
jiaraplc;,'ia.  'I'lic  pyraniidal  lihres  lielow  the  lesion  under;j;o  the  secomlaiv 
(Iej,'eneralion,  and  tluTe  is  an  asceiuling  de;^'eneration  of  the  posterioi'  me- 
dian columns.  If  the  lower  sejfments  of  (he  cord  are  involved  tlir  Ic^'s 
■jmiy  remain  ilaccid.  In  sonii^  instaiuTS  a  transverse  myelitis  of  the  ddrsiil 
rcfrion  inv(»lvcs  ttie anterior  horns  ahove  and  lielow  the  lesion,  prudiirinc; 
llaccidily  of  the  muscdes,  with  wasting,',  lihrillar  contractions,  and  the  reac- 
tion of  de<i[eneration.  More  conimonly,  however,  in  the  cases  which  lust 
many  months  there  is  more  or  less  rigidity  of  tlic  muscles  with  spa.-iu  or 
persistent  contraction  of  the  lU'Xors  of  the  knee. 

(•-i)  Trans  re  rsc.  J/i/rlifis  of //it',  ('crvinil  Hvijiitn. — If  at  the  level  of  the 
sixth  or  seventh  cervical  nerves,  there  is  paralysis  of  the  upper  extrcniiiics 
more  or  less  comjdete,  soinetinu's  sparing  the  muscles  of  the  slioulijci'. 
(iradually  there  is  loss  of  sensation.  The  jjaralysis  is  usually  complete  \k- 
low  the  point  of  lesion,  but  there  are  rare  instances  in  whi(di  the  arms  (Hily 
are  aU'ected,  the  so-called  cervical  j)araple<,Mii.  In  addition  to  the  sviiip- 
toms  already  mentioned  there  aro  several  which  are  more  characteristic  df 
transverse  myelitis  in  the  cervical  region,  such  as  the  occurrence  of  voiui;- 
ing,  hiccough,  and  slow  pulse,  whiidi  may  sink  to  twenty  or  thirty,  \n\\  iHiin 
cdianges — myosis — sonu>times  attacks  of  dyspliagia,  dys])n(ea,  or  syncope. 

II.  Myklitis  of  ntio  AvTEiaon  Iloitxs 

{Piilio-}niirll/is  Aii/crldt' ;  A/rajt/zir  Spiind  Panthjxis). 

Definition. — An  afTcction  occurring  most  commonly  witiiin  the  lirst 
three  years  of  life,  characterized  by  fi'ver,  loss  of  power  in  certain  iiiiin- 
clcs,  and  rapiil  atrophy. 

Etiology. — The  cause  of  the  disease  is  unknown.  It  lias  lucii  at- 
triljuted  to  cold,  to  tlu'  ii'ritation  from  <lentition,  or  to  overi'xcitinii. 
Since  the  days  of  ^lephibosheth,  parents  have  been  inclined  to  allri'Hiic 
this  form  of  ^laralysis  to  the  carelessness  of  luirses  in  letting  the  children 
fall,  but  very  rarely  is  the  diseasi'  induced  by  traumatism,  and  in  pciiiap-a 
majority  of  the  cases  the  child  is  attacked  while  in  full  health.  As  SinkKr 
has  pointed  out,  the  cases  are  more  common  in  the  warm  months.  Hlly:^ 
are  more  liable  to  1)0  afTected  than  girls.  Several  instances  of  the  onur- 
rence  of  numerous  cases  together  in  epidemic  form  have  l)eeu  dcsciiiicil. 
Mediu  reports  from  Sto(d<holm  an  epidemic  in  whiidi  from  the  '.'ili  nf 
August  to  the  'VM\  of  September  20  cases  came  under  observation.  1;.  t\^" 
instaiu'es  two  (diildren  iu  the  same  family  were  attacked  within  a  fev.  days. 


APUTK  AFFKCTIONS  OF  TIIM  SLMNAL  rOilD. 


893 


TIio  most  rciiiiirkal>I('  ('pidi'mic  is  tliuL  which  occurred  in  tlie  vicinity 
„f  Ii'iiliiuul,  \'t.,  iiixl   which   hiis  lu-cn   recorded  by  Cuverly  (New  York 

Miilial    l}( I'd,  ISDJ,  ii).     One  liimdrcd  iiiid    nineteen   cases  occurred 

(liu'iiii;  tilt!  suiiinier  of  ISltt  ;  eij;lity-live  were  under  six  yetird  of  ago ; 
li^'litcen  died. 

AIihou<,di  most  fre(|neiit  in  <  lijldrcn,  it  develops  oeeufsionuliy  in  young 
uphills,  or  even  in  niiddie-a^eil  persons. 

Morbid  Anatomy.  'i"he  disease  is  oftenost  seen  in  either  the  ecr- 
viwil  or  liMnl)ar  eulap^'cniciits.  Ii:  very  early  cases,  sndi  as  tliose  de- 
jrritH'd  hy  ha.iil  Drunmiond  and  (  iiarlewood  'Turner,  tlie  lesion  lias  ])een 
ihat  of  an  acute  ha'inorrha;,Me  myelitis  with  deijeneration  and  rapid  do- 
.tniclion  of  tiie  large  ganglion  cells.  The  condition  may  he  strictly  con- 
fiiiL'd  to  the  anterior  cornua ;  in  some  instances  there  is  slight  meningeal 
involvement.  The  investigations  of  (ioldscheider,  Sienierling,  and  other!-; 
liiive  den.oustrated  the  arterial  origin  of  the  disease,  which  is  locali/ed 
ill  the  parts  supplied  by  the  anterior  median  branch  of  the  anterior  spinal 
iirti'i'v.  Occasionally  the  changes  are  fonnd  in  the  region  of  distribution 
iif  the  anterior  radicular  arteries.  Marie  thinks  that  the  initial  process  is 
I'liibdiism  or  thrombosis  of  the  arteries  of  the  anterior  horns,  the  result 
(if  an  aonto  infection.*  In  cases  in  which  the  exandnation  is  not  made 
f)r  s(»nie  months  or  years  the  changes  are  very  characteristic.  The  an- 
ti'i'idr  coriui  in  the  alTccted  region  is  greatly  atrophied  and  the  large 
iiuitor  (('lis  arc  cither  entirely  absent  or  only  a  few  remain.  The  affected 
half  of  the  cord  may  be  considerably  smaller  than  the  other.  The  antero- 
liitcral  column  may  show  slight  sclerotic  changes,  chictly  in  the  pyramidal 
trart.  The  corresponding  anterior  nerve  roots  are  atrophied,  and  (he 
imiscles  are  wasted  and  gradually  undergo  a  fatty  and  sclerotic  change. 

Symptoms. — In  a  majority  of  the  cases,  after  slight  indis[iosition 
ami  fcverishncss,  the  child  is  noticed  to  have  lost  the  u«o  of  one  limb. 
Cniiviilsions  at  the  outset  arc  rai'e,  not  constant  as  in  the  acute  cerebral. 
palsies  of  children.  Fever  is  usually  ])resent,  the  tem])erature  rising  to 
I'lr,  sometimes  to  1(>I]°.  Pain  is  rarely  comi)lained  of;  there  may  oc- 
'•a-ioiially  be  slight  aching  in  the  joints.  The  paralysis  is  abrupt  in 
its  onset  and,  as  a  rule,  is  not  progressive,  but  reaches  its  maximum 
ill  II  very  short  tinie,  even  within  twenty-four  hours.  It  is  rarely  gen- 
eralized, '{'he  sudilenness  of  onset  is  remarkable  and  suggests  a  pri- 
mary alfeetion  of  the  blood-vessels,  a  view  which  the  ha'inorrhagic  char- 
iii'ftM-  of  the  early  lesion  supi)orts.  The  distribution  of  the  ])aralysis  is 
Very  vi'.riablo.  One  or  both  arms  may  be  alTectcd,  one  arm  and  one  leg, 
1)1'  lioth  legs;  or  it  may  be  crossed  paralysis,  the  right  leg  with  the  left 
iii'in.  In  the  iipper  extrenuties  the  paralysis  is  rarely  complete  and  grou])8 
of  nniscles  may  be  alfected.      As  Ueinak    has   j)ointed  out,  there  is  an 


*S(0  K.  T.  Williiuiison's  Studies  on  the  Rclntiou  of  .Spiiml  Dispjiscs  to  the  Distri- 
bution iintl  Lesions  of.  the  Blood- Vcssols,    Midital  Chronicle,  New  Series,  vol.  ii. 


3  i'-         ;3?J 


w.m:^  '■ 


li 


894 


DISEASES  OF  THE   NERVOUS  SYSTEM. 


uppor-arm  iuid  a  lower-arm  type  of  palsy.  The  deltoid,  the  biceps,  bra- 
cliiiilis  antieus,  and  supinator  longiis  may  be  alTected  in  tlie  fonncr,  aiul 
in  the  latter  the  extensors  or  flexors  of  the  fingers  and  wrists.  'I'lii,.;  di^. 
tribwtioii  is  due  to  the  fact  that  the  groups  of  nerve-cells  are  attacked 
whicii  i)reside  over  certain  muscles  acting  functionally  together. 

In  the  legs  the  tibialis  antieus  and  extensor  grou])s  of  muscles  are  inoiv 
alTectc(l  than  the  hamstrings  and  glutei.  'I'iie  muscles  of  tiie  face  an 
very  rarely,  the  sphincters  hardly  ever  involved.  While  the  rule  is  fur 
the  paralysis  to  be  abru])t  anil  sudden,  there  are  cases  in  which  it  v^wwi 
on  slowly  and  takes  from  three  to  live  days  for  its  development.  At  lii>t 
the  atTectcd  limb  looks  natural,  and  as  children  between  tno  and  tluce 
are  usually  fat,  very  little  change  may  be  noticed  for  some  time  ;  l)itl  the 
atrophy  }(rnceeds  rapidly,  and  the  limb  becomes  llaccid  and  feels  soft  luid 
llabby.  U.  tially  as  early  as  the  end  of  the  first  week  the  reaction  of  lic- 
generation  is  present.  The  nerves  are  found  to  have  lost  their  irritaliilitv. 
The  muscles  do  not  react  to  the  induced  current,  l)ut  to  the  consiani  ciir- 
rent  they  respond  by  r,  sluggish  contraction,  usually  to  a  weaker  c  iiit'iit 
than  is  normal,  and  more  to  the  positive  pole  than  to  the  negative.  Tlu' 
paralysis  remains  stationary  for  a  time, and  then  there  is  gradual  iMipnivi-- 
ment.  C^omplete  recovery  is  rare,  and,  when  the  anatomical  condiliim  is 
considered,  is  scarcely  to  be  ex])ccted.  'J'iie  large  mo'i.u-  cells  of  the  cof- 
iiua,  when  thoroughly  disintegrated,  cannot  be  restored.  In  too  iinuiy 
cases  the  improvement  is  oidy  slight  and  {)ermanent  paralysis  rctiiaiiis  in 
certain  groups.  Sensation  is  unaifected ;  the  skin  reflexes  are  absent, 
and  the  dee[)  reflexes  are  usually  lost. 

When  the  paralysis  persists  the  wastnig  is  extreme,  the  growth  nf  ilie 
bones  of  the  afl'ectt'd  limb  is  arrested,  or  at  any  rate  retaided,  and  the 
joints  may  be  very  relaxed  ;  as,  for  instance,  wl'cn  the  deltoid  i>  allVdiil 
the  head  of  the  humerus  is  lu)  longer  kej)t  in  contact  with  tiic  glci'iid 
cavity.  In  the  later  stages  very  serious  dc'orndties  are  ..roduccd  by  tlif 
contriM'liirc  of  the  muscles. 

Diagnosis. — 'riic  condition  is  only  t  )o  evident  in  the  majoii'v  of 
cases,  'i'lierc  is  a  llaccid,  tlabby  })aralysis  oi  one  or  more  limbs  whidi  liu- 
set  in  al)ruptiy.  The  rapid  wasting,  the  lax  state  of  thi  mus'lis,  tlic 
electrical  reactions,  and  the  abs'Mice  of  rellcxes  distinguish  it  fi'mii  the 
cerebral  palsii's.  The  psciulo-parcsis  uf  rickets  is  a  condition  to  lie  miv- 
fully  distinguished.  In  this  the  loss  o''  power  is  in  the  legs,  ri'pid  aii'i|iliy 
is  not  prcseut,  cerrain  nutvements  arc  possil)le  but  painfid.  'i'he  grinial 
hypcrn'stiiesia  of  the  skin,  the  characteristic  changes  in  the  bones,  and  the 
diffuse  sweats  are  pn'scnt.  Disea.se  of  the  hip  or  kiu'c  may  prodiuc  a 
pseudo-jiaralysis  whicli  can  with  care  bo  readily  distinguished. 

Prognosis. — The  outlook  ii'  .iny  case  for  co:nplete  recovery  i-  liinl. 
The  natural  c(»urse  of  the  discai-c  must  be  inu-nc  in  mind:  the  siulilfii 
onset,  the  rapid  but  not  progri'ssive  loss  of  po'.er,  a  stationary  period,  tiu'ii 
imvkcd  improvement  in  certain  muscle  groups,  and  linally  in  many  eua's 


,  the  biceps,  bra- 
tlie  fnnufr,  aiul 
ristti.  This  (hs- 
■Us  are  ulturkni 
^ether. 
inuseles  areiiioiv 

of  tlie  face  lu'i' 
e  the  r\ilc  is  fifi' 
I  wliich  it  coiiii's 
[)iiient.  At  lir>t 
'11  t'vo  ami  tiller 
le  time  ;  Imt  tliu 
ml  feels  i-o[t  miuI 
e  reuetidii  ef  ilc- 

tlieir  irritahility. 
the  eoiistaiii  ciir- 
a  wealier  c  inviit 
0  negative.  Tin.' 
gradual  iiii|in)\\'- 
iiical  ci)ii(iitii)ii  \i 
r  cells  of  I  lie  c(jr- 
il.  Ill  too  iiiany 
ulysis  reiiiaiiis  in 
lexes  are  absent, 

he  growth  nf  tln' 
•etiiitleil.  ami  \\w 
eltoid  i^  alTcctcil 
with  the  glci"ml 
.rodiieed  hy  tlu' 

the  iiiajori'v  uf 

liiiihs  which  IvA- 

\\\h    imisi'Ks,  tlu' 

liisii   it    iVuiii  the 

lliticn  to  lie  cMI'r- 

L^s.  refill  atrii[iliy 
III.     The  gnu'ral 
lie  bones,  ami  the 
may  produce  a 
Fhed.^ 

recovery  i^  Imil. 

Iiiul;   tlu'  sicluell 

liarv  perio'l.  llieii 

Iv  in  maiiv  cases 


ACUTK   AFPKCTIONS  OF  THE  SPINAL  CORD. 


895 


mntractures  and  deforinitios.  There  i.s  no  other  disease  in  wliieh  tho 
plivsician  is  so  often  siil)je('t  to  liiijnst  criticism,  and  the  friends  should  be 
tiijd  at  tho  outset  that  in  the  seven*  and  extensive  paralysis  complete 
ncincry  should  not  be  oxpeoted.  'I'he  best  to  be  hoped  for  is  a  gradual 
ri'stiiration  of  power  in  certain  muscle  groups.     In  estinuiting  th(>  probable 


L'l'ailc  o 


f  permanent  ]>aralysis,  the  electrical  examination  is  of  great  val 


lie 


Treatment  of  Acute  Myelitis.— In  the  rapidly  developing  form 
(liuM'itliei  to  a  ditfuse  inllammation  in  the  gray  matter  or  to  transverse 
iiivi'liiis,  the  important  measures  are:  Scrupulous  cleanliiu'ss,  care  and 
ivatchfiiluess  in  giiirding  against  bed-sores,  the  avoidance  t>f  cystitis,  either 
liv  systematic  catheterization  or,  if  there  is  incontinence,  by  a  carefully 
iidjiistcd  bed  urinal,  or  the  use  of  antisejitic  cotton -wool  r.'peatedly 
rhauged.  In  an  acute  onset  in  a  healthy  subject  the  spine  may  I'c  cupped. 
Coimter-irritation  is  of  doubtful  advantage,  ('hapman's  ice-bag  is  .some- 
tinu's  useful.  No  drugs  have  the  slightest  inilueiice  upon  an  acute  myelitis, 
iiml  even  in  subjects  with  well-marked  syjihilis  neither  mercury  >;or  iodidt* 
iif  iKitassium  is  curative.  Tonit;  remedies,  such  as  (|uiniii('.  arsenic,  and 
strychnia,  may  be  \\!ii'(\  in  the  later  stages.  When  the  muscles  havi>  wasted, 
massage  is  benelicial  in  maintaining  their  nutrition.  Klcctricity  should 
luit  he  used  in  the  early  stages  of  myelitis.  It  is  of  no  value  in  the  trans- 
verse myelitis  in  the  dorsal  region  w  ith  retention  of  the  nutritimi  in  the 
muscles  of  the  leg. 

The  treatment  of  acute  infantile  paralysis  has  a  bright  and  a  ilark  side. 
Ill  ii  case  of  any  lixtent  complete  recovery  cannot  be  expected  ;  on  the 
ntlicr  hand,  it  is  remarkable   ho.,    much   iin[u'ovenieiit   may  filially  take 

ai  I'  in  a  limb  which  is  at  first  completely  Haccid  and  helpless.     The  fol- 


r 


mil 


lowing  treatment  may  be  [uirsued  :  If  seen  in  the  febrile  stage,  a  brisk 
la.\ative  and  a  fever  mixture  may  be  givt'ii.  The  child  should  lie  in  bed 
(1  the  affected  limb  or  limbs  wrapped  in  cotton.  As  in  tlu'  great  majority 
III" eases  the  (hiniage  is  already  done  when  the  physician  is  called  and  the 
ilisease  make.'!  no  further  progress,  the  application  of  blisters  and  other 
fiiriiis  of  counter-irritation  to  the  back  is  irrational  and   oiilv  cruel  to  the 

rhil.l. 

The  general  nutrition  should  be  carefully  maintained  bv  feeding  the 
I'liilil  well,  and  taking  it  out  of  doors  every  dav.  ,\s  soon  as  the  child  can  bear 
friction  the  affected  jiart  slioiild  be  eari'fiilly  rubbed  ;  at  first  once  a  day, 
iilis('i(iienfly  morniii!  and  evening.  .Any  intelligent  mother  can  b(>  taught 
'^y.^t^'lllatically  to  rub,  knead,  and  pinch  'he  muscles,  using  cither  the  bare 
liaiiil  or,  better  stdl,  sweet  oil  or  cod-liver  oil.  This  i*  worth  all  the  other 
nipusiires  advised  in  the  fliscase,  and  should  le  systematically  praefised  for 
nimitlis,  or  even,  if  lu'-essarv,  a  vear  or  r.ore.  Klectricitv  has  a  much 
iiiiiri' 

tlU' 


limited  use,  and  cannot  be  compared  with  massage  in   maintaining 
nutrition  of  the  muscles.     Tli(>  faradii-  I'urrent  should  be  applied  to 


ii'wc  muscles  which  respond 


he  essence  of  the  treatment  is  in  main- 


I     ■   * 


V       1  ^ 


'■'lining  the  nutrition  of  the  muscles,  so  that  in  the  gradual  improvement 


57 


■  0  ni 


S      1     :.  !'l   SI 


890 


DISKASKS  OF  TIIK   NHIiVOrs  SYSTEM. 


which  takoH  place  in  parts,  at  least,  of  the  tilTected  segments  of  the  cord 
the  motor  impulses  may  have  to  deal  witii  well-nourished,  not  atinjihicd 
muscle  tihres. 

Of  medicines,  in  tin-  early  sta^j^e  erj^ot  and  belladonna  liasc  liccii 
warmly  recommended,  hut  it  is  unlikely  that  they  have  the  slii:lite>t 
influence.  Later  in  tiu!  disease  strychnia  may  he  used  with  advaiitairc  in 
one  or  two  minim  (hises  of  the  KKpior  stryehnina',  which,  if  it  has  uu  dtiur 
elTect,  is  a  useful  tonic. 

The  most  distressing  eases  are  those  which  come  untk'r  the  iKitircdf 
the  physician  six,  eight,  or  twelve  months  after  the  onset  of  ihe  |iaialvsi<. 
when  one  leg  or  one  arm  or  both  legs  are  thu-cid  and  have  little  or  im 
motion,  ("an  nothing  he  done?  A  careful  electrical  test  should  lie  iikkIi- 
to  ascertain  which  muscles  respoiul.  This  may  not  be  ajiparent  al  liivt, 
and  several  applications  may  be  necessary  before  any  contnu'tility  is 
noticed.  With  a  few  lessons  an  intelligent  mother  can  be  taught  td  n-v 
the  electricity  as  well  as  to  apply  the  massage.  If  in  a  case  in  wliicji  tlir 
j)aralysis  has  lasted  for  six  or  eight  ir.ontiis  no  observalde  improvtinciit 
tjikes  }»lace  in  the  next  six  inonths  with  thorough  and  systematic  tmit- 
nient,  little  or  no  hope  can  Ijc  entertained  of  further  change. 

In  the  later  stage  care  shoiUd  be  taken  to  prevent  the  defoniiitics 
resulting  from  the  contractions.  (Ireat  bfiK'iit  rrsults  from  a  cari'fiillv 
ai)i)lied  apparatus. 

111.  Acute  akd  Slmaciti:  1^lio-mvi:mtis  in"  Adult.s. 

An  acute  poiio-myelitis  in  adults,  the  exact  counteriiart  of  the  d\>vi\>f 
in  children,  is  rei'ognized.  A  majority,  however,  of  the  cases  descrilitd 
under  this  heading  have- been  multiple  neuritis;  but  the  suddenness  nt 
onset,  the  rapid  wasting,  and  the  mai'ked  reaction  of  degeneratinn  ;iir 
thought  by  sonu'  to  be  distinguishing  features.  Multiple  neuritis  niav. 
however,  set  in  with  rapidity  ;  then.'  may  l>e  great  wasting  and  the  rcartinn 
of  degeiu'ration  is  sometimes  present.  The  time  element  alone  may  d'.'td'- 
niiiu'  the  trui-  nature.  Recovery  in  a  case  of  extensive  nudtiple  jianilvsis 
from  polio-myiditis  will  certainly  be  with  loss  of  power  in  certain  gniii]'> 
of  mus(des;  whereas,  in  multiple  neuritis  the  recovery,  while  slow,  iii;i\ 
bo  perfect. 

The  subacute  form,  the  /»iraJi/sir  (inu'ralo  spinrde  nntvricurc  siilniiiin- 
of  Duidientu',  is  in  all  probability  a  ju'ripheral  palsy.  The  ])aralysis  usually 
begins  in  the  legs  with  atrophy  of  tin'  musidcs,  then  the  arms  are  involvi'ti. 
but  not  the  face.     Sensation  is,  as  a  rule,  not  involved. 


Mi 


IV.  AciTK  AsrKN'DiNci  (T/.\n?)I!y's)  Paijalysis. 

Definition. — An  advancing  paralysis,  beginning  in  the  legs,  rapiiHy 
extending  to  the  trunk  and  arms,  and  finally,  in  nuiny  eases,  involving tlif 
muscles  of  respiration.     It  presents  a  remarkable  similarity  in  its  syiiij- 


p!»'\ 


iits  of  lln'  cord 
,  not  ati'(i[ihu!d 

jiiii  liiuc  liccn 

c>  till'  ^liirlitcM 

til  advuntaLrc  in 

it  has  iiti  oiinT 

LH"   tllO    notice  cif 

[)f  Uk'  panilysis. 
lavc  little  nr  no 

Shoulll    \n-  IlKldi' 

ippaiH'iil  at  lii'st, 
■  (■()ntractility  is 
bo  taiij^'lit  t(i  ii-i' 
itise  in  \vlii(  ti  tlir 
)k)  iiiipi'dvi'iiiciit 
systciiKitic  trc;it- 
i<;o. 

llu'  (Irt'tinnilii- 
i'roni  a  can'lulK 


irt  of  tlu'  discasi' 
c  casi'S  dcsiTilnd 

\\V  Sll(l(U't)lH'^>"' 

(legoiuM'alinii  av< 

Iplc  neuritis  luav, 

and  till'  miitii'ii 

alone  may  d'.'tn- 

nultiide  i»iiraly.-i> 

n  certain  tn'i'U!'' 

while  slow.  iiKiv 

\tvvifiiir  siilri'mf 

paralysis  usually 

lirnisure  involvi'il, 


LYSIS. 

Ii  the  logs,  vapidly 

]iso8,involviii}:tlii' 
lurity  in  it^  ^vmi'- 


ACUTE  AFFECTIONS  OF  THE  SPINAL  COKO. 


897 


tdins  to  cortain  cases  of  polyueuritiis,  with  wliicdi  it  is  now  grouped  by 
iiKiny  writers. 

Etiology  and  Pathology. — The  disease  occurs  most  commonly  in 
i!i;dis  lictwi'on  the  twentieth  and  thirtieth  years.  It  has  sonietiines  fol- 
liiWfd  the  speidfic  fevers.  .\n  elaborate  study  of  ();5  eases  ('(dleeted  from 
tin' literature  has  been  made  liy  .lames  Hoss,  who  coueludes  that  in  etiol- 
Hi;v,  symptoms,  course,  and  termination  it  conforms  to  a  peripheral  neu- 
ritis. .Nenwork  and  l^artli  have  reached  a  similar  conclusion.  In  their 
liwaii  interstitial  neuritis  was  found  in  the  nerve  roots,  but  the  peripheral 
iii'i'vcs  were  normal.  On  the  other  hand,  cases  have  been  reported  of 
nipidly  asceiidin<2f  paralysis  in  which  the  periphral  nerves  and  nerve  roots 
uviv  uiiaiTccted.  In  a  case  of  eleven  days'  duration  recently  studied  by 
Hull,  the  lesions  wore  certainly  too  sli<^lit  to  account  for  the  advancing 
and  wide-spread  paralysis,  and,  with  mir  present  knowledge,  Ilnn  is  cor- 
rirt  in  stating  that  "acute  ascending  })aralysis — deliiied  so  as  to  I'xcliide 
all  cases  in  which  the  sensory  symptoms  are  prominent,  or  in  which  well- 
!ii;irkiil  bulbar  symptoms  are  not  present — must  therefore  be  regarded  as 
.iilinieal  entity  for  which  no  corresponding  lesion  has  as  yet  been  discov- 
iit'il."  It  is  not  improbable  that  some  toxic  agent  is  responsible  for  the 
<\iii|»t(inis. 

Symptoms. — Weakness  of  the  legs,  gradually  jirogressing,  often 
«itli  tolerable  rajiidity,  is  the  tirst  symi»tom.  In  .some  cases  within  a  few 
Imiirs  the  paralysis  of  the  legs  becomes  complete.  The  muscles  of  tlio 
inink  are  next  alTected,  and  within  a  few  days,  or  even  less  in  more  acute 
lascs,  the  arms  are  also  involved.  The  neck  miiscdes  arc  next  attacked, 
and  tiiially  the  mu.-;cles  of  respiration,  deglutition,  and  articulation.  The 
ritli'xcs  are  lost,  but  the  muscles  neither  waste  nor  show  electrical  changes. 
Till'  sensory  symjitoms  are  variable  ;  in  some  cases  tingling,  numbness,  and 
liypcnesthesia  have  been  present.  In  the  more  characteristic  cases  sensa- 
tion is  intact  and  the  sphincters  are  uninvolvcd.  Enlargement  of  the 
j|i|irii  has  been  noticed  in  several  cases.  The  course  of  the  disease  is 
Viiiiahle.  It  may  prove  fatal  in  less  than  two  days.  Other  cases  persist 
fi'ia  Week  or  for  two  weeks.  In  some  instances  recovery  has  occurred,  but 
ma  large  proportion  of  the  cases  the  disease  is  fatal. 

The  (/ii/f/nosis  is  ditViciilt,  |)articularly  from  certain  forms  of  multiple 
lii'Mritis,  and  if  wo  include  in  Landry's  paralysis  the  eases  in  wlii(di  seiisa- 
timi  is  iiividvcd,  distinction  belweeu  the  two  alTectioiis  is  impossilde.  We 
ii|iliaiviitly  have  to  recognize  the  existence  of  a  rapidly  advaiudng  motor 
[walysis  without  involvement  of  the  sphincters,  without  wasting  or  elec- 
Itrical  eluuiges  in  the  muscles,  without  trophic  lesions,  and  without  fever — 

atiires  suHicient  to  distinguish  it  from  either  the  acute  central  myelitis 
ji'i"  tile  polio-myelitis  anterior.      Jt   is  doubtful,  however,  whetiier  those 

larai'ters  always  siittice  to  enable  us  to  diitorcntiate  the  cases  ut  multiple 
I  iii'uritis. 


■^■:4.  M 


iiifi 


898 


DISEASES  OF  THE   NERVOUS  SYSTEM. 


CHRONIC    AFFECTIONS    OF   THE    SPINAL   CORD 


I.    Sr.VSTK!    I'AKAri.lXilA. 


.  ! 


,ni 


Definition.  —  r^oss  of  power  willi  spasm  of  tlio  muscles  of  tin  |(iu(r 
extremities. 

While  cliiiii'iilly  spiistic^  |)ariiple<jia,  or,  as  it  is  .sometimes  callcil,  A///«.v 
i/urs<ilifi  sj)(is))iii{/itjii(',\>^  a  well-delined,  readily  reco^fiiizable  a(Teetii)ii,ctio- 
logically  aiul  uiiatomieally  it  presents  marked  dilTerences,  and  various 
groups  must  be  separated,  all  of  wliicli  ijresent,  however,  the  cofidtiiiutiiiii 
of  spasm  with  los.s  of  power.  As  the  j)yramidal  tracts  are  involvi'd,  tlir 
term  lateral  sclerosis  is  sometimes  used  as  the  cfjiiivalent  of  spastic  para- 
plegia. The  lesion  is  in  many  cases  a  chronic  myelitis.  I  shall  ciiiu-iilir 
the  following  forms  : 

(1)  Secondary  Spastic  Paralysis.  — Following  a  transverse  lesion  of  tin; 
cord,  whether  the  result  of  slow  cDinpre.ssion  (as  in  caries),  cliroiiir  mw- 
litis,  the  pressurt!  of  tumor,  chronic  meiiingo-myelitis,  or  multipU;  sdcnivis, 
(legen'>ration  takes  place  in  the  pyramidal  tracts,  below  the  point  of  dis- 
ease. The  legs  soon  become  stilf  and  rigid,  and  the  rellexes  iiicrca-f. 
Hastian  has  shown  that  in  compression  paraplegia  of  tin;  transverse  ksidii 
is  coiinilcte,  the  limbs  may  be  flacciil,  without  increase  in  the  rcllext's— 
j)(tr(t]>h'iji('  Jliis(i)ii'  of  the  Frcnidi.  'i'he  condition  of  the  patient  in  tlicso 
sei!i)iulary  forms  varies  verv  much.  In  chroni(!  mvelitis  or  iii  uniltipk' 
S(derosis  he  may  be  able  to  walk  about,  but  with  a  characteristic  ^^a-^Xv 
gait.  In  the  com|)ression  myelitis,  in  fracture,  or  in  caries,  there  iiia\  lie 
com])lete  loss  of  power  with  rigidity. 

{•i)  Primary  Spastic  Paraplegia.— This  is  Ixdieved  to  depend  u|ioii  a 
primary  sclerosis  of  the  lateral  or  ])yramidal  tracts.  The  fjuestinii  is  still 
debated  whether  a  primary  lesion  of  the  lateral  tracts  ever  takes  pliicc.  <ir 
whether,  in  such  instances,  there  is  not  always  some  lesion  of  the  iiintur 
(icUs  in  the  anterior  horns.  Cases  may  jii-rsist  for  years  witlmut  iiny 
atrophy.  In  other  instances  there  are  .signs  of  involvement  of  the  posterior 
columns  as  well,  forming  the  condition  of  ataxic  paraplegia,  which  will 
be  considered  .se[iarately.  So  far  as  I  know,  the  only  (;ase  whi(di  is  claiiiin! 
to  (h'tnonstrate  the  e.xistence  of  a  primary  lateral  .s(derosis  is  that  of  IhvNh- 
feld's.  whi(di  occurred  in  ISKl. 

(;3)  Erb's  Syphilitic  Spastic  Paralysis.— C'liiucally  it  is  cotmnon  t" 
meet  with  ca.ses  in  adults,  particularly  in  syphilitic;  subjects,  wlmhau' 
jiains  in  the  back,  perhaps  a  girdle  sensntion,  Jind  a  gradually  dcvclo|iiiii' 
progressive  spastic;  parapK'gia.     It  amy  be  impossible  from  the  lii.-turvor 


■  !**' '  R  ;    V.' 
II, 


AL   CORD 


iisclos  of  tlic  liiwir 


ipU'giii,  wiiiili  «i 
so  wliicli  isi'liiiiiic 
i.sisthiit  III'  I'lv.-'i 


CriUONIO   AFFKCTIONS  OP  TUK   SPINAL  COUP. 


8SM.) 


the  pliN'.sical  exatniiiiitioii  to  dt'tiTmino  wlictlior  tlio  coiidition  is  scooiulary 
to  :i  Iran s verso  myelitis  or  a  ineniiiiro-niyelitis,  or  whether  the  lesion  is  a 
priiiiiiry  degeiioration  of  the  ])yramidal  tracts. 

Since  writing  this  })aragraph  in  the  first  edition,  Erb  has  described  a 
?viii|itoni  gronp  under  the  term  syjjhilitic  spinal  paralysis,  to  which  ninch 
attention  has  been  given.  The  points  upon  which  he  lays  stress  are  a 
very  gradual  onset  with  a  development  finally  of  the  features  of  a  sj)astic 
paresis;  the  tendon  reflexes  are  greatly  increased,  but  the  muscular  rigid- 
ity is  slight  in  comi)arison  with  tlie  exaggerated  dcoj)  reflexes.  There  is 
rarely  much  pain,  and  the  sensory  disturbances  are  trivial,  but  there  may 
bo  piira'sthesia  and  the  girdle  sensation.  The  bladder  and  rectum  are 
iisuiilly  involved,  and  there  is  sexual  failure  or  impotence.  And,  histly, 
improvement  is  not  infrequent.  A  majority  of  instances  of  spastic  paraly- 
HS  iif  adults  not  the  result  of  slow  compression  of  the  cord  are  assoeiated 
with  syphilis  and  belong  to  this  group. 

The  general  .syvipionin  of  spastic  parajjlegia  in  adults  are  very  distinc- 
tive. The  patient  comj)laiiis  of  feeling  tired,  of  stiffness  in  the  legs,  and 
perhaps  of  pains  of  a  dull  aching  character  in  the  back  or  in  the  calves. 
There  may  be  no  definite  loss  of  j/ower,  even  when  the  spastic  condition  is 
well  established.  In  other  instaiu'cs  there  is  definite  weakness.  The 
stiffness  is  felt  most  in  the  morning.  In  a  wcll-dcvdoped  case  the  gait  is 
most  characteristic.  The  legs  are  moved  stiflly  and  with  hesitation,  the 
toes  drag  and  catch  against  the  grouiul,  and,  in  extreme  cases,  when  the 
ball  of  the  foot  rests  upon  the  grouiul  a  distinct  clonus  develops.  1'he 
le;rs  are  kept  close  together,  the  knees  touch,  and  in  certain  cases  the 
mldiictor  spasm  nuiy  cause  cro-ss-legged  progression.  Un  examination, 
the  legs  nuiy  at  first  appear  tolerably  suj)ple,  perhaps  flexed  and  extended 
readily.  In  other  cases  the  rigidity  is  marked,  particularly  when  the 
limlis  are  extended.  The  spasm  of  the  adductors  of  the  thigh  nuiy  be  so 
(Xtreine  that  the  legs  are  separated  with  the  greatest  difliculty.  In  cases 
of  this  extreme  rigidity  the  patient  usually  loses  the  power  of  walking. 
Tliu  luttrifion  is  well  nuiintained,  the  muscles  nuiy  be  hypertrophied. 
The  reflexes  are  greatly  increased.  The  slightest  touch  ujjou  the  jiatellar 
tendon  produces  an  active  knee-jerk.  The  rectus  clonus  and  the  ankle 
domis  are  easily  obtained.  In  some  instances  the  slightest  touch  may 
throw  the  legs  into  violent  clonic  spasm,  the  condition  to  whicli  Krown- 
Se([iiard  gave  the  name  of  spinal  epilepsy.  The  superficial  reflexes  are 
abo  increased.  The  arms  may  be  unairected  for  years,  but  as  a  late  mani- 
festation rigidity  may  develop. 

The  diagnosis  is  readily  made,  but  it  is  often  very  difficult  to  deter- 
mine accurately  the  nature  of  the  underlying  pathological  condition.  A 
liistory  of  syphilis  is  present  in  numy  of  the  cases.  The  course  of  the 
liiseuse  is  progressively  downward.  Years  may  elapse  before  the  patient 
ishedridden.  Involvement  of  the  sphincters,  as  a  rule,  is  late  ;  occasion- 
li"),  liowever,  it  is  early.     The  sensory  symptoms  rarely  progress,  and  the 


>k  ,  ■ 


'-'-i 


i    r 


.-  r 


'f 


;  t' 


\m 


900 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


pationts  may  retaiii  tlie  {ijciuM-al  nutrition  and  enjoy  cxcoliont  lioaltli. 
Ociihir  syinptoiMs  iirc  niii'. 

(4)  The  Spastic  Paraplegia  of  Infants  (Pdniphuld  rrrchi-dlis  spusllnt 
—  Heine). — 'I'iiis  is  iisiiaiiy  a  hirlii  ])alsy,  oflcn  tliii  rcsiiit  of  (lillicnli  lalidr. 
In  t\V(!nty-tliroo  of  tho  twenty-four  of  Little's  cases,  there  was  either  iHlli- 
cult  lahor  or  ))reinature  (h'livery.  'I'he  stiiTness  of  tho  legs  may  imt  Ik.' 
noticed  for  some  montiis  after  ]»irth,  but  usually  on  dressiuif  tiie  cliiM  tin 
motlier  iiotices  the  ri.iridity.  Wlien  attempts  are  made  to  walk  the  stiiT- 
ness and  awkwardness  then  heeonie  aj)parent.  On  standing,  the  atiitinlv 
is  very  characteristic.  There  is  talipes  ecpiinus,  varying  from  the  sliglitist 
raising  of  the  heel  to  a  coiulition  in  wliich  the  child  stands  on  tiptuc  In 
older  children,  as  tliey  walk,  the  toe-cap  of  the  shoe  is  usiudly  inucli  worn. 
The  strong  al)duct()r  action  may  produce  typical  cross-legged  ]»rogre»i(iii, 
in  which  each  foot  is  drnggeil  over  and  planted  in  front,  or  even  on  the 
other  side  of  its  fellow.  In  attempting  to  flex  the  legs  there  is  a  niarkcil 
resistance,  which  gradually  yields — the  lead-i)ii)e  contraction,  ns  Weir 
Mitchell  calls  it.  The  reflexes  are  increased,  though  in  s)me  children  it  i> 
not  an  easy  matter  to  ol)tain  thetu.  The  ankle  clonus,  as  a  rule,  is  lint 
ohtainahle.  Sensation  is  uniin})aired,  and  the  bladder  and  rectum  are  imt 
involved. 

The  symptoms  of  this  afTection  in  children  are  almost  identical  witli 
the  spastic  paraplegia  of  adults.  The  arms  nuiy  he  involved — sjiastic 
diplegia.  The  disease  is  probably  of  ccn'tical  origin.  There  are  fre(ii;,'iilly 
symptoms  indicating  cerebral  defects,  suc'.i  as  idiocv',  imbecility,  iiinl 
nystagmus.  Some  of  the  cases  tlepend,  no  doubt,  upon  bilateral  nieiiiii- 
geal  ha'umrrhage  occurring  dining  delivery.  Others  are  prol)alily  iliir  tn 
arrest  of  develoi)UU'nt  of  the  pyramidal  tracts.  This  condition  in  cliildnn 
must  not  bo  confounded  with  tetany  or  with  the  pseudo-paralytic  rigidity 
80  often  as.sociated  with  rickets. 

(A)  Hereditary  Form. — Much  interest  has  been  aroused  recently  in  tliis 
type,  cases  of  which  have  been  described  by  (iee,  Bernhardt,  Latimer. 
Newinark,  Tooth,  Sachs,  and  (tthers.  Aj)parently  wo  have  to  distiniriii>li 
a  famUy  form,  in  which  the  disease  develo[)s  in  infancy  or  (diildliodd.  ainl 
the  cases  have  all  the  chai'acters  of  ix  jutrnpjpfiia  .ywxi ira  n'rcbroHs.  hi 
this  grouj),  the  presence  of  mental  disturbances,  nystagmus,  optic-iicni' 
atrophy,  aiul  the  speerdi  disturbances  indicate  quite  clearly  a  ecrdMiil 
lesion,  to  which  the  spiiud  alTcc^tion  is  con.secutivo.  On  the  other  liaml 
there  are  cases  of  spastic  paraplegia  occurring  in  members  of  the  saim 
family,  developing  later  in  life,  often  after  middle  age,  in  which  the 
lesion  would  appear  to  bo  confined  to  the  s[)inal  cord,  a  primary  degciicni- 
tion  of  the  pyramidal  fa.sciculi.  In  one  of  Stri'impel's  cases  the  cord  aim!' 
was  involved. 

(0)  Ataxic  Paraplegia.— This  name  is  applied  by  Oowers  to  a  dispibo 
characterized  clinically  by  a  cond)imiti(,n  of  ataxia  aiul  spastic  i)ara|d('gi!i, 
and  anatomically  by  involvement  of  the  posterior  and  lateral  columns. 


CIIRON[C   AFFECTIONS  OF  TOE   SPINAL  CORD. 


901 


CXOt'llojlt    lu'llltll. 

cerehrdlis  sjuisliiit 
t  of  (liniculi  hilu.r. 
re  was  cilluT  dilli- 
!  logs  may  not  lit.' 
ssiiijf  the  iliild  the 
!  to  walk  tlir  stil''- 
iiding,  tlie  allitiuK' 

from  tlio  .-liulitist 
,i\(ls  oil  tiiitiic.  Ill 
isually  much  wnm. 
logged  progvcv-imi. 
)nt,  or  oven  nn  the 

thoro  is  a  iiiarkcil 
iitractitiii,  as  Weir 
some  children  it  i- 
us,  as  a  ruh',  is  not 
iiiul  rectum  aiv  not 

iiost  identical  with 
^  involved— s[iii>lii' 
liorc  are  fn'i|i'..iiily 
•y,   imbecility,  ami 

I  bilateral  mciiiii- 
ire  probably  due  in 

idition  in  childnn 
o-paralytic  riL'iditv 

f^ed  recently  in  t!ii« 
ernhardt,  Liitinur, 
luve  to  distini:iii>li 

or  ohildhoiid,  aiitl 
licd  crrr/inilif.  In 
iginus,  oiitic-ncrvr 
elourly  a  eerebriil 
)n  the  other  liiunl 
Tibers  of  the  Hamc 
age,   in   which  the 

l)riniary  (legciura- 
asca  the  eord  almii 


The  disease  is  most  cojnmon  in  middle-aged  males.  K\jiosiiro  to  cold 
and  traumatism  liave  been  occasional  antoceilonts.  In  striking  contrast 
to  ordinary  tabes  a  history  of  syj)hilis  is  rarely  to  be  obtained. 

The  anatomical  features  arc  a  sclerosis  of  tlie  pustcrior  columns,  which 
i«  not  more  marked  in  the  lumbar  region  and  not  s|)ecially  localized  in 
the  root  zone  of  tht^  postero-external  columns  The  involvement  of  tlio 
hitcial  columns  is  ditTuso,  Jiot  always  limited  to  the  pyramidal  tracts,  and 
then  may  be  an  annular  s<dcrosis. 

The  sjiinphiins  are  well  delitied.  'IMie  patient  complains  of  a  tired 
felling  in  the  legs,  not  often  of  actual  pain.  The  sensory  symptoms  of 
true  tabes  are  absent.  An  unsteadiness  in  the  gait  grailmdly  develops 
with  jirogrossive  weakness.  The  reflexes  are  increased  from  the  outset, 
and  there  may  be  well-developed  ankle  clonus.  Rigidity  of  the  logs 
sldwiy  comes  on,  but  is  rarely  so  marked  as  in  the  uncom[)licated  eases 
(if  lateral  sclerosis.  From  the  start,  incoiirdination  is  a  Mcll-cbaracterized 
foature,  and  the  ditliciUty  of  walking  in  the  dark  or  swaying  when  the 
(Vi's  are  (dosed  may,  as  in  true  tabes,  be  the  first  symptoni  to  attract  at- 
tention. In  walking  the  patient  uses  a  stick,  keeps  the  eyes  fixed  on  tlie 
'.'round,  the  legs  far  apart^,  liut  the  stam[iing  gait,  with  (devation  and  siid- 
(li'ii  descent  of  the  feet,  is  not  often  seen.  The  incoordination  may  extend 
to  the  arms.  Sensory  symptoms  are  rare,  but  (Sowers  calls  attention  to  a 
(hill,  aching  jiaiii  in  the  sacral  region.  The  sphincters  usually  become 
involved.  Eye  symptoms  are  rare.  Late  in  the  disease  mental  symptoms 
may  develop,  similar  to  those  of  general  paresis. 

In  well-marked  cases  tlie  ili(i(i»tisix  is  easy.  The  combination  of 
marked  incoordination  with  retention  of  the  ridl(>\es  and  more  or  less 
spasm  are  (diaracteristic  features.  The  absence  of  ocular  and  sen.sory 
syniptoms  is  an  im]>ortant  point. 

(?)  Hysterical  Spastic  Paraplegia.- There  is  no  siiinal-cord  disease 
which  may  be  so  accurately  mimicdvcd  by  hysterical  patients  as  spastic 
paraplegia.  Ther(>  is  wasting  in  the  hysterical  para])legia,  the  .sensory 
symptoms  are  not  marked,  the  loss  of  power  is  not  eomiiloto,  and  there  is 
Hot  that  extensor  spasm  so  characteristic  of  organic  disease.  The  hyster- 
ical contracture  will  be  considered  later. 

The  rellexes  are,  as  a  rule,  increased.  The  knee-jerk  is  present,  and 
tlicre  may  be  well-develojied  ankle  <donns.  (iowers  calls  attention  to  the 
fact  that  it  is  usually  a  spurious  clonus,  "due  to  a  half-voluntary  contrac- 
tion in  the  calf  muscdcs."  \  true  clonus  does  occur,  however,  an''  there 
may  he  the  greatest  difliculty  in  deterniining  whether  or  not  •  ca.se  is 
"He  of  hysterical  paraplegia. 

(^)  Primary  Combined  Sclerosis  (Putnam). — In  addition  to  the  ataxic 
piiniplegia  just  mentioned,  here  may  be  considered  certain  cases  wliiehare 
characterized  anatomically  by  a  relatively  chronic  sclerosis  of  the  posterior 
columns,  of  the  lateral  columns,  chiefly  the  pyramidal  tract,  and  also  of 
the  cerebellar  tract.     With  these  arc  usually  associated  more  acnte  changes 


Ili'J 


''!■  ' 


J  Ml! 

.ill!; 


902 


DISEASES  OF  TFIH   NERVOUS  SYSTEM. 


in  juljoiiiinj:;  ivreas,  either  difTiise  or  systemic,  some  grade  of  (lecjeneriitinn 
in  the  ^niy  mutter,  and  itivdlvemciit  of  the  nerve  roots.  This  foirn  Im. 
been  stiulied  by  .J.  .1.  I'litnain  and  Dana.  'I'he  eases  are  nsiially  in  wuiiiin 
— seven  (Mit  ol'  nineteen  ('(inectcd  Ijy  Dana;  the  a<,'es,  from  I'ortv-livc  lu 
sixty-four.  'J'he  disease  runs  a  ratiier  ra{)id  eoiir.se.  Neiiroj)atliic  inhiiii- 
ancc  is  present  iii  some  instances.  Putnam  thinks  that  possibly  both  had 
and  arsenic  phiy  a  j)art  in  the  etioh)iry. 

The  t<i/iiij)t()iits  are  botli  sensory  and  motor.  Tiie  oiuset  is  usnallv  with 
minil)ness  in  tlie  extremities,  progressive  h).ss  of  strongtii,  and  eniariiitiun. 
Paraplegia  gradnally  develoj)s,  before  which  tliere  Inive  been,  as  a  nili, 
spastic  symptoms  with  exaggerated  Jxiiee-jerlv.  'i'he  arms  are  alTccti'd  Kw 
than  tlie  legs.  Mental  symplums  similar  to  dementia  })aralyti<'a  inav  ilr- 
velop  toward  the  close. 

The  diit(jn(>sis  of  this  mixed  sclerosis  rests  upon  the  combinatimi  of 
sensory  and  motor  symptoms  with  the  presence  of  exaggerated  rclli-xcs. 
As  stated,  tile  sensory  features  consist  chieny  of  para'sthesia,  and  tlicn; 
may  be  dilliculty  in  distinguishing  the  condition  from  muUiple  iu'iniii«, 
Tlie  frecjuency  of  the  di.sease  in  more  or  less  enfeebled  or  aniemic  woiiuii 
past  middle  life  is  also  an  important  feature. 

Treatment  of  Spastic  Paraplegia.— In  the  majority  (tf  (a>is 
spastic  paraplegia  is  incurable.  The  ca.ses  which  result  from  traiisitrnv 
compression,  as  in  caries,  may  get  well ;  but  in  the  other  forms  the  disiav 
is  uniforndy  j)rogrcssive,  and  remedies  have  little  or  no  control.  Wiiiii 
syphilis  is  suspected  u  thorough  course  of  mercury  and  iodide  of  j)()tassiiiiii 
should  be  given.  Scriij)nlous  attention  should  be  paid  to  the  liladiKr 
symj)toms,  and  the  sauie  measures  may  be  used  as  will  be  advised  in  loiu- 
motor  ataxia.  In  the  infantile  form  of  paraplegia  much  may  be  done  bv 
the  orthojja'dic  surgeon  to  overcome  rigiility  and  contracture.  In  st'vcnil 
instances  I  have  known  i)ersistent  friction  with  forcible  flexion  and  exti'ii- 
sion  and  the  ap])lication  of  jtroper  apparatus  enable  a  patient  to  get  alwut 
comfortably. 


II.  Locomotor  Ataxia. 

{Tdbcs  Dorsal  18 ;  Posterior  Spinal  Sclerosis). 


Definition. — An  affection  of  the  nervous  system  characterizt'd  clin- 
ically by  incoordimition,  sensory  aiul  trophic  disturbances,  and  in- 
volvenu'nt  of  the  special  senses,  particularly  the  eyes.  Anatomicnlly  llu'if 
are  found  sclerosis  of  the  posterior  columns  of  the  cord,  degeneration  of 
the  spimil  ganglia  and  of  the  posterior  roots,  foci  of  degeneration  in  tlu' 
basal  ganglia,  and  sometimes  chronic  degenerative  changes  in  the  cortex 
cerebri. 

Etiology. — It  is  a  wide-spread  disease,  more  frequent  in  cities  tliiui  i" 
the  country.  The  relative  proportion  may  be  judged  from  the  fiiit  thai 
of  l,8l(i  cases  in  my  neurological  di8])en8ary  in  two  years  there  won'  >•' 


CHRONIC   APFKCTIONS  OF  THE  SIMXAL  CUllI). 


9o.*3 


casos  of  locomotor  ataxia.  Males  arc  attu(.'kc'(l  iikitc  fr(>(|ii('iitly  tlum 
fviiiiik'S,  the  proportion  lit'iiij;  at  least  ten  to  one.  .Mileliell  lias  called 
iittciilion  to  the  faiit  that  it  is  a  rare  diseast-  in  the  ne^ro.  Of  '^'>  cases  at 
mv  ilitiic,  3  were  in  nejjroes.  It  is  a  tlisease  of  adnlt  life,  a  majority  of 
the  cases  oeenrrini;  hetween  the  thirtieth  and  fortieth  years.  Occasionally 
r;isc.>  are  .seen  in  yoiin;,'  men.  The  form  of  ataxia  wiiicii  occurs  in  cliil- 
(livii  is  u  dilTerent  di.sease.  Of  special  causes  syphilis  is  the  most  im- 
]i(iil:nit.  According  to  the  ligures  of  I'lrl),  l-'oiirnicr,  and  (lowers,  in 
from  fifty  to  seventy-five  per  cent  of  all  cases  there  is  a  history  of  this 
(list'H-e.  Krl)'s  recent  figures  are  most  striking ;  of  ;!(iO  eases  of  tal)es  in 
|iriv;ile  jtractice  S!)  per  cent  had  had  sypiiilis.  In  Kournier's  recent  Lcs 
Afriiitns  rarasypliililiqueH  the  whole  question  is  treated  in  a  nnisterly 
iiiaiiiier. 

Mxcessive  fatigue,  overexertion,  exjiosure  to  cold  and  wet,  and  sexual 
oxl■^■^f•es  are  all  assigned  as  causes.  There  are  instances  in  which  the  dis- 
lasc  lias  closely  followed  severe  exposure.  James  Stewart  has  noted  that 
tlif  Ottawa  lumhermen,  who  live  a  very  hard  life  in  the  camj)s  during  the 
winter  months,  are  frefpiently  the  suhjeets  (»f  locomotor  ataxia.  Trauma 
has  Iteen  noted  in  a  few  cases.  Alcoholic  excess  does  not  seem  to  [iredis- 
po.se  to  the  disease.  Among  patients  in  the  hetti-r  classes  of  life  1  do  not 
i'i'iiionil»er  one  in  which  there  had  heen  a  previous  history  of  prolonged 
ilniiikeliness. 

Morbid  Anatomy  and  Pathology.  — When  a  patient  has  died  in 
ilii' ihl\anced  stage  of  the  disease  the  following  are  llie  most  important 
I'liiuiges  : 

{a)  The  perij)licral  nerves  may  show  signs  of  degeneration.  Neuritis 
may  indeed  he  ])resent  even  when  there  have  heen  no  special  symptoms 
iiiilicating  it.  In  other  instances  there  is  not  only  neuritis,  but  muscular 
atroiiliy. 

(//)  'I'ho  posterior  roots  (ami  their  ganglia)  of  the  spimil  cord  are  small, 
gray,  and  atrophic,  and  the  cells  of  the  ganglia  are  degenerated. 

('■)  The  meninges  of  the  posterior  ami  lateral  columns  are  thickened, 
more  lirmly  adherent  than  normally,  and  the  blood-vessels  usually  show 
signs  of  arterio-sclerosis. 

('/)  The  changes  in  the  spinal  cord  are  as  follows:  (1)   In  advanced 
•  asos  the  jiosterior  columns  are  uniformly  sclerotic  and  the  dorsal  and 
hiniliar  regions  arc   most   extensively  involved.     In    long-standing   cases 
there  is  generally  an  increase  of  connective  tissue  throughout  the  cord  and  \ 
tlicre  may  he  degeneration  (2)  of  the  ascending  antero-lateral  tract  ;  (.'J)    \ 
of  the  direct  cerebellar  tract;  (4)  of  the  pyramidal  tract. 

('')  The  cerebral  changes — of  less  consequence  than  the  spinal— may 
consist  of  (1)  s(!lerosis  in  the  restiform  bodies,  in  the  inferior  jteilnneles 
of  the  cerebellnin,  and  of  certain  of  the  cranial  nerves,  particularly  the 
lliirckthe  optic, and  the  auditory;  (2)  cortical  changes, consisting  in  some 
cases  of  a  diffuse  meningo-encephalitis. 


l;i.:. 


904 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


i  i>M-    <^ 


I 


Our  coiifoiition  of  t;il)o.s  (lorsalis  liiis  iintlorjjoiit'  nidical  altorati'in,  and 
the  studios  (if  Iji-ydeJi,  IN'iUicli.  Marie,  iitid  others  liiivc  sliowii  tliat  it  cum 
no  Idiigor  ho  regarded  as  a  iirimary  systemic  selomsis  of  tlio  itoMrridv 
ooliitiiiis.  'Piiese,  it  will  be  nMiiemliered,  are  made  ii|i.  in  irreat  part.df  the 
iixis-eyiiiider  pnicesses  of  tlie  spinal  gatiirlia,  and  tlie_\,  with  tlieii-  hraiiclics. 
rciirosoiit  ii\  the  cord  the  paths  of  sensory  eotidiietion.  'I'he  periphcml 
sensory  nerve><  repi'csent  tlie  pidlophisniic  processes  of  tlie  spinal  guiijrliii. 
wliieh  important  strnetiires  are  the  trophic  centres  l)oth  for  the  sensorv 
nerves  as  well  as  for  the  axis-cylinder  jiroeosses  which  make  up  llic  [kjs. 
terior  columns  of  the  cord.  Marie  calls  attention  also  to  the  possihjljtv  cf 
the  oxi-iteiico  of  poriplicral  or  tcrmiiiid  ixaULMinn  cells  which  are  rniiinj  in 
<lilTerent  organs — cells  from  which  eci'taiii  of  tlio  sensory  til  ires  are  deriviil 
which  go  to  form  the  posterior  nerve-roots.  According  to  the  gciu'ral 
laws  of  nerve  physiology,  as  mcntioiu'd  at  page  SIO,  lesions  of  iIk;  ncrvc' 
T ganglia  would  he  followed  by  degeneration  of  the  posterior  root-ti!ires  ami 
i]  of  their  continuation  in  the  cord,  and  this  is  [iractically  wliat  the  recciii 
theory  of  tal)es  involves.  The  clianges  in  the  [tostei'ior  columns  arc  lucii'lv 
a  sequence,  aiul  not  tlie  primary  disease.  The  fibres  of  tlie  posterior  root 
are  divided  into  three  .st'ts : 

(1)  'IMie  short  fibres,  which  pass  almost  directly  into  the  posterior 
coriui  after  entering  the  co 

('i)  l-'ibi'cs  of  moderate  length,  wliich  run  upward  in  the  cord;  somo 
of  them  enter  the  posterior  horn  at  its  middle  jiart,  wliile  others  pass  into 
Clarke's  column.  The  fibres  of  this  group  run  in  the  column  of  Hiir- 
dach. 

(3)  A  group  of  long  fibres,  which  are  derived  chiefly  from  the  roots  of 
the  Cauda  ec|uiiui,  and  wljich  i)ass  the  whole  length  of  the  cord  t(»  enter 
<  certain  nuclei  in  tlu?  nuMlulla.     Tliey  form  the  column  of  (ioll. 

The  initial  cord  lesion  in  tabes  is  found  in  the  posterior  root-zone  nm! 
in  the  zone  or  tract  of  Lissaner,  a  luirrow  portion  sitmitod  between  tlic 
nuirgin  of  the  cord  and  the  apex  of  the  jiosterior  horn.  In  the  coliiimi  of 
IJurdach  the  sclerosis  is  in  almost  direct  proportion  to  the  duration  of  tin 
disease,  slight  at  first  and  centrally  placed,  and  becoming  wide-s])reii(l  n? 
the  disease  advances.  J'he  column  of  (ioll  is  affected  slightly  in  tlic  enilv 
stages,  but  in  the  advanced  stage  there  is  extensive  sclerosis.  Marie  cor- 
relates the  sclerosis  of  these  ditferetit  parts  with  the  ditTerent  groups  of 
nerve-fil)res  of  the  posti'rior  root,  the  posterior  root-zone  and  the  zuup  of 
liissauer  degenerating  from  the  involvement  of  the  short  fibres;  the  scK- 
I'osis  of  the  columns  of  Burdach  and  the  disappearance  of  the  uctwoik 
of  the  nerve-fibres  in  the  column  of  ("larke  beijig  due  to  the  degenoni- 
tion  of  the  second  group,  the  fibres  of  moderate  length;  while  the  sck- 
rosis  of  the  columns  of  (loll  is  caused  by  the  degeneration  of  the  tliinl 
group,  namely,  the  long  fibres.  lie  suggests  also  that  groups  of  I'Me- 
in  the  different  posterior  roots  are  not  simultaneously  alTectcd,  ami  'li' 
lesions  may  be  in  an  advanced  stage  in  one  region  and  but  slight  in  tlit 


(•ill  iiUoratinii,  and 
shown  tliiii  ii  (MM 
s  of  tlio  i>ii-trriiir 
I  <.M'i'iil  piirt.  nf  the 
ill)  tlicir  l)raticlK'S. 
1.  'V\\v  [icriiihcral 
tho  spiiKil  ;:.iii,L'liii, 
)t\\  for  tlu'  stMisory 
niiiko  141  I  lie  ["i>- 

0  the  jxtssiliility  cf 
•liicli  am  I'niiiiil  ill 
•y  iiUri's  aiT  dcrivcil 
ilig  to  thr  uciuTul 
■sions  of  the  iici'vo 
ri(ir  root-lilircs  iiiid 
llv  wliat  tlic  recent 
f'olutiiiis  are  merely 
f  tlic  poritiM'ior  n"'t 

into   tlio  posterior 

1  ill  tlio  (Mini ;  sumo 
ile  others  pass  into 
lio  col II 111  11  of  Bur- 

Iv  from  tlio  root<of 
tlio  cord   to  enter 

of  Coll. 
rior  root-zone  iiiu! 
latod  between  tlio 
In  the  eoliiiiiii  "1 
he  duration  nf  ilio 
inti'  \vi(lo-spre;ul  :i- 
io-litly  in  the  e;iiiy 
ei'ftsis.     Marie  eei- 
litToront  <rroui>s  M 
10  and  tho  znneof 
rt  Hbros;  tho  scK'- 
ico  of  Iho  network 
to  the  (lojronora- 
th;  while  tho  rIo- 
ration  of  the  tliini 
at  jjroiips  of  li'if'' 
y  affected,  nml  '^  • 
I  but  slight  in  tin 


rilRONK     AFKKCTIONS  OF   TIIK  SlMN.\r,  CoUD. 


m:> 


ic 


other.  "  y/ir  h'sious  iif  the  xjiiiiiil  rovil  in  hihcx  urnir  hif  snimciils^  viwh 
jHPSterior  root,  liriii;:ii\L,'  into  the  [posterior  eoliiiMn  a  fresh  coiitiiif^ent  of 
ill  _'enorat('d  fibres." 

Aecordin;,',  too,  to  tlii<  inlerestini;  hypothesis  the  lesions  of  tlie  pinpliai 
(if  tho  p().sterior  roots  are  responsible,  in  part  at  least,  for  the  peripheral 
lu'iiiilis,  sine(^  in  do^^eiieration  of  the  spinal  <,'an<;!ia  and  consefpient  h)S.s  of 
trii|iliic  inllnence  thei'e  woiihl  neeessarily  l)e  ih'p'iieration  in  the  pcriph- 
( nil  nerve-trunks.  I'os.sibly,  Iim.,  Marie  sii<rLtests,  the  (h'i,'eneratinn  of  tiie 
pfri/i/i(  i((/  gaiiylion  cells  may  iiave  a  good  deal  to  do  with  tiie  neuritis  of 
!alie>. 

Symptome. — 'Pliese  are  best  eon-idered  under  the  three  stages  of 
|in'-ata\ic.  ataxic,  and  paralytic. 

Pre-ataxic  Stage.— The  following  are  the  most  (diaraelcristic  features 
iif  this  period  : 

/'(^'//.v',  usually  of  a  sharp  stabliing  character;  hence  the  term  liglit- 
iiing  pains.  They  last  for  (Uily  a  scrond  or  two  and  are  most  common  in 
llic  legs.  'IMiey  may  lie  as.soeiated  with  11  hot,  burning  feeling.  Occasion- 
iilly  herpes  may  develop  at  the  site  of  the  pain.  They  may  occur  at  irregii- 
liir  intervals,  and  are  more  ju'oiic  to  follow  ex<"es.ses  or  to  come  on  when  the 
lirtilth  is  impaired. 

Ocular  i^f/ni/i/'iins. —  (a)  Ptosis,  wliieh  may  be  single  or  double  and  is 
liy  III!  means  uncommon  cither  alone  or  (/>)  in  association  with  external 
strahisnius.  The  first  compl.'iint  maybe  of  double  vi-ion.  Occasionally 
tliiTi'  may  be  paralysis  of  all  the  external  muscles  of  the  eye,  producing 
ii|iliihalmoplegia  externa,  {r)  Argyll- Iiobcrtson  juipil,  in  which,  as  alreadv 
iiiintioned,  there  is  loss  of  the  iris  rellex  to  light,  but  eoiitraclion  during 
aivnimiiodation.  The  pupils  are  usually  small— spinal  myosis.  {1/}  <>[i- 
tic  atrophy.  This  is  ofti'U  an  early  or  even  the  first  .symptom.  'I'he  loss 
of  vi.sion  progresses,  and  in  a  large  majority  of  ca.ses  leails  to  total  blind- 
ness. 

Ao.v.s'  of  the  I\)ic('-j<'rk. — This  is  one  of  tho  earliest  symptoms,  and 
may  occur  years  before  there  is  ataxia.  Taken  alone  it  is  of  no  riiomeni, 
as  there  are  individuals  in  whom  the  knee-jerk  i-  absent;  but  in  connee- 
tiun  wiih  the  lightning  pains  and  the  ocular  synij»toms,  it  is  of  especial 
importance.  These  are  the  most  comnnui  symptoms  of  the  preataxic 
'taire,  and  may  persist  for  years  without  the  devidopmeiit  of  incoordi- 
nation. The  patient  may  look  W(  II  ami  fc(d  well,  and  be  troubled  only 
tiy  occasional  atta(d\S  of  lightning  jiains;  or  there  is  persistent  ptosis, 
external  strabismus  develoi)s,  or,  what  is  more  serious,  a  jirogre.ssivo 
utrojihy  of  the  optic  nerve.  There  is  often  a  gradual  loss  of  sexual 
power. 

The  disease  may  never  progress  beyond  this  stage,  and  when  ojitic 
iitriiphv  develops  early  and  leads  to  blindni'ss,  tiie  ataxia  rarely,  if  ever, 
~iipervi  Mcs.  There  is  a  sort  of  antagonism  between  the  ocular  symptoms 
iiiiJ  tho  progress  of  the  ataxia.     Charcot  laid  considerable  stress  upon  thi.s, 


T       V 


900 


DISIOASKS  ol'    rilK   N'KltVOirS  SYSTKM. 


'i 


!  4,  - 


iiinl  I)t''jt''riii('  a.ssiircd  me  lliiit  of  llif  uiiurmiMis  taliclic  niatoriiil  at  ila. 
Hicrtri'  in  not  a  sinirlc  instance  in  which  (iptic  atrophy  liad  coini,'  on  caiiv 
and  prof^rcsscil  to  lilindncss  was  the  patient  ataxic,  altlioiij,'h  Ihiiv  wtic 
cases  wl  lie  h  had  had  the  li^ditning  pains  uinl  ioioiis  of  ihe  opijc  11,1  vis  f,,r 
twenty-live  ycai's. 

Ataxic  Stage.  — .!/"/''/•  Si/hi/i/dhis. —Tht'  ataxia  develops  ;,'ra(lii;illv. 
One  of  the  lif.-.t  iinlications  to  tiie  patient  is  inal)ility  to  get  ahont  iVinlil; 
in  the  liark  or  to  maintain  his  cipiilihrinni  when  washing  his  I'a. ,.  with 
_  the  eyes  shnt.  Wht'ii  tlic  patient  stands  with  the  feet  together  ami  ih,. 
eyes  closeij,  he  sways  and  has  dilliculty  in  maintaining  his  po.-itinn,  ninl 
he  may  he  qnitc  nnahh'  to  stand  on  one  leg.  'Phis  is  known  as  IfmnlM  r;'\ 
symptom,  lie  does  not  start  olT  promptly  at  the  word  of  (  omniand.  On 
tiiridng  (piickly  ho  is  apt  to  fall,  lie  descends  stairs  with  ditlieiijiv. 
(iradiially  the  characteristic  ataxic  gait  develops,  '['he  patient,  as  a  rule. 
walks  with  a  stick,  the  eyes  are  directed  to  the  ground,  the  hody  is  liirnwn 
forward,  and  the  legs  are  wide  apart,  in  walking,  the  leg  is  thrown  out 
violently,  the  foot  is  raised  too  high  and  is  hronght  down  in  a  atainpini.' 
manner  with  the  heel  lirst,  or  the  whole  sole  comes  in  contact  with  tlir 
ground,  iritiimitely  the  patient  may  he  nnahle  to  walk  without  the  as>ist- 
'.nee  of  two  canes.  'I'his  gait  is  very  characteristic,  and  unlike  that  scfii 
in  any  other  disease.  TIh!  incoorilination  is  not  only  in  walking,  but  in 
the  performance  of  other  movements.  If  the  patient  is  asked,  wliiii  in 
the  recumhent  posture,  to  toiu'h  the  knee  with  one  foot,  the  irregiilaritv 
in  the  movement  is  very  evident.  Incoi'irdination  of  the  arms  is  less  coiii- 
moll,  hut  usually  develops  in  some  grade.  It  may  in  rare  instances  c.xi.^t 
hefore  the  incoordination  of  the  legs.  It  may  he  tested  by  asking  tlio  [w- 
tient  to  close  his  eyes  and -to  touch  the  tip  of  the  nose  or  the  tip  of  the  car 
with  the  linger,  or  with  the  arms  thrust  out  to  bring  the  tips  of  the  tiiifrcr- 
together.  The  incoordination  may  early  bo  noticed  by  a  dilliculty  which 
the  patient  experiences  in  buttoning  his  collar  or  in  performing  (Hic  ol 
tiie  ordinary  routine  acts  of  dressing. 
I  One  of  the  most  striking  features  of  the  disease  is  that  with  marked 
'  incoordination  there  is  no  loss  of  muscular  power.  The  grip  of  tlie  liaii(i> 
'•  may  be  strong  and  firm,  the  power  of  the  legs,  tested  by  trying  to  flex  thcni. 
;  may  be  unimpaired,  and  their  nutrition,  exc-ept  toward  the  close,  may  In 
iinafTected. 

/^etisori/  Si/iii/ifoms. — The  lightning  pains  juay  jiersist.  They  vary 
greatly  in  difTcrent  cases.  Some  j)atii'nts  are  rendered  miserable  by  tliu 
frequent  occnrrence  of  the  attacks;  others  escape  altogether.  In  aililiticii, 
common  symptoms  are  tingling,  pins  and  needles,  particularly  in  the  feci, 
and  areas  of  hyperaisthesia  or  of  ana'sthesia.  The  patient  may  coiii|ilain 
of  a  change  in  tlie  sensation  in  the  soles  of  the  feet,  as  if  cotton  was  inter- 
posed between  the  floor  and  the  skin.  Sensory  disturbances  ocnir  lew 
frequently  in  the  hands.  Ketardation  of  tactile  sensation  is  comnmii,  ami 
a  pin-prick  on  the  foot,  instead  of  being  instantaneously  felt,  is  not  per- 


CIIUONIC    AFI'KCTIONS   OK   TIIK   SlMNAfi  COlih. 


007 


ccivicl  for  ii  sccmid  nr  two  or  miiy  Im-  ildavtMl  Tor  as  niiicli  as  tci»  siMMirids. 
The  |»aiii  felt  limy  persist.  A  ciiriuiis  iilit'iKniiciioii  is  the  loss  of  tlic  power 
,if  liMiili/iiij,'  till)  pain.  I'"nr  inslaiirc,  il'  llif  paliciil  is  prirkcil  ini  diif  liiiih 
ill' iiiav  sav  tliat  Ik*  I't't'ls  it  on  llif  iitlicr  (ailoi-liciria),  or  ti  pin-prifk  on  tlu! 

fiHil   may  lie   I'flt    in   Ixttii   Irct.     Tlu'  iniij^cnlar  sense  Ik ines  iriiicli   iin- 

p.iiiiij  and  tlie  patient  no  lonyer  reeoirni/es  the  position  in  wliieh  his  lindis 
;irc  |ilaecd.     'I'his  may  lie  prescid  in  the  pic-ataxic  staji^e. 

1,'iilrrrs. — .\s  mentioned,  the  loss  of  the  knee-jerk  is  one  of  the  earliest 
>vin|iloms  of  the  disease.  <  ►eciisionally  a  ease  is  fonnd  in  whieh  it  is  re- 
liiiiii'il.  The  skin  rethxes  may  at  lirsl  he  inerea.sed,  hiil  later  are  usnally 
iiiviilved  with  the  deep  rellexes. 

SjitiidI  ,SV'y/.sr.v.—  'The  eye  symptoms  noted  aliove  may  he  pi'esent.  Init, 
lis  iiKiitioned,  ataxia  is  rare  with  atrophy  of  the  optic  nerve. 

neal'iiess  may  develop,  due  to  lesion  of  the  auditory  nerve.  There  may 
iilsii  ill'  attacks  of  verti^^o.     Olfactory  symptoms  are  rare. 

lisccral  Si/iiiji/oiiis. —  Ainon^  the  most  remarkahle  sensory  di>tiirhaii(!C3 
lire  the  tahetie  crises,  severe  paroxysms  of  pain  referred  to  various  viseeni; 
tlm>  larynjfcal,  j^Mstrie,  iiephraluic,  rectal,  nrethral,  and  clitoi'al  crises  havo 
liiriidi'serihed.  The  most  common  are  the  jfastric  and  laryiiLreal.  In  the 
I'lirnicr  there  are  intense  pains  in  the  stomach,  vomitinj,',  and  a  secretion 
if  hyperacid  i,^astrie  jnice.  'i'he  attack  iiiay  last  for  sevei'al  ilays  or  even 
liiiiircr.  There  may  he  severe  pain  without  any  vomitin<;.  The  attacks 
;uv(it  variahle  intensity  and  nsnally  ri'fpiire  morphia.  I*aro\ysnis  of  rectal 
pain  and  teiiesnuis  are  desci'ihed.  They  have  not  hecn  commuii  in  my 
experience.  Laryiif^eal  crises  also  are  rare.  Thei'c  may  he  true  spasm 
with  ilyspiuea  and  noisy  insj)iration.  In  one  instance  al  least  the  patient 
1ms  (lied  in  the  attack. 

The  sphincters  are  fre(|nently  involved.  Karlv  in  tlic  disease  there 
may  he  ii  retanlation  or  hesitancy  in  m.akiuLr  water.  Later  there  is  reteii- 
tiiiii.  and  (cystitis  may  ocenr.  I'nless  <r-eat  care  is  taken  the  inllammation 
may  extend  to  the  kidneys.  Constipation  is  extremely  common.  Late  in 
till' disease  the  spliiiu'ter  ani  is  weakened.  The  sexnal  jjower  is  usnally 
I'l-t  in  the  ataxic  sta.i?e. 

'I'nipliic  f'/i/i)if/»'s. — Skin  raslies  may  develop  in  the  course  of  the  lii^ht- 
iiiii,!^  pains,  such  as  herpes,  ledema,  or  local  swcatiiiL^  .Mteiatioii  in  the 
nails  may  occur.  A  j)erforatinif  ulcer  may  develop  on  the  foot,  usually 
'"'iicitli  the  jjreat  toe.     Onychia  may  prove  very  trouhlcsome. 

The  arthropathies  or  joint  lesions  alTect  chieily  tlic  knees.  They  are 
'inqiiestionably  a.ss()(uated  with  the  disease  it>elf,  and  not  necessarily  a 
risiilt  of  trauma.  The  condition,  known  as  Charcot's  joint,  is  unatoinic- 
iilly  similar  t')  that  of  chronic  arthritis  deformans.  The  cITusioii  may  hn 
rapid  and  ther.>  may  he  jfreat  disintei:ration  and  destruction  of  the  earti- 
liijos  and  hones,  leadin^jc  to  dislocation  and  deformity.  I'lis  was  present 
ilia  well-marked  Charcot's  joint  in  a  patient  of  C.  K.  Mills  at  tlie  Phila- 
ilvlldiia  Ilosjiital.    Spontaneous  fractures  may  oci-u r.    A mong  otlier  trophic 


<S.t 


fiiU 


i  I 


•  I 


^ , 


liil 


\\    '< 


1fl 


D08 


DISEASHIS  OF  THE  NERVOUS  SYSTEM. 


disturbiUK'cs  inny  be  mciitioiicd  iitn)|)]iy  «)f  the  nuiscles,  wliicli  is  ii.--u;i 


late  iiiiiiiifostatiou,  hi.t  iiiav  be  localiztMl  and 


associ 


iitfd  with  iicMi'iii>.     li 


any  vcrv  Iar<,'c  folloctioii  of  cases  many  iiistanccs  kA  atropliy  aio  rdiiii 
cither  to  iiivolvcmeiit  of  the  anterior  iionis  or  to  peripheral  neuritis. 


,  iliii' 


( 'irrlnuil 


\'/"'J 


Hunts 


—  W 


eiiiil)k\i:ia  may 


(h'V 


cli»l)  at   any  slap' 


the 


disease,  niofe  conmioidy  wlieii   it   is  well  ailvauced.     It  may  lie  due 
ha'Miorrliii.i,M(!  sct'teiiinji;  in  conse()uenee  of  disease  of  the  vessels  or  to 


mi- 


<i;ressive  cortical  chan  U'S.     Ileuiiana'sthesia  is  sometimes  ])reseut.     \  irv 
rarely  the  liemiple^fia  i;  (hie  to  coarse  syphilitic  disease. 

l>ciiicntia  piiralytica  i'recpieiitly  exists  with  tabes,  and  it  may  lie 
tremely  dilliciilt  to  determine  which  has  been  the  primary  aifeclioii.     In 
a  majority  of  the  cases  the  locctniotor  ataxia  lias  preceded  the  symptdins 
of  yeiieral  paresis.     In  other  iiidtauees  melancholia,  dementia,  or  parai 
develop. 

('•)  Paralytic   Stage. — After  ])ersistin<?  for  an   indefinite  numi 


lOlil 


ler   III' 


walKii! 


md  become- 


years  the  patient  ^.(radiially  losi's  the  power 

ridden  or  paralyzed.     In  this  condition  he  is  very  hkely  to  t)e  carried  nil' 

by  some   intercurrent  aU'ection,  such  as  j>yelo-nephritis,  pueuuioiiia,  ur 

tuhercuiosis. 

The  Cdiirsc  of  llw  Disease. — A  jiatient  may  remain  in  the  jire-atiixir 
stage  for  an  indeiinite  period  ;  and  the  loss  of  knee-jerk  and  the  <:\-m 
atro])hy  of  the  o|)tic  nerves  may  be  the  sole  indications  of  the  true  iiiituiv 
of  the  disease,  in  such  cases  incoordination  rarely  develops.  In 
jority  of  ca.ses  the  progress  is  slow,  and  after  six  or  eight  years,  sc;; 
less,  the  ataxia  is  well  devi'loped.     The  symptoms  may  va'v  a  good  'I 


il  lii;i- 


illlir; 


eul 


thus  the 


uaiiis,  w 


hid 


1  niav  have  been  eX( 


ive  at  lirst,  oftv-n  les.sei 


disease  may  remain  stationary  for  years ,  then  exacerbations  occur  niul  ii 
makes  rapid  [)rogress.  Occasionally  the  disease  seems  to  be  arroini. 
There  are  instances  of  wdiat  may  be  called  acute  ataxia,  in  which,  within 
n  year  or  even  less,  the  incoordination  is  marked,  and  the  paralytic  st;ij.v 
may  devehip  within  a  W'W  months.  The  disease  itself  rarciy  causes  death, 
and  after  l)econuiig  bedridden  tlie  patient  :u:iy  live  for  fifteen  or  tweiiiy 
years. 


H'o- 


nir- 


Diagnosis. — In  the  ju-e-ataxic  stage  the  combination  of  ligliiiiiii; 
j)ains  and  tin-  abs(Mice  of  knee-jerk  is  distinctive.  The  association  of  [ 
gressive  atrophy  of  the  optie  nerves  with  loss  of  knee-jerk  is  also  c  lia 
teristic.  Thi'  early  ocular  palsies  are  of  the  greatest  importance.  A  s(|iiiiit, 
j)tosis,  or  the  Argyll- Robertson  ])upil  may  be  the  first  symptom,  aini  may 
H  exist  with  the  lo.ss  only  of  the  knee-jerk.  Loss  of  the  knt'c-jerk  iil 
however,  d(-es  occasionally  occur  in  healtliy  individuals. 

The  diseases  most  likely  to  be  confounded  with  locomotor  ataxia 
(1)  /'criii/icnd  \i'i/ri/is. — The  })seudo-tabotie  gait  of  arsenical,  alcol 
or  dial)etic  paralysis  is  'juite  unlike  that  of  locomotor  ataxia.     In  thcsi' 
forms  there  is  a  piiraly.-is  of  the  feet  and  the  leg  is  lifti-d  high  in  <inlii' 


1 


MllO. 


lelji' 


that  the  toes  may  clear  the  lloor.     The  use  of  the  word  tabes  in  thi^ 


cull- 


CHRONIC   AFFE(TIONS  OF  TFIE  SI'INAL  CORD. 


i)09 


licll  is  u.-u;illy  ii 
th  neurit i-.  In 
y  are  r(>iiir.l,(liu' 
il  neuritis, 
ly  sta^LTc  III'  the 
may  Ite  due  in 
easels  or  tn  lu'd- 
jiresent.      \  rvy 

I  il  may  lie 
ry  iilVertinii.     in 
li  the  sym|itiinh 
iitiu,  or  paraiiiii.t 

uitc  nmniirr  of 
1(1  becomes  lni|- 
to  be  earried  oil 
,  pneuniniiia,  or 

in  the  |ire-ata\ir 

rk   and   the  irni\ 

f  tlie  true  nature 

ohtps.     In  a  iiia- 

yeai's,  so'Vuiiiiii'.- 

i''v'  a  ,i;'()ik1  deal; 

t'li  lessen.     Tli" 

Ills  ocelli'  anil  il 

to   lie   arrotnl. 

n  which,  within 

•  [)aralytic  siup' 

■iv  causes  death, 

tii'teen  or  twi'iiiy 

ion  (d"  liii-htniiiL' 
^(icialioii  of  [ii'd- 
•k  is  also  chanir- 
taiu'e.  A  sijuiiit, 
nptom,  and  may 
knee-jerk  id'Hio, 

ot(n-  ataxia  aiv; 

;cnical,  alcolieli''. 

iitiixia.     Ill  tlH'^t' 

i-(l  hifjh  in  enk 

[abes  in  tlii~  ('""'■ 


lUM'tlul 


1  .slioiild  no  Ioniser  he  contiiuieil.     IT  in   anv  doiihl,  the  absence  of 


the  li;,flitniii<^  [lains  and  eye  symptoms  and  the  histoi'y  will  siillic:'  in  the 
majority  of  eases  to  inako  the  dia<::nosis  (deaf.  In  (li|ilitlicritic  |iaralysis 
the  e.irly  losi  of  knee-jerk  and  the  asso(datcd  eye  syni[)loiiis  may  sii;r,Ljest 
tahes,  hut  the  history,  the  existence  td'  paralysis  of  tlic  t!iit>al,  and  the 
ahseiice  of  pains  render  a  diaj^iiosis  easy. 

('.')  Afd.n'r  /'in'iij)li'!/i<i. — ^Marked  incoiirdinatioii  with  spastic  iKindysisj 
is  eharatderistic  of  tin*  condition  whi(di  (iowers  has  termed  ataxic  para- 
|ilei;ia.  In  a  majority  of  the  cases  this  aU'ectioii  is  distin,i,'i.ished  also  by 
ilie  ahseiiee  of  pains  and  of  eye  symptoms. 


(:!)  ( 'iri'Jii'ihir  Disease. — The 


cendxdlar  mcorndinatinn  has  only  a  super 


tin 


ial  rescnililaiicc  to  that  of  licomotor  ataxia;  the  knee-jerk  is  prc.-cnt, 
■re  are  no  liLfhtninix  pain.:,  no  sensory  distnrbai 


ices:   u  bile,  on  ihc  other 


land 


there  arc  hcadacdie,  oidic  n 


cir 


and  voniilini 


t)  Some  (iiii/e  ajf'n/iiii/s  involviii.;'  the  posterior  columns  of   the  cord 


lie  followeil  bv  incoiirdination  and   resemble  ta 


ics  \i'v\  cios( 


■Iv.        1 


n  a 


•as,'  recently  uvider  my  care,  the  piit  was  (diaracterislic  and  lioinberir's 
<yiii|itom  was  present.  The  knee-jerk,  however,  was  retained  and  there 
wen' no  ocular  symptoms.     The  condition  had  devclopeil  •.vitliin  three  or 


■iiiir  iiioi 


iths,  and   there  was  a  W(dl-inaiked    liislorv  of  sNidiilis.      I'l 


liter 


larjie  doses  of  iodide  of  iiotassinm   the  ataxia  and  other  symplinns  eoin- 
jilett'ly  disa|)peared. 

(."i)  (li'itcnd  /'(ircsis. — In  some  cases  this  olfers  a  serious  diriicully.  In 
the  tirst  place,  in  f^eneral  paresis,  tabetic  symptoms  oflci\  develop;  on  ilvj 
niher  liaiid,  there  are  eases  of  locomotor  ataxia  in  whi(di,  toward  the  end, 
there  are  symptoms  of  jfeneral  paresis.  Cast's  of  unusually  aiaite  ataxia 
nil  'i^al  symptoms  bidoiii^,  as  a  rule,  to  the  foi-nier  disease.     The  (|Ues- 


ivith 


tiuii  will  ho  consKlered  ninler  general  ])aresi 
(<i)  N'isccral  crises  and  neii 


I  t' 


raluic  symploms  may  lead  to  error,  and  in 
iiiidille-ai^ed  men  with  severe,  recnrriiii.''  attacks  of  ;;aslral^ia  il  is  always 
Well  to  bear  in  mind  the  possibility  of  tabes,  and  to  make  a  careful  cxam- 
liiatiiDi  (d'  the  eyes  and  of  the  knee-jerk. 

Prognosis.— Com plet;'  recovery  cannot  bi  cxpeeted,  but  arrest  'if  the 
liriiiri'css  is  not  nncoinuion  and  a  marked  aiiielioration  id"  tlic  .  \nipto:ii.-  is 
trei|iu'iit.  Optic-nerve  atrophy,  one  of  the  most  serious  events  in  the  dis- 
I'lise,  has  this  li()|)eful  aspect— that  incoiti  dination  nifely  fidlows  and  tlu^ 
pr(iy:res-!  maybe  arrested.  The  optic  atrophy  its'.'lf  is  occasionally  idiecdied. 
hole,  the  proufiiosis  in  talu's  is  bad.     The  expeiience  of  sik  h  men 


III,  i! 


II  tile  w 


;'>\\iir  .Mitchell,  Charcot,  and  (iowers  is  distinctly  opposed  to  the  hclief 
tliat  idcomotor  ataxia  is  ever  completely  cured.*  >io  such  '  4,anee  has 
'"'111'  under  my  personal  observation. 

Treatment. — To  arrest  the  |>ro<iiress  and  to  relieve,  if  possible,  the 
■}iii|itoiiis  life  the  obj(H'ts  whiidi  the  practitioner  -lioiild  have  in  view.      ,\. 

'For  11  bluily  (j[  repiiled  eiiivs,  see  b.  C.  liniy,  >.'.  V.  Medical  J  eurniil,  Nuviiiibi'V,  1^811. 


,  •'.     * 


910 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


quiet,  woll-rojTulatod  mothod  of  li^o  is  ossontial.  It  is  not  well,  iis  a  rii!i.. 
for  ;i  patient  to  jijivo  up  his  occupation  so  lonij  as  ho  is  al)lc  to  keep  alKiut 
a  1(1  pcrt'nrn)  orclinarv  work.  I  know  tal)ctics  wlio  have  for  years  cdiMliictcil 
larjjfo  businesses,  and  tlierc  have  been  several  notable  instances  in  our  pro- 
fession oi"  men  who  have  risen  to  distinction  in  spite  of  the  existence  i>\'  this 
disease.  Kxct'sscs  of  all  sorts,  more  particularly  ui  /xirc/io  vt  /vv/^'/t,  slionjii 
be  carefnlly  avoided.     A  man  in  the  pre-ata\ic  statje  should  not  inarrv. 

Care  should  be  taken  in  the  diet,  jjarticularly  if  gastric  crises  have  oc- 
ourreil.  To  secure  arrest  of  the  disease  niauy  remedies  liave  hciii  v\\\. 
■])loyed.  Althoufjfh  syphilis  ])lays  such  an  important  roi''' in  the  ctici|iiir\. 
it  is  universally  acknowled<red  that  neither  mercury  nor  the  iodide  df  p,,. 
tassiiim  liav(!  as  a  rule  the  sliifhtest  inlhu'iice  o'-er  the  tabetic  lesions.  Tii 
this  there  is  but  one  exception— when  the  sy])hilis  is  comparatively  rccciif 
when  the  syniptoms  develop  within  two  years  of  the  primary  infcciidn, 
ihi'iT  is  then  a  possibility  of  arrest  by  mercury  and  iodide  of  potassium. 
However,  they  (h)  not  always  relieve.  In  two  cases  of  very  rapidiv  iirn- 
^ressin;^  tabes  following?  syphilis  this  nieijicration  was  of  no  avail.  .Ndt 
oidy  is  an  anti-syphilitic  treatment  of  no  benelit  m  the  majority  of  ciw< 
of  locomotor  ataxia,  hut  my  experience  tallies  with  that  of  (lowers  in  that 
it  may  even  hasten  th<'  pr..<rfess  of  the  disease.  Of  remedies  wliicli  inav 
be  trie(l  and  are  believcii  by  .some  writers  to  retard  the  pro,j,n'ess,  the  I'dl- 
lowing  ari'  recommemh'il  :  .\rsenic  in  full  dos(>s,  nitrate  of  sdver  in  (|tuu't(';' 
grain  doses,  C-iiabar  bean.  ( I'^^oi,  and  the  preparations  of  irold. 

'i'he  treatment  by  suspension  introduced  a  few  years  ajro  has  alrciidy 
been  pra<'tically  abanihmed.  (iood  effects  ccrtaiidy  have  followed  in  u  fi'W 
cases,  but  it  was  unreasojiable  from  the  outset,  ci+hcr  »ni  therapeuti("  or 
s<'ientinc  jrronnds,  to  hope  that  l)v  siudi  a  ineasuri'  permanent  cbaui^f- '■,,iil(| 
he  indiu'cd  in  the  })atho!o,u:ical  condition.  The  l)enetits  wen-  due  in  irnat 
part  to  su^'jicstion  and  to  psychicid  effects.  In  any  ca.^e  it  must  he  a>tvl 
with  caution. 

For  the  pains,  comjdete  rest  in  bed,  as  advised  l)y  Weir  Mitchell,  anil 
counter-irritation  to  the  spiiu'  (either  blist(M's  or  tin'  thermo-canter\ )  iiiiiy 
be  employed.  The  severe  spells  which  come  on  particularly  after  e\ei'.<sos 
of  any  kind  arc  often  promptly  relieved  by  a  hot  bath  or  i)y  a  'I'urkisli  hath. 
\  prolonj.''cd  course  of  nitrate  of  silver  seems  in  some  cases  to  allay  the 
jmins  and  lessen  the  liability  to  the  attacks  I  have  never  seen  illelT..ts 
from  its  use  in  the  spinal  scU-roses.  Antii)yrin  ami  antifebrin  may  he  t'lii- 
])loyed,  and  occasiotially  do  ,irood,  but  their  analiresic  powers  in  this  ili.si'uw 
liave  been  jjfreatly  overrated.  ('ann;d)is  indica  is  sometimes  useful.  In 
the  severe  paroxysms  of  pain  hypodermics  of  nutrphia  or  of  ciii'Miiu' 
must  be  \\^v^\.  The  u.so  of  morphia  should  be  postpone<l  as  lontr  a-  |iii>>i- 
ble.  Electricity  is  of  very  little  ))eiierit.  For  the  severe  attacks  of  ,ail^• 
tralgia,  morphia  is  also  rcfptired.  The  larynjxeal  crises  are  rarely  daiiiror 
ouH.  An  application  of  cocaine  may  i)e  made  diirin<f  the  spasm,  uraft'^ 
whifTs  of  chloroform  may  be  given,  or  nitrite  of  amyl.     In  all  cases  of  tahes 


CHRONIC   AFFECTIONS  OP  THE  SPINAL  COKI). 


Oil 


lot  well,  !i>  a  mil'. 
ihle  to  kcc|i  iilioiit 
)!•  years  ('(inducted 
itiinees  in  (Hir  pm- 
le  existciico  nf  tlii> 
(I  rf  I'fHcVf,  shoiiM 
nild  IK  it  marry. 
trie  crises  liave  (ic- 
es have  been  (mii- 

olc  ill   the  ('tin|(iir\. 

ir  the  idiiidc  nf  jki- 
iihi'tie  lesions.  'I'd 
iiparatively  recent  • 
primary  iiifcctidn. 
ilidi"  of  |i(itassiiiiii. 
f  very  ra[ii(llv  |ini- 
of  no  avail.  .Not 
le  majority  of  ca.<c- 
t  of  (iowers  in  tliiit 
I'mcflics  winch  iiiav 
'  |)ro«j;rfss,  tiic  fcl- 
of  silver  ill  (|U;irtcr 
if  irolil. 

irs  acfc  lias  already 

followeil  ill  a  tVw 

(»ii   tiiera]ieiitie  dr 

■lit  eltailiresciillM 

were  due  ill  LTcat 

c  it  must  lie  iist'ii 

Weir  >riteli(dl.  and 

rmo-caiitery)  may 

arly  after  exetwcj 

l)y  a  Tiirki-hliatli. 

eases  to  allay  tlu' 

ver  seen  ill  etTct- 

felirin  may  lie  cm- 

wers  in  tins  .liscaw 

■times   useful     I" 

lia   or   of   cncaiiii' 

ed  as  lon«r  a-  y^'^- 

■re  attacks  ef  ,uav 

lire   rarelv  ilaiiL'""' 


the  spasm. 


i,r  a  ft"'* 


III  all  eases  (if  talics 


ffith  increased  artoriul  tension  the  prolonj^ed  use  of  nitro<flycerin,  j^iven 

in  iticreasinf?  doses  until  the  physiolocfical  effect  is  jinKJueed,  is  of  great 
jci'vice  in  allayinj^  the  iieiiral<ric  pains  and  diminishiii<f  the  fre(pieney  of 
the  cri.-^es.  Its  ii.se  nmst  be  [juarded  when  there  is  aortic  insutriciency. 
The  special  indication  is  increased  tension.  The  iiladder  symptoms  de- 
niind  constant  care.  When  the  orj^aii  cannot  be  perfectly  emptied  the 
catheter  should  be  used,  and  the  patient  may  be  taught  its  use  and  how 
1,1  keep  it  thoroughly  sterilized. 

III.   IIi:iti:i)iT.VKY  At.\.\i.\  {Frici/rrirli's  Ataxia). 

In  ISfil  Friedreich  re])ort«d  six  ca.ses  of  a  form  of  liereditary  ataxia, 
an  I  t!ie  alTection  has  usually  gone  by  his  name.  Unfortunately,  /i(rrai)ii/(i- 
('iiHM.v  iiii///iplr.r  is  also  called  Friedreich's  disease  :  so  it  is  best,  if  his  name 
Misi'il  in  connection  with  this  alTection,  to  term  it  I-'riedreicirs  idaxia.  It 
1- a  very  ditTerent  disease  in  many  respects  from  ordinary  tabes.  It  may 
uMiluv  not  he  hereditary.  It  is  really  a  family  disea.'^e,  .sevend  brotliers 
;iiid  sisters  being,  as  a  rule,  alTected.  The  14;{  cases  analyzed  by  (Jrillitli 
i»rarred  in  71  unrelated  families.  In  his  series  inheritance  of  Ihe  disease 
,;■  If  occurred  in  only  . '{I}  ca.ses,  \'arious  iutliieiices  in  tiie  parents  have 
irii  ipited;  alcoholism  in  only  T  eases.  Syphilis  has  rarely  been  present. 
of  the  14:5  cases,  80  were  males  and  r»7  females.  The  disease  sets  in 
riiiy  ill  life,  and  in  (JrilUtirs  leries  1.")  occurred  before  tlie  age  of  two 
year.s  .'I'J  before  the  sixth  year,  4.")  between  the  sixth  and  tenth  years,  ••.*() 
i.  twceii  the  eleventh  and  tifteeiith  years,  IS  between  Ihe  sixtei  nth  and 
twentieth  years,  and  ."i  between  the  tweiiti'/th  and  twcnty-tifth  years. 

Tile  worhid  atiato)))}!  shows  an  extensive  sclerosis  of  the  posterior 
and  lateral  columns  of  the  s))iiial  cord.  The  periphery,  and  the  cen'- 
iiillar  tracts  an?  u.sually  involved.  'I'iie  recent  ob.servations  of  I)ejeriin« 
mill  Letiillc  are  of  special  interest,  since  they  seem  to  iudicrate  that  the 
'hanire  in  this  di.sease  i,--  a  iienrogliar  (ectodermal)  sclerosis,  dilfcrinLr  en- 
tirely from  th(!  ordinary  spinal  .sclerosis..  .Vccording  to  this  view,  Fried- 
riiih's  di.sease  is  a  gliosis  '  '  the  posterior  columns  due  to  developraiental 
irrors:  but  the  question  is  still  unsettled. 

Symptoms. — 'Ihe  ataxia  is  unlike  the  ordinary  form.  The  in*H>- 
iinliiiaiiDii  begins  in  the  legs,  but  the  gait  is  peculiar.  It  is  -wavnig, 
rivgnlar,  aJid  more  like  that  of  a  drunken  man.  There  is  not  I  lie  char- 
I  aoteristie  stamping  gait  of  the  true  talies  liomberg's  symptom  mayor 
niay  not  be  present.  The  ataxia  of  the  arms  occurs  early  and  is  vfry 
iiiarkcd  ;  the  niovemcits  are  almost  choreiform,  irri'gnlar.  and  soim^what 
>waying.  In  makiiiir  any  viduntary  mnv(>ment  the  action  is  overdone, 
tile  prehension  is  claw-like,  and  the  fingers  may  Iw  s[)read  or  overex- 
timk'd  just  before  grasping  an  object.  The  hand  ftequently  moves  about 
■ill  idijeet  for  a  moment  and  then  suddeidy  pounces  upon  it.  There  are 
ifii'j.nilur.  swaying  movements,  .some  of  which  are  choreiiorni.  of  the  head 
68 


912 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


and  slioiilders.  'I'hcre  is  prosciit  in  niiiny  niscs  wlmt  is  known  as  statjp 
ataxia,  tliat  is  to  say,  ataxia  of  rinict  actio!i — irrcfjular,  slow  inovoiiionts  of' 
tlu'  tinkers  or  tlu-  hands  wliili'  at  rest. 

Sensory  symptoms  arc  not  nsually  present.  Tiie  reflexes  may  lie  Idsi. 
In  (irillitli's  (able  they  were  aholishecl  in  !»1  ciises. 

Nysta^nins  is  u  eharucteristic  sytnptoiii.  Atropliv  of  the  optic  iicrw 
rarely  occurs.  A  striking  feature  is  t-arly  deformity  of  tiu!  feet.  TIuti' 
is  talipes  ecpiinus,  and  the  [tatient  walks  on  the  outer  j^dgo  of  the  fwt. 
The  bi{^  toe  is  Hexed  dorsally  on  the  lirst  phalanx.  I,at(!rul  curvature  of 
the  spine  is  very  common. 

'i'rophic  lesions  are  rare.  As  the  disease  advanees  paralysis  coine!i  (jm 
and  tnay  ultinuiti-ly  he  complete.     Some  of  the  patients  never  walk. 

Disturbance  of  speech  is  eonimon.  It  is  usiudly  slow  and  seaimiuif; 
the  expression  is  often  dull ;  the  mental  power  is,  as  u  rule,  nifintaiiuii, 
but  late  in  the  disi'ase  becomes  impaired. 

'Vhf  t/i(ii/i/(i.<is  i)i'  the  disease  is  not  dillicult  when  several  meMdu'rM.f 
a  family  are  alTected.  The  onset  in  childhood,  the  curious  form  of  iiiin- 
ordination,  the  early  talijx'S  e(piiiuis,  the  position  of  the  j,n'i'at  toe,  tlic 
scoliosis,  the  nystagmus,  and  scanning  sp(-ech  make  up  an  unmistakalik' 
picture.  The  disease  is  often  confouude(l  will)  chorea,  with  the  ordinarv 
form  of  which  it  has  nothing  in  common.  With  heredita'.y  chorea  it  lia> 
certain  similarities,  but  usually  this  disea.se  does  not  set  in  until  alter  tln' 
thirtietii  year. 

The  diseasi'  lasts  for  many  years  and  is  incurable.  Care  should  be 
taken  to  prevent  contraetures. 

Cerebellar  Type.— There  is  a  form  of  hereditary  ataxia,  de.soril)eil  by 
Marie  as  ri'rrhrlldr  liprcdn-dhi.iiti.  which  starts  later  in  life, after  the  aircnf 
twenty,  with  disability  in  the  legs,  but  the  gait  is  less  ataxic  than  "gniiTiry' 
'I'he  knee-jerks  are  retained,  and  a  spastic  conditioji  (d'  the  legs  Mltiinatilv 
develops.  There  is  no  .scoliosis,  nor  does  club-foot  develop.  Sanger  liruunV 
ca.ses,  twenty-iiv"  in  one  family,  and  J.  H.  NetT's,  thirteen,  appear  to  Inlomr 
to  this  type.     The  cerebellum  has  been  fouiul  atrophied  in  two  ca.-cs. 

IV.     SvinXdO-MYKI.TA. 

Definition. — .\  gliomatous  new  formation  about  the  ccntnd  canal  of 
the  spinal  cord,  with  cavity  format Mtn. 

Etiology  and  Morbid  Anatomy.— Syringo-myelia  rmist  l»o  liv 
tinguished  from  dilatation  of  the  central  canal— hydrom_,>'liis—,-ii.;'li' 
grades  of  whi(di  are  not  very  uncommon  either  as  a  congetntal  c<  "■' "' 
as  a  result  of  the  j)ressure  of  tumors.     The  cavity  of  syringe  ..i  i"'- '■ 

variable  extent  in  the  cord,  sometimes  existing  in  the  entnv  K  ligtli.  bit  in 
many  cases  involving  oidy  the  cervical  and  dorsal  rcgiitisor  a  juoiv  liiinl" 
area.     It  is  usually  in   the  posterior  poriion  of  the  conl  and  ma\  iMi' 
ouly  into  oue  posterior  coruu.     The  transverse  sectiou  muy  be  oval  ur  .ir 


CimONK^   AKFECTIONS  OF  THE  SPINAL  ('OKI). 


913 


cflexos  mav  In-  losi. 


U).     Care  shoiild  lu' 


(Milar  or  narrow  atul  fisiiuroilike.  It  varies  at  (HfTorent  levels.  The  ooiuli- 
tioii  is  now  re<,'artle(J  as  a  ^/mv/.*,  a  development  of  embryonal  neurojzliar 
tissiir  in  wiiicii  liitMnorrliaj,'!'  or  defeneration  takes  place  with  tlie  fdrrnatioii 
,.f  cavil ies. 

Of  11)0  cases,  1.'];)  were  in  men,  ")7  in  women  (Schlcsinirer).  A  lari^e 
niajiiiity  of  the  cases  begin  before  the  thirtieth  yt-ar.  'J'he  disease  has 
!i  III  met  with  in  liiree  members  of  the  same  family. 

Symptoms. —  The  clinical  features  are  extremely  complex.  In  the 
rla.^siial  form  tliere  are  irrejjjnlar  pains,  chielly  in  the  cervical  region; 
muscular  atropiiy  develops,  which  may  be  confined  to  the  arms,  or  some- 
tiiiH's  extends  to  the  legs.  The  reflexes  are  increased  and  a  spastic  condi- 
liiin  develops  in  the  legs.  Ultimately  th.e  clinical  picture  may  be  that  of 
all  aiiiyotrophi(!  lateral  sclerosis,  'i'lie  tactile  sensation  is  usually  intact 
rtiul  the  muscular  sense  i'  retained,  but  i)ainful  aiul  thermic  sensations  are 
not  recognized,  or  there  may  be  in  rare  instances  com|ilet(;  amesthesia  of 
the  skin  and  of  the  mucous  membranes  (Dejeritu').  This  combination  of 
loss  of  painful  and  thtrmic  sensations  with  paralysis  of  an  ainyotrophio 
tvpe  is  regarded  as  pathognomonic  of  the.  diswise.  The  special  senses  are 
usually  intact  and  the  sphincters  uniuvolvcd.  Trophic  troubles  are  tiot 
imcdiinnon.  Owing  to  the  loss  of  the  painful  an<i  heat  sensations,  the 
putifiits  are  apt  to  injure  themselves.  Scoliosis  also  may  be  present  in 
tlieso  eases.  'I'he  loss  of  painful  and  thermic  impressions  is  due  to  the 
fact  that  these  {)ass  to  (he  brain  in  the  peri-ependymal  gray  matter,  par- 
ticiilaiiy  that  ])orti(Ui  in  the  pDsterior  roots,  which  is  almost  constantly 
involved  in  syi'ingo-myelia.  The  tactile  sensation  is  retained  because  the 
postcro-exteriial  column  is  uninvdved.  ^ 

Selilesinger,  in  his  recent  monograph  (ISftT)),  recognizes  the  following 
lypcs:  (1)  With  the  classical  fi'i:tures  above  dcscriiicd,  which  may  begin 
ill  the  cervical  or  lumbar  regi.ms ;  {'i)  a  motor  type,  with  the  picture  of 
an  amyotrophic  uv  a  spastic  ['aralysis — the  sensation  may  b(>  undisturbed 
fur  years;  (;{)  with  predominant  sensory  fi-atiircs,  simulating  hysterical 
iu'iiii|ilegia,  or  with  geiu-ral  pain  and  tem])erature  anasthesia  ;  (4)  with 
indiieiiuced  trophic  distiirliaiices — to  this  type  l)elong  the  cases  described 
it»  .Morvan's  disease,  an  alfection  characterized  by  neuralgic  pains,  cuta- 
ncmis  aiuesthcsia,  aiul  painless,  destructive  whitlows;  and  (.'>)  the  talx-tic 
type,  either  a  combination  of  the  symptoms  of  tabes  in  the  lower,  and  of 
Aringo-myelia  in  the  upper  extremities,  or  a  pure  tabetic  syniptom-coin- 
plt'X. line  to  invasion  by  the  gliosis  of  the  posterior  columns  (()[ipeiiheirii). 
Artliropatliies  occur  in  about  ten  ])er  cent  of  the  cases. 

in  typical  cases  the  diaf/iioxis  is  easy.     The  comi)ination  of  an  amyo- , 
'  i'li;'   paralysis,  the  picture  of  progressive  muscular  atrophy  of  the  Aran-  I 
''uclieiiiH"  type,  with  retention  of  tactile  and  loss  of  thermic  and  painful  \ 
^'Hfutioii,  is  probably  pathognomonic  of  the  disease.     Of  affections  with 
^'liich  it  may  be  confounded,  ana'sthetic  leprosy  is  the  most  important, 
A'WQ  I  he  aiia'sthesia  and   the  wasting  may  closely  simulate  it;  but,  as  a 


■1^- 


914 


DISHASMS  OK  TIIK   NKIiVOUS  SYSTEM. 


rule,  in  leprosy  trophiu  {ilmiif^os  ure  more  or  less  murktid.  Tliorc  is  dfton 
loss  of  |)lialati<,'i'.s  aiul  tlicrc  is  no  cliiiriicterislic  dissociation  of  Musdiy 
impressions. 

V.  CoMl'Kl'SSiov  OF  TMio  Si'iNAr.  f'oiM*  {(\m]ircssi(ni  Miirlitis). 
Definition.  —  Interruption  of  the  functions  of  the  cord  hy  slow  (((tn- 

JU'CSSJOM 

Etiology. — Caries  of  th(!  spine,  new  j,fr(i\vtiis,  aneurism,  and  pain- 
sites  are  the  iin])ortant  causes  of  slow  (;ompressi(>n.  Caries,  or  Putt's  di.-i. 
ease,  as  it  is  usually  called,  after  the  sur^'cion  who  first  descrihed  il,  is  in 
the  lijrcal  majority  of  instances  u  tnherculous  affection.  In  a  few  cases  ii 
is  due  to  syphilis  and  occasionally  to  (ixtcnsion  of  disease  from  tiii'  plmr- 
ynx.  It  is  most  common  in  early  life,  l»iit  may  occur  after  middle  iiije. 
It  follows  trauma  in  a  few  cases.     Coniijression  occasionally  rcsidt>  rrmii 

aneurism  of  the  thoracic  aortaor  the  abdominal  uortu,  in  the  iieighhoiii 1 

of  the  co'liac  axis. 

Malignant  growths  frequently  cause  a  compression  paraple;_M;i.  A 
retroperitoneal  sarcoma  or  the  lymphadeiionuitous  jfrowlhs  of  llnilirkinV 
disease  may  invade  the  vertel>ra'.  More  commonly,  however,  the  nnoUe 
ment  is  secondary  to  scirrhu.s  of  the  breast. 

Of  parasites,  the  I'chinococcus  and  the  cysticercus  occasionally  iKvur 
in  the  spinal  canal. 

Symptoms. — These  nuiy  be  considered  as  tiioy  alTeet  the  hones,  the 
nerves,  and  the  cord. 

(1)  Vertebral. — In  nudijjmmt  disease  otid  in  aneurism  erosion  of  the 
bodies  nuiy  take  phu'c  without  prodncinj^  any  deformity  of  the  sjiiiir. 
Fatal  haMuorrlia<rc  nniy  follow  (u-osion  of  the  vertebral  artery.  In  caries, 
on  the  other  hand,  it  is  the  rule  to  (irul  nu)re  or  less  deformity,  atnuuiitiii;' 
often  to  anj^ular  curvature.  The  compression  is  larf^ely  due  to  the  tliiek- 
eninu  of  die  dura  and  the  presence  of  (Gascons  aiul  inflammatory  pnidiicts 
between  this  membrane  ami  the  bomt.  The  compression  is  rarely  \)W- 
diu'cd  directly  by  the  bone.  I'ain  is  a  constant  ami,  in  the  case  of  aneu- 
rism and  t u nu)r,  ac;onizin};  feature.  In  caries,  the  spimil  processes  of  the 
affected  vertebra'  are  tender  on  pressure,  and  pain  follows  jarrinj:  iiinvi- 
ments  or  twistinj,'  of  the  spine.  There  may  be  extensive  tubeivi.lmi. 
disease  without  much  def(»rmity,  particularly  in  the  cervical  rejrioii. 

(2)  Nerve-root  Symptoms. — These  residt  from  compression  of  iki 
norve-roots  as  they  pass  out  between  the  vertebra\  A  cervico-luaeliinl 
nonraliria  nuiy  be  un  early  symptom.  It  is  re?iuirkable  how  fni|iii'iitl). 
even  in  extensive  caries,  \\\v.y  esciape  and  the  {)atient  does  m)t  eoiiijilaiii  "f 
radiatinj^  pains  in  the  distribution  of  the  iwrves  f rom  the  alfeeted  si  ;.'iii('iii 
Pains  are  more  eommon  in  cam-er  of  the  spiiu'  secondary  to  tiial  ef  'Ik' 
breast,  and  in  such  case-,  may  lu'  agoui/.infr.  There  may  lie  acutely  |iiiiiifiil 
areas  the  aiia'slhisiK  Uo/nrosa,  or  regions  of  tlu'  skin  which  arc  im- 
•sthetic  to  tactile  and  painful  improssiuns.     Trophic  distinbaii' i."  >«!>) 


A. 

(1.  TluM'c  is  iifton 
ciution  of  stii.sory 

.v/(//;  Mi/di/i.y). 
curd  l)y  >slow  ((un- 

HMiristn,  ami  |i;ira- 
irics,  or  I'ntr.s  ilis- 

(Icscrihcd  il,  is  in 

III  11  few  ciisi's  it 

ISC  fi'oiii   tlic  iiliiir- 

iil'tcr  niiiliilr  iii,'c. 
)iially  result.^  rrum 
1  lliL'  iiciyhl)(iili(iuil 

m  jiaraplc^n;!.  A 
w  ills  of  ll(Mli:kiir> 
wtvor,  llic  iii\(il\f 

occasionally  ncciir 

ITcct  tlio  l)oii('s,  till' 

rism  erosion  of  the 

lity  of   the  siiiiii'. 

arlcry.     In  caries, 

irniity,  anioiiiitiii;.' 

due  to  llic  tliiik- 

Minatory  pidiliKls 

qoii   is  rarely  |ii'ii- 

the  case  of  aiitii- 

al  |»i'occsses  uf  lin' 

)\vs  jarrinjr  nmvt- 

■iisivc  tuheiiul(iu> 

ical  rcjiioii. 

impression    of  il'i' 

A  ccrvico-liriii'lii:il 

how   fre(|Ut'iitlv, 

s  not  coinpliiiii  "f 

alTccleds.;riiii'iit. 

iiry  to  that  ef  llie 

lie  acutely  |iaiiifiil 

ill    which  arc  im- 

distmban'cs  nuiy 


("IIHONK;   AKFK(TI()NS  of  TIIK  spinal   COUI). 


JU5 


ocriir.  particularly  herpes.  In  the  cervical  or  liiinhar  rc<jions  pressure  on 
ilio  anterior  roots  may  give  rise  to  wasting  of  the  niusclcs  supplied  hy  tlio 
alTi'i'ti'd  nerves. 

(.1)  Cord  Symptoms.  (n)  Crrrinil  Rcf/idn. — Not  iiifrequently  the 
ciirit's  is  high  up  between  the  axis  and  the  atlas  or  between  the  latti-r  and 
the  occipital  bone.  In  such  instanc(!S  a  nitropharyngcai  a'>scess  may  be 
present,  giving  rise  to  diirnMilty  in  swallowing.  There  ma\  be  spasm  of 
the  cervical  nuLScles,  th((  head  may  be  lixcti,  and  movements  may  cither 
III'  iiiipo.ssiblo  or  cjvuso  great  pain.  In  a  case  of  this  kind  in  the  Montreal 
(ieiicral  Hospital  movement  was  liable  to  Ik*  followed  by  transient,  instan- 
tiiiu'iiiis  paralysis  of  all  four  extremities,  owing  to  compression  of  the  cord. 
In  om'.  of  these  iittatdts  the  patient  died.  • 

111  the  lower  cervical  region  there  may  be  signs  of  interference  with 
tlio  cilio-spinal  centn!  and  dilatation  of  tlm  pupils.  Occasionally  there  is 
tliisliing  of  the  face  ami  ear  of  one  side  or  unilateral  sweating.  Dcforin- 
iiv  is  not  so  common,  but  healing  may  take  place  with  the  proiiiictii»n  of 


ealliis  o 


f  enormous  breadth,  willi  complete  rij'idilv  ( 


if  tl 


IC    I1C( 


k. 


(//)  hursdl  Iki'ijiiin. — The  deformity  is  here  more  marked  and  pressure 
<yni]it(!ins  are  more  common.  The  tinier  of  onset  of  the  paralysis  varies 
Very  iiiiich.  It  may  be  an  early  symptom,  even  before  the  ciirvaliiri'  is 
manifest.  More  commonly  it  is  late,  occurring  many  months  after  the 
nirvature  has  developed.  The  para{ilegia  is  slow  in  its  devclopr.ieiit  ;  the 
|iati('iit  at  first  feels  weak  in  the  legs  or  \\\w-  disturbance  of  sensation, 
iiiiiiihncss,  tingling,  pins  and  needl"«.  The  girdb^  sensation  may  be 
iiiaikt'il,  or  severe  pains  in  the  course  of  the  intercostal  nerves.  .Motion 
In  as  a  rule,  more  (piickly  lost  than  .sensation.  I'"inally,  there  is  complete 
interruption  witli  the  production  of  paraplegia,  usually  of  the  spastic  type, 
with  exaggeiation  of  the  rcllexes.  This  may  p.ersist  for  months,  or  even 
fur  iiion*  than  a  year,  and  recovery  still  be  possible. 

('■)   Lnin/xir   Itniiini. —  In   the   lower  dorsal   and    lumbar    regiiuis  the 


>VllllitliII 


is  arc  [iractically  the  .siiiic,  but  the  sphincter  cciitr 


cs  arc  111 V( lived 


:inil  the  rellexes  wv   iiof  cxairijcraled. 


Diagnosis. 


-( 


lines  is 


by  far  the  most  fre<pient  cause  of  slow  com- 


pressidii  of  the  cord,  and  when  there  are  external  signs  the  recognition  is 
•  :i''v.  There  are  ea.ses  in  which  the  exudation  in  the  spinal  canal  between 
the  iliira  and  the  bone  leads  to  compression  before  there  ari' any  signs  of 
"ii'ies, and  if  tlu;  root  symptoms  aVe  aliseiit  it  may  be  extremely  difVicult 


t'l arrive  at  a  diagnosis,     .lancway  has.  callecl  attention  to  persistent  liiiii- 

)tt's  disease,  particularly 
or  and 


''ii;'o  as  a  symptom  of  iniportanc((  in   niaskci 

after  mil 


iry.     Hrown-Sc(|iiard's  paralysis  is  nnu'i^  common   in  tiini 


injuries  than   in  cari 


I'rcssiire  on   the  nerve-roots,  too,  is  less  fre- 


'I'litit  in  caries  than  in   malignant  disease.     Tl;c  cervical  form  nf  pacliy- 
itiL'itii  also  produces  a  pressure  paralysis,  the  symptoms  of  which  have 


iii'ii 


ilivadv  been  detailed.      Pressure  from  cancer  is  naturally  suggested  when 
*|iiii!il  symptoms  follow  within  a  lew  years  after  un  operation.     In  para- 


h"-i  t. 


1  ifH 

f 

W 

'  ''1 

■   'l     ■ 

>. 

.f 


910 


DISKASKS  OF  'PIIH   NKIlVOUS  SYSTEM. 


})U'giii  followinj^  tiiinor  of  the  vertebra  socondury  to  cuneer  of  tli.  Knast, 
and  in  the  erosion  of  tlie  spine  by  retroperitoneal  j^rowtlis,  tlie  sulV.  imj^r  i, 
most  intense.     'I'he  coii'litioii  bus  been  well  termed  inunjiUinn  duUintsu, 

Treatment.  —  In  compression  by  aneurism  or  tumor  the  eomiition  j^ 
hopeless.  In  tiie  former  the  pains  are  often  not  very  severe,  but  in  the 
latter  morjihia  is  always  necessary.  On  the  oilier  hand,  eompres^inn  In 
caries  is  often  su(X'essfully  relieved  even  after  the  paralysis  lias  per.-isU'ii 
for  a  Ions,'  period.  When  caries  is  recojinized  early,  rest  and  siippiirt  to 
the  spine  by  the  various  methods  now  u.sed  by  snr<ji'ons  may  do  iiimh  in 
jtrevent  the  onset  of  parai>lejfia.  When  paralysis  luis  developed,  rest  wiiL 
extension  gives  the  best  hope  of  recovery.  It  is  to  l)e  n'menilxrtd  that 
restoration  may  o(,'ciir  after  compression  of  the  cord  has  lasted  for  niaiiv 
months,  or  even  more  than  a  year.  Cases  have  been  cured  by  rest  aluiie; 
the  extradural  and  inllammatory  products  are  ab.sor bed  and  the  caries  ln'ul. 
The  most  brilliant  results  in  these  cases  have  been  (jbtained  by  suspnoinM.a 
metliod  introduced  by  J.  K.  Mitchell  in  lS'.it»,  and  pursued  with  reiiiiukalMe 
success  l)y  his  son,  W  eir  Mitchell.  During'  my  association  with  the  Inlirinarv 
for  Nervous  Diseases  I  had  numerous  ojjportunities  of  witnessing;  tlicicallv 
remarkable  elTects  of  persistent  suspension,  even  in  applircntly  dc.-|i(iaif 
and  protracted  ea.ses.  Mitchcirs  conclusions  are  that  suspension  shuiiM 
be  employed  early  in  Pott's  disease;  that  used  with  care  it  enables  us 
slowly  to  lessen  the  curve;  that  in  thc.se  cases  there  must  be,  in  sdiiic 
form,  a  replacement  of  the  crumpled  tissues;  that  unless  there  is  irival 
loss  of  power  the  use  of  tiu(  spine-car  or  chair  of  .1.  K.  Mitchell  cnnliki. 
su.s])ension,  especially  in  children,  to  be  combined  with  some  exercist'; 
that  no  case  of  I'ott's  di.scase  should  be  considered  desperate  witlicjiit  ii- 
trial ;  that  sus|)ension  has  .'succeeded  after  failures  of  other  accepted  iiuili- 
ods;  tliat  the  pull  ])robably  acts  nioic  or  less  directly  on  the  (!onl  IimIi. 
and  that  the  gain  is  not  ex})licable  merely  by  obvious  elTects  on  the  iiiiirii- 
lar  bony  curve;  that  the  methods  of  extension  to  be  u.sed  in  carious  cast^ 
may  be  very  varied,  provided  oidy  we  get  active  extension  ;  that  the  |iliiii 
and  the  length  of  time  of  extension  must  be  made  to  conform  to  tin- 
needs,  endurance,  and  sensation  of  the  iinlividual  ease.  It  nuiy  be  inoiiiii; 
before  there  are  any  signs  of  improvement.  In  protracted  eases,  iifiir 
suspension  lias  been  tried  for  months,  laminectomy  may  be  eonsiih-rcil, 
and  has  in  some  instances  been  successful. 

The  general  treatment  of  caries  is  that  of  tuberculosis — fresh  air,  <,'(i("i 
food,  cod-liver  oil,  and  arsenic.  Counter-irritation  in  these  instaiicos  is 
of  dor.btful  value, 

VI.  Lksions  of  thk  C.vud.v  E()iin.\  an'd  OoN'i's  Mkdii.i.aims. 

'I'he  spinal  cord  extends  only  to  the  second  lumbar  vertebra.  Injiuv, 
tumors,  and  caries  at  or  below  this  level  involve  not  the  cord  it.'clf,  Init  tin' 
bundle  of  nerves  knowji  as  the  caiida  e(piina  and  tln^  tirminal  poitiniicf 
the  cord,  the  couus  medullaris.     Much  attention  has  been  given  rtcciiiv 


lU  \ 


'  'H : 


:m. 


CIIIIONIC   AFFECTIONS  OF  TIIK  SPINAL  COUD. 


!tr 


iiiccr  of  til''  tiit'ust. 
Ills,  the  siilTcriiii;  is 
y(tpli(jia  </(il(irii.^(i. 
lor  the  (jomiitioM  is 

/    Sl'Vt'lH',  but    ill  tlic 

lul,  (;(ini|trfs>iiiii  hv 
ulysis  lias  |MT>i,>i(il 
•est  and  siipimrl  tu 
(lis  may  do  iniicli  in 
ik'VL'loiH'd,  rest  will. 
)(•  rt'iiicnilMTcd  tluit 
las  lasted   Un  iiiiiny 
;urt'd   by  rest  alniie; 
atul  tlie  caries  liial. 
lied  liy  siispetisidii,  a 
lied  witli  reiiiaikithle 
III  with  the  liiliiiimiv 
tvitiiessiiij;  tlie  nully 
,|t|iii!'eiitly  de.-|ii'riili' 
it  siis|iei>sioii  slioiiM 
1  care   it  enables  us 
c   must  be,  in  siniic 
unless   there  is  jriiai 
K.  Mitcdiell  eiiiiMi! 
ith   some   extn'i?t; 
'spei'ale  witiidiit  iw 
[her  aceepted  imtli- 
on  the  (!ord  IImIi', 
■ITeets  on  the  aiiL'ii- 
ised  in  carious  cum- 
don  ;  that   the  |il;iii 
to  conform  to  liif 
It  may  be  niniilli< 
otrac.ted  cases,  iifur 
may  bo  considercil, 

osis — frosh  air,  <i'i"'i 
II  those  instaiii'L's  ii 


rs  Mki»ii,i.akis. 

ir  vertcl)ra.     Injury. 

oconl  it.'^idf,  I'll!  \\y 

terminal  portioiiof 

been  given  n  riii!'.;' 


to  ii'.-ion.s  of  this  part.  The  whole  subject  is  admirably  (liscii.ssed  in  'I'hor- 
Imrn's  work.  l''racturcs  and  dislocations  are  common  in  the  lumbo-sacnil 
ivudoii,  tunntrs  not  infreqiuMitly  involve  the  tilaments  of  the  caiida  c(|uiiia, 
;iiiil  s.ime  of  llio  nerves  may  be  eiitanirled  in  the  cicatrix  of  a  spina  bilida. 

ill  a  fracture  or  dislocation  of  the  first  lumbar  vertebra  the  conns  me- 
.liillaiis  may  bo  (•omprcssed  with  the  last  sacral  nerves  ;:ivcn  olT  from  it. 
In  11 1  "ISO  recently  reported  by  KirchhofT  there  was  laceration  of  the  conns 
with  I'omplote  paralysis  of  the  bladder  and  rectum,  a  caM'  which  is  held  to 
that  the  ano-vesical  centre  in  man  is  situated  in  this  rci,Moii 
iif  tli(M!ord.     'i'liere  art^  .several  instances  on  record  in  wlii.di  injury  of  the 

la  eipiina  has  produced  paralysis  of  the  Idadder  and  rectum  alone, 
limes  with  a  slijifht  patch  of  an;estlicsia  in   the  nei<,'hborhood   of  the 

vx  or  the  r)erinii'iiin.     .Mor(>  commonly  branches  of  the  .sacral  or  lum- 


favor  the  view 


caiK 

•ollll 


('()(•(' 


bar  nerve-roots  are  invcdved,  prodticinir  im  irrciriilarly  distributed  motor 
and  sensory  paralysis  in  the  lei;s.  When  the  lumbar  nerve-rooi-  from  the 
Stroud  to  the  llfth  are  compressed  there  is  paralysis  of  the  mii~iles  id"  the 
lo<;s,  with  the  exception  of  the  llcxors  of  the  ankles,  the  peroniei,  the  lonir 
tli'xors  of  the  toes,  and  the  intrinsic  muscles  of  the  feet,  and  loss  of  scn.sa- 
tinii  in  the  front,  inner,  and  outer  })art  of  the  tliiijhs,  the  inner  side  of  the 
loff^,  and  the  inner  side  of  the  foot.  The  sacral  roots  may  alone  bo  in- 
vdjvfd.  Tluis  in  a  ease  wlii(di  I  have  reported  the  patient  fcdl  from  a  bri<l<,'e 
and  had  paralysis  of  the  logs  and  of  the  bladder  and  rectum.  When  scon 
sixteen  years  after  the  injury,  there  was  slitjlit  weakness,  with  wastiii!,'-  of  the 
li'ft  lei,';  there  was  complete  loss  of  the  function  in  the  ano-vesicul  and  jrcii- 
ilal  centres,  and  amvsthosiii  in  a  strip  at  the  back  part  id"  the  tliiirh  (in  the 
distribution  of  the  small  sciatic),  and  of  the  perini«um,  scrotum,  and  penis. 


Mc  II  n 


thra 


was  also  insensitive. 


Starr's  table  and  Head's  fiirnro.",  given  in  the  crcneral  introduction,  will 
be  fdiind  u.sefiil  in  determining  the  nerve  tlbres  and  segments  involved  in 
these  cases  of  injury  of  the  caudu  e(piina. 

\'1I.     TlMOllS   Ol'   Till';    Si'INAI,    Colfli    AM)    IIS    M  |;m  111!  A  N  T.S. 

New  growths  may  develop  in  the  cord  or  in  its  membranes,  or  may 
i'Xtcii  1  into  them  from  the  spine.     The  first  two  alom 


Wll 


1)0  coiisiilcred 


""'easionally  lipoma  and  ])arasitos  occur  in  the  extradural  spaee.  \\  ithin 
the  dura  libromata,  sarcomata,  anil  syphilitic  and  tiiberciiloiis  growths  are 
most  common.  In  the  cord  its(df,  and  attached  to  the  pia  mater,  the 
tuboreulous,  .syphilitic,  and  glioinatoiis  growths  are  most  frei|uent.  Of 
•")0  cases  of  tumor  of  the  spinal  cord  and  its  eiividopi's  aiialy;v'd  \>y  .Mills 
i:id  Lloyd,  only  .'{  were  parasitic.  Of  these  ".'li  wei'c  some  form  of  neo- 
I'iiistii,  of  which  .sarcomata  were  most  common,  '*  were  <.nimiiialoiis,  ami  4 


tiibi 
tl 


icn 


iilous.      llerter  has  recently  reported  .'{  cases  of  siditary  tiibertde  in 


10  eonl 


and 


has  atuilvzed  other.**  from   the  literature.     Of  -it  cases  in 


^^liiili  the  age  was  given,  15  occurred   between   the  ages  of  tiflceii  and 
liiiilv-live,  and  5  before  the  tifth  year.     The  tumor  is  most  common  in 


L, 


'if'-'"-*":  ) 


nis 


PISKASKS   OF  Till-;   NKIJVOIS  SVSTKM. 


thu  dorsal  and  liiiiiliar  n'''ii»iis,  and  is  usuallv  met  willi  in  coiuicri 
tulinrculous  lesions  clscwiicn'. 

Tlic  uniitoinical  clTrcts  of  tumors  arc  vcr.-  varied.     SI 


iMll     Ultl, 


o\v  <'oin|in.ssi,,i| 

is  usually  proihiced  liy  ^'rowtlis  external  to  the  eord,  and  il  is  reimnkalil,. 
what  a  hi^di  ;^raile  of  eoiujiressioii  the  cord  will  hear  wilhonl  seriuii>  inicr. 
ferenee  with  its  fniietions.  in  eases  of  |ii'olonLred  inlerru|itinn  useeiidin.r 
uiid  (lesc('t»dinj(  dej;i'nerati<»iis  occur.  'I'nniors  devidopinjr  within  tliemKl 
nniy  lead  to  syrin^o-iiiyeliii.  Ami,  lastly,  liiinors  not  infrei|iicntl\  excite 
intense  myelitis. 

Symptoms.  These  will  naturally  vary  a  ;.food  deal  with  the  M;.r|,|,,„^ 
i?ivolve(l  iuid  with  the  di'jj;reo  of  pre.ssnn!  and  the  extent  of  im|ilicaiii>ii  of 
the  nerves- roots. 

Within  the  eord  the  symptoms  are  those  of  a  L'radually  ]iroLrn'ssiiijj 
parapleijia,  which  may  at  tirst  have  the  picture  of  a  l)rown-^clplard  panil- 
ysis.  Atrophy  fidlows  the  involvement  of  the  anterior  cornua,  and  \,imi- 
motor  tlistnrluiiiees  may  he  mai'ked.  '['he  retlexes  are  lost  at  the  lc\(l  nf 
the  lesion,  hut  if  in  tlu*  dorsal  c(trd,  the  retlexes  are  retaineil  in  the  lr;:s. 
The  svmptoms  are  apt  to  he  eomplieated  witii  those  (d'  acute  or  stdniriiti' 
myelitis,  whi(di  may  eomplettdy  alter  the  clinical  picture.  Tumors  df  lii,. 
spinal  momhraiies  are  charactci'izcd  hy  the  early  onset  and  ocrsisleiici'  'if 
the  root  symptoms,  which  consist  of  radiatinjf  pains,  jfirdio  sensutiim, 
hypera'sthesia,  or  ana'sthesia  in  various  portions  of  the  trunk.  There  iiiiiv 
even  he  severe  [)ain  in  the  ana'sthelic  areas.  Irritation  (d'  the  mot<ir  mol^ 
miiy  eiuisc  spasm  of  the  musidcs  supplied,  oi-  vvasiiui''  with  paralysis.  Tlir 
juraplefjia  supervenes  some  time  after  the  occurrence  id'  the  rout  syMi|i- 
tom.s.  In  the  dorsal  re^xion  the  levtd  of  the  irrowth  is  usually  acciiralrlv 
(lulined  hy  the  lev(d  of  tlie  pain  and  the  condition  of  the  reflexes. 

The  dia<,'nosis  of  tumor  within  the  cord  is  sometimes  easy,  the  liiarai- 
toristle  tVatures  l)eimj:  the  constancy  and  sevei'ity  (d"  the  root  symptenisat 
the  level  of  the  jjrowth  and  the  pro<fressive  paralysis.  Caries  may  iiiiisi> 
ideidica!  symptoms,  hut  the  radiatinj,'  pains  are  randy  so  severe.  Cervica! 
menin^fitis  simulati's  tumor  very  (dosidy,  and  in  reality  produces  ideiiliral 
otTects,  hut  the  very  slow  pro^'ress  and  the  bilateral  churueter  from  tlu' 
outset  may  be  sutlleient  to  distinjjuish  this. 


Ill  (dironic  transvi'i'se  mytditis  the  symptoms  mav,  aeeordinji;  to  (i 


iiW- 


ers,  simulate  tumor  very  tdosely  and  present  radiatiiij^  ))aiiis,  a  sense  nf 
eoiistriction,  and  proi^ressive  paralysis. 

The  nature  f)f  the  tumor  can  rar(dy  be  indicated  with  precision.  With 
a  marked  syphilitic  history  umnriia  may  naturally  \n.  suspected,  and  with 
coexistin;,'  tuberculous  disease  a  solitary  tuben  le. 

Treatm.ent.  —  If  the  [tossii)ility  of  syphilitic  infecdion  is  j)resciit  the 
iodide  of  j)otassium  should  be  <>:iven  in  larije  and  increasing  doses.  Fur 
the  severe  pain.s  counter-irritation  is  sometimes  beneficial,  particularly  thf 
thermo-eantery  ;  morphia  i.s,  however,  often  necessary. 

In  a  few  instiinces  tumors  of  the  cord  or  of  the  membranes  are  uiinna- 


»[. 


CIIIIONIC   AI'l'IK  TIONS   (»F   TIIK   SPINAL  Vi)\l\\ 


llll> 


Mo  tn  siirfiicnl  trciitrnctit.     Tlic  removal  liy  llnr-lcy  nf  a  ;rr<'\vtli  fmni  (lie 
>|iiii:il  rru'iiiltraiics  \va.-  oii(>  of  tlir  must  hrilliaiil  uf  recent  operaiioiis. 

.\lisrfss  uf  llir  fiiril  is  ii  rare  lesidti,  uf  wliieli  diily  tliree  or  t'lHir  eases 
|i:i\i'  liei'li  ileseril)e(l,  all  iiietastatie.      It  may  (iceiir  witliuiit  iiieiiiii;;iti.s. 

\'lll.    l'K()()ui:ssi\  i:  (Si'iNAi.)   Misft  i,AK  Ariiui'iiY 

^chronic  Jh  (/i  ni  rutiim  nf  thi   Muttir  Xiiclii — I'uliomi/i  litis  Aiiliimr  Chrnnicii). 

Definition. — A  disease  cliarai'teri/ed  l)y  (ie^feiieratioii  ol"  ^'roiifts  <if 
the  iiiiiior  iiiii'lei  in  the  eorti  ami  meiliilla,  with  wa.-tin;^'  nf  the  eurres|i(in(l- 
ini:  iiiiisrles.  'I'lie  pyramidal  trai'ts  are  usually  involved,  and  the  paralysis 
iiiiiv  have  a  spastie  ehai'ai'tei'.  In  some  eases  the  defeneration  has  been 
tiiircd  to  the  ;rari;,dion  eells  of  the  motor  cortex. 

Three  all'i'ctions,  as  a  ride  descrihed  apart,  lielon;,'  to<fether  \\\  this 
latcirnry  :  [a)  I'roijressive  nniscnlar  atrophy  ot"  spinal  ori;,nn  ;  {!>)  amvo- 
lni|iliic  lateral  sclci'osis;  and  (r)  proffressive  lailliar  paralysis.  A  slow 
;itni|FlMc  clian;u'«'  i"  the  motor  nuclei  is  the  anatoniiral  hasis,  ami  the  dis- 
ease, as  CharcoL  states,  is  one  of  the  whole  motor  path,  involvinL'.  in  many 
Hiscs,  the  cortical,  hulltar,  and  spinal  ceidres.  Thi-re  may  hi'  simple  miis- 
ciilar  atrophy  with  littli'  or  no  spasm,  or  pro;,'ressivo  wastimr  with  marked 
■piisiii  and  fjreat  increase  in  the  nllexes.  in  others,  tlierc  are  added  symp- 
tiiiiis  oi"  involvement  of  the  mot  ir  nuclei  in  the  uiedulla  -a  ^dosso-laliio- 
larviii.'cjd  paralysis;  while  in  other.-,  a;^ain,  with  atrophy  (csitecially  of  the 
iiriiis),  a  spastic  condition  of  the  Ic^rs.  and  hulhar  phenomena,  tremors 
ili'Vclop  and  si:,nis  of  cortical  lesion.  These  various  stages  may  he  traced 
in  the  same  case.  I  have  for  ten  ycai's  had  under  oli-crvat  ion  a  man  whose 
illiios  !)ei.Mii  with  weakness  and  atrophy  of  the  hand  muscles.  (Jradually 
lln'  Icijs  he^'an  to  ji;et  still"  and  the  ^ait  spastic;  the  arms  subseipu'iitly 
«asiiil  and  the  rt-tlexes  were  increased.  After  these  symptoms  had  ]»er- 
■!-lfi|  witl'i  increasinu:  intensity  for  six  or  seven  years,  certain  of  the 
iii'iliir  nuclei  of  the  medulla  hecanie  involved,  the  speech  hecame  thick, 
ami  the  movements  of  the  lips  and  tongue  were  impaired.  Ti'iMuor  has 
ili'Vfjiiped  of  late  in  the  arms  and  hands.  With  these  chronic  chanj,^'S  the 
visceral  functions  have  remained  unimpaired  and  the  mind  unalTected. 
It  I'iis  heen  a  lesion  of  the  motor  sc;,nncnts,  hcninniiiLT  in  the  lower  and 
L'l'ailiially  exteinlini.f  upwar<l.  The  (lisea.s(t  heirau  as  proirressive  atrophy, 
ami  Liradually  assumed  a  ty]»ical  jiicfurc  of  amyotrophic  lateral  siderosis, 
ami  iHiw  the  hidhar  features  are  well  marked  and  the  tremor  would  iii- 
liiiatr  that  the  cortex  is  also  invohcd, 

l;'iir  co!ivcnieiK'e,  hulhar   paralysis  will  he  considered  separattdy,  and  I 

-liall  here  take  up  together /^/'wy/v.v.s'/'/v  iniiscitlur  tifrdjilni  and  omi/n/rii/i/nr 

h'JiTiil  sr,'"r<isis. 

i'lic  di    ':ise  is  known  as  the  .Xran-Duchenne  type  of  jirojrressive  mus- 

I'lliir  atrophy,  at'tur  the  French  physicians  who  early  descrihed  it,  and  as 

,      ,.,..,,„. Ill-    H   'nivcilhior's  palsv.     Lockluird  Clarke  ili'iiionstratcd   that  it  was  a  spiual 

ibranes  are  uaKiia     ^m  i      .  i 


n  eonncelidii  with 

Slow  coiiipiis-imi 
id  it  is  rcuiarkiiiiji' 
hold  serion>  inltr- 
•nipt ion  a.-rciiihi|ir 
iil;  wit  hill  the  idnl 
infreiliieiitly  cxiiiu 

I   wilh    the  .>e;r||lc|lt 

t  of  implicaiiMii  ,,i 

idmdly  proj:ri's>iii:; 
>wn-Se<piaril  panil- 

cornua,  and  \aMi. 

lost  at  the  lc\M  n[ 
■taiiied  in  tiic  \v^-. 
\'  acute  or  siiharutf 
re.     Tumors  nl  die 

and  i)ersi>tciicc  'jf 
*,  girdle  sensatinii, 
trunk.     There  iiiiiy 

of  the  motor  jdiils 
ith  paralysis.     TIh' 

of  the  root  s\iii|i- 

usually  acciirali'ly 
rellexes. 

■s  easy,  the  cliarai- 
root  syin|iloiii<  at 
("aries  ma\  cmiih' 
;o  severe.     (\'rvica'i 
irodueos  ideiitiral 

diaracter  from  tlic 

lU'i'ording  to  (idW- 
])ains,  a  sense  uf 


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precision.    A\  ilii 
spectud,  and  with 


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PhotogTttphic 

Sciences 

Corporation 


23  WEST  MAIN  STREET 

WEBSTER,  N.Y.  14580 

(716)  872-4503 


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III 


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I      ^ 


020 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


lesion.  CliaiTot  scparati'd  the  two  typcis— oiU'  \.ith  simple  wastincr.  in 
wlueli  llm  anterior  horns  aro  aioi  c  involvoij  ;  and  tlic  otlior  in  w  liirh.  with 
dosronoration  of  the  cormia,  tlio  i)vranii(iai  tracts  aro  allVctcd,  cMiisin'r 
wastinj^  jihi.s  a  spastic  condition,  'i'o  tliis  lie  travc  the  name  of  aiuvotid- 
pliic  lateral  sclerosis.  There  is  hut  little  evidence,  however,  to  show  that 
the  anterior  horns  are  ever  atrected  without  secondary  changes  in  iIk 
pyramidal  tracts,  and  Leytien  and  (luwcrs  regard  the  tn'o  diseases  as  i(li'ii. 
tical. 

Etiology. — The  cause  of  the  disease  is  uidsuown.  It  is  more  frc'iiinit 
in  males  tlian  in  females.  It  attacivs  adults,  (levelo[)in<;  after  the  thirtidli 
year,  thouijh  occasionally  younger  jiersons  are  attacked.  A  large  niajdiitv 
of  all  cases  of  progressive  muscular  atrophy  under  twenty-tive  years  nt'  ;ilv 
are  of  myopatiiic  (i.  e.,  nnisculai'),  not  myelopatiiic  (i.  e.,  s[)inal)  oriirin. 
Cold,  wet,  I'xposure,  fright,  and  mental  worries  are  mentioned  as  possiiilr 
causes.  lioreditary  inilueiu'cs  are  ])rcsent  in  certain  cases.  The  father  nf 
the  man  whose  case  is  referred  to  ahove  died  of  progressive  wastii\g  nt'  the 
muscles,  but  there  have  been  no  other  cases  in  the  family.  It  is  lii;.f|ily 
probable  that  when  many  members  of  a  family  are  aifected  the  disease  in 
not  sj)iiuil,  but  un  idiopathic  nniscular  atrophy;  and  yet,  in  the  hirr 
family,  which  I  reconk'd  a  few  years  ago,  in  which  thirteen  meiuhers  \wrc 
all'ected  in  two  generations,  with  the  exception  of  two,  tiie  cases  (ircunvil 
or  proved  fatal  al)ove  tlie  age  of  forty,  and  the  late  onset  speaks  ratlur 
for  a  spimd  affection.  The  amyotrophic  form  may  develop  late  in  Ht'c— 
after  seventy — as  a  senile  cliange. 

Morbid  Anatomy. — The  following  are  the  important  anati.iiiiinl 
changes:  {(i)  The  muscles  waste  and  undergo  fatty  and  sclerotic  ( liaiiiri"'. 
The  terminal  branches  of  the  motor  ium'vcs  are  degeni'rate(|.  (//)  Tlir 
anterior  roots  arc  atrophied  in  those  sections  of  the  cord  (orrespondiiiLr  tn 
the  wasted  muscles,  (r)  The  gray  matter  shows  the  most  nuu'ked  altcni- 
tion.  1'he  large  ganglion  cells  of  the  anterior  horns  are  atrophied,  oy.  in 
places,  have  entirely  disa]»])eared,  the  neurogliar  tissue  is  increased,  ninl 
the  fibres  of  the  anterior  nerve-root  passing  thnnigh  the  white  matter  arc 
wasted.  ((/)  In  a  majority  of  all  the  cases  tliere  is  sclerosis  in  the  aiitrro- 
lateral  tracts,  but  the  direct  cerebellar  and  tlie  antero-lateral  asceiiiHiiL' 
tracts  are  spared.  It  was  to  this  coml)ination  of  atrojihy  of  the  antcrinr 
horns  and  sclerosis  of  the  antero-lateral  columns  that  Charcot  gave  llir 
name  amyotrophic  lateral  scderosis.  {r)  The  degeneration  of  thf  irniy 
matter  is  rarely  confined  to  the  cord,  but  extends  to  the  nuMlulla;  tln' 
motor  nuclei  are  found  extensively  wasted  in  cases  which  havi'  -liuuii 
bulbar  symptoms  during  life.  (/)  Cerebral  changes  also  orciir.  The 
pyramidal  tracts  have  been  found  d.'gem'rated  through  the  pons  ami  caii- 
sule,  and  in  the  motor  cortex  the  large  ganglion  cells  are  wasted. 

The  essential  anatomical  change  is  a  slow  degeneration  of  ilu  iiintdr 
path,  involving  specially  the  nerve-cells  of  tht^  anterior  cornun  ami  tlu' 
anterior  root-fibres,  to  which  the  loss  of  power  and  wasting  in  the  mii-rk's 


simple  wasl'mir,  in 
uthcr  ill  wiiich,  with 
re  iilTc'cti'ii,  causiiij; 
u;  iiaiiic  dl'  iiiiivdtn]- 
)\vev('r,  to  sliiiw  tlmt 
ary  chaii.ii'fs  in  tin- 
'Avo  (lisca.sL's  as  idcii- 

It  is  iiHirc  t'nM|U(.nt 
g  aftiT  tlic  tliirtii'lh 
1.  A  lar^'c  iniijoriiv 
iity-tivt'  years  nl'  u;:*.' 
(i.  ('.,  spinal)  (iriiriii. 
(.■ntioiifd  as  i^s.-iiilc 
uses.  Tlu'  fatiicr  nf 
.>ssive  wastinjr  of  the 
'ainily.  It  is  liii.'hly 
IVctfil  tlir  discas;'  i- 
ul  yet,  in  tlir  j-'iirr 
rtci'M  iticnilxTs  Ufiv 
),  tlio  cases  occurn'd 
onset  speaks  ratluT 
evelo}»  late  in  lilV— 

i]»ortant  anat(.tiiiriil 
1(1  sclenitii'  eliaiii.'!'^. 
fctierati'il.     (//)  Tiic 


CHRONIC  AFPECTIOXS  OF  TFIE  SPINAL  COllD. 


921 


an  M'condary.  The  upper  se<fiueiit  is  also  involved,  either  simultaueou:ily 
(ir  ai  a  later  })eri()d. 

Symptoms.  —  Irro,irular  pains  may  ])re('rde  the  onset  of  the  wasting. 
Ill  (i]ii'  case  the  jiains  were  ubuut  the  lu[>  and  shoulder  joints  and  tlie  pa- 
tirni  was  treated  for  chronic  rlieumatism.  The  hands  are  first  atl'eeted, 
and  ihere  is  ditheulty  in  i)erfonnin<,^  delicate  mani[iulations.  'I'lu'  muscles 
ijf  the  hall  of  the  thumb  waste  early,  then  the  interossei  and  Inmhrieales, 
It'iiviuif  marked  depressions  between  the  metacarpal  boiu's.  I'ltimatelv  the 
niiilraetion  of  the  tli'Xor  and  extensor  museli'S  and  the  extrenu!  atrophv 
uf  the  tluunb  muscles,  the  interossei,  and  hnnl)ricales  produces  the  claw- 
hiiiiil  -iiKiiii  I'll  f/riffe  of  Ducheiine.  The  llexoi's  of  the  fori'arm  an-  usu- 
ally inv(/lved  before  the  extensors.  Jn  the  shonlder-frirdh-  the  deltoid 
\\ii>t(s  first ;  it  may  waste  even  before  the  other  muscles  of  the  upjier  ex- 
tiTiiiity.  The  trunk  muscles  are  gradually  attacked  ;  the  upper  jiart  of 
till'  trapezius  long  remains  unatrected.  Owing  to  the  feebleiu'^s  of  the 
iniiscles  which  sui)i)ort  it,  the  head  tends  to  fall  forward.  The  platysina 
iiivdides  is  unaifected  and  often  hyjH"-tro]>hies.  'I'he  arms  and  the  ti'nnk 
imiscles  nuiy  be  much  atrojjhied  bel'oi-e  the  legs  are  attacked.  The 
L'hitfi,  the  vasti,  anil  tlie  til)ialis  anticus  aiv  iirst  attacked  when  the  dis- 
lasi'  begins  in  the  legs.  In  the  member  of  the  I''arr  family  who  came 
umlir  my  notice  (if  this  was  really  a  myelo[)athii-  disorder)  the  wasting 
lii'jriui  in  the  ghiteal  and  hamstring  muscles  of  the  left  leg.  The  face 
imiscles  are  attacked  late.  I'ltimately  the  inti'rcostal  and  abdominal 
imisrles  may  be  involved,  the  wasting  proceeds  to  an  extreme  grade,  and 
tlir  patient  may  be  actually  "skin  and  bone,"  and,  as  "living  skeletons," 
till' cases  are  not  uncommon  in  "  museinns  "  and  "  .■■ide-shows."  Deformi- 
ties and  contractures  result,  and  lordosis  is  almost  always  [)resent.  A 
millions  twitching  of  the  muscles  (librillation)  is  a  connnon  symptom,  and 
limy  iMM'ur  in  muscles  which  are  not  yet  attacked.  It  is  not,  as  was  for- 
ninly  supjiosed,  a  characteristic  feature  (tf  the  disease.  The  irritability 
lit' the  muscle  is  increaseih  Sensation  is  ui.im])aired,  but  the  patient  may 
i'iiiii|)l;in  of  numbness  and  coldness  of  the  alfected  limlis.  The  galvanic 
ami  liiradic  irritability  of  the  muscles  progressively  diminishes  and  may 
lii'idMie  extinct,  the  galvanic  persisting  for  the  longest  time.  In  ca>es  of 
laiiiil  wasting  and  jiaralysis  there  may  be  the  reaction  of  degeneration. 
The  I  xcitability  of  the  nerve-trunks  may  persist  afti'r  the  muscles  have 
I'liiscii  to  respond.   The  loss  of  power  is  usually  proportionate  to  the  wasting. 

The  foregoing  description  a{>})lies  lo  the  group  of  cases  in  which  the 
i'trupliy  and  paralysis  are  Haccid — (thinic.  as  (lowers  calls  it.  In  otiier  cases, 
ilinsc  which  Charcot  describes  as  amyotrophi(!  lateral  sclerosis,  with  the 
**:i>tiiig  there  is  more  or  less  spasm,  which  may  exist  from  the  outset. 
Hiis  tmiic  atrophy  may  involve  the  legs  chietly  or  is  present  in  the  arms 
iiml  'cgs.  The  reflexes  are  greatly  increased.  It  is  one  of  the  rare  eon- 
'iitieiis  in  which  a  jaw  tionus  nuiy  be  obtained.  The  most  typical  condition 
ol  s|i;istic  paraplegia  may  be  produced.     (Jn  starting  to  walk,  the  patient 


/'■•'W^l' 


'  '-'11' 


J)22 


DISEASES  OF  THE  NKRVOUS  SYSTEM. 


Kooms  frilled  to  tho  (ground  and  iiiukcs  iiiclFcctual  attempts  to  lift  the  tncs; 
tlicii  four  or  live  sliort,  (juick  Kt('[).s  are  taki'ii  on  tho  toes  with  tlic  IhkIy 
tlirowii  forward  ;  and  finally  ho  starts  olf,  soniotinu's  with  groat  rii|iiilitv. 
Sonio  of  the  pationts  can  walk  up  and  down  stairs  bottor  than  on  the  Kvcl. 
'J'ho  wasting  is  novcr  so  extronie  as  in  tho  atonic  form,  and  ths.'  Inss  df 
pow(!r  may  ho  out  of  jiroportion  to  it.  J'hc  sphinotors  aro  uiialTci  tcil. 
Sexual  power  mav  bo  lost  early. 

As  tho  dog(!noration  extends  upward  an  important  cliange  takes  phiir 
from  the  dovelopmont  of  bull)ar  symptoms,  which  may,  however,  iiicccdt. 
the  spinal  man'fostations.  The  li[)s,  tongue,  fa(  e,  [jharvtix,  and  larvnx 
may  be  involved.  Tiie  lips  may  bo  atfe''*^ed  and  articulation  im[)aii'(il  fur 
years  before  serious  symptoms  occur.  In  the  final  stage  there  may  be 
tremor,  the  memory  fails,  and  a  condition  of  dementia  may  doveloj). 

(lowers  gives  the  following  useful  classification  of  the  varieties  ef  this 
atlection  :  (1)  Atonii' atrophy,  Ijecomiiig  extreme  ;  ('-i)  muscular  weakius-; 
with  spasm,  but  without  wasting  or  with  only  slight  wasting;  ami  (:j) 
atonic  atrophy,  rarely  oxtrenio  in  degree,  with  excess  of  the  nHi\(<. 
These  (!onditions  may  "  coexist  in  every  degree  and  combination — bet\v(rii 
universal  atonic  atrophy  on  tho  one  hand  and  universal  spastic  pai'al\>i.< 
without  wasting  on  the  other." 

Diagnosis. — The  affection  must  be  distinguished  from  the  piimaiv 
muscular  atrophies  which  usually  occur  in  younger  persons,  often  alTnt 
many  inembiirs  of  a  family,  and  have  a  diil'eivnt  distribution,  begiimiii;; 
either  in  tho  muscles  of  the  shoulder  gird'e — s})aring  the  hands  or  involv- 
ing the  face  and  upper-arm  nuisclos — or  tho  peroneal  group.  MiiMiilar 
atrophy  in  tho  adult,  beginningjn  tlu^  muscles  of  the  thumbs,  gradually 
involving  the  intorossei  and  lumbricales,  as  a  rule  is  of  myelo])athic  oriLriii. 

Treatment. — The  disease  is  incurable.  I  luive  never  seen  the 
slightest  benefit  from  drugs  or  electricity.  Tho  downward  i)rogress  i^ 
slow  but  certain,  though  in  a  few  cases  a  temporary  arrest  may  take  plain. 
With  a  history  of  syphilis,  mercury  and  iodide  of  potassium  may  be  tricil, 
and  ( lowers  recommends  courses  of  arsenic  and  strycluKne.  Probably  the 
most  useful  means  is  systenuitic  massage,  })articularly  in  tho  spastic  easw. 

Bulbar  Parnhjsis  {(lloxso-hdno-laryrajpal  Paralysis). 

An  affection  of  the  motor  nuclei  of  tho  medulla  oblongata,  rai'ely  pri- 
mary, more  comnujidy  a  part  of  a  general  degenerative  affection  nf  the 
nuclei  of  tho  motor  path  The  disease  is  sometimes  called  by  the  iiaiiu'  of 
Duchonne.     Acute  and  chronic  forms  may  be  recognized. 

(1)  Acnfc  bulbar  paralji^is  may  be  due  to  {a)  hivmorrhagic  or  onilmlii' 
softening  in  the  pons  ami  medulla;  [b)  acute  infiammatory  softeiiiiii.', 
analogous  to  polio-myelitis,  occurring  occasionally  as  a  post-febrile  atfic- 
tion. 

The  onset  is  usually  sudden,  hence  the  term  a])o])lectiform.    Tli.  ra>(s 


CHRONIC  AFFK(rriONS  OF  TlIK  SIMXAL  COIil). 


'.):2;5 


its  to  lift  tl\('  tncs ; 
)es  with  the  hddy 
.tl\  groat  nipiility. 
tbiin  on  tlu'  level. 
11,  and  thv  luss  (if 

,'l'ri   ai'f    UnulTertetj. 

;hange  takts  |il;icc 

I  hoWOVt'l-,    IM'eceili' 

arynx,  ami  larviix 
atiou  impaifiil  fer 
tage  thoro  iiiiiy  be 
may  develop, 
he  varieties  of  this 
muscular  weakness 
wasting;  ami  ('■]) 
ss  of  the  retle.\e>. 
d)ination— hetweeii 
ul  spastic  pai'al\>is 

from  the  iiriiiiaiT 

ersons,  often  allVet 

ribution,  l)egiiiimiL' 

lie  hands  or  iiivi.lv- 

grouj).     MiiM-ular 

tliunil)S,  grailiially 

invelopathic  oriLnii. 

never    seen   \\w 

nward  progress  is 

st  may  take  place. 

.^ium  may  he  trieil, 

lie.     Prohably  the 

the  spastic  eases. 

intli/fis). 

ongata,  rarely  pri- 

.ve  affection  nf  tli'' 

led  by  the  nanu'  ef 

cd. 

)rrhagic  or  embelii' 
iimatory  sofietiiii;:. 
post-febriK'  utTcf 

.•tiform.    The  eases 


lire  almost  invariably  bilateral.  ,\s  tlie  nuclei  ])resi(ling  over  the  muscles 
iif  the  tongue  and  lips  arc  involved  tli(>  speech  is  almost  or  entirely  lost. 
The  -aliva  drools,  the  li|is  are  llabby  and  flaccid,  swallowing  may  be  difli- 
lult.  and  there  nniy  be  loss  of  power  in  the  laryngeal  musclcH.  Usually 
these  ca.ses  rapidly  prove  fatal,  but  occasionally  a  case  with  a  sudden  onset, 
Hke  that  figured  by  (lowers,  may  become  chronic,  in  these  acute  cases 
tiiere  may  be  lo.ss  of  j)ower  in  one  arin,  or  hemi|)legia,  sometimes  ulternato 
heiiii[ilegia,  with  paralyses  on  one  side  of  the  face  and  hws  of  power  on  the 
(illier  side  of  the  body. 

(•.')  Chrrntir  hidlxir  jxtrahjsis  is  an  affection  of  adult  life,  rarely  b(>gin- 
iiiiig  under  the  fortieth  year,  and  in  a  great  majority  of  the  cases  it  is  only 
part  (if  a  general  degeneration  of  the  motor  nuclei.  The  disease  usually 
hfirins  w.  .  .slight  defect  in  the  si)cech,  and  the  patient  has  ditliculty  in 
|ir,)ii(iuncing  the  dentals  and  Unguals.  The  paralysis  starts  in  the  tongue, 
aiul  the  sujjcrior  lingiuil  mu.scle  gradiudly  becomes  atrophied,  and  finally 
the  mucous  membrane  is  thrown  inlo  transverse  folds.  In  the  ])ro(;ess  of 
wasting  tlie  fibrillary  tremors  are  seen.  Owing  to  tlie  loss  of  power  in  tho 
tMiigue,  tlie  food  is  with  difliculty  pushed  back  into  the  pharynx.  The 
■aliva  also  may  be  increa.^^ed,  and  is  apt  to  accumulate  in  the  mouth.  When 
the  lips  become  involved  the  ]tatient  can  neither  whistle  nor  iirimounco 
the  vowels  o  and  u.  The  mouth  looks  largi,  t!ie  lips  are  prominent,  and 
there  is  constant  drooling.  'I'he  food  is  masticated  with  ditliculty.  Swal- 
luwiiig  becomes  ditlicult,  owing  partly  to  the  regurgitation  into  the  nos- 
trils, partly  to  the  involvement  of  the  pharyngeal  muscle.s.  The  muscles 
iif  the  vocal  cords  waste  and  the  voice  becomes  feeble,  but  the  laryngeal 
paralysis  is  rarely  so'oxtreme  as  that  of  the  lips  and  tongue. 

The  course  of  the  disease  is  slow  but  progressive.  l)(>ath  often  results 
fniiu  an  asjiiration  pneumonia,  sometimes  from  choking,  more  rarely  from 
inviilvement  of  the  respiratory  ccnti'cs.  The  mind  usually  rem;uns  clear. 
The  jiatient  may  l)ecome  emotional.  In  a  majority  of  the  ca.ses  the  dis- 
'iise  is  only  part  of  a  progressive  atrophy,  either  sim])le  or  a.s.sociated  with 
;i  spasti(!  condition.  In  the  latter  stage  of  amyotrophic  lateral  sclerosis 
tlie  bulbar  lesions  may  })aralyze  the  lips  long  before  the  pharynx  or  larynx 
'"■eiiines  affected. 

The  (Uarpiosix  of  the  di.sease  is  readily  made,  eitlier  in  the  acute  or 
ihi'iinic  form.  The  involvement  of  the  lips  and  tongue  is  usually  well 
marked,  while  that  of  the  palate  may  be  long  deferred.  A  condition  ha.s 
liieii  described,  however,  which  may  closely  simulate  l)idl)ar  ])aralysis. 
Tliis  is  the  so-called  pseudo-hulbar  form  or  bulbar  pal.-^yof  cerebral  origin. 
Hilateral  disease  of  the  motor  cortex  in  the  lower  part  of  the  ascending 
tVdiitul  convolution  may  cause  paralysis  of  the  lip.s  and  tongue  and  pharynx, 
«hieli  closely  simulates  a  lesion  of  the  nu'dulla.  Sometimes  tlie  symptoms 
iiplH'ar  on  one  side,  but  in  many  instances  they  devehjp  suddenly  on  lioth 
'i'les.  A  bilateral  lesion  has  usually  been  found,  but  in  several  instances 
tlie  disease  Avas  unilateral. 


:,;i 

%-i'-  i- 

924 


DISKASES  Ob'   TIIK   NERVOUS  SYSTEM. 


•im 


Progressive  bulbar  paralysis  is  an  iucurablo  alTcctioii.  Tratisi>  iit  in,. 
provt'int'iit  may  occur.  Strycliniuo  may  be  tried.  Klectricity  is  of  ilnnht- 
ful  beiielit.  Special  care  must  be  taken  in  feedinu:  tbese  pati"iit-,  aiiii 
when  (ieglutitiun  becomes  much  imi)aired  the  stomacli-tube  sIkhiIiI  W 
employed. 


!i 


IV.  DISEASES   OF  THE   BTIAIX. 

I.  TOPICAL  DIAGNOSIS. 

Only  certain  regions  of  the  brain  give  localizing  symptoms.  TIksc 
arc  tiie  cortical  motor  centres,  the  speech  centres,  the  centres  f(ir  the 
special  senses,  and  the  tracts  which  connect  these  cortical  areas  with  each 
other  and  with  other  parts  of  the  nervous  system. 

The  following  is  a  brief  summ  iry  of  the  eifects  of  lesions  from  tlie 
cortex  to  the  spinal  cord  : 

1.  The  Cerebral  Cortex.— («)  Destructive  lesions  of  the  motor  c(>vU-\ 
cause  ,sp(is/ic  pant/i/sis  in  the  muscles  of  the  opposite  side  of  the  'mlv. 
The  extent  of  the  jjuralysis  depends  upon  that  (»f  the  lesion.  It  is  a  to 
be  limited  to  the  muscdes  of  an  extremity,  g'ving  rise  to  the  cerebral  nid  • 
plegias  (l"'ig.  11,1).  A  lesion  may  involve  two  centres  lying  close  togctlur, 
thus  producing  paralysis  of  the  face  ami  iirm,  or  of  the  arm  and  Icir,  but 
not  of  the  face  and  leg  without  iiivolvemer.t  of  the  arm.     Verv  rarciv  the 


whole  motor  cortex  is  involved,  causing  paralysis  of  one  side — cortira! 
hemiplegia. 

Combined  with  the  muscular  weakness  there  is  usually  some  distiirli- 
ance  of  sensation,  particularly  tiictile  impressions  and  those  of  the  iiiu- 
cular  sense. 

(/;)  IrrituLive  legions  cause  locilized  spasms  as  described  above.  TliofO 
convulsions  are  usu  Jly  preceded  and  accompanied  by  sensory  imprefisions. 
Tingling  or  {)ain,  or  a  senof  of  motion  in  the  part,  is  often  the  fn'niwl 
syinploin  (Seguin),  and  is  of  great  importance  in  determining  the  i-eat  uf 
the  lesion. 

Lesions  are  often  both  destructive  and  irritative,  and  we  have  cfinilii- 
nations  of  the  symptoms  produced  by  each.  For  instance,  certain  iinisclc! 
may  be  ])aralyzed,  and  those  represented  near  them  in  the  cortex  may  k' 
the  seat  of  localized  convulsions,  or  the  paralyzed  limb  itself  may  lie  at 
times  subject  to  convulsive  spasms,  or  muscles  which  have  been  coiivulsod 
may  become  paralyzed.  In  this  manner  it  is  often  possible  to  tnioe  tlie 
progress  of  a  lesion  involving  the  motor  cortex. 

We  have  seen  in  a  previous  section  that  lesions  involving  the  eontrcs 
for  the  special  senses  may  give  rise  to  focal  symptoms,  and  shall  simply 
refer  to  them  here.  The  sym{)toms  caused  by  lesions  of  the  speech  icntivs 
will  be  described  under  aphasia,  and  it  is  only  necessary  to  note  the  v.n: 


TOPICAL   DIAGNOSIS. 


9^5 


;)f  ksions  from  tlic 


jitiiMfioii  of  llio  motor  speccli  aiVii  (IJrocii'.s  contrr)  in  IIk;  k'ft  tliird 
fiiiutal  coiivolutioii  to  the  centres  of  tlie  fao^  und  ariii  on  tliat  side,  and  to 
itiitc  that  nidlor  aphasia  is  often  associated  with  inonii|ilei:ia  of  the  riylit 
fiile  iif  the  face  and  tlie  rii,dit  arm.  Acconiitanyin/  the  paralysis  foilow- 
iiiir  a  .lacksoiiiun  lit  of  tiie  ri;,diL  face  or  arm  lliere  is  often  a  transient 
motor  apliasia. 

(■>')  Centrum  Ovale. —  licsions  in  tliis  ])art  of  the  motor  |)atli  caiiso 
paralysis,  wiiicli  iias  the  distribution  of  a  cortical  palsy  wlieii  the  lesion  i.s 
nt'iir  the  cortex,  and  of  that  due  to  a  lesion  of  the  internal  capside  when 
it  is  near  that  re^io?i.  They  may  be  associated  with  symptoms  due  to  the 
interruption  of  the  other  system  of  (ibrcs  runnin^^  in  the  centrum  ovale, 
aii'l  there  may  be  sensory  disturbances — hemiana'sthosiaand  hemianopia — 
iiMil  if  the  lesion  is  in  tht'left  hemisphere  one  of  the  diHerent  forms  of 
ii|ilia-ia  may  accon^jany  the  paralysis. 

(;i|  Internal  Capsulei. —  Here  all  the  libres  of  the  upper  motor  se;:ment 
;irr  iralhered  together  in  a  compact  bundle,  anil  a  lesion  in  this  region  i.s 
;i[il  to  cau.so  complete  lienuplegia  of  tlu^  opposite  siile,  and  if  the  lesion 
involves  the  hinder  third  of  the  posterior  limb  there  is  also  hcmiantestho- 
>i;i.  including  even  the  special  senses  (Fig.  4). 

(4)  Crura  Cerebri. —  Fi'ojn  this  level  through  the  pons,  meilulla,  and 
cord,  the  upper  and  lower  motor  segments  are  represented,  the  lirst  by 
thi'  pyramidal  libi'es,  the  latter  by  the  motor  nuclei  an.d  the  nerve  fibres 
arising  from  them,  licsions  often  alTect  both  motor  .segments,  and  pro- 
duce i)aralysis  having  the  charactei'istics  of  each,  'riuis  a  single  lesion 
may  involve  the  pyramidal  tract  and  cause  a  spastic  paralysis  on  the 
iii|iosite  side  of  the  body,  and  also  involve  the  nucleus  or  the  fibres  of  one 
111  the  cranial  nerves,  and  so  produce  a  lower-segment  paralysis  on  the 
-aiiii'  side  as  the  lesion — crossed  paralysis.  In  the  cms  the  third  aiul  fourth 
i.niniiil  nerves  run  over  the  pyramidal  libres,  and  a  lesion  of  this  region  is 
ipt  to  involve  them,  causing  paralysi.s  of  the  muscK^s  of  the  eye  on  the 
■aiiie  side  as  the  lesion  combined  with  a  hemiplegia  of  the  opposite  side 

ii'V-  n,  3). 

The  optic  tract  also  cro.sses  the  cms  and  may  be  involved,  giving 
k'liiianopsia  in  the  opposite  halves  of  the  visual  fields. 

(•'i)  Pons  and  Medulla.— Lesions  involving  the  pyramidal  tract,  to- 
geilier  with  any  one  of  the  motor  cranial  nerves  of  this  region,  cause 
iiiKsed  })aralysis.  A  lesi*)n  in  the  lower  part  of  the  pons  is  apt  to  cause  a 
lower-segment  paralysis  of  the  face  on  the  same  side,  aiul  a  spastic  pa- 
ra]y,-is  of  the  arm  and  leg  on  the  opposite  side  (Fig.  11,  4).  'i'he  abdu- 
oons  and  hypogjo-ssus  nerves  nniy  also  be  paralyzt'd  in  the  >ame  manner. 

When  the  sensory  libres  of  the  fifth  nerve  are  interrupted,  together 
with  the  sensory  tract  (the  fillet)  for  the  rest  of  the  body,  which  has 
iilroady  cros.sed  the  middle  line,  there  is  a  crossed  sensory  ])aralysis — i,  e., 
lislurbed  sensation  in  the  disti'ibution  of  the  fifth  on  the  side  of  the 
bion,  and  of  all  the  rest  of  the  body  ou  the  opposite  side. 


■ : 

f 

HSl^S^J^     ; 


'  iv 


:    I 


m 

h 


I 


920 


DISEASES  OF  THE   NEIlVOrs  SYSTEM. 


In  lesions  of  tlio  pons  the  psitient  often  lias  a  tciidciicy  to  fall  t(,\vanl 
t'lc  side  on  wliieli  the  Icsifin  is,  due  i)rob;ibly  to  inipliciition  of  Mic  iiiidiHe 
peduncle  of  tiie  eerelieiliini. 

The  symptoms  prodiieed  by  involvement  of  tlie  dilTerent  eriinial  nvv\i:i 
liiiv(!  Ik'cii  ciiiisidi'rcd  in  detail  in  a  [irevi(»ns  sertiim. 

{(i)  Cerebellum.— 'I'lie  funetions  (if  tilis  pai't  of  the  brain  aiv  still 
under  eoiisiderat ion,  Lueiani,  wiiose  nmiiiiirrapli  is  the  most  exliaii>tive. 
rej^urds  it  as  "  im  end  or^im  directly  or  indirectly  related  to  ecrlniii  pc- 
ripiierul  sensory  organs  and  in  direct  elTerent  relationsliip  with  icitain 
giingliii  of  the  ccrebro-spinal  axis,  and  indiiectly  with  the  motor  a|i|)aiatiis 
in  general.  It  is  functionally  homogeneous,  each  jiart  exercisiii;,'  the 
functions  of  the  whole,  but  having  special  relations  to  the  muscles  nf  the 
corresponding  side  (jf  the  body"  (Krauss). 

Affections  of  the  lateral  lobes  atTeet  the  corresponding  side  df  ili,. 
body,  while  lesions  of  the  middle  lobe  alTeet  both  sides.  Partial  ninnval 
is  followed  by  transient  muscular  weakness ;  complete  rejimval  liy  extrciiK' 
inco()r(Iiiuition.  Its  one  imjiortant  function  would  appear  to  be  the  coor- 
dination of  the  muscular  movements. 

W.  (,'.  Krauss  has  recently  analyzed  the  lesions  and  symptoms  in  jod 
cases  of  disease  of  this  part.  The  morbid  rotiditions  were  as  follows: 
Sarcoma  in  'i'i  eases;  tubercle  in  2'i\  glioma  in  IS;  abscess  in  K);  tuiiior 
of  unspe(ulied  nature  in  1!];  cyst  in  7;  and  one  case  each  of  softciiiiii:. 
endothelioma,  cyst  and  sarcoma,  caucer,  gumma,  fibronui,  and  lia'iiinr- 
rhage.  The  left  lobe  was  affected  thirty-two  times,  the  right  lobe  thirty- 
two  tinu's,  and  the  middle  lobe  seventeen  times.  Thus,  tumor  constituted 
by  far  the  most  important  alTection.  There  may  be  no  sym])toMis  wh.'it- 
cver  if  it  is  in  one  hemisjihere  only  and  does  not  involve  the  middle  lobe. 
The  most  common  symptoms  in  tumor  are  as  follows  ; 

Vcrti(j(i,  which  is  more  constant  in  this  than  in  affections  of  any  other 
region  of  the  brain.  Some  believe  this  to  be  due  to  the  central  relations 
of  the  semicircular  canals  with  the  cerebellum.  It  was  present  in  IS  of 
the  cases  of  Krauss's  collection,  not  rejiorted  in  4:5.  Ilcadxrlic  was  priseiit 
in  83  cases.  Vomifing  occurred  in  09  cases,  not  reported  in  'i'^.  d/ili'' 
nenri/is  was  fouiul  in  GO  cases,  not  reported  in  'i'-i. 

Of  symptoms  which  are  designated  as  more  particularly  cerolu'lhir. 
ataxia  is  the  most  important.  The  gait  is  irregular  and  staggering,  ami 
in  attempting  to  walk  the  patient  sways  to  and  fro  like  a  drunken  iiiiiii. 
As  a  rule,  the  patient  walks  and  tends  to  fall  toward  the  affected  side,  but 
the  rule  is  not  certain. 

Paresis  of  the  trunk  muscles,  manifest  in  an  inability  to  perform  tiie 
movements  of  bending,  erection,  and  lateral  flexion  of  the  trunk,  maybe 
present  (llughlings  Jackson). 

Other  less  constant  but  suggestive  symptoms  are  neuralgic  ))iiins  in  tin 
region  of  the  neck  and  occiput ;  blocking  of  the  venie  Galeni,  and  diliita- 
tiou  of  the  lateral  ventricles,  causing  iu  children  hydrocephalus;  pressure 


APHASIA. 


027 


cut  cranial  lu  rvcs 


on  llio  nirdiilla,  ])r()(liu'iiis;  ininilvscs  of  tli(\  rnuiial  norvcs;.  wliicli  may 
cause  ixlycdsiiria  or  siiddcii  dcalli ;  atui,  lastly,  bilatiTal  ri,i;iiiity  I'roiii  jH'Os- 
.iiiT  on  I  111'  motor  paths. 

'I'lic  rcllt'Xos,  liowovcr,  arc  very  variable,  and  wore  absent  in  twelve 


elites. 


II.    APHASIA. 


Tlic  speeoli  meelianism  consists  of  rcccplive,  pcrceittivc,  and  emissive 
(Tillies  in  tlie  cortex  cerebri,  distnrbances  of  which  canse  fi/Jnisi/i,  and 
(•(■Hires  in  the  medulla  which  preside  over  tiie  muscles  of  articulation,  dis- 
turli.'iucc  of  wliicdi  ])ro(luces  <ni(iii/iri(i,  the  condition  of  gradual  loss  of 
jiower  of  speech,  such  as  occurs  in  l)uli)ar  paralysis. 

The  suidies  of  I>astian,  Kussmaul,  \Vcriii(d<e,  Ijiclitheim,  and  others 

liave  widcni'i'   enormously  our  knowledge  of  s[ice(di  disorders.      Language 

!« LTiidually  acfpiired  by  imitation.     Thus,  in   teaching  a  chihl  to  say  //(•//, 

ihc  Miiiiid  of   tlu^  uttered  word   enters  il,"  alTcrent  path   (auditory  nerve) 

;iii(l  reaches  the  auditory  perceptive  centre,  from  which  an  impulse  is  sent 

til  the  emissive  or  motor  centre  }>residing  over  the  nuclei  in  the  medulla, 

tlireiigh   which   the  muscles  of  artictdation  are  set  in  action.     The  are 

ill  hi'htheim's  schema  (Fig.  10)  is  ii  A,  -Mm.     The  child  gradually  ae- 

ijuiivs  in  this  way  word  memories,  which  an!  stored   at  the  centi'e  A,  aiui 

mlur  memories — the  memories  of  the  co-onlinatcd  muscular  tnoveinents 

lU'ct'ssary  to  utter  words — whiclT  are  stored  at  the  (!entre  .M.     In  a  similar 

iimiiiier,  when  shown   the  bell,  the  child  accpiires  vi.suid  mei/torirs,  wliicli 

[m  (•(uiveyed   through  the  optic 

tiii'\c    to    the   visual    perceptive 

iriitns,  o  ().     So  also  the  memo- 

lics  of    the   sound    of    the   bell 

uiicii  struck,     '['he  memory  piet- 

uie  of  the  shape  of  the  bell,  the 

mc'iiiory  of  the  ap})eurance  of  the 

wiinl    bell    as   written,   and    tlie 

motor  memories  of  the  muscular 

nioveiuents  required  to  write  the 

Wdi'd    are    distinct    from    each 

other;    yet   they  uro   intimately 

(•oiui(H;ted,    and    forin     together 

what  is  termed  the  word-imaf/e. 

Ill  addition  to  all  this  the  child 

I'ladiialiy  ac([uircs  in  his  education  ideas  as  to  th.e  use  of  the  bell — 

iiilellectual  concepts — the  centre  for  which  is  represented   at  I   in   the 

Jiajrram      In  volitional  or  intellcc^tual  8[)eech,  as  in  uttering  the  word 

W/,  the  path  Avould  be  I,  M  ni,  and  in  writing  the  word,  I,  M,  W,  h. 

Tlit'sc  various  "memories"  are  as  a  rule  stored  or  centred  in  the  left 

iHTiiisphere  (see  Fig.  3). 

59 


Y\^.  10, — Lif-hthpim's  srhpma. 


^  %::t 


h:mm 


■\   •':'■     ' 


nur 


928 


DISKASKS  OF  TIIK   NKRVOrS  SYSTKM. 


'I'lic  rcliitidiis  of  written  iiiid  spokoii  lim,!;ii!ij;('  uro  tlion  witli  {n]  sen. 
Wdvv  pd'ci'iitivf  cciitrcs  (lit'iiriii.if  mid  si<rlit  iiml,  in  the  hliiid,  tuiicli) ;  (/,) 
(diiissivf  or  motor  ('ciitn's  I'oi'  s|i('ccli  and  wi'itinjf ;  and  (<)  psydiii;!!  ci'ii- 
trcs,  tliroii^li  wtiicli  wr.  obtain  an  intfllcctiial  (Mjncc^ption  of  ulmt  i< 
said  oi'  wi'iLtcn,  ami  l»y  wiiifii  ui-  fxpn-ss  voluntarily  our  ideas  in  Imi- 
j,nui,i,'e. 

Tliere  are  two  eliief  I'ortns  of  a|ili;Hi:i — si'itsnri/  and  iiin/nr. 

(1)  Sensory  Aphasia;  Apraxia;  Word-blindness;  Word-deafnoss.— lU 
upnixia  is  understood  a  condition  in  wldeli  there  is  loss  or  iin|iiiiriiiriii  uf 
till!  power  to  reeo^iiizi!  the  nature  and  eliaraeteristi(\s  of  objects.  IVrsoiisso 
atTeeted  act  "as  if  tli<'y  no  longer  possessed  siudi  object  memories,  for  llu'v 
fail  to  roc'Offiiizc  thin<,fs,  formerly  familiar.  A  fork,  a  cane,  u  jiiii,  in.iv  lie 
taken  up  and  looked  at  by  siudi  a  person,  and  yet  held  or  used  in  a  iiianiirr 
wliieli  clearly  sliows  that  it  awakens  no  idea  of  its  use.  And  tl!issvni|i- 
tom,  for  which  at  lirst  the  term  l)lindiiess  of  mind  was  used,  is  foiniii  to 
extend  to  otiu'r  senses  than  that  of  si^dit.  'I'liiis  the  tick  of  a  w.iteh.  the 
sound  of  a  Ixdl,  a  melody  of  music,  may  fail  to  arouse  the  idea,  which  ii 
formerly  awakened,  and  the  |)atient  has  then  deafness  of  miml.  ur  an 
odor  or  taste  no  loiiffer  calls  up  tiie  notion  of  the  thin;,'  snielliil  nr 
tasted  ;  and  thus  it  is  found  t'aat  each  or  all  of  the  sensory  or^^arl^,  when 
eallod  into  play,  niay  fail  to  arouse  an  intelli^fent  perception  of  the 
object  exeitinjf  them.  For  the  j^eneral  syiriiitoms  of  inability  to  reeo^f- 
nize  the  iisi'  or  import  of  an  objegt  the  form  tipnuiK  is  now  eiu]tl(n(d." 
(Starr.) 

Apraxia  may  occur  alone,  but  more,  commonly  is  associated  with  vaiit'- 
ties  of  sensory  and  motor  aphasia.  The  [latient  may  be  able  to  reail.  iial 
tlie  words  arouse  no  intelligent  impression  in  his  mind.  While  hhiul  to 
memory-pictures  aroused'  through  sight,  the  percej)ti(Mis  may  lie  siiinii- 
lated  by  toiudi ;  thus  there  are  instancies  on  record  of  ai>raxic  patients  un- 
able to  read  by  sight,  who  could  on  tracing  the  letters  by  touch  iiaiat' 
them  correctly.  Of  the  forms  of  apraxia,  mind-blindness  and  iiiiud- 
deafuess  are  the  most  important. 

The  cases  of  mind-hUnchicsH  collected  by  Starr  indicate  that  the  \vAm 
exists  in  the  left  hemisphere  in  right-handed  {)i'rsons,  and  in  the  ri;;lit 
hemis[)liere  in  left-handed  persons.  The  disease  usually  involves  tlic 
angular  and  supramargituil  gyri  or  the  tracts  jiroceeding  from  ihcni- 
Hlin<]ness  of  the  "  mind's  eye  "  may  at  times  be  functional  and  tiaiisitnn. 
and  is  associated  with  many  forms  of  mental  disturbance.  Jn  a  niiiark- 
able  case  reported  by  Macewen,  the  iiatieiit,  after  an  injury  to  the  luail. 
had  sulfered  with  headache  and  melancholia,  but  there  was  no  paralysi'. 
He  was  psychically  blind  and  though  he  could  see  everything  pertVrlly 
well  and  could  read  letters,  objects  conveyed  no  intelligent  imprcssiiHi. 
A  man  before  his  eyes  was  recognized  as  some  obj(!ct,  but  not  as  a  man 
until  the  sounds  of  the  voice  led  to  the  recognition  through  the  auihton' 
centres.     'J'he  skull  was  trephined  over  the  angular  gyrus  and  the  \\m^ 


M'lIASIA. 


'JL>S> 


llCll   witll   {ii]  M'U- 

)lin(l,  ti)ii('li) ;  (//) 

(■)  psycliiciil  (111- 

itioii    (if   uliiii   i^ 

uiir   ideas  in  Inn- 

i(i/iir. 
Drd-deafniiss.— I'v 

(IV  iiiipairiiKiil  of 
ijt'cls.  l\'rsiiii.s>u 
lU'iiitirics,  for  ilicy 
me,  ii  pill,  may  lie 
c  usi'd  ill  a  uianiirr 
Aiul  ll'.is  syinp- 

\    used,  is  fnlllul  tn 

;!<  of  a  walrii.  [\\v 
the  iilca^  wliiili  it 

ss  (if  mind,  or  an 
tliiii<i;   siiiclli'il  (ir 

isory  ()^^■all^,  wlii'ii 
pert!i'l)ti(iii  of  till' 
inability  to  icnii;- 
is  now  cnijildvcil." 

ociiitod  willi  vaii  - 
)o  iihlf  to  rcuil.  lull 
ll.  Whili'  liliiul  10 
Ions  may  1h'  siiinii- 
praxic  patient.-  lin- 
ers bv  toiieli  niiiiM' 
idness   and   min'l- 

■ato  that  the  Icsi^ni 
Is,  and  in  the  I'i.i-'lii 
liially  involves  tlic 
leding  from  thrni. 
Inal  and  tran^iti'i'v. 
iiec.  In  a  reiiuuk- 
Injiiry  to  tlu'  l'*:'"'- 
was  no  piiralysi''. 
[orythiniT  peilVitly 
jlUgcnt  inipivssioii. 
1,  but  not  as  ;i  man 
Irough  tlie  aiiiiitt"'}' 
Iriis  and  Hic  ii"H'r 


tahle  was  found  to  be  depressed  and  a  portifni  had  been  driven  into  the 
lirain  in  this  iv<;ion.  'i'lie  patient  reeovered.  Mind-blindness  is  tiie  eipiiva- 
Iriit  "f  visual  anuiesia. 

W  ni'd-blindness  may  oeenr  alone  or  with  iimiur  aplnnia.  In  iiii- 
eitinplieiited  cuses  the  patient  is  no  jonirer  alile  to  recall  the  appear- 
iiiiirs  of  words,  and  does  not  reeoi^-ni/.e  them  on  a  printed  or  written 
pap'.  The  patient  may  be  abh  |o  proiioimee  the  letters  and  ean 
it'trn  write  I'oi'reetly,  Init  hi'  eaiinot  read  mii!erstaiidiiiijly  what  hi'  has 
writt'ii.  It  is  I'are,  however,  for  the  jiatient  'o  be  able  to  write  with 
liny  (lejfree  of  faeility.  'i'here  are  instanees  in  which  the  palieiit.  iin- 
iililc  to  read,  has  yet  been  able  to  do  mathenialical  problems  and  to 
rccoiridze  play  cards.  The  lesion  in  cases  of  word-blindness  is,  in  a 
majority  of  eases,  in  the  aiiLi'iilar  and  siipramar^niial  tryri  on  the  left  side. 
Il  is  commonly  associated  with  hemiaiiopia,  and  not  iiifreipiently  with 
mind  blindness  (Fi<^.  :{). 

Miii(l-(h'(ifiirss  is  a  eondition  in  whieh  sounds,  thonirh  heard  and  per- 
ivivfil  as  >ii(di,  awaken  no  intellip'nt  perception^.  ,\  person  who  knows 
linthini,'  of  French  has  mind-deafness  so  far  as  the  French  lanL,'iiaLre  is 
I'liuc'iTiied,  and  thonirh  he  reeoiriiizes  the  words  as  words  when  spoken, 
and  ean  repeat  them,  they  awaken  no  auditory  memories.  The  nmsieal 
faculties  nniy  be  lost  in  aphasics,  who  may  become  note-deaf  and  unable 
!m  appreciate  melodies  or  to  read  music  (iiiniisin).  This  may  occur  with- 
niit  the  existence  of  motor  a])hasia,  and,  on  the  other  hand,  there  are  eases 
oil  record  in  whieh  with  motor  aphasia  for  ordinary  speech  the  patient 
iiiiild  sinp:  !iii*l  follow  tunes  correctly.  Mind-<leafness  is  also  known  a,s 
i'jilitory  amnesia.  Word-deafness  is  a  condition  in  which  the  jiatient  no 
liiiip/r  understands  sjioken  language.  The  memory  of  the  sound  of  the 
ivord  is  lost,  and  can  neither  be  recalled  nor  recognized  when  heard.  It  is 
iHiially  associated  with  other  varieties  of  aphasia,  though  tlu^re  are  cases  in 
uiiiih  the  patient  has  been  able  to  read  and  write  and  speak.  The  lesion 
i!i  woid-dcafnoss  has  been  accurately  lielined  in  a  number  of  cases  to  be  in 
till'  posterior  portion  of  the  iirst  and  second  temporal  convolutions  on  the 
k'ft  side  (Fig.  :i). 

Other  nuiuifestations  of  mind-blindness  arc  met  with;  thus  a  young 
man  with  secondary  .syphilis  had  several  convulsive  seizures,  after  one  of 
«i;irli  ho  remained  unconscious  for  some  time.  On  awakening,  the  niem- 
"I'v  pictures  of  faces  and  ])laces  were  a  blank,  and  he  neither  knew  bis 
laiciits  nor  brothers,  nor  the  streets  of  the  town  in  which  he  lived.  lie 
' '.'1  no  aphasia  proper,  and  no  paralysis. 

CM  Motor  or  ataxic  aphasia  is  a  condition  in  vvhiidi  the  nu>mory  of 
iiio  I'llorts  necessary  to  pronounce  words  is  lost,  owing  to  disturbaiu^o 
!»  the  emissive  centre'!.  This  is  the  variety  long  ago  recognized  by 
I'l'ica.  the  lesion  of  which  was  localized  by  him  in  the  third  left  frontal 
"involution.  In  pure  cases  the  patient  is  able  to  read  (not  aloud)  and 
uiulcrstauds   perfectly   what   is   said.     He   may  not   be  able  to   utter  a 


'■■■'iyl 


•^JMlflliyi';: . 


Ipliliti 


mm 


9.% 


DISKASKS  OK    rilK    NllltVOrS   SVSTIIM. 


single  Wdivl ;  iiKirc  curiiiiiniily  ln'  run  sjiy  niic  n\-  two  words,  snili  n.^ 
"no,"  "yes,"  mill  lie  iini  inrrciiuciitly  is  iihic  to  n'|iciit  words.  \\  hen 
shown  nil  ohjcct,  |Ii(>iil;Ii  in't  iililc  to  luiiiui  it,  lie  iiiiiy  cvidciillv  rccdir. 
iiizc  whul  it  is.  If  told  llic  name,  he  iimy  bo  ahic  to  repeat  it.  A  iniin 
kiiowiii^'  the  French  and  (lertnan  lan;.''nai,'C'S  may  lose  the  fiower  (jf  (v- 
prossinj,'  his  thonj,'hls  in  tlicni,  wliile  retaininf:^  his  niother-tonLriU';  nr, 
if  eoni|)letely  aphasie,  may  recover  one  hel'on!  tiie  other.  As  the  ihini 
left  fr  mtal  con\ohition  is  in  close  contact  with  the  centres  for  the  luce 
and  arm,  these  are  not  uncomnionly  invohvd,  with  the  production  nf  u 
partial  or,  in  somi^  instances,  a  coniplde  riiiht-.-idcil  hcmiple<ifia.  A/i/in, 
or  inaliility  to  ri'ad,  occurs  with  motor  aphasia  and  also  willi  woni- 
blind''ess. 

As  a  rule,  in  motor  aphasia  thei'c  is  also  inaliility  to  write- 
nf/nrp/iia.  When  there  is  riuht  hrachial  monoplegia  it  is  dillicnlt  tu 
test  the  capaliility,  hut  there  ai'c  instances  of  motoi"  aplla^ia  uithniit 
paralysis,  in  which  the  power  of  voluntai'y  writinir  is  lost.  'Ihe  cuu- 
(lilion  varies  very  much;  tluis  a  |)atieiit  may  not  he  ahh^  to  wiiic 
volui'.farily  or  from  dictation,  and  yet  may  copy  ])erfectly.  It  is  slill 
u  (|ue'''on  whether  tlierc  is  a  special  writin^T  centi'e.  It  has  heen  |ilaccil 
by  somo  writers  at  the  base  of  the  second  frontal  convolution,  imt  in  ,, 
recent  sturly  Uejerine  concludes  that  it  is  not  .separate  fi'om  the  H[ice(li 
centre. 

There  is  a  form  known  as  mi.m/  (ijihaxia^  or  puni/z/iiisii/,  in  \\\\'w\\ 
the  j)atieiit  inulerstands  what  is  said,  and  speaks  even  joni;-  scnti'iicis 
correctly,  but  lu^  constantly  tends  to  misplace  woi'ds,  and  diu's  iidi 
express  his  ideas  in  the  proper  words.  All  grades  of  this  may  he  nut 
with,  I'rom  a  state  in  which  only  a  word  or  two  is  iinsplacid  In  mi 
extreme  eondition  in  which  the  palient  talks  jarj^on.  In  these  rd<v< 
tbe  association  tract  is  interruptiMl  between  the  auditory  perct'piivi' 
and  the  emissive  centres,  hence  it  is  sometimes  known  as  WeniiikiV 
aphasia  of  conduction.  The  lesicm  is  usually  in  the  insula  and  in  the 
convolutions  wbicli  unite  tbe  frontal  and  temporal  lobes.  Liclitliciin's 
schema  will  assist  the  student  in  obtaining  a  rational  idea  of  the  vaiiniis 
of  apbasia : 

1.  In  tlic  condition  of  apraxia  or  mind-lilindness  the  ideation  (■('iitiV':, 
I,  are  involved,  often  with  the  auditory  uud  visual  perceptive  cenlivs,  A 
and  0. 

2.  A  lesion  at  A,  the  centre  for  the  auditory  memories  of  wonls  (tii>t 
left  temporal  iryrus),  is  as.sociated  with  word-deafness. 

3.  A  lesion  at  (),  the  centre  for  visual  memories  (angular  and  supni- 
marginal  gyri),  causes  word-blindness. 

4.  Interruption  of  tbe  tracts  uniting  A  M  and  0  M  causes  the  coiidin- 
tion  apbasia  of  Wernicke — paraphasia. 

5.  Destruction  of  tbe  centre  M  (Broca's  convolution)  causes  piiiv 
motor  aphasia,  in  which  tbe  patient  cannot  express  tbouglitd  in 
speech. 


AIMIASIA. 


!>:n 


()  words,  fiiK'li  iw 
111  words.  When 
V  cvidciitlv  rcidi;. 
iTpciit  it.  A  Hum 
tlic  power  of  i\. 
lotliiT-toiiLMic;  (ir, 
icr.  As  the  ihini 
I'litrcs  for  llic  fair 
II'  |iro(lu('tiiin  iif  :i 
inilili'.LMii.     Ali/id, 

I  iilso   with   WDi'd- 

il)ility    to    write 

II  it  is  (litliciilt  I'l 
)i'  ii|iiiii>iii  uitliiiiit 
is    lost.      'I  lie  I'liii- 

lic  mIiIc  to  uriic 
ri'crtly.      It   is  still 

It  liiis  hccii  |ilii('iil 
iwolutioii,  lillt  ill  > 
Lu  i'miii  llic  spi'irii 

riijilKixid.  in  wliirli 

Ivfll     loll^'    SClltl'IICtS 

Irds,  iiiid  doi'S  imt 
f  this  niiiy  W  iiiri 
is  inis|il:ic(  d  In  aii 
111  tiuse  eiisi'S 
luditory  [)ciru|iti\v 
own  as  Wcrnirki'V 
iiisulii  and  in  tl"' 
i)l)('S.  larlitlu'iiir.'^ 
(lea  of  tilt'  varii'lii> 

lie  idi'ation  ci'iitrts 
.Tceptivc!  (■(.■idivs.  .\ 

bfit's  of  words  (tiivt 

Inif^ular  and  supni- 

caiises  the  eoudur- 


A  lesion  iit  M  nsualiy  destroys  also  the  jwuver  of  writintr.  lait,  as 
).t;ili  d,  it  is  helieved   hy  many  that  tlu'  rcntrc  for  wrilin<r,  W,  is  distinct 

fi'diii   that  of  sp h.      \\\    this  ease  a   lesion   at    .M.  whii  li   wonhl   destroy 

the  power  <d*  vuhintary  spceeh,  miiilit  iciive  open  the  cDnnetdions  he- 
twceii  (>  \V  and  A  \\\  iiy  which  the  piitient  eoidd  eupy  or  write  from 
iJictMtion. 

The  prohleins  (d'  apluisia  are  in  reality  excessively  eomplieated,  and 
the  student  must  luit  fur  a  nioineni  suppose  that  ejises  are  as  simpl(> 
\\<  diii^rams  indicate.  .\  majority  of  them  are  very  complex,  hnt  with 
[iiitieneo  the  diiiLMiosis  (d"  the  dilTercnt  varictli's  can  often  he  worked 
(lilt. 

The  followini:  tests  should  he  applie(l  in  each  e;ise  of  aphasia  :  ( 1)  The 


lillWi 


of   rccojfiuziiii;   the  nature,  ii. 


an 


d    relations    of   ohjccts — i.  »• 


ulii'tlier  apraxia  is  present  or  not;  (•.')  the  power  to  recall  the  name  of 
iMiiiiiiar  ohji'cts  seen,  sinellcd.  nr  '">ted,  or  of  a  sound  when  heard,  or 
Iif  Jill  ohject  touclu'd  ;  (l{)  the  powe.  to  understand  spoken  words;  (J) 
lilt  ("ipahility  of  iinderstandiiii;  ori-ited  or  written  laiiji'uafjo ;  (5)  the 
pipwrr  of  appreciatinir  and  uiiderstandiini:  musical  tunes;  ((1)  the  jinwc^r  of 
Voluntary  spec(di — in  this  it  i.-  to  he  noteil  particularly  whether  he  iiiis- 
pliices  words  or  not;  (T)  the  power  of  reading,'  aloud  and  of  undcrstandinp^ 
uliiit  he  reads;  (S)  the  power  to  write  v(duntarily  and  of  readirii,'  what  he 
lilts  written  ;  (!•)  the  power  to  copy  ;  (1(»)  the  power  to  write  at  dictation  ; 
;iii(i  (11)  the  power  of  repeatini:  words. 

Prognosis  and  Treatment.— In  y<ain.tr  person;-  the  outlook  is 
iriKiil,  and  the  power  of  spectdi  is  gradually  restored  a])])arently  hy  ihc 
iiliiiation  (d"  the  centres  on  the  opposite  side  of  •he  hrain.  In  adults  the 
(iiiidition  is  less  hojiefiil,  particularly  in  the  cases  of  conipUde  motor 
:i|ili;isia  with  right  hemiplegia.  The  })alieiit  may  remain  speciddciss, 
tlidiigh  capahle  of  understanding  everything,  and  attempts  at  re-education 
may  lie  ."utile.  Partial  recovery  may  occur,  and  the  patii'iit  may  be  able 
to  talk,  but  misplaces  W(jrds.  In  sensory  ajdiasia  the  condition  may  he 
only  transient,  and  the  dilTert'iit  forms  rarely  persist  alone  without  impair- 
liu'iil  of  th(^  powers  of  expression. 

Tile  education  of  an  aphasic  person  retpiires  the  greatest  care  and 
iiaticiiee,  particularly  if,  as  so  often  happens,  he  is  emotional  and  irritable. 
Ii  is  best  to  begin  by  the  use  of  detached  letters,  and  advance,  not  tm) 
i'a[iidly,  to  words  of  only  one  syllable.  Children  often  make  rai)id  prog- 
ress, Imt  in  adults  failure  is  only  too  frecpient,  even  after  tlie  most  pains- 
taking elforts.  In  the  cases  of  right  hemiplegia  with  aphasia  the  patient 
iiiay  ijc  taught  to  write  with  the  left  liuntl. 


lition)   causes  piiiv 
l)rcs3    thoughts  i" 


J! 


982 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


^n.    AFFECTIONS    OF    THE    MENINGES. 


i 


DisKASKs  OF  Tin:  Dru.v  ]\rATi:u  {Parlnimcnlugitis). 

(a)  Pachymeningitis  Externa. — Ilasmorrliage  often  occurs  as  a  result 
of  fracture.  Inllauiuiatiou  of  the  external  layer  of  the  dura  is  nuc. 
Claries  of  the  bone,  either  extension  from  miilille-ear  disease  or  diw  to 
syphilis,  is  the  prineii)al  cause.  In  the  sypliilitic  eases  there  may  l)e  a 
great  thickening  of  the  inner  table  and  a  large  collection  of  pus  between 
the  dura  and  the  bone. 

Occasionally  the  i)us  is  infiltrated  between  the  two  layers  of  the  (hini 
mater  or  nuiy  extend  through  and  cause  a  dura-arachnitis. 

'IMie  symptoms  of  external  i)acl;ymeningitis  are  indefinite.  In  tln' 
syphilitic  cases  tiiere  may  be  a  small  sinus  communicating  witii  the  ex- 
terior.    Compression  syinptoms  may  occur  with  or  witiiout  paralysis. 

(/>)  Pachymeningitis  Interna.— This  occurs  in  three  forms:  (1)  Psciidn- 
membranous,  {2)  j)urulent,  and  (15)  httmorrhagic.  The  first  two  are  un- 
important. Pseudo-membi'anous  inllammatiou  of  the  lining  mctiiluaih' 
of  the  dura  is  not  usually  recognized,  but  a  most  characteristic  exuiniili' 
of  it  came  under  my  observation  as  a  secondary  process  in  pneiunniiia. 
Purulent  pachynuMiiiigitis  may  follow  an  injury,  but  is  more  couuimnlv 
the  result  of  extension  from  inllammatiou  of  tlie  pia.  It  is  reniarkublr 
how  rarely  pus  is  found  between  the  dura  and  arachnoid  mendjraucs. 


H.-EMORRiiAGic  Paciiymkxingitis  {Hipwatouui  of  the  Dura  Mitln-]. 

This  remarkable  ccmdition,  first  described  by  Virchow,  is  very  nuv  in 
general  medical  practice.  During  ten  years  no  instance  of  it  came  nnilir 
my  observation  at  the  ^fontrcal  (ieiicral  Ifospital.  On  tlie  othci' liaii'!- 
in  the  post-mortem  room  of  the  Philadelphia  lIosi)itat,  which  I'lrcivil 
material  from  a  large  almshouse  and  asylum,  the  cases  were  not  uneniii 
mon,  and  within  three  months  I  saw  four  characteristic  examples,  tliive 
of  which  came  from  the  medical  wards.    On  the  other  hand,  the  fniiueniv 


i^pHPfl 


AFFECTIONS  OF  THE  MENINGPIS. 


mt^ 


GES. 

Ill  (/it  in). 

occurs  lis  a  rcf^iilt 
the  dura  i.s  niiv. 
disease  or  dnv  to 
IS  there  may  lie  a 

DU  of    pus  bl'lWW'U 

hiyers  of  tiw  diiiu 
is. 

ndefinite.     In  tin' 

tiuif  Willi  tlu'  I'X- 

)ut  paralysis. 

.rms:  (1)  IVcuiki- 

first  two  ai'o  uii- 

iniui?  nieiiitinuu' 

U'tt-risLic  examiil'' 

ss  in  ])iu'uiiiiiiii;i. 

inore  (Miiiiiuni'.lv 

It  is  rouiarkulilf 

meiuljraius. 


of  the  condition  in  asyhini  work  may  1)e  <rat]icred  from  the  fact  that  Wi<r- 
(flcsudrtli  found  4'i  cxan)i»lcs  in  a  scries  of  400  unsclectcd  post-mortem 
cxiini  illations. 

'I'iic  disease  is  found  cliiefly  in  males  and  in  jier.sons  over  fifty  years  of 
aijc.  It  is  most  fre(|uent  in  forms  of  chronic  insaTiity  and  in  chronic 
alcdliolism.  It  has  also  heen  found  in  profoutid  anannia  and  other  blood 
toiiilitioiis,  and  is  said  to  have  followed  certain  of  the  acute  fevers. 

The  morbid  anatomy  is  intercstintr.  XircluAv's  view  that  the  delicate 
vascular  membrane  ])recedes  the  ha'morrhaue  is  undoubtedly  correct. 
I'ractically  we  see  one  of  three  conditions  in  these  cases:  (a)  Subdural 
vascular  mend)ranes,  (»ftcn  of  extreme  delicacy  ;  (/')  sitnple  subdural  ha'm- 
iirrliai,^! ;  (<^')  combination  of  the  two,  va.scular  membrane  and  bl(»oil-clot. 
CtTtainly  the  vascular  membrane  may  exist  without  a  trace  of  ha'morrhage 
— sii'iply  a  fibrous  sheet  of  varyinir  thickness,  permeated  with  large  vessels, 
wliicli  may  form  beautiful  arborescent  tufts.  On  the  other  hand,  there 
arc  instances  in  which  the  subdural  ha'niorrlia<re  is  found  alone — in  lA  out 
iif  W  igglesworth's  42  cases — but  it  is  possil)le  that  in  .some  of  these  at 
least  the  ha'morrhage  may  have  destroyed  all  trace  of  the  vascular  men'- 
liranc.  In  some  cases  a  series  of  laminated  clots  are  found,  forming  a 
layer  from  .i  to  5  mm.  in  thickness.  Cysts  may  occur  within  this  niem- 
Imitie.  The  source  of  the  Ineniorrliage  is  [iroliably  thedural  ve.ssels.  Hu- 
iri'iiin  and  others  hold  that  the  bleeding  comes  from  the  vessels  of  the  pia 
iiialer,  hut  certainly  in  the  early  stage  of  the  condition  there  is  lU)  evi- 
ilcncc  of  this;  on  the  other  hand,  the  highly  va.scular  subdural  menibrane 
iiiiv  be  seen  covered  with  the  thinri(>st  jiossible  shei'ting  of  clot,  which  has 
rvidcntly  come  from  the  dura.  'I'he  subdural  Inemorrhag'  is  usually  asso- 
'iateil  with  atrophy  of  the  convolutions,  and  it  is  held  that  this  is  one 
rrasdn  why  it  is  so  common  in  the  ins'iiie;  but  there  must  be  some  otiier 
factor  than  atropliv,  or  we  should  nu'ct  with  it  in  phthisis  and  various 
laclicctic  conditions  in  which  the  cerebral  wasting  is  as  (common  and  almost 
;is  marked  as  in  cases  of  insanity. 

The  symptoms  are  indeiinite,  and  the  diagnosis  cannot  be  made  with 
trrtiiitity.  lleadaciie  lias  been  a  ]u-omineiit  symptom  in  some  cases,  and 
when  the  condition  exists  on  one  side  there  may  be  licmi])legia.  KxteU' 
sivc  bilateral  disease  may  exist     .th<nit  any  symptoms  whatever. 


he  lUirn  MhIt). 

ow,  is  very  raiv  iii 
of  it  came  mul''"' 

n  the  other  liaii'l. 

il,  which  iTccivc'l 
were  not   uncoiii- 

ic  example-.  iIhvi' 

and,  the  iivr^mv^ 


I>1SI;a.s|;s    ()!•■    rili:    I'lA    ^^ATIOR. 

(ii)  Acute  Leptomeningitis. — In  this  form  the  exudation  is  between 
the  pia  iiud  the  arachnoid  nieinbrams. 

Etiology. — Acute  innamiiiatioii  of  the  pia  mater  occurs  under  the 
fdllewing  circumstances  :  (1)  As  a  result  of  an  eru[)ti(m  of  tubercles,  most 
frcfjiieiitlv  in  the  basal  meninges,  forming  the  basilar  or  tuberculous  men- 
iiiiritis  which  has  been  already  considered  (.see  tul)er(ailosis).  (".*)  In  the 
qjiilemic  cerebro-.spimil  fever.     (:>)  Secondary  to  acute  general  diseases, 


i^' 


* 


n  I! 


n' 


mm 


ill 


1 


934 


DISEASES  OF  THE   NERVOUS  SYSTEM. 


more  particularly  pneumonia,  less  frequently  small-pox,  typlidid  fever, 
rheumatic  fever,  whoopin<(  cough, s(>arlet  fever,  and  measles.  In  crN^iieliis 
meningitis  may  arise  eitlier  by  infection  tiirough  tiie  blood  or  hv  direci 
extension.  Cases  in  which  the  intlaiinnation  passes  through  tlie  Ikiiic 
are  extremely  rare;  on  the  other  hand,  lliere  are  instances  of  exien. 
sive  erysii)elas  of  the  face  in  which  the  disease  travels  along  the  nerve- 
roots  and  so  reaches  the  meninges.  In  this  grou|>  pneumonia  is  tlie  unlv 
disease  which  is  fre(piently  followed  by  meningitis.  In  one  hiuuhvM] 
autopsies  at  the  Montreal  (jcneral  Hospital  in  pneumonia,  meniiigiti,-,  uiis 
found  eight  times,  and  I  had  sevei'al  opportunities  of  seeing  cases  of  simi- 
lar character  in  I'hihuUilphia.  In  septic^aiuiia  and  pya-mia,  including' 
ulcerative  endocarditis  in  tliis  category,  acute  meningitis  is  not  verv  rare. 
In  ulcerative  enihjcarditis  it  is  common,  as  may  be  Judged  from  the  statis- 
tics wliich  I  collected  of  :^()!)  cases,  of  which  ^5  were  com|)hcaieil  with 
meningitis.  Xo  instance  has  fallen  under  my  observation  in  cdnneelidii 
with  typhoid  fever  or  rheumatic;  fever. 

(4)  Injury  or  disease  of  the  l)ones  of  tiie  skull,  perforating  wouiuls  df  the 
orbit,  or  as  a  sequentte  of  abscess  whic-h  is  the  result  of  injury.  I'liJer  this 
section  l)y  fai'  tlie  most  frequent  cause  is  necrosis  in  the  petrous  ixnlidii  of 
the  temporal  bone,  which  may  excite  either  extensive  intlammatioii  nf  the 
])ia  mater  or  abscess  of  the  brain.  (5)  In  c(?rtain  constitutional  comlitioiis, 
su(;h  as  gout  and  Hright's  disease.  This  form  is  usually  basilar  and  I'luiu.- 
on  insidiously,  (iout  is  usually  mentioned  as  a  cause  of  meningitis,  but  it 
must  be  extremely  rare.  Duckworth  does  not  refer  to  it  in  his  unrk.  ami 
the  symptoms  of  the  so-called  cerebral  gout  can  scai'cely  be  .separatcil  Ifota 
those  of  ura'uua.  On  the  other  hand,  in  Bright's  disease,  I  have  met  with 
at  least  three  instances  of  well-marked  meningitis,  chiefly  of  the  base. 

(6)  While  in  a  great  ntajority  of  all  cases  of  basilar  meningitis  in  rhil- 
dreii  tubercles  may  be  found,  a  simi)lo  Irp/omt'iiinr/i/i.s  iii/dxl itm  must  alsn 
be  recognized,  ('ases  are  not  very  uncommon.  Two  occurri'd  in  drliili- 
tated  children  under  my  care  at  the  Iid'aiits'  lIoni((  in  Montreal,  and  I  saw 
at  least  two  specimens  of  the  kind  at  the  I'hila(lel])hia  Hospital.  '\'\w 
condition  may  Ik;  limited  to  the  m.eninges  at  the  base,  particularly  at  the 
posterior  part,  and  to  the  under  surface  of  the  cerebellum.  It  luis  alsd 
\wc\\  termed  occlusive  meningitis,  owing  to  the  fact  that  involving  chictly 
the  posterior  j)ortion  of  tlu;  meninges  aliout  the  cerel)ellum  and  incdiilla. 
tlu!  foramen  of  Magendie  may  be  closed,  with  the  result  of  acute,  sniiu- 
tinies  purulent  hydrocephalus,  as  described  by  (Jee  and  Harlow.*  ill 
Otlier  causes  nuMitioned  are  sun-stroke  and  excessive  study,  whirli  aiv 
probal)ly  doubtfid.  Syphilis,  which  is  a  common  cause  of  chronic  iiiuiiiii- 
gitis,  rarely  induces  the  acute  form. 

Morbid  Anatomy. — The  basal  or  cortical  meninges  may  bt;  invdlvri 
In  the  form  associated  with  pneumonia  and  ulcerative  endocarditis  the 

*  On  the  ("orvical  Opisthotonos  of  Infants,  St.  Burtholoniew's  Ho.spilul  lleiiorts,  1878. 


AFFECTIONS  OF  THE   MENINGES. 


935 


(,  typhoiil  fcvor, 
OS.  Ill  crvsipflas 
)lo()d  1)1'  In  (linM'i 

U'Oll^'l'     tiK'    liiilli' 

iliUK't's  (iT  cxtun- 
aloiiix  the  ucrvc- 
iiuitiiii  is  the  (uilv 
In  one  hmulrctl 
11,  iiu'u'miiiti.^  '.\as 
'iii;i;  cases  ol'  siiiii- 
yiL'iuia,  iiichulin;; 
s  is  not  very  rare. 
(1  from  tlif  stalis- 
compliraU'd  with 
ion  ill  eouiK'ction 

;ing  wouiuU  of  tlu' 
ijury.     riulcr  this 
petrous  ])(irtiiiii  nf 
thumnatioii  dI'  the 
itional  coiulitioiis, 
l)asilar  and  comrs 
iiu'iuni,nlis.  but  it 
t  in  liis  work,  and 
bu  separated  from 
I  have  met  witli 
(d'  the  tiase. 
enin^ilis  in  eliil- 
'(tii/tiiii  must  alsii 
nrred  i"  dehili- 
ntreal.aiid  I  saw 
Hospital.    T\w 
irticuiarly  al  thf 
un.     It  has  alsu 
involviii.ir  chirlly 
mi  and   iiinliilla. 
of  aeiitf,  siiiiH'- 
liarlow.  *    I') 
study,  wliii'li  !i'''' 
Df  chronic  iiiciiin- 

s  may  he  iiivoho'l. 
cndocanHtis  the 


ee 


It 


ispilal  U(.'l"'il>.  ^^''^' 


(]isi'a>e  is  l)ilateral  and  usually  limited  to  the  corti'x.  Tn  extiMision  from 
disease  of  the  ear  it  is  usually  unilateral  and  may  he  aeeonipanied  with 
abs('e>s  or  with  thronil)Osis  of  tlie  sinuses.  In  the  non-tiihereuloiis  form 
iiicliildreii,  in  the  iiienin<fitis  of  (diroine  liriizht's  disease,  and  in  cachectic 
luiidilioiis    the  liase  is  usually  involved.      'The  vessels  are  injected,  the 


11 


iii^o 


The  aracdmoid   is 
I'ljid,  and  there  niav  lie  a  vcdlowish-white,  creainv  exudate,  or  a  urav- 


laiaeliiioiu  tiuul  IS  increased  and   hecomes  opai|Uc, 


-Ui'ee 


n  i)uruh'nt  matter  beneath  the  aracdmoid 


I 

-pare  may  he  (;ompletcly  lilled  with   tlu   exudate,  w 


he  iiiter|)ediincular 
n  the 


iKli  exti'iids  lino 


mider 


■iurfi 


ice  (d  the  cereix'llum.     In  the  cases  secondary  to  piu'umonia 


the  etfusion  beneath  the  aracdmoid  ludx  be  ve.-y  thiid<  and  purulent,  com 
telv   hilling  the  convcdutions.     The  vciitrudes  also  mav  he  involved 


pie 


t!i(HiL;li  in  these  simple  forms  they  rarely  ])reseni  the  distention  and  soft- 
(iiinir  which  is  so  frequcjit  in  the  tuherculoiis  nieiiinj^dtis. 

The  h'j)h)in('ni)i(iitis  iiifantiDH  may  ])resent  a  picture  very  similar  to 


tuherculoiis  disease.     There  is  exudation  about  tlu'  ( 


iptic  (diiasma  ui 


id 


ill  the  Sylvian  fissures  and  toward  the  cerebellum.  In  some  instances  wo 
r;in  say  delinitely  that  the  condition  is  not  tuberculous  only  after  the  most 
nii'eful  search  in  the  menini(es  and  central  arteries,  and  when  no  tiibercdes 
ai'efduud  in  the  lungs  and  broiudiial  glands.  In  other  instances  the  mcn- 
iiiiritis  may  bo  limited  to  the  jiostcrior  ])art  of  the  base,  a')out  the  pons, 


diril 


mil, 


and 


fourth 


veil 


tri(di 


and   the  lateral  vei'trudts  mav  prest'Ut  a 


iimsi 


■markable  cjicndyniitis.  In  a  specimen  recently  sii.;wn  to  me  by 
W.'W  Howard,  dr.,  from  a  (diild  aiicd  three  iiioiiths  (which  had  had  an 
iilieratidii  performed  for  inijierforate  anus),  there  was  jxisterior  Ijasilar 
udtis,  the  fourth   ventritde  was  lilleil  with  pus,  the  walls  thi(d\ened, 

and  inliltrated  with  pus;  the  lateral  vciiti'iides  were  enormously 
li.-teiided  with  pus,  and  the  c{)endyina,  wliitdi  was  from  two  to  three  milli- 

in  diametir,  was  softenetl  and  in  a  condition  of  purulent  inliltra- 


iiii'imi 
nmuii, 


rtlV' 


)US. 


a  SI  I 


wa- 


.V  coccus  and   the  harfcrinm  roli  roiniiUDie  were  found  in  the  \ 
mewhat  similar  case  at  the  l'liiladel})hia  Hospital  the  ependymitis 
limited  to  the  posterior  ai.<l  descending  cornua,  whicdi  were  greatly 
steaded  and  containei!  ])us.     The  anterior  cornua  were  little,  if  at  all, 


i;ted. 


ow 


in«r  doubtless  to  the  inllucncc  of  y'ravitv.     This  condition  of 


intense  purulent  ependymitis  is  rare  in  tlio  adult,  but  I  rememher  to  have 
■It'll  an  instance  of  it   in  a  patient  id'  Pepper's  at  tlu'  rniversity  Hospital, 

I'liiladeliihia. 


n  at  lenirth  ol  the  (dinica 


il  feat 


11  res 


Symptoms.  —  1  have  already  sp 
"!'  tuliriculoiis  meningitis,  whicdi  is  by  far  the  most  common  and  impor- 
'M\\  fdi'in.  The  other  varieties  have  a  general  resemblance  to  it,  particu- 
l^ii'ly  those  in  which  the  base  is  alTeeited.  I  have  already,  on  .several  occa- 
^imis,  called  attention  to  the  fact  that  cortical  meningitis  is  not  to  he 
rceogiuzed  by  any  .symptoms  or  .set  of  symptoms  from  a  condition  which 
muy  he  produced  by  the  poison  of  many  of  the  spocilic  fevers.  Tn  the 
te's  (if  so-called  cerebral  pneumonia,  unless  the  base  is  involved  and  the 


1 


n 


h  : 


ih 


906 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


nerves  iiffected,  tlie  disease  is  unrecognizuble,  sine,'  identical  svniptonis 
maybe  ])r()dti(;ed  by  intense  engorgement  of  tbe  niciiingcs.  In  t\|ili(,i,l 
fever,  in  wbicb  meningitis  is  very  rare,  the  twitebings,  spa.^nis,  ami  i,.. 
tractions  of  tbe  neck  are  abnost  invariably  associated  witli  ccrchr.i-.^iiii,;,! 
congestion,  not  witli  meningitis. 

A  knowledge  of  tbe  etiology  gives  a  v(M'y  important  clew.  TKih.  in 
middle-ear  disease  tbe  development  of  liigb  fever,  delirium,  Vdinitin;.'. 
convulsions,  and  retraction  of  tbe  bead  and  neck  would  be  extrenirlv  siii:- 
gestive  of  meningitis  or  abscess.  Ileadacbe,  wbicb  may  be  severe  ami  con- 
tinnoi'.s,  is  tbe  most  common  syra])tom.  In  tbe  fevers,  ])articularlv  in 
pneumonia,  tliero  may  be  no  complaint  of  beadacbe.  Delirium  i>  tn- 
qucntly  early,  and  is  most  marked  wben  tbe  fever  is  bigb.  Convnl.-i.i!,. 
are  less  common  in  simple  tban  in  tul)ercnlous  meningitis.  Tln'v  wi  r, 
not  present  in  a  single  instance  in  tbe  cases  wbicb  I  bave  seen  in  |»iii  ii- 
monia,  ulcerative  endocarditis,  or  septica'^mia.  In  tbe  simple  nicninirii:- 
of  cbildren  tbey  nniy  occur,  liigidity  and  sj)asm  or  twit(biiig<  nf  li;. 
muscles  are  more  common.  StitVness  and  retraction  of  tbe  mus(lc>  . : 
tbe  neck  are  important  symptoms;  but  tbey  are  by  no  means  (•(iii<t;iii', 
and  are  most  frequent  wben  tlie  inilammation  exteiuls  to  tbe  incuiii-. - 
of  tbe  cervical  cord,  ^'omiting  is  a  common  sym})tom  in  tbe  eai'lv  siai;  -, 
particularly  in  basilar  meningitis.  Constipation  is  usually  ]»resenL  OpiV 
neuritis  is  rare  in  tbe  meningitis  of  tbe  cortex,  but  is  iu>t  uiicomuKiu  win  n 
tbe  base  is  involved. 

lm))ortant  symptoms  are  due  to  lesioTis  of  tbe  lu'rves  at  tlir  Ihin'. 
Strabisnnis  or  ptosis  may  occur.  Tbe  facial  nerve  may  be  involviij,  jnn- 
ducing  sligbt  paralysis,  or  tbere  may  be  damago  to  tbe  Hftb  nerve.  |i|m- 
ducing  ana'stbesia  and,  if  tbe  (bisserian  ganglion  is  affected,  tropbic  (■llaIlL''^- 
in  tbe  cornea.  Tbe  pui)ils  are  at  lirst  contracted,  subsequently  dilatnl. 
and  perbaps  unecpud. 

Fever  is  present,  moderate  in  grade,  rarely  rising  above  1(II3°.  In  tin 
non-tuberculous  leptonuMiingitis  of  debilitated  cbildren  and  in  liriirln'- 
(lisease  tbere  may  be  little  or  no  fever.  Tbe  ]tulse  may  be  incnaMil  in 
freipu'ucy  at  first  and  subsequently  is  .sbjw  and  irregular. 

Treatment. — Tbeie  are  no  remedies  wbicb  in  any  way  cotitrnl  the 
course  of  acute  meningitis.  An  ice-bag  sbould  be  applied  to  iIh'  luii'l 
and,  if  tbe  subject  is  young  and  full-blooded,  general  or  '  id  (Iciilcii'Hi 
may  be  practised.  Absidute  rest  and  ({uiet  sbould  be  cnjoineij.  Ulim 
disease  of  tbe  ear  is  present,  a  surgeon  sbould  be  early  called  i".  f"n- 
sultation,  and  if  tbere  are  symptoms  of  meningo-encepbalitis  wlii'li  <"iii 
in  any  way  be  localized  trepbining  sbould  be  practised.  An  cccasii'ii- 
al  saline  purge  Avill  do  more  to  relieve  tbe  congestion  tban  blister*  aii'l 
local  d(M)letion.  I  bave  no  belief  wbatev^r  in  tbe  efficacy  of  countti- 
irritation  to  tbe  back  of  tbe  neck,  ami  to  apply  a  blister  to  a  [latinitj 
sufTering  witb  agonizing  beadacbe  in  meningitis  is  lu'cdlessly  t"  iM  t'' 
tbe  suffering.     If  counter-irritation  is  deemed  essential,  tbe  tluinuHaii- 


Tf?^^^^WT^ 


•nticiil  syiiiiitoms 
igfs.  In  t\ii!ioiil 
i,  spiisius,  aiui  rc- 
ith  ciTc'liiM-.-^iiiuil 

it  clew.  'I'lius  ill 
'liriuiii,  Vdiniliiig, 

be  fxtrcnu'ly  suj;- 
be  si'Vi'i'c  ami  coii- 
rs,  particularly  in 
Delirium  i.s  frc- 
liiih.  ('oiivnlsiMn.< 
iiuiti^;.  Tlicy  wt'R' 
lavc  siH'ii  ill  |iiii'U- 

sin\pU'  iiH'iiintriti^ 
'  twitchinu-  of  ilii- 

of  tlio  innsclcs  <•( 
i\()  nicaiis  (■(iiistiiiit. 
i1s  to  till'  iiiciiiiiu'i- 

iu  till"  oarly  st;r_'(-. 
ally  ])rosriil.  (tiit> 
.ot  uiR'Oiiuuoii  whni 

nerves  at  tlic  Ihh''- 
av  be  iiivolveil,  in'"- 
lie  tifth  nerve,  in-n- 
ted,  trophic  clian'.'i^ 
ubseciiieiitly  ililatc'l, 

labovo  Wf.     Ill  ''"■ 

■en  and  in  I'li'-'ln'^ 
inav  be  iiirrcaMil  in 

ur. 

luny  -\vi\y  oentrel  tlic 
iipplied'  to  tlu'  licii'l 
ll  or  '    -id  (leplrti-ii 
lie  enjoined.     Wli''^ 
larly  ('idled  h\  r^n- 
■•eplialitis  wlii''li  m  I 
lised.     An  n<r:W"n-' 
In  than   blisters  itu'l 
letTiciuw  of  rountcr- 
I  blister  to  ii  piitii'"'! 
Meedlessly  tM  ii'H  t" 
tial,  tlie  thenuo-raii- 


AFFECTIONS  OF   TllH   BLOOD-VESSELS. 


937 


•,rv,  liirlitly  applied,  is  more  satisfactory.  T.arge  doses  of  tho  percliloride  of 
;roii,  iiidide  of  iiotassinm,  and  niereniT  are  recommended  by  some  authors. 
The  applioatiou  of  an  iee-ea}),  attention  to  the  bowels  and  stomach, 
;iml  keeping  the  fjver  at  a  moderate  heiglit  by  sponging,  are  the  necessary 
nii'iisiircs  in  a  disease  recognized  as  almost  invariai)ly  fatal,  and  in  whicli 
; he  cases  of  recovery  are  extremely  doubtful.  Quincke'.- 
\<w  page  'JlU)  has  been  used  with  success  by  I'Mirbringer 


liindiar  puncture 


(Id 


c.  c.  oi  cloudv 


diiiil  were  removed,  in  which  tubercle  bacilli  were  found.  Tim  headache 
ami  other  cerebral  .symptoms  di.sa])peared,  ami  the  patient,  a  man  of 
twenty,  recovered.  Wallis  Ord  atul  Waterhouse  re|)ort  a  ease  of  recovery, 
in  a  child  of  live  years,  after  trephining  and  drainage. 

(i)  C/ironic  /.rji/iniioiiiii/i/is. — '{"his  is  rarely  seen  a])art  from  syidiilis 
or  tuberculosis,  in  \\lii<'li  the  meningitis  is  associated  \\ith  the  growth  of 
thefrraiiulonuita  in  the  meninges  and  about  the  vessels.  The  symptoms 
in  such  eases  are  exlivmely  variable,  depending  entirely  U[ion  the  situa- 
tion (if  the  growth.  They  may  closely  resemble  tho.se  of  lunu)r  ami  be 
;t!S()i'iated  with  localized  convulsions.     The  leptomeningitis  infantum  may 


W  rlil'niiic 


111   the   cases  ri'ported    bv(iee  and    Uai'low 


he   (liiralinii  ui 


-"iiic  instances  extended  even  to  a  year  and  a  half.  'I'hc  iuvolvcnu'tit  of 
:lic  iMisterior  part  of  the  meninges  ami  of  the  vciiti'iclcs  may  lead  to  dilala- 
;ioi\  and  hydi'occ|)halus.     The  symjitoms  upon  which    tlii'se  authors  lay 


are  convulsions,  and  retraction  of  th 


Head 


wliU'li    is   iiai'ticiilariy 


marl 


kcd  when  the  child   is  made   to  sit  up.     There  iiiav  be  rijriditv  of  tl 


limbs 


inn 


I  epileptiform  convulsions. 


IV.    AFFECTIONS  OF  THE   BLOOD-VESSELS. 

II  vi'i:i;.i:mi.\. 

f'liiigestion  of  the  brain  has  played  an  important  part  in  cerebral 
i"itliiil(igy.  riidoiibtedly  there  are  great  variations  in  the  amount  of 
'il'ioil  in  tho  cerebral  vessels;  this  is  universally  concctled,  l)ut  how  far 
iiost'  clianges  are  associated  with  a  deHiiite  grou])  of  symptoms  is  not 
iiiite  so  clear.     The  hypera'iiiia  may  be  either  active  or  jiassive. 

.['■lire  lijiperaimid  is  associated  with  febrile  conditions,  with  increased 
J'tioii  (if  the  heart,  cliilliiig  of  the  surface,  <'onti'action  of  the  superlicial 
V'.'wls,  and  with  the  supjiression  of  certain  customary  discharges.  Among 
iitliiT  recognized  cau.ses  are  plethora,  functional  irritation,  such  as  is  asso- 
'iatcil  with  excessive  brain  work,  and  the  action  of  certain  sulistaiices,  such 
t  j-iilciiliol  and  nitrite  of  amyl. 

Piissivc  Inijx'rtVDiia  results  from  obstruction  in  the  cerebral  sinuses 
Uii'i  Veins,  engorgement  in  the  lesser  circulation,  as  in  mitral  stenosi.s, 
t'liiphysema,  from  })re,ssiir(!  on  the  superior  cava  by  aneurisms  and  tumors, 
UihI  ill  the  venous  engorgement  which  takes  place  in  prolonged  straining 


rt- 


^•'      '^rxi' 


9;38 


DISEASES  OF  THE   NERVOUS  SYSTEM. 


clTorts.  Ill  its  most  intense  form  it  is  seen  in  the  compression  of  ihe 
superior  I'iivji  \)\  liimoi's  and  in  ileatli  from  stnuii^nliition. 

Tlu!  unutomieal  clianLi'es  in  congestion  of  llie  l)rain  are  Ity  no  nicaiis 
strikin,!^.  Artivi'  livpera-mia  is  never  visiliie  post  mortem.  Tim  vein-  ,,i 
tlio  cortex  ai'e  (li.steiuied,  the  j^Tay  mutter  iuis  a  deejun'  color,  and  iis 
vessels  are  full.  The  arteries  at  the  hase  and  in  the  Sylvian  fissures  cuii- 
tain  blood.  .\othin,L,%  however,  can  he  mori'  uncertain  or  indefinite  tlian 
the  post-mortem  appeiirances  of  liypenvmia  of  the  brain.  'J'he  most  inteiisu 
distention  of  th((  vessels  is  seen  in  early  death  duriiiii'  the  s|)ecilie.  fevers, 
or  in  tile  si'condary  pi.ssivo  congestion  due  to  obstruction  in  the  superioi' 
cava  or  in  tho  lesser  circidation. 

Symptoms. — 'i'here  are  no  characteristic  or  c<tiistant  features  of 
cerebral  hy|K'ra'Uiia.  it  may  exist  in  the  most  extreme  <;-ra(h'  without  llio 
sli,«fhtest  disturbance  of  the  cerei)ral  functiotis,  as  is  witnessed  i'reiiueiitly 
in  the  pressure  of  tumors  on  the  su])erior  vena  cava.  How  far  the  heiul- 
ache  ami  delirium  of  the  early  sta<;"e  of  the  infectious  level's  is  to  he 
assiifned  to  hvpei'a'mia  of  the  hlood-vc^sels  of  the  l)rain  it  is  not  easv  tu 
(letermine.  The  liea(hiche,  dizziness,  and  uni)lcasant  sensations  in  aortic 
insuiliciency  and  in  some  instances  of  hypertrophy  of  the  heart  may  be 
due  to  the  cerebral  coniicstioii. 

As  a  separate  clinical  entity,  congestion  of  the  brain  rarely  comes 
under  observation.  1  have  uo  knowledge  of  instaiu'cs  associated  with 
delirium,  fever,  insomnia,  and  convulsions,  or  of  the  so-callcil  apoplectifortii 
variety  described  by  some  writers.  \'ery  pletlioric  jier.sojis  are  subject  to 
attacks  of  headach'-  with  Hushing  of  the  face  aiul  irritability  of  temper. 
attacks  which  may  recur  frequently  and  arc  sometimes  relieved  by  lilceil- 
ing  at  the  nose.  These  are  usually  attributed  to  congestion  of  the  brain. 
When  ])assive  hy})era'mia  reaches  a  high  grade,  there  nuiy  be  tor{)or,  diil- 
ness  of  the  intellect,  and  ultimately  deep  (!oma. 


An^';mia. 

This  may  be  induced  by  loss  of  blood,  either  quickly,  as  in  luvinnr- 
rliage,  or  gradually,  as  in  the  severe  primary  and  secondary  atiiemias. 
The  ana'iuia  may  be  local  and  due  to  causes  which  inlo;'fere  with  tlu'  bldud 
supply  to  the  brain,  as  narrowing  of  the  vessels  by  endarteritis,  pressure, 
narrowing  of  the  aortii;  orifice,  or  it  may  follow  an  unequal  distribution 
of  the  blood  in  consequence  of  dilatation  of  certain  vascular  tei'ritories. 
Thus,  rai)id  distention  of  the  intestinal  vessels,  siu'li  as  occurs  after  the 
removal  of  a.Ncitic  fluid,  may  cause  sudden  death  from  cerebral  anaMiiia 
The  (jommonest  illustration  of  this  is  the  fainting  fit  from  emotion,  in 
whi(!h  the  blood  su])ply  to  the  l)rain  is  insutricietit  on  account  of  t!ie 
diminished  arterial  pressure.  Anannia  of  the  c(U'ebral  vessels  may  he 
caused  by  pressure  of  fluid  in  the  ventrichis.  The  partial  aniPniia  result,-; 
frt  a  obliteration  of  branches  of  the  circle  of  Willis  by  embolism  or  throiu 


oiTiprossion  of  iho 

II. 

1  iii'o  by  no  iiu'.ins 

I'lii.     'riic.  voiiis  (if 

|H'r  colnr,  and    ii,^ 

viaii  lissui't's  cun. 
or  iiuk'linitc  tlmn 

'.riic  most  intense 
he  s|)C't'ilic  fevers, 
on  in  the  snperinr 

istant  featiiri's  of 
;j,Ta(le  witlioiit  tlio 
tiiessed  t're(iiieiitly 
low  far  the  head- 
iis  fevers  is  to  lie 
ill  it  is  not  easy  to 
eiisations  in  aorlic 
'  the  heart  may  bo 

irain  rarely  coincs 
I'S  associated  with 
idled  apopleetiiorm 
■!oiis  are  subject  td 
itability  of  tempi  r. 
;  relieved  by  blecd- 
stion  of  the  brain. 
nay  be  torpor,  dul- 


AFFECTIOXS  OF  THE   BLOOD-VESSELS. 


9.30 


bi'-is.     T.igaturc  of  one  carotid 
■1  and  (listurbanee  of  function 


III 


Tlu!  anatomical   condition  o 


sometimes  canoes  a  transient  marked  unav 
oii  one  side  df  the  liraiii. 


Iirain   in  aiKeinia    is   v 


Tlie  m(!ml)ralu^s  are  |iale,  only  the  Iav'H'  veil 
tl 


«trik 


iriir. 


IS  are  full,  tiie  small  vess(ds 


r  tin   jyri  are  empty,  and  an  unusual  amount 
-cut.     On  section   both  t 


le  irrav  and  w  liitc  m; 


ter  l( 


IIIM 


the  cut  surface  is  moist.     Verv  ft 


•reliro-,-.|)inal   fluid  is 
ink  extremely  ])ale 


'W  jlKlichl   /'(fsrtf/ii.y//  \\\\'  .^(.(.| 


Symptoms.— The  eifeets  of  ameniia  of  the  brain  arc  well  illustrated 
In  a  faintin.u-  lit  in  wlii(di  loss  of  consciousness  follows  t 


he  result  of   ha'm()rrha";e,  there  are  drowsi 


When 

til  stand,  llaslu's  of  li<rlit,  and  noises  in  t 

rii'i 


ic  heart  weakness. 

ness.  iiiddiiic-^s,  inability 

le  car  ;  the  rcs|iiratinii  liccdiiies  liiir- 


aiid  <i-radiiail\,  if  tin 


hli 


in; 
In   ( 


I  ;  the  skin  is  cool  and  covered  with  sweat 

■  coiitiuue.s,  consciousness  is  lost  and  death  may  occur  ^vith  convulsions, 
irdinary  syncojio  the   loss  of  consciousness  is  usuallv  transient  and 


ice   to   restore  t 


the  recumbent  |iosture  alone  niav  sut1 
.scioiisness.     In   the  more  (diroiiic  forms  of 
from  the  irradual   impoverishment  of  the  hh 
ill  starvation,  the  condition  known  as  irrital 
ctl'ort  is  ditli(ailt,,  the  sli<rlitest  irritation  is  followed 
the  patient  complains  of  iiiddiness  in 
liiillucinatioiis  or  delirium.     'I'hese  svi 


le 


patient   to  con- 


liraiii  amemi; 


-iicli  as  resii 


It 


d,  as  in  ])rotracted  illii 


or 


Me  weakness  resul 


.Mental 


)v  undue  cxcifcinenl 


id   noises  111  the  cars,  or 


M'l'c  mav  li(( 


niitoins  arc  met  with   in  an  cxtrcice 


LM 


ade  as  a  result  of  ])r()longed  starvation. 
.\ii   interest iii;f  set  of  symptoins,  t 


o  which 


was  applied  by  Marshall  il; 
iliarrlnea  in  children.     The  clii 


the  term   /i//i/rriirrp//(il(ih/. 
occurs  in  the  debility  jiroduced  hy  proionijcd 


lycs  open,  the  ])iipils  contracted,  and  the  bmtanelle  dej 


Id  IS  ill  a  seiiii-eomatose  condition  with  tlu^ 

iresscd.      In   tlui 


rill 


lier  ])eri()d  there  may  be  convulsions.  The  coma  may  <rradiially  deepen, 
the  pupils  become  dilated,  and  there  may  be  strabismus  and  even  retrac- 
tion of  the  head,  symptoms  which  closely  simulate  basilar  meniimitis. 


r-kly,  as  in  lianiier- 
econdary  ameniias. 
;-fere  with  the  bluuil 
darteritis,  ])ressiirr, 
nequal  distribiitieii 
vascular  territories, 
as  occurs  after  tin 
fi  cenOiral  amciniii 
t  from  emotion,  in 
on  account  of  tlir 
nil  vessels  may  ln' 
;'tial  anaMnia  results 
Bnibolism  or  thrmu 


G']i)i;m.\  of  Tin:  BitAix. 

Tn  the  ]iatholoiry  of  brain  lesions  (edema  formerly  ]ilaved  a  n'l/r  almost 
oqual  in  im})()rtance  to  con<festioii.  It  occurs  under  the  fnllowin^^M'ondi- 
tiiins:  In  ji^oieral  atro)thy  of  the  convolutions,  in  which  case  the  o'dema 
is  represented  by  an  increase  in  the  ccreiiro-spinal  fluid  and  in  that  of  the 
meshes  of  the  jiia.  In  extreme  hypera'iiiia  from  obstruction,  as  in  mitral 
stenosis  or  in  tumors,  there  may  he  a  condition  of  coiiirestive  (cdciiia.  in 
which,  in  addition  to  jj^rcat  tillini^  of  the  hlood-vessels,  the  sul)stance  of 
the  brain  itself  is  unusually  moist.  The  most  acute  (edema  is  a  local  pro- 
fess found  around  tumors  and  ab.sces.ses.  An  intense^  infiltration,  local  or 
fieneral,  may  occur  in  Hri,<;ht's  disea.se,  and  to  it,  as  Traube  suggested,  cer- 
tain of  the  nroemic  sympt()ms  may  be  due. 

The  nnafomir.nl  r/iniif/rs  are  not  unlike  those  of  an.Tmia.  When  a 
sequence  of  pnjgrossive  atrophy,  the  fluid   is  chiefly  within  and  beneath 


!  f 


1>40 


DISUVSKS  OF  TIIK   N'KllVOUS  SYSTEM. 


tlir  iiu^dibram'S.  'I'lic  bniin  siibstaiirc  is  atiii'iiiic  and  insist,  and  Im-  a 
wt'l,  ^distciiiii,^^  a])|)caraiii'<',  wlndi  is  \rv\  (diarai'tcristii'.  In  sonic  in- 
slanci's  tlic;  (I'dcina  is  iiKirc  inlcnsc  and  local  and  tlio  brain  sid)staiicc  mav 
look  inliltrat(;d  willi  llnid.  'J'lic  aiuoiint  of  ilnid  in  tbc  ventricles  is  n-ii- 
iilly  increased. 

'I'lii^  si/iii/i/iiiiis  are  in  j,'reat  part  those  of  an;cinia,  and  are  not  uclj 
delined.  As  jtisl  stated,  sonu'  of  the  eereliral  features  of  nra'inia  nia\ 
de|ii'nd  upon  it.  Of  late  years  eases  have  been  reported  by  IJayniond. 
Teiineson,  and  Di'rciiin,  in  which  nidlateral  convulsions  or  paralysis  lia\c 
ocu'.urred  in  connection  with  chrcjidi'  IJriii'lit's  disease,  and  in  wliicli  the 
eondition  appeared  to  l)e  associated  with  (cdciua  of  the  brain.  The  oMcr 
writers  laiil  ^i'ri'at  stress  npoii  an  apojilexia  si'rosa,  which  may  really  have 
been  u  general  aMlenni  of  the  hrain. 

CeHKB11.\L    IL-EMOUHirAdK. 


The  bleeding  may  eonie  from  bramdies  of  either  of  the  two  great 
groups  of  cerebral  vessels — the  /jdsal,  eonijirising  the  circK'  of  Willis  am! 
the  (central  arteries  passing  from  it,  or  the  fin'tirdl  ij raiip,  \\w  anterior, 
middle,  and  the  posterior  cerel)ral  vessels.  In  a  majority  of  the  cases  thu 
Ini'iiiorrhage  is  from  the  central  braiudies,  more  ])artienlarly  from  those 
given  olT  by  the  middle  cert'bral  arteries  in  tlie  anterior  perforated  spai  c^, 
ami  whic.'h  supply  the  corpora  striata  .ind  internal  capsnles.  One  of  the 
hirgost  of  tlu^se  branches  which  pa.-^ses  to  the  third  division  of  the  lenticiilai 
nncleiis  and  to  the  hiniler  part  of  the  internal  cap-nle  is  so  frequently  in- 
volved in  Inemorrhage  that  it  has  been  called  hy  ('\vAYy{){  llic  (oici  ij  nf 
cercbrdl  //a'liiorr/niijc.  The  bleeding  may  be  into  the  substance  of  the 
brain,  to  which  alone  the  torm  eerel)ral  apoplexy  is  a|)plied,  or  into  the 
membranes,  in  which  ease  it  is  termed  meningeal  Ineniorrhage ;  hotli. 
li()W((Vor,  are  usually  included  under  the  terms  intracranial  or  eerehral 
Inemorrhago. 

Etiology. — The  eonditions  whidi  produce  lesions  of  the  blooil-vcs- 
sels  play  a  very  im))ortant  part ;  thus  the  natural  tendency  to  (U'generalion 
of  the  vessels  in  advaiuied  lifi'  makes  apoplexy  much  nioi'e  common  afi'  r 
the  fiftieth  year.  It  may,  Imwever,  occur  m  children  under  ten.  On 
ueeount  of  the  greater  liability  to  arterial  disease  (associated  prol)ahl,v 
with  mu.sciilar  exertion  an\l  the  abu.se  of  alcoliol),  men  are  more  subject 
to  cerebrul  luemorrluige  than  women.  Heredity  was  formerly  thought 
to  bo  an  important  factor  in  this  alfectioii,  and  the  apoplectic  hahitux  er 
build  is  still  referred  to.  T?y  this  is  meant  a  stout,  ]i]ethorie  l)ody  of  me- 
dium size,  with  a  short  neck.  Ileretlity  inlluences  cerebral  liannorrhngc 
entirely  througli  tlie  arteries,  and  there  are  families  hi  which  they  degener- 
ate early,  usually  iu  a.ssoeiatioTi  with  renal  t'hanges.  The  secondary  hyper- 
trophy of  the  heart  brings  with  it  serious  dangers,  which  have  already 
been  discussed  iu  the  section  upon  arteries.     The  three  spetaal  factors  in 


AFFECTIONS   OF  THE   HEOOD-VESSELS. 


01 1 


iiiiliii'infi;  artorio-sclci'Dsis— tlic  iilmsc  of  iilrohol,  sy|pliilis.  aiiil  iiroloiij^i'd 
iiiii-i'iiliir  oxoi'tioii — arc  t'diind  to  he  imiiortaiil  iuitccrdtiits  in  a  lar^'c  iiiini- 
ln'i'  oT  casL'S  of  ciTi'hral  lui'iiiorrliaL.a'. 

Tlic  (-'iiilocarilitis  of  rlR'iiiiiatisni  and  otlicr  fcviiv  inav  indircdlv  lead 
Id  a|)<)j)k'xy  l)y  caiisiiijf  cinholisni  iMid  anciii-i.-ni  (.f  tlu'  vessels  of  the 
lirain.  Ccrcljral  lia'iiiorrlia^^'  orcni's  occasionallv  in  I  he  .-pfcilic  f(\('rs 
and  ill  profound  altorations  of  tlic  lilond,  as  in  Icnkaniia  and  |icrni(ioiis 
iiiiaiiiiii.  TIk'  actual  t'Xcitiii.i,' cause  of  the  lueiiiorrlia,i;-c  is  iioL  I'vidciit  in 
the  majority  of  cases.  The  attack  may  lie  sudden  and  without  any  pre- 
liiniuary  syiiiptoiiis.  In  other  instates  \iulent  cxcrliou,  particularlv 
Mrainiiij;  eiruils,  or  the  excitc(raclion  of  the  heart  in  emotion  iiiav  cause 
a  rupture. 

Morbid  Anatomy. — 'I'he  K'.-ions  causing-  apophxy  are  almost  iu- 
vaiialily  in  the  cerehral  arteries,  in  which  the  following  (hanges  may  lead 
(lin'ctly  to  it : 

(u)  Periarteritis  with  the  ])roduetioii  of  miliary  aiieurisms,  rupture  of 
which  is  the  most  common  cause  of  cereliral  ha'iii(»ri'ha,L;-e.  'I'Ikt  occi'"  most 
ln(|iiently  on  the  central  arteries,  hut  also  on  the  sniallcr  liranclies  ^>]'  the 
iiirtical  vessels.  On  section  of  the  brain  suhstaiicc  the\  mav  he  seen  as 
jiicalized,  small  ilark  liodii'S  ahout  the  size  of  a  pin's  head.  Soiiietiines 
they  are  seen  in  numhers  upon  the  arteries  carefully  withdrawn  from  the 
anterior  perforated  sjiaees.  Aci:oi'diii_in'  to  Charcot  and  iJoiudiard,  who  liavt; 
tli'scrihed  them,  they  are  most  fre(|uent  in  the  central  ,i:'aii;j:]ia.  In  a[)o- 
|»lexy  after  the  fortieth  year  if  souirht  for  they  are  rarely  missed. 

{//)  Aneurism  of  the  hraiiches  of  tlic  ■  irele  of  Willis,  'i'lu'se  are  hy 
no  means  inieominoii,  and  will  he  considered  sul)se(jueiitlv. 

(r)  Kndarteritis  and  periarteritis  in  the  cerdiral  vessels  most  comiuoidy 
Iwid  to  apoplexy  hy  the  production  of  aneiiri>ms,  either  miliary  or  coarse. 
There  art;  instances  in  which  the  iiiM-t  canfid  search  fails  to  reveal  any- 
tliiuu;  hut  dill'use  dei^enerution  of  the  cerehral  vessels,  particularly  of  tho 
smaller  branches;  .so  that  we  must  conclude  tiiat  siioiitaneous  ru[)turc 
may  oc'cur  without  the  jirevioiis  formation  of  aneurism. 

'JMio  hiemorrlu'ti'e  may  be  meiiinii-eal,  ccreliral,  or  intraventricular. 

MeiniKjctd  Ild'iinirrlnKjr  may  he  outside  the  dura,  between  this  moin- 
hrane  and  the  bone,  or  ln't  ween  the  dura  ami  aracdmoid,  or  l)etween  the 
arachnoid  and  the  pia  mater.  The  followiiiu'  are  the  chief  causes  of  this 
form  of  Inemorrha^e  :  Fracture  (d'  the  skidh  in  whi(di  case  the  blood  iisii- 
iilly  comes  from  the  laeorated  inenih^cal  \essels,  .•sometimes  from  tlu;  lu.n 
sinuses.  In  these  eases  the  blood  is  usually  outside  the  dura  or  between  it 
:md  the  siracdinoid.  The  next  most  fre(|ueiit  cause  is  rupture  of  aneurisms 
oil  the  ItU'tier  cerebral  ve.sscds.  The  blood  is  usuallv  subarachnoid.  An 
iiitraeerebral  luvmorrhaijo  may  burst  into  the  mcniiii^es.  A  special  form 
of  meningeal  haMiiorrhage  is  found  in  the  new-born,  associated  with  injury 
iliiriug  birth.  And  lastly,  meningeal  luemorrhage  may  occur  in  the  con- 
lititutional  diseases  and  fevers,     'J'ho  blood  may  bo  in  u  large  (juantity  at 


WP: 


u    ^i- 


f. 


im 


f  r'i! 


942 


niSKASES  OV  TIIK   NKIIVOUS  SYSTEM. 


the  l)!is(';  ill  ciiscs  of  ni|iliir('(l  Miiciirisin,  purl  ii'iiliirly,  it  ni;iy  cxfi'tii]  jntf; 
tl',' cord  or  upon  the  coi'tcx.  Ouiiiu'  to  the  ^rc:itri' ri'i'i|ii('iii'y  of  iIm;uii.||. 
risiiis  ill  llif  middle  ccri'liral  \c.-si'l-,  tlic  SyUiaii  lissurcs  arc  ofti  i  dj,. 
ti'iidcd  willi  hlood. 

I  III  niciTihral  Int'iiKirrlKifif  is  most  IVc(|iiciii  in  the  iiciuidiorliond  ii|'tli(, 
(•or|iiis  striatum,  |iarliciilariy  toward  tlic  outer  scctiiui  of  tlic  Iciiiiciilin- 
nucleus.  Tile  liaMiiorrliaiif  may  lie  small  and  limiteii  to  tiie  IciiliiMilnr 
liody  and  the  internal  ca|isiile,  or  it  may  lireak  the  centrum  ovale,  or  liuist 
into  tli(^  lateral  ventricle,  or  exti'iid  to  tlu-  insula.  llaMiiorrhairt  ■^  (mi- 
fined  to  till!  white  niiitter — the  ceiitriini  ovale — are  rare,  l-ocali/.ed  I  Irid- 
in,!.,Mnay  occnr  in  the  crura  or  in  the  pons.  I  !a'morrha,i/e  into  tliecrri'. 
helium  is  not  iiiieomiiion,  and  usually  comes  from  the  superior  ceriljrjlnr 
artery.  The  extravasation  may  !);•  limiti'd  to  the  siiii.-lance  or  riiiitiire 
into  the  fourth  ventricle.  'I'wice  I  Ikpv  known  sudden  death  in  ;:irl-i 
under  twenty-live  to  he  i\\\v  to  iH'i'ehcllai   ha'inorrhap'. 

\'riilri<'iiltir  lliriii()rrli(Kji'.—'V\\\j,  rarely  comes  from  the  vessels  of  thu 
plexuses  or  of  the  walls.  It  i.-riiot  infreipicnt  in  early  life  and  may  (icciir 
diirinii  hirtli.  Of  !)1  ca-cs  collecti'd  hy  Kdward  Sanders,  "'occurred  diiniiL' 
the  lirst  year,  and  If  under  the  twentieth  year.  In  the  cases  which  I  liavi' 
Keen  in  adults  it  has  almost  always  l)een  caused  hy  rupture  of  a  vessel  in 
the  nei^llll()rllood  of  the  caudate  nucleus.  The  hlood  may  Ik-  foiniij  in 
one  ventricle  only,  hut  more  commonly  it  is  in  both  lateral  ventricles,  ur.il 
may  pass  into  the  third  ventricle  and  tliroui.;h  the  aipiediict  of  Sylvius 
into  the  fourth  ventricle,  formin.ir  Ji  com[»lete  mould  in  hlood  of  tJM' 
ventricular  system. 

Si(bsrijiii'iit  C/iiiiif/rs. — TIio  blood  gradually  clianixes  in  color,  and  ulti- 
mately the  ha'inoLflohiii  is  conve)'t''d  into  the  rcddish-lu'own  ha^niatniilin. 
Inflamniation  occurs  about  "tlio  a]ioplectic  area,  rmiitinir  ii'id  conliniiiL'  it, 
and  iilliuiately  a  delinite  wall  may  he  produced,  inclosiiiL,'  a  cyst  with  lluil 
contents.  In  other  instances  a  cyst  is  not  formed,  but  the  connective-i issue 
proliferates  and  leaves  a  ]ni:;mente(I  scar.  In  meiiintrcal  lia'inorrhap'  the 
elTused  blood  may  be  gradually  absorbed  and  leave  only  a  .staininir  of  the 
meinbranes.  In  other  cases,  particularly  in  infants,  when  the  eiriisinii  i> 
cortical  and  abundant,  there  may  be  localized  wasting  of  the  coinohitimi'i 
and  the  proiliiction  of  a  cyst  in  the  meninges.  Possibly  certain  ef  tln' 
cases  of  porencephaly  are  caused  in  this  way. 

Secondary  degeneration  follows  when  the  motor  cortex  or  motor  ]iiii!i 
is  involved.  Thus,  in  ])ersons  dying  some  years  after  a  cerebral  apoplcxv 
which  has  produced  hemiplegia,  the  degeneration  may  be  traced  in  the 
crns,  in  the  anterior  ])art  of  the  pons,  in  the  pyramidal  fibres  of  the  iiie- 
dulla,  in  the  direct  fibres  of  the  cord  of  the  same  side,  and  in  the  crossed 
pyramidal  fibres  of  the  opposite  side. 

Symptoms. — These  may  bo  divided  into  primary,  or  those  connccteil 
Avith  the  ons(!t,  and  secondary,  or  those  which  develop  later  after  the  (>;irlv 
manifestations  have  ])assed  away. 


AFFKCTIONS  OF  THE   IlLOOD-VKSSKLS. 


043 


niiiy  cxfciiil  intf, 
ciicy  til"  till'  alien, 
cs  arc  iil'ti  i  (liv 

,U'lll)(prll(inil  nf  ill,. 

of  llic  Iciiiiciiliir 

to  tiic  Ictitii'iiliii' 

im  (i\;il",  nr  liin'.t 

;i'innrrliii:_'i -^  imi- 

l,iir!lli/.C(|   Mciil- 
I'^C    illtit     tllr  rr|V. 

ii|K'ri(if  {•(■I'clH'lliir 
laiicc  (ir  I'liiiliiiv 
•11   (K'litli    in   ;^iii-: 

the  vcs.-cls  iif  th,. 
f'c  iiiid  iiiiiy  orciir 
'i  occiirri'il  diiriiiL' 
■iiscs  wliicli  I  li;ivc 
tufc  (if  ii  vessel  in 

may  \h'  fdiiiiil  in 
ral  vcnti'iclcs,  iind 
u'lliii't   (if  Sylviii> 

in    1)1(10(1   (if  tJM' 

color,  ami  ulti- 
own  lia'matdidin. 
and  confiniiiL'  it. 

a  cyst  with  llui'l 
coniu'ctivc-tissui' 

lia'inorrliau'e  the 
a  stainin.ir  d'  tlic 
'11  the  I'lTiisi'iii  i^ 

the  con\(ihitieiH 
)ly  certain  of  tJK' 

ex  or  motor  path 
•ereln'al  apeiilixv 
lie  traced  in  tlu^ 
(ihl'-'S  of  the  me- 
lul  ill  the  crosr^ed 


Priinari/  S//niji/oiiis.  —  Premonitory  indications  are  rare.  Ah  a  rule, 
the  iialieiil  is  .seized  while  in  i'lill  lu'aitii  or  uhoiit  the  jierrormance  of  .some 
(;V('i'y-(hiy  aelion,  occasionally  an  action  rt(jiiirin^'  strain  or  extra  e.\er- 
tiiiii.  Mow  and  lluMi  instances  ai'e  found  in  which  there  are  si'iisatioiis  of 
miinhne.ss  or  tin^diiii;  or  jiaiiis  in  the  limhs,  or  even  tdioiviform  iiiovenu'iits 
ill  the  muscles  of  the  oi)posite  side,  the  so-c,ille(l  |)relieniii)leiric  chorea. 
Till'  on.set  of  the  aj»oj)lexy,  as  cerehral  ha'im»rrha;;e  is  usually  called,  varies 
greatly.  'I'iiere  may  be  sudden  lo.ss  of  eons(^iousness  and  cctmplete  relaxa- 
ii(jii  of  the  extremities.  In  such  instances  tlie  name  tijxijilrv/ic  .sfrake  is 
|i.iniciilar]y  a])iiro|iriate.  In  other  eases  the  onset  is  more  jiradual  and 
ijie  loss  of  conscioiisiu.'.ss  may  not  occur  for  a  few  minutes  after  the  patient, 
lias  i'allen,  or  after  the  paral3'sis  of  the  limbs  is  manifest.  In  the  apoplic- 
lie  attack  the  coiiditi(jn  is  as  follows:  'i'liere  is  deep  iincoi  sciousness ;  the 
jialieiit  canncjt  be  roused.  'J'iic  face  is  injected,  sometimes  cyanotic,  or 
iif  an  ashen-^ray  hue.  'J'lie  ])n)iils  vary ;  usually  they  are  dilated  and  in- 
active. The  res])irations  arc  slow,  noisy,  and  accompanied  with  stertor. 
^iiiiietimos  the  Cheyne-Stokes  rhythm  may  bo  ])n\sont.  The  chest  move- 
ments on  the  ))iiralyzed  side  may  be  restricted,  in  rare  instances  on  the 
(i|i|M)sito  side.  The  pulse  is  usually  full,  slow,  and  of  increased  tension. 
The  temperature  may  be  normal,  but  is  often  found  subnormal,  and,  as  in 
u(.'iise  reported  by  Uastian,  may  sink  below  Uo°.  In  cases  of  basal  luemor- 
rhiige  the  temperature,  on  tiie  otiier  hand,  may  Ix'  iiijuli.  The  urine  and 
fii'ces  are  usually  i)ass(!d  involuntarily.  C'(Mivulsions  are  not  common.  It 
may  be  dillicull  to  decide  whether  the  condition  is  apoiilexy  associated 
with  hemiplegia  or  sudden  coma  from  other  causes.  An  indication  of 
hemiplegia  may  be  discovered  in  the  dill'ercnce  in  the  tonus  of  the  muscles 
(in  the  two  sides.  If  tlie  arm  or  the  leg  is  lifted,  it  drojis  '"  dead  "  on  the 
affected  side,  while  on  the  other  it  falls  more  slowly.  IJigidily  also  may 
be  present.  In  watching  the  movements  of  ilie  facial  muscles  in  the  ster- 
ttjnais  respiration  it  will  be  seen  that  on  the  jtaralyzed  side  the  relaxation 
peniuts  the  cheek  to  be  blown  out  in  a  nioie  marked  manner.  The  head 
and  eyes  may  be  turned  strongly  to  one  side — ctmjiigate  deviation. 

In  other  cases,  in  which  tiie  onset  is  not  so  abrupt,  the  patient  may  not 
\()ie  coiLscioiisness,  but  in  the  course  of  a  few  hours  there  is  loss  of  pow- 
er, unconsciousness  gradually  develojis,  and  (]ee[)eiis  into  profound  coma. 
This  is  sometimes  termed  ingravescent  ajwjjlcxy.  The  attack  may  ocjcur 
(hiring  sleep.  The  patient  may  be  found  unconscious,  or  wakes  to  find 
timt  the  power  is  lost  on  one  side.  Small  ha'inorrhages  in  tlu;  territory 
of  the  central  arteries  may  cause  hemiplegia  without  loss  of  coiis(;ioiisiicss. 

I'sually  within  forty-eight  hours  after  the  onset  of  an  attack  there  is 
febrile  rci'ction,  and  more  or  less  constitutional  disturbance  associated 
with  inllanimatory  changes  about  the  luemorrliage.  The  ]iatient  may 
i!ie  in  this  reaction,  or,  if  consciousness  has  been  regained,  there  may  l)e 
(ielirium  or  recurrence  of  the  coma.  At  this  jicriod  the  so-called  early 
ligidity  may  develop  in  the  paraly.'ied  limbs.  Trophic  changes  may  occur, 
t)0 


044 


PFSKASKS  OF  TIIH   VKIIVOTS  SVSTMM. 


Hiich  ns  sloujrliiti^'  or  tlic  funiijilinn  of  vrsicIcM.  'I'Ih'  most  scrioii>  (,f  (Ik.jq 
is  the  sloii-^'liiii;,'  cscliai'  of  flic  lower  part  of  the  hack,  or  on  the  pMahzcd 
side,  wliicli  rimy  appear  witliiii  forty-eij^lit  hours  of  tlie  onset  ami  !-•  usiiallv 
of  ^'nivc  si<,MiilicaiH'e.  The  eoii^estioii  at  the  bases  of  thi' hiii<,'s  Pd  ctiiii'. 
moil  in  apoplexy  is  rej^MnhMl  hy  soinc  as  a  tropliic  chan^'c. 

Cinijiujdtc  nrritifinn. — In  a  ri^^'ht  heniiph'j,'ia  IIk;  eyes  and  Inail  iii;iv 
he  turned  to  tli(>  left  side;  that  is  to  say,  the  eyes  look  toward  thecerelnid 
lesion.  'I'liis  is  almost  tiio  rule  in  the  eonju,i,'ate  deviation  of  the  luad 
and  eyes  \vhi(di  occurs  early  in  hcini[de_i^ia.  When,  however,  coiivulsiiuis 
or  spasm  develop  or  tin-  state  of  so-called  early  I'i^idity  in  liemipl('i;ia,  tln' 
conju^rjitc  (h'viation  of  the  head  and  eyes  may  he  in  the  oppdshc  (liicitimi ; 
that  is  to  say,  the  eyes  look  away  fi-om  Ihe  lisinn  an<l  the  head  is  rdtalnl 
toward  the  convidscd  side.  'I'liis  symptom  may  lie  associateil  with  cdrtiiid 
lesions,  particularly,  according'  to  sonu'  authors,  when  in  Hk;  inii^dilidr- 
hood  of  the  supramaririmil  and  anp-ular  ,!:'\ri.  It  may  also  orcur  in  ;i 
lesion  of  the  internal  capsule  or  in  the  pons,  hut  in  the  latter  Mluiitinii 
the  conjuLrate  deviation  is  the  reverse  of  that  which  octairs  in  dtlKr 
eases,  as  tlu^  patient  lo  >k  ;  aw;'y  from  the  Ic  ion,  and  in  spastn  or  cui . 
vulsion  looks  toward  tlie  lesiMi.  In  cases  in  wliiidi  couscicusnos  i:-i. - 
stored  ami  the  patient  iin[U'ovt'S,  the  uiMhitt'ial  paralysis  which  pcr.-i,«i-  i> 
known  us 

Ili'iiilplciiid. —  IIeniiplej:ia  is  cotnpleto  when  it  involves  fac",  iii'iii,  ;iip| 
leg,  or  partial  when  it  involvt's  only  one  or  other  of  these  ])arls.  Tl!- 
may  he  the  result  of  a  lesion  (a)  of  the  motor  cortex  ;  (//)  of  the  pyrariiiil.;! 
iihres  in  coi'ima  radiata  ami  in  the  inlcrnal  ca[isulc ;  {r)  of  a  lesion  in  tli,' 
crus  cerebri;  or  {d  \  in  the  pons  A'arolii  (see  Jiage  !(4r)).  Ila'uioirlinijr  i> 
jierhaps  the  most  cominon  i-'iuse,  but  tumors  and  spots  of  softeiun;,'  iiiiiy 
also  induce  it.  The  spe"i:d  details  of  the  hi'miplegia  may  here  hr  cnii-M- 
ered.  The  face  is  iiuolvcd  on  the  same  side  as  the  arm  aid  le;/.  Ti  i< 
results  from  the  fact  that  the  facial  muscles  stand  ii!  preeise'y  the  saaic  il- 
lation to  the  cortical  centres  as  those  i>f  tlu^  arm  and  lej;,  tue  Iihres  ef  ih'' 
upper  motor  seirinent  of  the  facial  lu'rvc;  from  the  (iortt-x  decussiitiiiLT  jii-', 
as  do  those  of  the  nerves  of  the  limbs.  The  facial  ])aralysis  is  partial,  i: - 
volving  only  the  lower  portion  of  tlm  ner\e,  so  that  the  oi'hicularis  inii'i 
and  the  frontalis  muscles  are  nniuvolvcd.  The  signs  of  the  facial  pMriil\>is 
are  usually  wcdl  marked.  There  may  bea  sliglit dillicnlty  in  (dcvalin^' thr 
eyebrows  or  in  closing  the  eye  on  the  paralyzed  side,  or  in  rare  case-  the 
facial  paralysis  is  complete,  ])ut  the  movements  may  be  present  with  ciini- 
lion,  as  laughing  or  ci'ying.  The  hypoglossal  nerve  also  is  invohiil.  la 
conserpient^e,  the  jtatient  cannot  put  out  the  tongue  straight,  but  it  ilivi- 
ates  toward  th  paralyzed  side,  inasmuch  as  tin,'  genio-hyo-glossus  nf  lln^ 
sound  side  is  nno]ij)osed.     AVilh  right  hemiplegia  there  may  be  aplinsia. 

The  arm  is,  as  a  rule,  more  com])letely  jiaralyzed  than  the  Lir.    TIio j 
loss  of  power  nuiy  bo  absolute  or  })artial.     In  severe  cases  it  is  at  fii.-t 
complete.     In  others,  wdien  the  ])aralysis  in  the  face  and  arm  is  c'liii- 
plete  that  of  the  leg  is  only  partial.     The  face  uud  arm  may  alone  bo  par- 


« '  ,?T 


vitiii.-  iif  ilii'se 
thf  |iiiralyz('il 
1111(1  is  usually 

luili,'S  ^^.  fdlli- 

iiml  Iliad  iii:i\ 

•(I    lln'  fCl'cljllll 

ill  o{  IIk'  lit'uii 
■r,  coiiMiI.-ii'ii- 
iciuililrf^ia.  tli'' 
»siU'  (lirt'rliol;  ; 

hcinl  is  votati'! 
•d  witli  cortiral 

thf  iifiL^lilMir- 
uls<»  (ici'ur  ill  a 
latter  yitiiali'ni 
K'curs  ill  'iilii  I" 

spusiii  'ir  c'li;- 

;ci(UlSll('>S    i-  IV- 

,vhirli  privi^ls  is 


lla'iiinn-liaj;<'  i^ 
,1'  si.ftfuiu^'  luiiy 


SC'V  till'  SllllU'  I'l 


in  clrvatiii^' tlui 
lin  nu-o  oasc-  tlio 
losoiit  witli  i'"i"- 


rht,  but  it  ^Kvi- 


A1-'FK(TI<)NS  ((K   TIIK   IU-()()I»-VHSSKLS.  945 


■■iSb 


■  11.—  Iiiaj;nim  of  iimtor  jiatli  from  rijriit  l)rain.  Tlu'  iiiipcr  sc^rinout  is  liliick,  tlio 
I'lWir  i"tl.  The  luidci  of  the  motor  cniiiial  iutvi's  arc  sliowii  on  liie  left  >i(li';  mi 
tliu  iii,'lit  side  till' cranial  nerves  of  lliat  side  are  indicated,  A  lesion  at  1  wniiid 
i-iiiM'  u|i[ier  sej,'iiienl  [laralysis  in  the  arm  of  the  o|>|)o.->iti;  side — ('creliral  iiiono- 
|'ii.i;ia :  at  2,  ii|i|)er  segment  paralysis  of  the  whole  opposite  side  of  the  Ijody — 
iiiiiii|il('gia;  al  ;>,  upper  segment  paralysis  of  the  o|)posite  face,  arm,  and  leg,  and 
!"Wer  segment  paralysis  of  the  eye  muscles  on  the  .same  side — crossed  paralysis ; 
lit  I.  upper  segment  paralysis  of  opposite  arm  anil  leg,  and  lower  segment  paraly- 
^i>  111' the  face  and  the  external  rectus  on  the  same  side— crossed  [laralysis:  at  .^, 
upper  segment  paralysis  of  all  muscles  below  lesion,  and  lower  .segment  {laralysis 
"fmii-cles  represented  at  level  of  lesion — spinal  paraplegia:  at  0,  lower  segment 
jiiiialysis  of  muscles  h)cali/,ed  at  seat  of  lesion — anterior  poliomyelitis.  (Van  (ie- 
liiulitni,  moditied.) 


I 


'&■> 


940 


DISEASES  OP  THE   NERVOUS  SYSTEM. 


f    I , 


:  i  ■  1 


silyzed,  while   tlio  log  escapes.     Less  commonly  i!  "  leg  is  movo  alTootoi] 
than  the  iinii,  and  tiie  I'ace  may  be  only  slightly  involved. 

Certain  muscles  escape  in  hemiplegia,  particularly  those  ass(i(  iatcd  in 
symmetrical  movements,  as  the  thoracic  and  abdominal  muscli's,  a  fa,  t 
which  P)roadbeiit  exi)lains  by  supi)osiiig  that  as  tiie  spinal  nuclei  conrrol. 
ling  these  movements  on  both  sides  constantly  act  together,  tlicv  iniiv.  In 
means  of  this  intimate  connection,  be  stimulated  by  impulses  coming  from 
only  one  side  of  the  brain. 

Croi^sed  HeniipJegin. — A  paralysis  in  which  there  is  loss  of  function  in 
a  cranial  nerve  on  one  side  with  loss  of  iiower«(or  of  sensurion)  (ui  tin' 
ojiposite  side  of  the  body  is  called  a  crossed  or  alternate  liemipl(i;ia.  \\  i< 
met  with  in  lesions,  commonly  haunorrhage  in  the  crns,  the  ])oiis,  and  tiic 
medulla  (Fig-  11,3  and  4).  , 

{(i)  Criis. — The  bleeding  may  come  from  vessels  traversing  the  cnis 
to  reach  the  thalamus,  or,  most  important  of  all,  from  rupture  of  theururyl 
of  the  motor  oculi  nuclei.  In  the  classical  case  of  Weber,  on  section  of  tliej 
lower  part  of  the  left  cms  an  oblong  clot  15  mm.  in  length  lay  just  hclmv 
the  internal  and  inferior  surface.  The  characteristic  features  uf  a  It-imij 
in  this  locality  are  paralysis  of  arm,  face,  and  leg  of  the  opposite  ^ide,  aiid| 
motor  oculi  paralysis  of  the  same  side — the  syndrome  of  Weber.  Sensurvi 
aiul  motor  changes  have  also  been  present.  Ihumorrhage  into  the  W: 
meutum  is  not  necessarily  associated  with  hemi})legia,  but  there  may  Le^ 
incomplete  paralysis  of  the  nu)tor  oculi  nerve,  with  disturbance  of  seiis;i-| 
tion  on  the  opjiosite  side  of  the  body, 

(b)  Pons  (Old  Medulln. — Lesions  may  involve  the  pyramidal  tract  aiid| 
one  or  more  of  the  cranial  nerves.  If  at  the  lower  aspect  of  the  jion.s.  tlie 
facial  nerve  maybe  involved,  causing  paralysis  of  the  face  on  t  ho  same 
side  and  hemiplegia  of  the  opposite  side.  The  fifth  nerve  may  be  invnlvedj 
with  the  fillet  (the  sensory  tract),  causing  loss  of  sensation  in  tlic  area  u^ 
distribution  of  the  fifth  on  the  same  side  as  the  lesion  and  loss  ofriensaLinn^ 
on  the  opposite  side  of  the  body. 

The  sensory  disturbances  are  variable.     Ilemiana^sthesia  may  coexisB 
with  hemiplegia,  but  in  many  instances  tlu-re  is  only  slight  nuiubncss  o| 
sensation.     When  the  hemianiusthesia  is  marked,  it  is  usually  the  )■('> 
of  a  lesion   in  the  internal  capsule.     Li  C.  L.  Dana's  study  (d'  srii^i'i'j 
localization  he  found  that  ana'sthosia  of  organic  cortical  origin  Avas  alw;iy| 
limited  or  more  pronounced  in  certain  parts,  as  the  face,  arm,  or  K's:,  ai 
was  generally  incomplete.     Total  aiuesthesia  was  either  of  funciionai  o|| 
subcortical  origin.     ]\Iarked  anaesthesia  was  much  more  cominen  in  ^f 
ening  than  in  hajmorrhage.    Cora})lete  hemiaiutsthesia  is  certainly  ran'  in 
haemorrhage.     Disturbance  of  the  special  senses  is  not  „oi  unon.    Ih'ini 
unopia  may  exist  on  the  same  side  as  the  lesion,  aiul  there  may  bo  diin^ 
nution  in  the  acuteuess  of  the  senses  of  hearing,  taste,  and  snudi. 

As  a  rule,  there  is  at  first  no  wasting  of  the  paralyzed  limhs.    'Hil 
deep  reflexes  are  increased  on  the  paralyzed  side,  and  ankle  cloi  us  may 


AFFECTIONS  OF  THE   BLOOD-VESSELS. 


947 


1  moro,  iiftocti' 


present.     Tho  plantar  and  otlior  superficial  reflexes  arc  usually  dimin- 
isheil.     The  sphincters  are  not  aflfected. 

The  cniirsr  of  the  disease  dejieuds  upon  the  situation  and  extent  of 
ilif  lesion.  If  slight,  the  hemiplegia  nuiy  disappear  c()Ui])lelely  williiu  a 
fewdiiys  or  a  few  weeks.  In  severe  cases  the  rule  is  that  tho  leg  gradually 
recovers  before  the  arm,  and  tho  muscles  of  the  shoulder  girdle  and  upper 
anil  licfore  those  of  the  forearm  and  haiul.  The  face  may  recover  qiuckly. 
Except  in  the  very  slight  lesions,  in  which  the  heniii)legia  is  transient, 
(himircs  take  place  which  may  be  grouped  as 

Sirnndanj  SyinptoDis. — These  corres])oiid  to  the  chronic  stage.     In  a 

ia>o  ill  which  little  or  no  improvement  takes  place  within  eight  or  ten 

wirks.it  will  he  found  that  tiie  paralyzed  limbs  undergo  certain  (;hanges. 

Tlic  log,  as  a  rule,  recovers  enough  power  to  enable  tlie  i)atient  to  get 

I  jhniit.  although  the  foot  is  dragged.     In  both  arm  and  leg  the  condition 

I 'if  .wo»f/rr/7/  rontrartion  or  hitc  7'i(/i(lif>/  comes  on  and  is  always  most 

[mrked  in  the  upper  extremity.     The  arm  becomes  permanently  flexed  at 

ilio  elbow  and   resists   all  attempts  at  extension,      'i'lie  wrist    is   flexed 

I'iipon  tlio  forearm  and  the  fingers  upon  the  baud.     The  [tositioii  of  the 

arm  and  hand  is  very   characteristic.     Tliere  is  frequently,  as  the  con- 

hrai'tures  develop,  a  great  deal  of  pain.      In  the   leg  the  contracture   is 

raivly  so  extreme.     The  loss  of  power  is  most  marki-d   in  the  niuscl(s  (;f 

::u' foot,  and  to  prevent  the  ti)es  from  dragging  the  knee  in  walking  i;; 

Iniiii'h  flexed,  or  more  comnioidy  the  foot   is   swung   round   in   a   half- 

I  circle. 

The  reflexes  are  at  this  stage  greatly  increased.     These  contractures 

Ifff  [icniianent  and  incurable,  and  are  associatetl  with  a  secondary  desceiid- 

|i;i'jscli  rosis  of  the  motor  path.     TiuTe  are  instanc'cs,  however,  in  which 

Iridililv  ami  contracture  do  not  occur,  but   the  arm   remains  llaccid,  the 

.'.' luiviiig  regained  its  power.     ^I'liis  //cim'jjlrt/ic  jlii,'<ijii('  o\'  Hiiudiard    is 

I'lmd  most  conunonly  in  children,     .\mong  other  secondary  clianges  in 

I'jto  hcniiplegia  may  be  mentioned  the  following:  'i'remor  of  the  ail'ectcd 

jinuli>,  |r.ist-paralytic  chorea,  the  mobile  sjiasm  known  as  athetosis,  arthropa- 

j'iiirs  in  the  joints  of  the  aA'ccted  side,  and  muscuhir  atrophy.      Athetosis 

jiinl  [>ost-hemi])legic  chorea  will  be  consideri'd  iu  the  hemiiilegia  of  cliil- 

liMi,     X  word  may  here  be  said  u[)on  the  subject  of  muscular  atrojihy  of 

'■"ilii'iil  origin. 

A-;  a  rule,  atrophy  is  not  a  marked  feature  in  hemiplegia,  l)ut  in  some 
iWaiiccs  it  does  develoji.  It  has  heeu  shown  to  lie  due  in  som(>  cases  lo 
Is'imilary  alterations  iu  the  gray  matter  of  the  anti'rior  horns,  as  in  a  case 
pportril  by  {,'harcot.  Uecently,  however,  attention  has  been  called  by 
lljiiiiiiko  to  the  fact  that  atrophy  may  follow  as  a  direct  result  of  the  cere- 
I'lral  Ksidu.  In  his  case,  atiophy  of  the  arm  followed  the  development  of 
lU'lionia  in  the  anterior  central  convolutions.  The  gray  matti-r  ol  the 
liiitfrior  horns  was  normal.  This  wasting  of  cerebral  origin  oi'curs  uujst 
p'lueiitly  in  children. 


ll 

I^R'r 

i';^|'aK|j 

I  Ai  yg  i  > 

i  |l  mm 

i   ;''-^* 'jmIj-;' 

948 


DISEASES  OF  THE   NERVOUS  SYSTEM. 


Diagnosis. — TIhtc  arc!  tlirce  groups  of  cases  wliich  offer  inercasinj; 
dinicnltv  ill  recognition. 

(1)  Cases  ill  wliieli  tlie  onset  is  gradual,  a  day  or  two  ola])sini:  licfdrc 
tlie  paralysis  is  fully  developeil  and  conscioiisness  completely  Inst.  ;in> 
readily  recognized,  though  it  may  be  dilTlcult  to  deterniijio  wlicthcr  tbi- 
lesion  is  due  to  thronihosis  or  to  luvmorrhage. 

{■>)  In  the  sudden  apoplectic  stroke  in  whi(di  the  patient  rapidly  Idsps 
consciousness,  the  difficulty  in  diagnosis  may  be  still  greater,  particiilarlv 
if  the  patient  is  in  deep  coma  when  first  seen. 

The  first  point  to  be  decide(l  is  the  existence  of  heniij)legia.  This  muv 
bi^  flirti(!ult,  although,  as  a  i-ule,  even  in  deep  coma  the  limbs  on  the  i>;ir;i- 
lyzed  side  are  more  flaccid  and  drop  instantly  when  lifted;  wliercaN  mi 
the  non-pandyzed  side  the  muscles  retain  some  degree  of  toiuis.  Tlie 
reflexes  may  be  increased  on  the  alTected  side  and  there  may  be  conjiiLriiti' 
deviation  of  the  head  and  eyes.  Iiigidity  in  the  limbs  of  one  side  is  in 
favor  of  a  hemiplegic  lesion.  It  is  practically  impossible  in  a  uiiijoiiry  of 
these  cases  to  say  whether  the  lesion  is  due  to  haemorrhage,  embolism,  or 
thrombosis. 

(;>)   Large  ha'morrhage  into  the  venfri(des  or  into  the  pons  iiiiiy  pro- 
duce  sudden   loss  of  consciousness  with  complete  relaxation,  so  that  tln' 
condition  may  simulate  coma  from  ura^nia,  alc()holisin,  ojiium  pciisimiiiL', 
or  e)iilei)sy.     The  previous  history  and  the  mode  of  onset  may  give  valua- 
ble information.     In  epilepsy  convulsions  have  preceded   the  coma;  in 
alcoludism    there  is  a  history  of  constant  drinking,  while  in  oj)iuin  poison- 
ing thecoma  develops  more  gradiudly;  but  in  many  instances  tlie  (liffi- 
culty  is  pra(Mically  very  great,  and  on  more  than  one  occasion  F  have  saMi 
mortifying  post-mortem  disclosures  under  these  circunistanci's.     In  ven- 
tricular  luemorrhage   the  coma  is  sudden  and   develojjs  rapidly.     Tho 
hemiplegic  symptoms  may  be  transient,  (iui(d\ly  giving  ]>lace  to  iinnjilctoj 
relaxation.     Convulsions  occui*  in  many  cases,  and  may  be  the  very  syni] 
tom  to  lead  astray — as  in  a  case  of  ventricular  luemorrhage  which  (iccunvilj 
in  a  ])uer[)cral   ])atient,   in  whom,  naturally  enough,  the  condition  win 
thought  to  l»c  ura^nic.     IJigidity  is  often  })resvMit.     In   ha>morrhatre  into) 
the   pons  convulsions  are  fre(pient.     The  ])upils  may   be  stroiiLdy  kh;- 
tracted,  conjugate  deviation  may  occur,  and  the  tem])erafure  is  ii|it  torisoj 
rapidly.     The  contraction  of  the  pui)ils  in  ])oiitin(»  ha-niorrhagc  naturiillyj 
suggests  opium  |)oisoning.     The  dillVrence  in  temperature  in  the  twocim-j 
ditions  is  a  valnai)le  diagnostic  point. 

It  may  b^  impossible  at  first  to  give  a  definite  diagnosis.  In  aditiissionaj 
to  liospitals  or  in  emergency  cases  the  physician  should  be  particnlaiiyl 
careful  about  the  following  points:  '.  b.  xamination  of  the  head  for 
jury  or  fracture;  the  urine  should  betf.  ted  for  albumen  and  cxiiminidl 
for  sugar;  a  careful  examination  should  be  made  of  the  lind)s  wiili  nti-r-j 

ence  to  their  degree  of  relaxati(ui  or  the  presence  of  rigidity,  ami  tlit ii-i 

dition  of  the  refle.xes;  the  state  of  the  pupils  should  be  noted  ami  the 


AFFECTIONS  OF  THE   BLOOD- VESSP:LS. 


949 


f[cr  inoivasuif; 

k'ti'ly  li'st.  art; 
\o  wlu'thcr  the 

lit  riipitlly  liwes 
or,  |i!irtii'iiliivly 

il)S  (111  the  iiani- 
>{\ ;  wlicrvas.  mi 
of  toiiii^.  Till' 
ay  lie  coiijiiL'atf 
of  one  >iili'  i-^  ill 
in  a  inajiiriry  nf 
f^o,  cniliolisiii,  '»r 

lO  pons  may  [<]•<>■ 
ition,  so  that  tln'  ^ 
)l)iiun  jioisniiiiiir.  ;1 
t  may  give  vahia-  '| 
h1   the  roiua;  in 
ill  opiiuu  poison-  m 
iiinoes  the  ililli-  * 
lisiiin  T  liavf  simmi 
itaiici's.     Ill  \''ii- 
;  rapidly.     Th- 
ihice  to  compli'tc  | 
„.  tlie  very  syiiip- 1 
e  wliich  ncciirivil 
iU'  coiiditiiiu  \va< 
livinorrha^rc  in'" 
e  stroiiL'ly  I'l";- 
|turo  is  apt  tori.-o^ 
ivrliaiTf  naturally 
V  in  till'  two  ('"11-! 

Ill  ailiiii^^i""^! 

|l  Ir.  par!i''iilii''iy| 

tlu'  head  for  in-1 

L   and  cxaiiiim'ill 

llimlis  with  voter.] 

lity,  and  thciMm-l 
L  noted  aiul 


temji 


■rature  taken.     Tlie 


nio; 


't  serious  mistakes  are  made  in  the  case  of 


patients  wlio  are  drunk  at  the  time  of  the  attack,  a  combination  liy  no 
means  uneommoii  in  the  class  of  jiatients  admitted  to  liospital.  Under 
these  cireumstances  the  case  may  be  I(j(d\ed  uiioii  as  oiu'  of  alcoholic  conia. 
It  is  best  to  n^fjard  each  case  as  serious  and  to  bear  in  mind  that  this  is  a 
comlilion  in  which,  above  all  others,  mistakes  are  common. 

Prognosis. — From  cortical  Inemorrhat^e,  unless  very  extensive,  the 
rtvov(  ry  may  be  complete  without  a  trace  oi'  contracture.  'I'his  is  more 
(imnnun  when  the  lufnun-rhafje  follows  injury  than  when  it  results  from 
ilisease  of  the  arteries.  Infantile  meninj^eal  hamiorrha<j:e,  on  the  other 
iiiiid,  is  a  condition  whi(di  may  produce  idiocy  or  sjiastic  dii)leo;ia. 

Larire  ha'inorrhaires  into  the  corona  radiata  and    those  whi(di  riniture 


mto  the  ven 


tricle.- 


s  rapidly  prove 


fatal. 


The  hemiplegia  \vhi(di  follows  lesions  of  the  internal  capsule,  the  re- 
-ilt  of  rupture  of  the  artery  of  the  corjius  striatum,  is  usually  persistent 
iiiiil  followed  by  contracture.  When  the  posteri(»r  libres  arc  invtdved 
ikr(3  nmy  be  hemianavsthesia,  and  later  hemichorca  or  athetosis.  In  any 
{;i?o  of  eerebi'al  apojilexy  the  foUowinjf  sym[)toiiis  are  of  o:i'av(^  omen  :  jier- 
.•i>uii(e  or  deepening  of  the  coma  during  the  second  and  third  day;  lapid 
rijo  iu  temiierature  within  the  lirst  forty-eight  hours  after  the  initial  fall. 
lu  the  reactioii  which  takes  jilace  on  the  second  or  third  day,  the  tem- 
[ifratiire  usually  rises,  and  its  gradual  fall  on  the  third  or  fourth  day  with 
riturii  of  consciousni3.ss  is  a  favorable  indication.  The  rajiid  formation  of 
inil-sore.s,  particularly  the  malignant  deculiitus  of  Charcot,  is  a  fatal  indi- 
alion.  The  occurrence  of  albumen  and  siigai',  if  abundant,  iu  the  urine 
tan  unfavorable  symptom. 

When  consciousness  returns  and  the  jiatient  is  improving,  the  (pics- 
•inii  is  anxiously  asked  as  to  the  paralysis.  The  extent  of  this  cannot  lie 
literiiiined  for  some  weeks.  With  slight  lv.'.sions  it  may  jniss  oil"  entirely. 
If  persistent  at  the  end  of  a  month  some  grade  of  jiermanent  jialsy  is  cer- 
;;iiii  tu  remain,  and  gradually  the  late  rigidity  supervenes. 

E.MHOLisM  AM)  TiiHOMBOsis  {('cn'ht'al  S'lifton'nf/). 

(")  Embolism. — The  emlxdus  usually  enters  the  carotid,  rarely  the 
'Fiohral  artery.  In  the  great  Jiiajority  of  cases  it  comes  from  the  left 
>;at  and  is  either  a  vegetation  of  a  fresh  endocarditis  or,  moi\    com- 

Inwiily,  of  a  recurring  endocarditis,  or  from  the  segments  involved  in 
an  ulcerative  jirocess.      Less  often   the  endxjlus  is  a  p(M'tion  of  a  clot 

phieh  has  formed  in  the  auricular  appendix.  Portions  of  clot  from  an 
ffli'iirism,  thrombi  from  atheronui  of  the  aorta,  or  from   the  territory 

Irftht'  pulmonary  veins,  may  also  cause  blocking  of  the  branches  of  the 

JMele  of  Willis.  In  the  puerperal  condition  cerebral  embolism  is  not  in- 
frwiui'iit.     It  may  (jccur  in  women  with   heart-disease,  hut  in  other  in- 

I'taiiccs  the  heart  is  uninvolved,  and  the  condition  has  been  thought  to  be 


950 


DISEASES  OP  TITR  NERVOUS  SYSTEM. 


as«ofiiito(I  with  tlio  dovclopniont  of  heart-clots,  owinij  to  iiioroasod  coauu- 
hibility  of  the  bUxid.  A  majority  of  cases  of  embolism  occur  in  heaii- 
(lisease,  89  per  cent  (Saveliew).  Cases  are  rare  in  the  acute  endocanliii-; 
of  rheumatism,  chorea,  and  febrile  conditions.  It  is  much  more  comiiinn 
in  the  secondary  rccurrinir  endocarditis  which  atta(;ks  old  sclerotic  valves. 
Thf  embolus  mosl  frequently  passes  to  the  left  middle  cerebral  artery,  ;is 
it  enters  the  left  carotid  oftener  than  the  right  because  of  the  more  dii'cct 
course  of  the  blood  in  the  former.  The  posterior  cerebral  and  the  veitc- 
l>ra]  are  less  often  alTected.  A  large  j)lug  nuiy  lodge  at  the  bifurcation  nf 
the  basilar.     Embolism  of  the  cerebellar  vessels  is  rare. 

Embolism  occurs  more  frequently  in  women,  owing,  no  doubt,  to  tlic 
greater  frequency  of  mitral  stenosis.  Contrary  to  this  geiu-ral  statemciii. 
Xewton  Pitt's  statistics  of  79  cases  at  Guy's  Hospital  indicate,  howi'vcr. 
that  males  are  more  frequently  affi'cted  ;  for  in  this  series  there  weie  14 
males  and  ;}.■)  females.     Saveliew  gives  04  per  cent  in  women. 

(h)  Thrombosis. — Clotting  of  blood  in  the  cerebral  vessels  occurs  abdut 
an  embolus,  as  the  result  of  a  lesion  of  the  arterial  wall  (either  cndaiii - 
rilis  with  or  without  atheroma  or,  jiarticularly,  the  syj)hilitic  arteritis),  in 
aneurisms  both  coarse  and  miliary,  and  very  rarely  as  a  result  of  abiioi'ninl 
conditions  of  the  blood.  Thrombosis  occasionally  follows  ligation  of  tlif 
carotid  artery.  The  thrombosis  is  most  common  in  the  middle  cerebral 
and  in  the  basilar  arteries.  According  to  Kolisko,  softening  of  limited 
areas,  sufTicient  to  induce  hemiplegia,  may  be  caused  by  sudden  culhi|i>e 
of  certain  cerebral  arteries  from  cardiac  weakness. 

Aintlomical  Cha)i(jes. — Degeneration  and  softening  of  the  territory  suit- 
plied  by  the  vessels  is  the  ultimate  result.  Blocking  in  a  termimd  ai'tiiv 
may  be  followed  by  a  condition  resembling  infarct,  in  which  the  territoiv 
is  deeply  infiltrated  with  blood.  More  commonly  the  change  is  much  lo^ 
SI  liking,  and  the  atTected  region  nuiy  look  only  a  little  paler  than  noiiual 
or  sliglitly  softer,  (rradually  the  process  of  softening  jtroeeeds,  the  tissue 
is  in  iltrated  with  serum  and  is  moist,  the  nerve-tibres  degenerate  ami 
bccoMC  fattv.  The  neuroglia  is  swollen  and  oHlematous.  The  color  nf 
the  softened  area  depends  upon  the  amount  of  blood.  The  hamu)gle»liiii 
umlcrgoes  gradual  transformation,  and  the  early  red  color  may  give  plaee 
to  yellow.  Formerly  much  stress  was  lai<l  upon  the  difference  betweoii 
red,  yellow,  and  white  softening.  The  red  and  yellow  are  seen  chiellv 
on  the  cortex.  Sometimes  the  red  softening  is  particularly  marked  in 
cases  of  embolism  and  in  the  neighborhood  of  tumors.  The  gray  matter 
shows  many  punctiform  ha-morrhages — capillary  apo])lexy.  There  is  a 
variety  of  yellow  softening — the  plaques  jmaies — common  in  elderly 
persons,  which  occurs  in  the  gray  matter  of  the  convolutions.  The  s[mi;> 
are  from  one  to  two  centimetres  in  diameter,  sometimes  are  angular  in 
shape,  the  edges  cleanly  cut,  aiul  the  softened  area  is  represented  by  eitlur 
a  turbid,  yellow  material,  or  iu  some  instances  there  is  a  space  crossed  by 
fine  trabecuke,  iu  the  meshes  of  which  there  is  fluid.     White  soften  ing 


M. 

0  inoroasod  c'Oii;;ii- 
ism  occur  in  liciirt- 

aciito  en(looanli'i> 
inch  iiioro  coiniihiii 
old  sclerotic  valvis. 
'  cerebral  artery,  as 

of  the  more  direct 
'bral  iind  the  vcrtc- 
t  the  bifurcation  (jf 

ig,  no  doubt,  to  the 
;  sronoral  stateincnt. 
,1  indicate,  howrvcr. 
series  there  weie  44 
vomen. 

vess^els  occurs  abmit 
•all  (cither  ciuhiitt'- 
philitic  arteritisK  in 

1  result  of  abnormal 
Hows  lifjation  i>f  thr 

the  middle  ccrt'bial 
softening  of  liniitcl 
1  by  sudden  colla[i>«' 

of  the  territory  suu- 
m  a  terminal  artLi'v 
which  the  territory 
change  is  much  ]('>« 
e  paler  than  normal 
proceeds,  the  ti.-suc 
res  degenerate  ami 
tons.     The  color  "( 
The  ha^mogloliiii 
;olor  may  give  plan- 
difference  between 
i)\v  are  seen  chiclly 
Itiindarly  marked  in 
IS.     The  gray  matter 
oplexy.     There  is  :i 
Icommou   in   eldevly 
dutions.     The  si»)ts 
mes  are  angular  in 
lepresentcd  by  either 
|is  a  space  crossed  by 
White  softening 


AFFECTIONS   OF  THE  BLOOD-VESSE[,S. 


051 


or>curs  most  frequently  in  the  white  matter,  and  is  seen  best  about"  tumors 
and  abscesses,  rnllaminatory  cliangcs  are  common  in  and  about  the  soft- 
ened areas.  When  the  embolus  is  derived  from  an  infected  focus,  as  in 
ulcerative  endocarditis,  suppuration  may  follow,  'llu;  liual  changes  vary 
very  mutdi.  The  degenerated  and  dead  tissue  elenuMits  arc  gradually  but, 
slowly  removed,  and  if  the  region  is  small  may  be  replaced  !)y  growth  of 
iduuective  tissue  and  tlu;  formation  of  a  scar.  If  large,  the  resorption 
results  in  tlie  formation  of  a  cyst.  It  is  sur])rising  for  how  long  an  area 
of  softening  may  jiersist  without  much  eiiange. 

Tiie  jiosition  and  extent  of  the  softening  depend  upon  the  obstructed 
artery.  An  embolus  which  blocks  the  middle  cerebral  at  its  ori'nn  in- 
volves  both  the  arteries  in  the  anterior  perforateil  space  and  the  cortical 
branches,  and  in  suidi  a  case  there  is  softiuiing  in  the  neigliborlmod  of  the 
ciirpus  striatum,  as  well  as  in  part  of  the  region  supplied  l)y  the  corti- 
cal vessels.  The  iTcedom  of  anastomosis  between  these  branches  varies 
a  good  deal.  Thus,  there  are  instances  of  end)olism  of  tlu'  middle  cere- 
bral artery  in  Avhich  the  softening  has  only  involved  the  territory  of  tlie 
central  branches,  in  ivhicli  case  blood  bus  readieil  the  cortex  through  the 
anterior  ami  jiosterior  cerebrals.  When  the  middle  <  erel)i;d  i^  Idocked  (as 
i>  ])erhaps  oftenest  the  case)  beyond  the  ]i(,int  of  oiigin  (  f  the  central 
arteries,  one  or  (jther  of  its  branches  is  usually  uio.-l  invol-.ed.  'i'lie  e!;!l)o- 
lus  may  lodge  in  the  vessel  passing  to  the  tliird  froiiia!  convolution,  oi'  in 
the  artery  of  the  ascending  frontal  or  asce'nding  ])a!ietal ;  or  it  may  lodge 
in  the  bramdi  pas.sing  to  the  supramarginal  and  angular  gyri,  or  it  may 
enter  the  lowest  bramdi  which  is  distribiitt'd  to  the  npiiier  convolutions  of 
the  temporo-sphenoidal  lobe.  These  arc  pr;ictically  terminal  arteries,  and 
instances  frecpiently  occur  of  softening  lindted  t  i  a  jiart,  at  any  rate,  of 
the  territory  supi)lied  by  them.  Some  of  the  mot  acciii'ate  focalizing 
lesions  art'  in  this  way  ])rodueed. 

Symptoms. — Jvxtcnsive  throndiolic  softening  may  exist  without  any 
sym[)toms.  It  is  not  uiu'oinnion  in  the  post-mortem  examiinition  of  the 
bodies  of  elderly  persons  to  find  the  pl/iqiws  JaiD/rs  ,<cattci'cd  over  the 
convolutions.  So,  too,  softening  may  take  place  in  the  "silent"  regions, 
a-  they  are  termed,  '\Tithout  exi'iting  any  symptoms.  When  the  central  or 
eortical  branches  of  the  middle  cerebral  arteries  arc  inv(»l\cd  the  symp- 
toms are  similar  to  those  of  lia'm(U'rliagi'.  Permanent  or  transient  lienu- 
jilegia  results.  AVhen  the  central  artei'ies  are  involved  the  softening  in 
the  internal  capsule  is  commoidy  followed  liy  })crnuiiu'nt  hemiplegia. 
There  are  certain  peculiarities  associated  with  embolism  and  with  llin^m- 
bosis  respectively. 

In  embolism  the  patient  is  usually  the  subject  of  heart-trouble,  or  there 
exist  some  of  the  comlitions  already  nu'utioned.  The  onset  is  sudden, 
without  premonitory  sym])toms.  Wlu'U  the  endjolism  blocks  the  left 
middle  cerebral  artery  the  hemiplegia  is  usually  aj^sociated  with  a})hasia. 
In  thrombosis,  on  the  other  hand,  the  onset  is  more  gradual;  the  patient 


k 


I'j: 


m 


952 


1)TS?:.\SKS   OK   THE   XKRVOUS  SYSTEM. 


has  prcvinusly  complainc.l  of  hotuliiche,  vertigo,  tingling  in  th"  fmaors' 
the  spoof'h  may  have  been  oinl)arni.ssc(l  for  somo  «hi_vs ;  tlic  paiicnt  L^^ 
had  loss  of  rneinorv  nr  is  inc()li('rci\t,  or  paralysis  begins  at  (uii'  |i;irr.  ;i< 
the  hand,  and  extends  slowly,  and  tlie  hemiplegia  maybe  incdinplctt.  nr 
variable.  Abrnjit  loss  of  eonseionsness  is  nuieh  less  common,  ninl  wlioi  1"^ 
the  lesion  is  simill  eonseionsness  is  retained.  Thns,  in  tIirombo>is  duo  \„  fi 
syphilitic  disease,  the  hemiplegia  may  eome  on  gradnally  without  tlic 
.slightest  disturbance  of  consciousness. 

The  hemiplegia  following  thrombosis  or  embolism  has  jiractii'iillv  tin' 
characteristics,  both  jirimary  and  secoiulary,  described  under  hn'inorrliairc 

The   followi]\g   maybe   the  effects  of  blocking  the  ditTerciit  vosssoU: 
{(i)    Vriirhritl. — The  left  branch  is  more  fre(|nently  plugged.     Tlic  otTect^ ' 
lire  involvenuMit  of  the  nuclei  in   the  medidla  and  symptoms  of  jiinitc 
bulbar  ]taralysis.     Tt  rarely  occurs  alone  ;  more  commonly  Avith 

{b)  Blocking  of  the  basiJirr  arfrri/.  When  this  is  entirely  occluilid, 
there  may  be  bilateral  paralysis  from  involvenu'nt  of  both  motor  patli';. 
Bulljar  symptoms  may  be  ])resent;  rigidity  or  spasm  may  occur.  The 
temperature  may  rise  rapidly.  The  symj)t<>ms,  in  fact,  are  those  of  api 
plexy  of  the  ])ons. 

(r)   The  ;^o,v/<  ;•/(■;;•  r^7V'/;y7r/ sup])lies  the  occipital  lobe  on  its  inner  fmv' 
and  the  greater  part  of  tlu^  tempoi'o-sphenoidal  lobe.     Localized  areas  (f  j 
softening  nuiy  exist  without  symptoms.     J51ocking  of  the  branch  ],assiiii: 
to  the  cuneus  may  be  followed  by  hemianf)])ia.     Ilemiamestiiesia  iiiaviv-i 
suit  from  involvement  of  the  posterior  part  of  the  intenud  caiisiilc 

('/)    hitrntifl  ('(trofid. — The  symptoms  are  variable.    As  is  well  kiimvi 
the  vessel   is  in  a  majority  of  cases  ligated  Mithout  risk.      In  other  in 
stances  transient  hemiplegia  follows  ;  in  othersagain  the  heini|)legiM  i-^  per-j 
manent.     These  variations  depend  on  the  anastomoses  in  tlu'  circle  of  Wil 
lis.     If  tlies(>  are  larger  and  free,  no  paralysis  follows,  but  in  cases  in  wlii(li| 
the  posterior  communicating  and   tiu>  anterior  communicating  vessels ; 
small  or  ai)sent,  the  paralysis  Tuay  persist.     In   No.  7  of  my  Mlwyu  seritsi 
of  cases  of  infantile  hemij)legia,  the  woman,  aged  twenty-four,  when  six 
years  old,  had  the  right  carotid  ligated  for  abscess  following  scarlet  tVwr. 
with  the  result  of  ])ernuinent  hejniplegia.     lilocking  of  the  internal  iii-j 
rotid  within  the  skull  by  thrombosis  or  embolism  is  followed  bv  heniiiiloLria, 
conui,  and  usually  death.      The   clot  is  rarely  (confined   to  the  eamtjilj 
itself,  but  spreads  into  its  branches  and  may  involve    the   ophtlialinicj 
artery. 

{(')  MidiUe  Cerebral. — This  is  the  vessel  most  commoidy  involved,  ai 
as  already  nu'utioned,  if  ])lugged  before  the  central  arteries  are  given  otfj 
pernument  hemiplegia  usually  follows  from  softening  of  the  interiuil  r;ip-j 
sule.  Blocking  of  the  branches  beyond  this  point  may  be  followeil  l>vj 
hemiplegia,  which  is  more  likely  to  be  transient,  involves  chiefly  the  ami 
and  face,  and  if  on  the  left  side  is  associated  with  aphasia.     The  indiviiiiiiilj 


AFFKC"J"rONS  OP  THE   BLOOD-VESSELS. 


053 


liranclioa  passinsf  to  tho  tliinl  frontal,  ascciKlini;-  jtarictal,  to  tlio  fJiipraiiiar- 
.'iiiiil  iiikI  aiiiriilar  fryri,  or  to  the  ti'iiiimral  <:vri  may  lie  pluj^-^'cd. 

{f)  .iti/rrid)'  rr;v7(/v'/.— \i>  syiii|il'ims  may  I'ollitw,  and  cvcTi  wlicii  tlio 
l.raiirlirs  wliicli  supply  \\\v  paracciital  Idluilc  and  tlic  top  ol'  tlic  ascending 
miivdlutions  arc  pluj.'ji'cd  tlif  1iran(du's  from  the  middle  eei'clu'al  are  usu- 
allviililf  to  (.'ITeet  a  collateral  circulation  in  these  parts.  Ilelietude  and 
/liijiu'js  of  intelloot  may  occur  with  obstruction  of  the  vessel. 

Tliere   is   unquestionahly   irreater    freedom    of  conimuiiicatioii   in    tlie 
Hi'tical  braiu'he.s  of  the  dilTerent   arteries  than   is  usuall_\    admitted,  al- 
iliniijrli  it  is  not  ])ossiI)le,   foi'  exam|ile,  to  inject   the   postei'ior  cerebral 
[hroULdi   the  middle  cereliral.  or  the  middle  cerebral  IVom  t' c  aiit.ei'ior ; 
Mit  tile  abseiu'o  of  s(d'teiMni;-  in  some  instances  in  \vlii(di  smaller  lii'an''hes 
Uro  liloi'ked   shows  how  completely  nniy  be  the  compensation,     'i'lie  dila- 
tation of  tho  collateral  braiudies  may  take  place  very  rapidly;  thus  a  pa- 
lifiit  with  (diroinc  nephritis  died  about  twenty-four  hours  after  the  hemi- 
I  jik'^'io  attack.  There  were  recent  ve<.U'tations  on  the  mitral  and  anend)oln3 
tho  right  middle  cerebral   artei'V  just  l)eyond    the  iirst   two  branches 
I  (temporal).       'J'he  central    ])ortion   of  the  lienus[)here   was    swollen  and 
ilfiiiatous.       The  right  anterior  cerebral  was  gr(>atly    dilated,  and   by 
I HK-asurement  its  diameter  was  found  to  be  nearly  three  times  that  of  the 
l.'fr. 
Treatment  of  Cerebral  Haemorrhage. —The  patient  should  be 

[ilacod  with  the  head  high,  ami  measures  immediately  taken  to  reduce  the 

hrlorial  pressure.  Of  these  the  most  rajiid  anil  satisfactory  is  venesecti<)n, 
which  should  be  practiced  whenevi'r  the  arterial  tension  is  much  in- 
creased. With  a  small  pulse  of  low  tension  and  signs  of  cardiac  weak- 
ness it  is  contra-indicated.  The  chief  dilliculty  is  in  determining  whether 
till' apoplexv  is  really  due  to  ha}morrhage,  or  to  thrombosis  or  end)olism, 

l-iiiir  ill  the  latter  group  of  cases  lileeding  ju-obably  does  harm.  As  a  rule, 
however,  in  middle-aged  men  with  arterio-sederosis,  an  accentuated  aiu'tic 

iMroiul  sound,  and  hypertro})hy  id'  the  lid't  veiitriide,  bleeding  is  indicated, 
tnrsley  and   Spencer  have  recently,  on    experimental    grounds,  recom- 

|nieiuk'd  the  practice,  formerly  employed  empirically,  of  com[)ression  of 
tho  carotid,  particularly  in  the  ingravescent    form  ;  or  even,  in  suitable 

I ("i>os,  ])assing  a  ligature  round  the  vesstd.  An  ice-bag  may  be  |ilaccd  (ui 
tiio  head  and  hot  bottles  to  the  feet.     The  bowels  should  be  freely  opened, 

I  fitlior  by  calomel,  or  croton  oil  placed  on  the  tongue,  ('ounter-irritatioii 
t'ltho  neck  or  to  the  feet  is  not  ne(;essary.     When  dyspniea,  stertor,  and 

pigns  of  mechanical  obstruction  are  present,  the  patient  should  be  turned 
the  side,  as  recommended  by  Bowles.      This  procedure  also  lessens 
?  lialiility  to  congestion  of  the  lungs. 
Special  care  should  be  taken  to  avoid  bed-sores  ;  and  if  bottles  arc  used 

I'rt  the  feet,  they  shouhl  not  be  too  liot,  since  blisters  may  be  readily 
(ausi'd  l)y  much  lower  temperature  than  in  health.  In  the  fever  of  reac- 
li'Jii,  aconite  may  be  indicated,  but  should  be  cautiously  used.     Stimu- 


U54 


DISEASES  OP  THE  NEIIVOUS  SVSTKM. 


i 


-'      1 


f   , 


SSR'- 


\ti' 


hints  arc  not  necessary,  unless  tlio  pulse  beeonics  fct  lilc  and  siun- of  ,(,1.1 
lapse  su|M'rv('n('. 

Tile  treiittiieiit  of  siif/oiiiif/  from  throiiihosis  or  enilxilisiu  i>  vcpv  un. 
satisfatitory.  Venesection  is  not  iiidicuted,  us  it  lowers  tiic  tciiMdii  uikIJ 
ratlier  promotes  clotllu}^.  If,  as  is  oftm  tlie  case,  the  heart's  ai'ljdii  id 
feel)le  and  irrcffular,  stimulants  and  small  doses  of  di;,dtalis  may  licjriviii! 
with,  if  necessary,  etiier  or  ammonia.  The  IjoucIs  should  l)e  Iu|||J,  ii|i,ii,j 
but  it  is  not  well  to  pur;;e  actively,  as  in  li;cmorrha;:;e. 

In  the  thrombosis  which  follows  syplulitir  disease  of  the  artcriis.  mhI 
which  is  met  with  most  frcijucntly  in  men  between  twenty  and  rurtviini 
whom  the  liemi[)l((,i;ia  often  sets  in  without  loss  cd"  consei(»iisni'ss),  tliel 
iodide  (tf  ])()tassium  should  be  freely  used,  f^ivinjj  from  twenty  to  tliir;vj 
grains  three  times  a  day,  or,  if  necessary,  larj;er  doses.  If  the  syphilis  Ima 
been  recent,  mercurials  are  also  indicated.  Practically  tliese  aic  the  nnlvj 
ca.ses  of  henn[)lej;ia  in  which  we  see  satisfactory  results  from  treat imnt. 

Ojierative  treatment  has  been  su^fj;esti'd,  and  when  the  dia,i:u(i>is  nfl 
subdural  ha'morrlia,i^e  can  be  made  it  is  justiliable.  An  attempt  Id  iviulij 
a  central  luemorrhage  in  the  neiifhborhood  id'  the  internal  cajisule  WMiikli 
oidy  increase  the  damage  to  the  l)rain-sul)stance.  \'cry  little  can  IkmImh,'] 
for  the  henuplegia  whicdi  remains.  The  damage  is  too  often  irrepuralii 
and  permaiu'ut,  and  it  is  very  im[)rol)able  that  iodidi-  of  putassiuni,  nriuijj 
other  renu'dy,  hastens  in  the  slightest  degree  Mature's  dealing  with  tlif 
bIo(jd-clot. 

The  paralyzed  limbs  nniy  be  gently  rubbed  onci;  or  twice  a  tiny,  mij 
tliis  should  be  systematically  carried  out,  in  order  to  maintain  the  laitri'^ 
tion  of  the  muscles  and  to  prevent,  if  possible,  contractures.  Aftti' ina 
lapse  of  a  fortiught  the  muscles  may  be  stimulated  by  the  faradic  ninviitj 
but  when  contractures  develop,  electricity  is  useless,  and  the  ])assivi'  iiiuv^ 
nieiits  and  frictions  are  alone  indicated. 

In  a  case  of  c()ini)lete  henn|)legia,  the  friends  should  at  the  oiitsi'l 
frankly  told   that  the  chances  of  full   recovery  are   slight.       i'liwir  \i 
usiudly  restored   in  the  leg  suflleient  to  enable  the  })atient  to  get  iilmutj 
but  in  the  majority  of  instances  the  finer  movements  of  the  liaml  aii'  prr^ 
nuini'Utly  lost.     The  general  health   should  be  looked  after,  the  lidWili 
regulated,  and   the  secretions  of  the  skin  and  kidneys  kept  activo.   Id 
permanent  hemiplegia  in  persons  above  the  middle  period  of  life,  iiunv 
less  mental  weakness  is  apt  to  follow  the  attack,  and  the  patient  may  lie 
come  irritable  and  emotional. 

And,  lastly,  when  hemiplegia  has  persisted  for  nion^  tlian  three  inoiitlij 
and  contractures  have  devel()})ed,  it  is  the  duty  of  the  physician  to  expliii 
to  the  patient,  or  to  his  friends,  that  the  condition  is  past  relief,  that  nitili 
cines  and  electricity  will  do  no  good,  and  that  there  is  no  possible  hup 
of  cure. 


AFFKCTIONS  OF  THE   nLOOD-VHSSHLS. 


\)oo 


iinil  siuiis  (it  iMil.! 


AxiaiiisM  01'  Tin:  Ckkici'.k.vi.  Aini:iui;s. 


Miliixrv  iuu'urisms  aiv  not  iiicliidfd,  liiit  I'cft'ivnci'  is  iiiado  only  to 
aiu'iiri.-iii  of  tlu' larirt'i' l)i'toi('li('s.  'I'lic  coiiilition  isiuit  iincoiiiiiioii.  'I'liciv 
«>n'  twelve  instiuices  in  my  lirst  eijrlit  liiuidred  autopsies  in  Montreal.* 
This  is  a  eonsiderahly  larfrer  ]iro|>ortion  than  in  Newton  i'ilt's  colleelion 
fidiii  (lily's  Hospital,  nineteen  times  in  nine  thousand  inspeetions. 

Etiology.  —  Males  are  more  frerpiently  alTeeted  than  fiMiiales.  Of 
nivtuelve  eases  seven  were  males.  'I'he  disease  is  most  eomiiU)n  at  the 
niiiMle  pi'i'iod  of  life.  One  nf  my  eases  was  a  lad  (d' six.  I'itt  de.-i'rilies 
Miu' ill  tlie  same  a.ijo.  The  chief  causes  are  (r?)  endarteritis,  eithiT  simple 
(ir syphilitic,  which  U'ads  to  weakness  of  the  wall  and  dilatation;  and  (/>) 
iml)iilism.  As  ])ointed  out  by  Cluindi,  thesi-  aneurisms  are  (d'teii  found 
with  endoourditis.  Pitt,  in  hirf  recent  study  of  the  subject,  ooiudndes  tluit 
it  \i  exceptional  to  find  cerebral  a?icuri>m  unassociatcd  with  funj^ating 
Hidnearditi.s.  The  cmbolu.s  disappears,  and  dilatation  bdlows  the  second- 
arv  iullammatory  (duin.ues  in  the  coats  of  the  vessel. 

Morbid  Anatomy. — 'i'iu.'  nuddle  ceri'hral  hranidies  arc  most   fiv- 

lf|iioiitlv  involved.     In  my  twelve  eases  the  distribution  on  tiu'  arteries  was 

;i<  follows:  Internal  carotid,    I;  nuddle  cerebral,  o ;  basilar,  ;i ;  anterior 

iiinuiumicaf iii'jj,  'b     With  the  exception  of  one  case  they  were  saccular 

;iiiil  ('(iiumunicated  with  the  lumen  of  the  vessel  by  an  orilice  smaller  than 

;iic  circumference  of  the  sac.     In  the  l")-4  eases  which  make  up  the  statis- 

Itiesof  Lebort,  Durand,  and   Bartholow  the  middle  cereliral  was  involvi'd 

in  It,  the  basilar  in  -41,  internal  carotid  in  '-l'.],  anterior  cerebral  in  14,  pos- 

|tirior  conununicatiuu:  in  S,  anterior  comuuinicatinj;  in  8,  verti'bral  in  7, 

[iii^turior  cerel)ral  in  <!,  inferior  cerebellar  in  ',]  ((lowers).     The  size  of  the 

laiH'urisin  varies  from  that  of  a  pea  to  that  of  a  walnut.     'I'he  ha-morrhago 

Iniiiv  l)e  entirely  meningeal  with  very  slight  laeonition  of  the  brain  sul>- 

iKaiK'c,  but  the  bleeding  may  bo,  as  Coats  has  shown,  entirely  within  the 

h'.ili.-raiice. 

Symptoms. — The  aneurism  may  attain  considerable  size  and  cause 
I nfi symptoms.  In  a  majority  of  the  cases  the  first  intimation  is  the  rupt- 
iiivaiKi  the  fatal  a])op!exy.  Distinct  symptoms  tii*e  most  frequently  caused 
by  aneurism  of  the  internal  carotid,  which  nuiy  compress  the  optic  nerve 

the  commi.-isure,  causing  neuritis  or  paralysis  of  the  third   nerve.     A 

Imunnur  may  be  audible  on  auscultation  of  the  skull.     Aneurism  in  this 

•ituatiou  nuiy  give  rise  to  irritative  and  jiressuro  symptoms  at  the  base  of 

'ill'  hiain  or  to  hemianopsia.     In  the  remarkable  ease  reporteil  by  Weir 

piitrlu'll  and  Dercum  an  aneurism  compressed  the  ehiasma  and  proiluced 

jtilatoral  tem})oral  hemianopsia. 

Aneurism  of  the  vertebral  or  of  the  basilar  may  involve  the  nerves  from 

*  Cunada  Medical  and  Surgical  Journal,  vol.  xiv. 


! 


^jjt. 


ii\ 


950 


DISEASES  OF   TflR   NM-IRVOUS  SYSTKM. 


the  fifth  to  tlio  twelfth.     A  liirgo  siir  at,  tln'  toriniiiiitioii  nf  fho  busihir  inav 
coiiipi'css  the  thh'd  nerves  or  the  enini. 

Tlic  (liiij^iiosis  is,  iis  ii  rule,  impossible,  'i'lie  liir;fer  sues  produce  llio 
syniptoiiis  of  tumor,  mid  their  rupture  is  iisuiilly  futid. 

EXD.VKTKUITIS. 

Ill  no  ^.n'oup  of  vessels  do  we  more  fre(|iieiitly  see  chrouie  de;j;eiiei'ii. 
tive  (•hiiii;.;es  thuti  in  those  of  the  eircde  of  Willis.  The  eouditioii  nr- 
eiirs  ll^ : 

(d)  .Irfi'n'ihscJi'riisis,  produeiiifj  loeiilized  or  dilTused  thiekenini^  of  the 
intima  with  tiie  formiitiou  of  iitlieromatous  piitches  or  ureas  of  ealeitira- 
tion.  In  the  later  sta^jfes,  as  seen  in  elderly  people,  the  arteries  of  the 
eirele  of  Willis  may  he  dilateil,  stilT,  or  almost  universally  calcified. 

{/))  SjipJiiUtic  /uitl(i)irri/is. — As  already  mentioned  under  the  seetinii 
of  syphilis,  gummatous  endarteritis  is  specially  prone  to  attack  the  cere- 
bral vessels.  It  has  in  itself  no  specifii!  characti-rs — that  is  to  say,  it  is 
impossible  in  given  sectitms  to  pick  out  an  endarteritis  syphilitica  from 
an  ordinary  endarteritis  oliliterans.  On  the  other  hand,  as  already  statcil. 
the  nodular  jieriarteritis  is  never  seen  except  in  syphilis. 

TlIUOMIJOSIS   OF    Tllli    CkUKUUAL    .SlN'LSES    AND    VlUXS. 

The  condition  may  be  primary  or  secondary. 

Primary  thrombosis  of  tlie  sinuses  and  veins  is  rare.  It  occurs  {it} 
in  children,  particularly  during  the  first  six  months  of  life,  usually  in  con- 
nection with  diarrhd'a.  •  It  has,  in  my  exjierieuce,  ])een  a  rare  conditidii. 
I  liave  never  seen  an  example  of  si>ontaiH;;()Us  thrombosis  of  the  sinuses  in 
u  child,  aiul  only  two  instances,  both  in  connection  with  meningitis,  in 
which  the  cortical  veins  contained  clots,  (lowers  believes  that  it  is  of  fiv- 
quent  oc(;iirrence,  and  that  thrombosis  of  the  veins  is  not  an  uiicomiiioii 
cause  of  infantile  hemiplegia. 

{/i)  In  connection  with  iddorosis  and  anannia.  Brayton  Hall  has  recently 
called  attention  to  this  interesting  association,  and  has  reporteil  one  ca.-e 
and  collected  ten  or  eleven  others  from  the  literature.  All  were  in  girls 
with  aiuumia  or  clilorosis. 

(r)  In  the  terminal  stages  of  cancer,  })hthisis,  and  other  chronic  dis- 
eases thrombosis  niav  gradually  occur  in  the  sinuses  and  cortical  veins. 
To  the  coagulum  de\elo2)ing  in  these  conditions  the  term  marantic  throm- 
bus is  applied. 

Secondary  Thrombosis  is  much  more  frequent  and  follows  extension 
of  iiillammati<m  from  contiguous  parts  to  the  siiuis  wall.  The  com- 
mon causes  are  disease  of  the  internal  ear,  fracture,  com})ression  of  the 
sinuses  by  tumor,  or  suppurative  disease  outside  the  skull,  particularly 
erysipelas.     In  these  cases  the  lateral  sinus  is  most  frequently  in/olvcd. 


'.M. 


AFFECTIONS  OK  TIIH    lU-OOD-VKSSKI.S. 


or.  7 


n  of  the  biisilivv  iiiiiv 


I't'  chronic  (lc<j;(MHi'ii> 
'I'liu  condition  ("•• 

!C(1  tlnckcninij  of  the 
or  areas  of  ciilcilicii- 
',  the  arteries  of  Ihc 
sallv  cah'iticd. 
11(1  unth'i-  the  section 
,e  to  attack  the  ccrt- 
-that  is  to  say,  it  is 
ritis  syphiUtica  from 
nd,  as  ah-eady  statcil. 
ilis. 

AM)  Vkin's. 

rare.     It  occurs  (»/) 

f  life,  usually  in  cm- 

It'cn  a  rare  condition. 

jiosis  of  the  sinuses  in 

\\  witii  meningitis,  in 

ieves  that  it  is  of  fiv- 

s  not  an  uncunuuuii 

:ton  Ball  has  recently 
lias  reported  one  cusi^' 
Ic.     All  were  in  girU 

Id  other  chronic  dis- 
|s  and  cortical  veins. 
n'n\  marantic  thrum- 
lid  follows  extension 
lis  wall.     The  com- 
comi)ression  of  the 
skull,  particulaily 
Ifrequently  iuvolvrJ. 


Of  57  fatal  cases  in  which  ear-disease  caused  death  witii  cerehrai  Icsioiis, 
tlnre  were  •^•.' in  wliich  throiiiljosis  existed  in  tlic  lateral  sinuses  (I'itt). 
Tlic  tiironilni.s  may  he  small,  or  may  till  tlio  eiilire  sinus  and  extend  into 
til''  internal  jugular  vein.  In  nKnc  than  one  half  of  these  in>tances  the 
tliiniiilms  was  suppurating.  'I'lie  disease  spreads  dii'ectly  from  llic  nccro- 
>i~iiii  the  posterior  wall  of  the  tympanum.  It  is  not  M>comiiion  in  disi'ase 
of  the  mastoid  cells. 

Symptoms.  —  Primary  throinlio-is  of  the  loiinrliudinal  .-inus  may 
(Mviir  without  exciting  symptoms  and  i-  found  aoridcniallv  at  the  pnst- 
iiiorter.  There  may  lie  mciital  duliu'ss  with  headache.  Convulsioiis  and 
vouiiting  may  occur.  In  otlici-  instances  there  is  nothing  distimtivc.  In 
a  iKiticnt  who  dic(l  under  my  care,  at  the  I'hiladelphia  Hospital,  of  phlhi>is, 
there  was  a  gradual  torpor,  (U'epeniiig  to  cuiiia,  without  loiiviilsioiis,  local- 
izing symptoms,  or  optic  neuritis,  '{'he  condition  Mas  thought  to  he 
line  to  a  terminal  meningitis,  in  the  chlorosis  cases  the  head  s\mp- 
toms  hiivo,  as  a  rule,  heeii  marked.  Hall's  patient  was  dull  and  stupid, 
liad  vomiting,  dilatation  of  the  pupils,  and  doulile  clmki'd  di>ks.  Slight 
paresis  of  the  left  side  occurred.  An  interesting  featui'c  in  her  case  was 
the  development  of  swelling  of  the  left  leg.  In  the  cases  rcportt'd  i)v  ,\n- 
(Irew,  Churcdi,  Tnckwell,  Isanihard  Owen,  and  Wilks  the  patients  had 
headache,  vomiting,  and  delirium.  Paralysis  was  not  present.  In  |)oug- 
l;i>  Powell's  case,  with  similar  symi)tonis,  thci'o  was  loss  of  power  on  the 
left  side.  Hristowe  reports  a  case  of  great  interest  in  an  an;eniic  giii  uf 
nineteen,  who  had  convulsions,  drowsiness,  and  vomiting.  Tenderness 
iiiul  swelling  developed  in  the  position  of  the  right  internal  jugular  vein, 
iUid  a  few  days  later  on  the  (ippositi>  side.  The  iliagiiosis  was  reiuh-rcil 
ili'liuitc  by  the  occurrence  of  phlehitis  in  the  veins  of  the  right  leg.  'The 
]iMtient  recovered. 

The  onset  of  such  .symjitoms  as  have  heen  mentioned  in  an  amvmic 
or  chlorotic  girl  should  lead  to  the  suspicion  of  cerehi'al  thromhosis.  In 
infants  the  diagnosis  can  rarely  he  made.  Involvement  of  the  cavernous 
sinus  may  cause  (cdema  ahnut  the  eyelids  or  p!'(»minence  uf  the  eyes. 

In  the  srf(iii(/(tri/  flinnnhi  the  symptoms  are  commonly  those  of  septi- 
I'lvmia.  For  instance,  in  over  seventy  per  cent  of  Pitt's  cases  the  mode  of 
death  was  hy  jmlmonary  ])va'mia.  This  author  draws  the  following  im- 
portant conclusions:  (1)  The  disease  spreads  oftener  frriin  the  posterior 
wall  of  the  middle  ear  than  from  the  mastoiil  cells.  (:.')  The  otorrliu'u 
i>  generally  of  some  standing,  hut  not  always.  (;i)  The  onset  is  sudden, 
the  chief  symptoms  being  jiyrexia,  rigors,  pains  in  the  occipital  region  and 
in  the  neck,  associated  with  ii  sei»tica'ini(^  condition.  (4)  Well-marked 
o[itie  neuritis  may  be  present.  (.">)  The  aiipearance  of  acute  local  pulmo- 
nary mischief  or  of  distant  suppuration  is  almost  conclusive  of  thrombosis. 
(•1)  The  average  duration  is  about  three  weeks,  and  death  is  generally 
from  pulmonary  jiva'inia.  The  chief  ])oints  in  the  diagnosis  may  bo  gatli- 
ered  from  these  statements. 


w^*^ 


9:.8 


DISKASES  OF  TliK   XEUVOrs  SYSTF^M. 


Pitt  rt'conls  mi  intci'CNtijij;  ciisf  of  rccdvcry  in  a  hoy  of  ten,  who  Ii.kj 
otnrrhii'ii  f(»r  yciirs  mid  w.m  iidiiiittnl  wiili  fever,  earache,  tciuh'rin'ss,  mul 
(I'lh'iiia.  A  vvcfk  liitrr  he  Inid  a  ri;ror,  mid  ojitic  neuritis  devi'lopetl  on  the 
rJL'iit,  side.  The  mastoid  was  explored  i;ii.s(u;cessfiiily.  'I'lie  fever  ami 
eiiills  persisting,  two  (hiys  later  tlie  lateral  sinns  was  explori'il.  A  mass  <>( 
foul  elot.  was  removed  and  the  jugular  vein  was  tied,  after  which  the  Imy 
made  a  satisfactory  recovery. 

In  the  recent  work  of  >racewen.  On  Pyn<renic  Infective  Diseases  of 
the  liraiii  and  Spinal  Cord,  will  l)e  found  the  most  exhaustive  preseiita- 
tiun  of  the  suhject  of  sinuis  ihrumbusiji  and  its  treatjnent. 


V.    HEMIPLEGIA    AND    DIPLEGIA    IN    CHILDREN. 

It  is  as  yet  lunvl  to  say,  without  fuller  knowledjre  of  th(»  etiolofjy  of 
these  common  conditions,  where  they  should  he  classilied.  In  a  majorifv 
of  the  cases,  whatever  the  nature  of  the  primary  patholoffical  (diange,  tin- 
final  state  is  one  of  a  chi'onie  encephalitis,  (d'teii  with  <rreat  atrophy  of  the 
convolutions  <jr  the  formation  of  large  cyst-like  Bpaoes — porence])halus. 

1.  IIkmii'Lkoia. 

Etiology. — Of  13.">  cases,  comprising  those  from  the  Infirmary  r<ir 
Diseases  of  the  Nervous  System,  IMiiladeliiliia,  from  the  KIwyu  Institution 
for  Feehle-niinde(|  Children,  under  Kerlin,and  from  my  clinic  at  the.Ioliii- 
Hopkins  nos|iital,  HO  were  in  hoys  and  7.")  in  irirls.  Kight  heniiple'.;ia 
occnrird  in  ^I),  left  in  oO.  In  1.")  cases  the  coiidiiiou  was  said  to  he  enn- 
genital. 

In  a  groat  majority  the  disease  sets  in  during  the  first  or  secojul  year; 
thus  of  the  total  niimher  of  cases,  !)5  were  under  two.  Cases  above  tiir 
fifth  year  are  rare,  only  10  in  my  series.  Neither  alcoholism  nor  syphilis 
in  the  jian.:nts  apjii'ars  to  play  an  important  role  in  this  aifection.  Dilli- 
cult  or  i  hnormal  labor  is  responsible  for  cei'tain  of  the  cases,  particularly 
injury  with  the  f<)i'rr/)s.  'rraunia.  such  as  falls  or  puncturing  wounds,  i? 
more  rare.  The  condition  followeil  ligation  of  the  conuiion  carotid  in  one 
case. 

Infectious  diseases.  All  the  authors  lay  special  .stress  upon  thisfaetei. 
In  1!)  cases  in  my  series  the  disease  came  on  during  or  just  after  one 
of  the  specific  fevers.  I  saw  oiu;  case  in  which  during  the  height  nf 
vaccination  convulsions  developed,  followed  hy  hemiplegia.  In  a  great 
majority  of  the  cases  the  disease  sets  in  with  a  convulsion,  in  which  tlie 
child  may  remain  for  sev«ral  hours  or  longer,  and  after  recovery  the  paraly- 
sis is  noticed. 


:ik-it 


\ 


IIKMII'I.KUIA   AM)   I>Il'I.i:uiA   IN   CllILDUKN. 


050 


who  had 

IH'SjI,  Kllil 

I'll  un  ilic 
'ever  iumI 
A  mass  of 
h  till'  Im.v 

lisi'iisos  ii[ 

pR'dOlUll- 


{EN. 

ctiolojiy  of 

ii  iiiajin'ity 

•Imiific,  llif 

i)|)liy  of  tli( 

'L'pluihlS. 


finnary  f^r 

institution 

tho.Toiin-i 

R'tuililcLM:! 
to  he  ciiii- 


this  factor. 
4  after  oiic 
|e  lu'iglit  of 

In  a  srn'Mt 


Morbid  Anatomy.— In  an  analysis  wliidi  I  liavc  mailc  of  no  aii- 

(o|i>ii's  rfpiM'toil    in  tJH'  lilcnitnrt',  the  lcsi((ns  may  lie  ;:r(in|n(I   nmlor  tlircf 
licailin;,'s : 

{it)  Mmlinlisin,  tlir<inil)()sis,  and  lia'tnnrrliao'i',  cnniiniMn;,'  ir,  cases, 
in  T  of  wliieli  thert^  was  Moekini;-  nf  a  Syhian  ai'terv,  ami  in  li  haiodr- 
riia.u'e.  A  stril<in;,'  feature  in  tliis  oi'mip  is  liic  aiUamcd  age  nf  onset. 
Ten  of  tlio  eases  occurred  in  eliililren  over  six  years  old. 

(/>)  Atrophy  und  sclerosis,  comprising  r»(i  cases.  The  wasling  is  cither 
of  groiip-s  of  convolutions,  an  entire  Inlie,  or  the  whole  henii>phere.  '['he 
nieninge!<  are  usu;illy  closely  adherent  over  the  allVeted  I'egioii,  though 
sonietinu's  they  look  normal,  'i'lie  convolutions  are  atrophied,  tirm,  ami 
hard,  contrasting  strongly  with  tli.'  nonmd  gyri.  The  ,-clei'osi.s  mav  lie 
(lilTnse  and  widc-spi'ead  ovci- a  hemisphere,  or  there  may  lie  nodular  pro- 
jections— the  liypertropliic  sclerosis.  Some  of  the  ea>es  show  reiiiarkahlo 
iniilateral  atrophy  of  the  hemisphere,  in  one  of  my  casi's  the  atrophied 
licmispliere  wcigiu'd  Hi'.)  graunnes  and  the  uoi'mal  OoIJ  gramnu's.  'I'jm 
lirain  tissue  may  ho  a  mere  shell  over  a  dilat  'd  seiitriele. 

{(■)  I'oi'cncephaliis,  wlii(di  was  present  in  •.' f  of  the  liii  aiitojisies.  This 
term  was  applied  l)y  llesidiel  to  a  loss  of  suhstaiice  in  the  form  of  ca\i 
ties  and  cysts  at  the  surface  of  the  hrain,  either  opeiung  into  and  liounded 
liy  the  araidinoid,  and  even  passing  deci)ly  into  the  hemisphere,  or  reacdi- 
iiig  to  the  vontri<de.  Ii\  the  stmly  hy  Andn^y  of  l(i;{  cases  of  poreiieepha- 
\n>,  hemiplegia  was  mentioned  in  08  cases. 

Practically,  then,  in  infantile  hemi[ilegia  cortical  siderosis  and  poren- 
ccphalus  are  the  inijiortant  anatomical  conditions.  The  pi'imai  v  (diange 
ill  the  majority  of  these  eases  is  still  uidoiown.  I'orcncephalia  may  result 
from  a  did'eet  in  develo[)mcnt  or  from  ha'morrhage  at  liirth.  '("he  etiology 
is  cleiu"  in  the  limited  nnnihci-  of  cases  of  h.emoi-rhage,  emiiolism,  and 
thi'oniltosis,  hut  there  remains  the  large  group  in  which  the  llnal  (dnmgo 
is  sclerosis  and  atrophy.  What  is  the  |irin';ii'y  lesion  in  these  instances? 
The  clinical  history  shows  that  in  nearly  all  lhe.se  eases  the  onset  is  sud- 
den, with  convulsions — often  with  slight  fever.  Striimpidl  liclievcs  that 
this  condition  is  du(>  to  an  intlammatiou  of  the  gray  matter — polio-en- 
cephalitis— a  view  wliiidi  has  not  heen  very  Avid(dy  accepteil,  as  the  ana- 
tomical ))roofs  are  wanting.  Ciowers  suggests  that  thi'omtiosis  may  he 
present  in  .some  instances.  This  might  prohahly  account  foi'  tlie  iinal 
condition  of  sclerosis,  hut  clinically  thrond)osi.s  of  the  veins  rarely  occurs 
ill  healthy  ohild.vn,  whicdi  a]i|)ear  to  he  those  most  freipieiitly  attacdced 
hy  infantile  hemiplegia,  and  post-mortem  proof  is  yet  wanting  of  the 
assoi'iation  of  tlironihosis  with  the  disease. 

Symptoms. — (^0  The  onset.  The  disease  may  set  in  suddenly 
without  spasms  or  loss  of  consciousness.  In  more  than  half  the  cases  the 
'hild  is  attacked  with  ])artial  or  general  convulsions  and  loss  'if  conscious- 
ness, whiidi  may  last  from  a  few  hours  to  many  days.  This  is  one  of  the 
most  striking  features  in  the  disease.    Fever  is  usually  present.     The 


if 


iSSB^'V    ie 


V'.V 


$ 


:i^ 


-1  , 

1:)' 


OGO 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


luiiniplogia,  noticed  as  thv  cliii.l  recovers  eoiiseioiisiiess,  is  jionerally  eoin- 
plete.  Sometimes  the  paralysis  is  not  complete  at  first,  but  develop:  allcr 
subsequent  convulsions.  The  rij^ht  side  is  more  frequently  aileeted  lliaii 
the  left.     The  face  is  coniniouly  not  involved. 

(//)  Hesidual  symptoms.  In  some  eases  the  paralysis  gradually  disip- 
})ears  aiul  leaves  scarcely  a  trace  as  the  child  jjjrows  up.  'L'he  k\ir,  as  a 
rule,  recovers  more  rapidly  and  imjre  fully  than  the  arm,  and  tlu' 
j)aralysis  may  Ije  c-carccdy  noticeable.  In  a  majority  of  cases,  however, 
there  is  a  characteristic  licmiplejiic  j^ait.  The  i)aralysis  is  most  marked 
in  the  arm,  which  is  isually  wasted  ;  the  forearm  is  flexed  at  ri,<,dit  audits. 
the  liand  is  Hexed,  ami  the  fingers  are  contracted.  Motion  may  l)e  idiimst 
completely  lost ;  in  other  instances  the  arm  can  lie  lifted  above  the  head, 
Late  rigidity,  which  almost  always  develo})S,  is  the  symjjtom  wliiili 
suggested  the  name  hoiiipJiijia  .'</i(is/ini  rcrrZ/nilis  to  Heine,  the  ortho- 
paedic surgeon  who  first  accurately  descril)ed  these  cases.  It  is,  however, 
not  constant.  'J'he  limbs  niay  be  quite  relaxed  even  years  after  the  onset. 
The  I'cilexes  are  usually  increased.  In  several  instances,  however,  1  have 
known  them  to  be  absent.     Sensation  is,  as  a  rule,  not  distur])ed. 

Aj)/i(i,si(i  is  a  iHjt  unconnnon  sym]>tom,  and  occurred  in  1(!  cases  of  uiv 
series — a  smaller  number  than  given  in  the  series  of  Wallenberg,  liaudard, 
and  Sachs. 

Mr/I /ill  7>r/'(v7.s'.— One  of  the  most  st'rious  consequences  of  infantilo 
hcmi])legia  is  the  failure  of  mental  di'velojunent.  A  considerable  numKer 
of  thest'  cases  drift  into  the  institutions  for  feeble-mindetl  children.  Tlnve 
grades  may  be  distinguished — idiocy,  which  is  most  common  when  the 
hemii)legia  has  existed  from  birth  ;  imlu'cility,  which  often  increases  with 
the  development  of  e})ile|)sy ;  and  feeble-mindodness,  a  retarded  rather 
than  an  arrested  develojinuMit. 

Epili'ps}j. — Of  the  c-ases  in  my  series,  41  were  subjects  of  convulsive 
seizures,  which  is  one  of  the  most  distressing  seqiu'nces  of  the  disease. 
The  .'seizures  may  be  either  transient  attacd<s  of  priit  imd,  true  .Jacksoniaii 
fits,  ])eginiiing  in  and  coiilineil  to  the  all'ected  side,  or  general  convulsiniiN 

Post-lii'itiiph'(jii;  MorcDioi/s. — It  was  in  eases  of  this  sort  that  Weir 
Mitcdiell  first  described  the  post-hemi[»legic  movements.  Tlii'y  arc  ex- 
tremely common,  and  were  ])resent  in  1)4  of  my  series.  There  nuiy  I'e 
either  slight  tremor  in  the  affected  muscles,  oi-  iiu'oordinate  choreifcrni 
nu)venuMits — the  so-called  ])ost-hendplegic  chorea — or,  lastly, 

Afliiiosis. — In  this  condition,  described  by  IIamuu»nd,  there  arc  re- 
markable spasms  of  the  paralyzed  extremities,  chiefly  of  the  fingers  and 
toes,  and  in  rare  instaiu'cs  of  the  muscles  of  the  mouth.  The  inoveuienl? 
are  involuntary  and  sonu'wliat  rhythnucal ;  in  the  liand,  movements  el 
a<lduction  or  abdiu'tion  uiul  of  supination  and  ]iromition  follow  each 
other  in  orderly  sequence.  There  may  be  hyi)erexteusion  of  the  fiu;:ers. 
during  which  th(>y  are  spread  wide  apart.  This  condition  is  much  iieiri' 
fre(pK'nt  in  children   than  in  adults.     In  the  hitter  it  nuty  be  con'.hiiui 


HEMIPLEGIA   AND   DIPLEGIA    IX   CIIILDREX. 


!Mi 


,  is  jirononilly  oom- 

hut  dt'veloi)'  lifter 

L-iillv  alTecteil  lluiu 


witli  hi>miiu>a'stli('siii,  iimi  tlii'  lesion  is  not  corticul,  but  basic  in  the  ncigli- 
li(iilic.()(l  of  tbii  thiilainns.  'I'hc  inoveini-nts  are  .sonictinK's  iiicivuscd  l)y 
tiiiotion.     They  usually  jicrsisl  during-  slci'i). 


is  gradually  di<;;ii- 
up.      The  leg,  us  ;i 
;he    arm,   and   ilii' 
of  eases,  ho\ve\i,r, 
lis  is  nuist  marked 
xed  at  right  an-Ks. 
ition  may  be  aliiinst 
ted  above  the  liciul. 
le    symi)tom   ■\vliicli 
Heine,  the  ortlm- 
ies.     It  is,  however, 
ears  after  the  onset. 
ces,  however,  I  havj 
;  disturl»ed. 
.'d  in  10  eases  of  my 
rallenl)erg,  (iaudanl. 

(luonces  of  infantile 

leonsiderable  nunil"'r 

lied  ehildren.    'i'lnve 

eommon  when  the 

fteu  increases  with 

a  retardetl  rather 


ijeets  of  eonvulsive 
(H'S  of  the  disease. 
Ill,  true  .laeksoiiiaii 
general  eonvulsimis. 
this  sort  that  Weir 
nts.  They  are  ex- 
There  nuiy  he 
in-dinate  ehoreiferm 
,  lastly, 

uiond,  there  are  re- 
s' of  the  lingers  aii'l 
th.  The  movements 
hand,  movements  et 
.nation  f-dlow  eaeh 
nsion  of  the  fui-ers, 
dition  is  much  n\<nv 
it  nuiv  be  con-biiieil 


III 


ru 


IT.  Spastic  Dii'i.kcia— Uiitrii   Pai.siks. 

In  this  condition  there  is  41  pai'alysis  with  s|)asiii  of  all  extremities, 
dating  from  or  shortly  sueeeeding  bii'lh,  more  rai'tdy  following  tlu'  fevers 
nr  an  attack  of  eonvulsions.  The  legs  are  usually  more  involved  than  the 
anus;  there  is  no  wasting,  no  disturbaiici'  of  sensation.  'I'he  n-llexes  ar(> 
increased.  The  nu'Utal  condition  is  pi'dfoundly  disturbed.  The  patiei-ts 
s   or   idiots,  helpless    in   mind   ami   bodv.     Ata.\ie  and 


are  usuallv  im 


beeih 


athetoid  movements  of  the  most  e.\aggeralc(l  kind  may  occur. 

While  a   limileil    number  oidy  of   cases  of   infantile   henuplcgia  an 


I'lUiiri 


iiital,  on   the  otiu'r  hand,  in   si 


ic  diplegia  a   large  j)ro|)oi'ti()n 


ho  eases  results  from  injury  at  Idrlii.   Practically  the  spastic  paraplegia  of 
■liildre)!  should  be  considered  wiili  this  conditinii,  as  its  ctiidogv  is  essen- 


tially the  same.     The  arms,  too,  niav 


Ue    Si  I 


lightlv  affected  as  to  make  if 


dillicult  to  deterjuine  whether  it  is  a  i  ise  of  diplegia  or  paraplegia.  'I'he 
eases  usually  date  from  birth,  and  a  majority  are  born  in  first  lalxu's  or 
are  forceps  cases.  Ross  suggests  that  in  feet  jirc-ciilat  ion  there  may  be 
laceration  or  tearing  of  the  cerebro-spinal  membr.-iiics. 

Morbid  Anatomy.  — 'i'he  l»irth  palsies  which  ultimately  indiu'e  the 
>|u-tic  di[ilegias  or  parapK'gias  are  most  freijuently  the  result  of  mening(>al 
ha-iiiorrluige.     The  imi)ortance  of  this  comlition  has  been  shown  bv  tlu^ 


iKIies   01 


at/.manu  a 


lid   S; 


irali 


.!.    Mc.Nutl.     '1' 


le    iijcedmir  niav  come 


frmii  th(>  veins,  or,  in  one  case  which  I  saw  with  Hirst,  from  the  longi- 
nidiiial  siinis.  The  bK'cding  has  in  many  cases  been  thickest  over  the 
iiiiilur  areas,  and  it  seems  [jrobable  that  the  sclerosis  found  in  these  eases 
ma\  result  fr(»m  the  compression  of  the  blond-clot,  in  other  instances 
'he  ■•onditiou  may  be  due  to  a  fietal  meniiigo-cnceplialitis.  In  sixteen 
aiitoi)sies  collecteil  in  the  liit'ratiirc.  in  wlii(di  the  patients  died  at  ages 
varying  from  two  to  thirty,  the  anatomical  condition  was  either  a  dilTusc 
;i*r(i|iliy,  wliich  was  most  common,  or  ])orem'cp]ia1ns. 

Symptoms. —.\t  first   nothing  abnorni.-il   maybe   noticed  about  the 


'iiiiii 


In   some    instances    then 


lia-e   been  eaidy   and    frecpienf   conviil- 

■^i'Mis;  then  at  the  age  when  the  ''iiild  should   begin  to  walk   it  is  noticed 

t'laf  the  limbs  are  imt  uscfj  readily,  and  on  examinafion  a  stiffness  of  the 

ie,'^  and  arms   is  found.     Even   at   the  ago  of  two   the  cliihl   may  not  be 

;ihle  to  sit  up,  ami  often  the  head  is  not  well  suitportt^d  by  the  neck  mus- 

'l"s.    The  rigidity,  as  a  rnk",  is  mon'  juarked  in  th(>  legs,  an<l  then>  is  ad- 

'tor  s))asm.     Wlien  supporteil  on  the  feet,  the  chilil  either  rests  on  its 

t'K's  and  the  inner  surface  of  the  feet,  with  the  knees  close  together,  or  the 

I l(',:;s  may  be  cro.s.sed.     The  stitTiu\ss  of  the  upper  limbs  varies.     It  may  bo 

■iircely  noticeable  or  the  rigidity  may  be  as  marked  as  in  the  '  'gs.     Cou- 

Gl 


,1        \  '  •     I- 


»  If    ^\^b    if,, 


'1 


'h' 


i)(;2 


DISEASES  OP  THE  NERVOUS  SYSTEM, 


stant  ir'Tirular  movcnioiits  of  tlio  anns  aro  not  'iiiooniinoji.  The  cliili] 
has  (jrcat  Hitliciilty  in  jriaspinjj  an  ohjoet.  'I'lit'  spasm  and  WL-akiicss  iiia\  hi 
more  evident  on  one  side  tiian  the  otlier.  The  mental  eondiiionis,  as  u 
ride,  derective  and  coiivnlsive  seizures  are  common. 

Associated  with  the  si)astic  paraplej^ia  are  two  allied  conditions  ,i|'  cm. 
siderahle  interest,  characti^rized  by  spasm  and  disordered  nioveinenls.  \ 
child  witii  spastic  diplegia  may  jtresent,  in  an  unusual  de<iree,  irreiriiliir 
movomonts  of  the  nmscles.  lu  attem|iting  to  grasp  an  oliject  the  liiiirci's 
may  bo  throwi\  out  in  a  stitf,  spasmodic,  irregular  mainu'r,  or  tiicrc  iii;i\  U' 
constant  irregular  movements  of  the  shoulders,  arms,  and  hands,  uiih 
slight  incoordination  of  the  liead.  Cases  of  this  desci'iption  have  hccnijt- 
Berilted  as  cluirr((  sjxtslini,  and  they  may  l)e  dillieult  to  separate  from  wnv- 
tipie  .".eif  rn-^is  and  fi'om  {''riedreiclTs  ataxia. 

<\  siUl  more  remarkable  condition  is  that  of  bi/ufcra/  tillninsis.xn 
ft'hii.'h  there  is  a  (■oinbinatioii  of  sjiasm  more  or  less  marked  with  tlu'  ihhm 
extraordinary  bizarre  movements  of  the  muscdes.  'riie  I'oiuliiiuii,  n,  , 
rule,  dates  from  infancy,  'riie  patient  may  not  be  able  to  w:dk.  'I'lic  \w\\<\ 
is  turned  from  side  to  side;  there  are  coiitinu'ri  ''"vo;;.  '  i'  mu',eiiunt>  ..i 
the  face  muscdes,  and  the  mouth  is  drawn  and  ■-■  .ustorted.  Tl.i 
extremities  are  more  or  less  rigid,  jiarticularly  in  exteiision.  On  makii.. 
the  slightest  attemjjt  to  move,  often  spontaneously,  tiiere  are  extiiioi<liii;i. 
movi'nii'tits  (d'  tlie  arms  and  legs,  ))articularly  of  the  arms,  somewhat  lik^ 
tiiough  nuich  more  exaggerated  than  athetosis.  The  patients  are  ulii  -i 
unal»h^  to  help  themstdves  on  account  of  these  movements.  The  follcxts 
are  increased.  'I'he  mental  eoi\(Iition  is  variable.  'I'lie  patieid,  may  1" 
idiotic,  btit  in  two  of  the  four  cases  whi(di  I  have  seen  the  patients  \vi  i 
intolligent.  Massalongo,*  wlio-intscarefidly  studied  tins  conditinn,(l(-rii!i - 
three  ctises  in  one  family.  1  have  eolli-eted  tifty-three  cases  frnm  [!.(■ 
literature,  thirty-three  of  which  occurred  in  males  and  twenty  in  feiiiiili -. 
There  have  bi'en  tiiree  autopsies.  In  Kurella's  case  there  was  [iii!li\- 
meinngitis  ;ind  bilattu'al  lesions  of  the  mot(.ir  convolutions.  I>ej<''i;:i'",-  j;i 
tieid  had  atropiiy  of  the  convolutions  on  l)oth  sides,  while  in  :  v  east' 'iiej 
brain  maeroscopically  preseiiti'(l  no  (dumges. 


HI.    Sl-ASTIC    Ta      VPLi^GTA. 


Tills  condition,  which  is  more  fully  described  under  "lo  section  iipnii 
the  spinal  eonl,  is  in  reality  a  ci-reliral  affection,  and  may  be  due  U>  w\'A\ 
tions  similar  to  those  found  in  spastic  diplegia.     Indeed,  it  may  at  liist  lej 
difficult  to  determine  whether  the  arms  are  invidved  or  ind.     Tli''Pvi 
dence  of  the  cerebral  origin   )f  the  alfectiou  is  basi'(l  upon  the  freipiciit  lu- 
existence  of  idiocy,  imbecility,  and  nystagmus,and  the  occur  •  .leeofcai^-i'ii 
spastic  di[»legia,  in  whi(di  the   piu'aplegic  symptoms  are  Me';tieiil.    Ail] 
grades  are  met  with,  fi'om  [aire  sjiaslic  [)ara|ilegia  witii  peii'ei,:    i-t  ot  ! "'« 


*  Deir  Atetosi  Doppia,  Collcziouo  ItuUuau  di  L  tture  sullu  Mediuiua,  Scrios  V,  N.3. 


SCLEROSIS  OF  THE  BRAIN. 


ih;3 


inmii.     The  i-hilil 

I  wi'iikiu'ss  may  In 

r(nuliu:>ii  is.  11^  ;i 

(•oIl(Utinll>  .if  riili. 

il  iiioVL'ini'nt-.  A 
1  (IffiToe,  irn'tiiilai- 
olijoct  tin-  tii\pi~ 
cr.  or  llu'vc  inuy  l^ 
,  anil  haiiil-,  wiili 
ition  liavi'  lu'cu  lir- 
sopiinili'  fruiii  iiiu''- 

l(l/rr<(l   iilld'hisi^.  ill 
Li'ki'd  willi  ihi'  iiU'M 
I'lic   (•(iiitlitinn,  as  a 
ti>  walk.     'I'lu'  hcail 
,'    nitiM'iiifUts  111' 
,tl      ,;istnrtr(l.     'I'll'' 
■n^ioii-     ^*i^  making 
L>iv  tiro  exlraoi'diuaiy 
iiriiis,  s()ii\i'\vlial  likr   :'| 
e  ]iiiti(-'nt,s  nw  '•ftrii 
lUMits.     Ttn'  ivlk'Xf>  ^ 
ic  jiaticnt.  may  ''!■  -'I 
,,1  the   jiatiriits  wirr  | 
siMiiuliti('n,(U'Schlus  J 
1,1-cf  I'lisi's  rrniu  tlio  I 
a  twenty  in  fciiiiilc^  | 
se  tliei-ii  was  [w\\y 
lions.     l)6j(:-i:.'''-  I'''- 
wliilo  in  '.V  ''J'«'  '■"'-' 


iirnis  to  the  most  extreme  l)ilateral  ppasiii.  'I'here  have  been,  so  far  as  I 
know,  only  two  autopsies  in  this  disease  :  ttie  case  of  Foi'ster,  in  whicli 
tliiTc  wus  a  niodei'ate  ^TaiU'  of  <,a'iieral  coi'tieal  sclerosis  with  slight  dilata- 
tion of  the  ventricles,  and  the  recent  case  of  Sachs,  in  Aviueli  there  was  u 
iiiciiiiijro-(Mice])hHlitis  with  atrophy  and  descending  degeneration  of  hotli 
Litrral  columns. 

Treatment. — The  possibility  of  injury  to  the  hrain  in  protracted 
liilor  and  in  forceps  cases  should  l)e  home  in  mind  hy  tlii'  pi'act  it  inner. 
I'lic  former  entails  the  greatest  risk.  In  infantile  hemiplegia  the  physi- 
liiiii  at  till!  outset  sees  a  case  of  ordinary  convulsions,  jierhaps  more  pro- 
tnictcd  and  severe  than  usual.  These  should  he  checked  as  rapidly  as 
jinv'ilili  hy  the  use  of  the  hromides,  the  application  of  cold  or  heat,  and  a 
:iri<k  purge.  During  convulsions  ehlorofoi'iii  niay  be  administered  with 
,-ifctv  even  to  the  youngest  children.  When  the  jiaralysis  is  established 
ii'it  iinioh  can  be  hoped  from  medicines.  In  only  rare  instances  does  the 
]iiralysis  entirely  disapjiear.  The  indications  are  to  favf»r  the  natural 
iciiilcucy  to  im);rove  hy  maintaining  the  general  nutrition  of  the  child,  to 
icvcii  the  rigidity  and  contractures  hy  massage  and  ])assive  motion,  and 
if  necessary  to  correct  deformities  hy  mechanical  or  surgical  measures. 
Muili  may  he  d(me  hy  careful  manipulation  and  rubbing  aiul  the  a])plica- 
tioa  of  a  proper  ajiparatus.  In  children  the  aphasia  usually  disap|)ears. 
Tlir  epilepsy  is  a  distressing  and  ohstinate  symittoni,  for  which  a  cure 
cm  rarely  be  anticipated.  Prolonged  [)erio(ls  of  quiescence  are,  however, 
not  uncommon.  In  the  .Faeksonian  lits  the  bromides  rarely  do  good,  un- 
!iss  there  is  much  irritability  and  excitement.  Operative  mi'asures, 
Miicli  have  been  carried  out  in  several  cases,  liave  not  been  successful. 
T!ie  lial)ility  to  feeble-mii.dedness  is  the  nn)st  si-rious  outlook  in  the  in- 
i'linlilc  cerebral  i)alsies.  In  many  cases  the  damage  is  irreparalile.  and 
:!ii<y  and  imbecility  result.  With  patient  training  and  with  care  many 
f  tin;  children  reach  a  fair  measure  of  intelligence  aiul  self-reliance. 


VI.    SCLEROSIS    OF    THE    BRAIN. 


Ider  '^e  soetiim  iip'Hij 
Lav  be  due  in  eoiali- 
(ed',it  may  at  first  lej 
Ld  <n-not.    Th-evi- 
Loii  the  Vreqiii'iit '>';] 
locciiV' iweofoasi'H 
I  are  Idi-.Hcal.    Ml 
Ih  l^^i\h•^  ■  'i^<    '^  '""•'' 

lledicma,  Scrii's  V.N.J 


General  Remarks. — 'I'he  connective  tissue  of  the  central  nervous 
system  is  of  two  kinds — oiu',  the  neuroglia,  special  and  peculiar,  derived 
fwiii  the  ectoderm,  with  distinct  morphological  and  cliemical  characters; 

nther,  derived  from  the  n;esoderm,  identical  with  the  ordinary  col- 
lii'-'i'!i(iiis  fibrous  tissue  of  the  body.  lioth  i)lay  im])ortant  parts  in  imbira- 
'lU'  |irocess(>s  in  the  brain  and  cord.  .\  convenient  division  of  the  cerebro- 
-I'inal  scleroses  is  into  (h^getierative,  intlamnnitory,  ami  (h'velopmental 
!"riiis. 

The  (Jcfiinirrdtivp  ncfrrfiyrK  comprise  the  largest  and  most  itu])ortatit 
'ii'iilivisioii,  in  whicli  ])rovisionally  the  following  groups  may  he  made: 
'")  The  eonimon  secondary  degeneration  which  follows  wlieu  uerve-libres 


•>r,4 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


1    .'i 


15  ■  '■ 


■rTi 


i 


I 


ff 


■  ■  ■  ■     's ,  (.-' 
.     ■      '  It:  ■ 


'■if 


s 


iire  cut  oiT  from  their  tnipluc  cfiitrcs;  (/>)  toxic  forms,  amoiif^  wlinh  in;iv 
be  placed  the  scleroses  from  lead  and  eri^ot.  and,  most  imj)ortaiit  (if  ;ill.il|, 
sclerosis  of  the  jtosterior  column,  due  in  such  a  large  ])roi)ortioii  of  cases  td 
the  virus  of  f5y])hilis.  Other  uid<uo\vn  toxic  agents  may  possihiy  iiuhhv 
degeiierati(»n  of  the  nerve-iii)i'es  in  certain  tracts.  The  systemic  jiatlis  ii; 
the  cord  dilfer  apparently  in  their  susceptil)ility  and  the  posterior  coliuiin- 
appcar  nujst  [)roiic  to  undergo  this  change;  (r)  the  sclerosis  assiicjui,,] 
with  change  in  tiu'  smaller  arteries  aiul  ca|)illaries,  which  is  met  with  as;i 
senile  process  in  the  convolutions.  In  all  prol>al)ility  some  of  the  funiis  nt 
insular  sclerosis  arc  due  to  prinuiry  alterations  in  the  hlood-vesscls;  Inn 
it  is  not  yet  settled  whether  the  lesion  in  these  cases  is  a  jtrimary  (lc;.'iii. 
oration  of  the  nerve  cells  and  tlhres  to  which  the  sclerosis  is  sccomlarv.  ni 
whether  the  essential  factor  is  an  alteration  in  nutrition  caused  hy  li'simi. 
of  the  capillaries  and  smaller  arteries. 

'IMie  injldmmatory  w/croww  embraco  a  less  important  and  less  extnisiir 
••oup,  comprising  secondary  forms  which  develop  in  consequence  of  irn- 
live  intlammation  about  tumors,  foreign  bodies,  luemorrhages,  and  al)S(vs.. 
histologically  these  are  chielly  mesodermic  (vascular)  scleroses,  which  arise 
from  the  connective  tissue  about  the  i)l()od-vesscls.  Possibly  a  siinjlm 
change  may  follow  tiu'  primary,  acute  encephalitis,  which  Striimpcll  linlil^ 
is  the  initial  lesion  in  the  cortical  sclerosis  which  is  so  commonly  foiiini 
post  n'lortcm  in  infantile  hemiplegia. 

The  ((vi'rldpiiK'iihd  sclcrosrs  arc  believed  to  be  of  a  purely  neuroirliar 
character,  and  end)race  the  lu'w  growth  about  the  central  canal  in 
syringomyelia  and,  according  to  recent  French  writers,  the  sclcnisis  nf 
the  posterior  columns  in  FriedreiciTs  ataxia.  it  is  stated  that  lii.-tn- 
logically  this  form  is  ditferent  from  the  ordinary  variety.  It  iii;iy  !»■, 
too,  that  the  diifuse  cortical  sclerosis  met  with  as  a  congenital  rnii^li- 
tion  without  thickening  of  the  meninges  belongs  to  this  type,  li  :• 
not  improbable  that  many  forms  of  sclerosis  are  of  a  mixed  chanulw, 
in  which  both  the  cctodermic  and  nu\soderiiiic  connective  tissues  aiv  in- 
volved. 

Anatomically  we  meet  with  the  following  varieties: 

(1)  Miliary  sclerosis  is  a  term  which  has  been  applied  to  scvcinJ  iliM 
ferent  conditions,     (iowers  mentions  a  case  in  which  there  were  griiyi>li- 
red  spots  at  the  junction  of  the  white  and  gray  matters,  and  in  whidi  tli. 
neuroglia  was  increased,     'i'here  is  also  a  condition  in  which,  on  tlicsiii- 
face  of  the  convolutions,  there  are  siiuill  nodular  ])rojections,  varyiii;'  t'i'0!n| 
a  half  to  live  or  more  millimetres  in  diameter.    Single  nodules  of  ihissortj 
are  not  uiu'ommon  ;  sometimes  they  are  abundant.    So  far  as  is  kimwii  ii"l 
symptoms  are  produced  by  them. 

('i)  Diffuse  sclerosis,  which  may   itivolve  an  entire  hemisphere,  nr  ;ij 
single  lobe,  in  which  case  the  tertn  sclerose  lohnire  has  been  applieil  I"'' 
by  the  French.     It  is  !U)t  an  important  condition   in   general  iiieili  •" 
practice,  but  occurs  most  frequently  in  idiots  and  imbeciles.    In  exti'ii"i«'| 


EiM. 


SCLETIOSIS  OF  THE  BRAIN. 


iMl") 


!.  imionj?  wliicli  mav 
iiiiportiuil  (tf  iilUli.' 
rnportioii  of  i;isi>  in 
tiuiv  possibly  imliin' 
lie  sy.stciiuc  ])iitlis  in 
lie  posterior  cnhiiiii!- 
_'  sclerosis  iissnciuini 
liieli  is  met  wilh  a>;i 
some  of  the  fnnns  ni 
le  hlood-vessels ;  liiii 
s  is  ii  in'imiU'v  (l(';:t'ii- 
■rosis  is  seeomlan,  nr 
ioii  ciiuseil  l>v  Ic.-ii.ii- 


pfirtic'iil  selorosis  of  one  hemisphere  the  veiitriele  is  iisiuilly  dilateil.*  The 
.vmiiloins  of  this  eomlitioii  depend  upon  the  region  jitl'eeted.  'I'here  mnv 
It'll  considenible  extent  of  sclerosis  without  symptoms  or  without  nuicli 
iiii'iitid  impairment.  In  a  majority  of  eases  there  is  hemi])le<iia  or  diple,i;ia 
with  iinhecility  or  idiocy. 

(:i)  Tuberous  Sclerosis. — In  this  remarkalile  form,  whicli  is  also  known 
,:H  livpcrtrophic,  there  are  on  the  convolutions  areas  projectinjf  hevond 
resurface  of  an  opaque  white  color  and  exceedinj^ly  tlrni.  The  sclerosis 
may  not  disturl)  the  symmetry  of  the  convolution,  but  simjdy  cause  a  <,n-eat 
t>ii!,irirement,  increase  in  the  density,  and  a  ehanire  in  the  color. 

These  three  forms  are  not  of  much  practical  interest  except  in  asylum 
:iii|  institution  work.  The  last  viiriety  forms  a  well-characterized  disease 
fconsiderable  importance,  namely: 


ant  and  less  extt'nM\' 
I  conseiiuence  nf  irn- 
lorrhaffes,  and  alisiv-. 
scleroses,  which  ann 
4.  Possibly  a  similar 
liicli  Striinipell  liol'ls 
s  so  eoinnionly  fouml 

»f  a  purely  neuroi'liar 
le  central  canal  in 
ters,  the  selcresit!  nf 
is  stated  that  lii>iH- 
rariety.  It  may  !"■, 
a  conf.';enital  I'mnii- 
to  this  type,  li  i- 
■  a  mixed  charactrr, 
lU'ctivt-  tissues  aiv  in- 


applied  to  sevcra.l  ilit-| 
1   there  w(>re  ,!:i'iiyi>!i- 

Icrs,  and  in  wliii'li  'I"' 
in  wliieli,  on  tlu'sni- 
jections,  varying' from  I 

;le  nodules  of  this  sort 
So  far  as  is  knn\viiU'i[ 

tire  liemispheiv,  or  ;i 
has  been  appli*''!  '"" 
I  in  i^eneral  nuili'i' 
ibociles.    In  extensive! 


(1)   Insii.ah  ScLi-Kosrs  {Srh'i'oxc  (')i  pidtjiii's). 

Definition. — A  chronic  affection  of  the  brain  and  cord,  cliaracterized 
y  liicalized  areas  in  which  the  nerve  eli'inents  are  more  or  less  replaced  by 
iiniu'ctive  tissue.  This  may  occur  in  the  brain  or  cord  alone,  more 
iiniiiionly  in  both. 

Etiology. — This  is  obscuiv.  Kahler,  Marie,  and  other's  assit,ni  ureat 
.iii|iiirtance  to  the  infei'tious  diseases,  particularly  .scarlet  fever.  It  is 
'luud  most  enmmoidy  in  younii  persons,  and  eases  are  not  uncommon  in 
Mrcn,  ill  whom  I'ritehard  stales  that  more  than  lifty  eases  have  been 
rijiiii'ted. 

Morbid    Anatomy. — The    sclerotic    areas    ai-e    widely    disti'il)nted 

j'.iiroii^ii  llie  brain  and  cord,  and  cases  liuiited  to  either  part  alone  are  almost 

inikiiown.     The  grayish-red  areas  are  scattered  indilTerently  through  the 

hfhiti'  and  gray  jnatter  (K.  \V.  Taylor).     The  patches  are  most  abundant 

the  neighborhood  of  the   ventricles,  and   in  the  pons,  cerebellum.  l)asal 

i -■iMLflia,  and   the   medulla.     The  I'ord   may   lie  oidy  slightly   involved  or 

:iii-rt'  may  be  irregular  areas  in  difl'erent  regions.     The  nerve-i'oots  and 

I tiic  branches  of  the  eauda  e(|iiina  are  oftt'ii  attacked.     Ilistoloincally  in 

;ii('  sclerosed  patches  there  is  great  inere:>se  in  the  connective  ti.^sue,  the 

l"'iris  (if  which  are  <lenser  and  lirmer.     The  gradual  growth  destroys  the 

liH'iliilla  of  the  nerves,  but  the  axis  cylinders  persist  in  a  remarkable  way. 

Symptoms. — The  onset  is  slow  and   the  disease  is  chronic.      Feel)le- 

ii-^siilihe   legs  with  irreguhir  i)ains  and   stifl'ne.ss  are  among  the  early 

hwniitoMis.     Indeed,  the?  clinical  picture  may  be  that  of  s[)astic  ]iai'aplci.Ma 

|«i!li  i^reat  increase  in  the  rell(!.\es.    The  following  are  the  most  important 

r'iitiu'cs : 

(")   ViiUtiiiiKtl  Trenior. — Thei-e  is  no  paralysis  of  the  arms,  but  on  at- 

*  111  my  iiioiinijnipti  on  Ccroiiiiil  i'.ilsics  dt  Cliildri'ii  1  have  t,'ivc'ii  ii  description  of 
''"'liMiibuliun  of  lliL'  sL'k'rosis  in  lea  speeinu'iKs  in  the  museum  iil  the  Ehvyu  InsLi- 

|!:,;i(in. 


or.G 


DISEASES  Ol'^  THE   NERVOUS  SYSTEM. 


iliv 


ti'iupliiii;  to  j)i('k  iij)  ;m  object  tlioro  i.s  trotiiblin<j:  or  rapiil  oscilliitiun. 
piitioiit  may  ho  iiiial)lo  to  lift  ovi-ii  a  ^'lass  of  wali'i"  to  the  month.  Tli 
ti'i'iiior  m;iv  1)('  markt'd  in  tho  U'l^s  and  in  the  head,  wiiich  shakes; 
lie  walks.  When  tho  patii-nt  is  roeumhont  the  musoles  may  be  |ieilcctl 
quiet.  Un  attomiitinff  to  raise  tho  head  fiom  the  pdlow,  troMdiJiiifr  i 
onoe  conios  on.  {//)  Srfi)itiin(/  Sprir/i. — The  word'i  are  pronounced  sldwl 
and  separately,  or  the  individual  syllables  may  he  aceentuati-d.  This  .-tm 
cato  or  syllabic  utterance  is  a  common  feature,  (r)  Nystagmus,  a  luiii 
oscillatory  niovomt'iit  of  both  eyes,  constitutes  an  important  symploni. 

Sensation  is  nnairected  in  a  majority  of  the  cases.  Optie  atnij 
sometimes  occurs,  hut  not  so  fre(|uei.tly  as  in  tal)es.  'l'h(>  sphincters. n 
a  rule,  arc  ujialTccted  until  the  last  stages.  .Mental  del)ility  is  not  iiiiciui 
moil.  Kemarkable  rcnnssions  occur  in  the  course  of  the  disease,  in  whiiii 
for  a  time  all  the  symj)toms  nuiy  im})rove.  N'ertigo  is  comnuJU,  and  tl 
nuiy  be  sudden  attacks  of  conui,  such  as  occur  in  geiu-ral  jiaresis. 

The  (/i(ii/i/(isis  in  well-marked  eases  is  easy.  N'olitional  tremor,  s( 
ning  speech,  and  nystagmus  form  a  characteristic  symptom-grou]».  With 
this  there  is  usually  nmro  or  less  spastic  weakness  of  the  legs.  l'araly-i< 
agitans,  certain  cases  of  general  ])aresis,  and  occasionally  hysteria  iikiv 
siniulato  the  disease  very  clo.sely.  If  tho  case  is  not  seen  until  near  lii 
eiul  the  diagnosis  nuiy  be  impossible.  Buzzard  holds  that  of  all  organi 
diseases  of  the  nervous  system  disscmiiuited  sclerosis  in  its  early  stagf.-ii 
that  which  is  most  commonly  mistaken  for  hy.steria.  The  points  t 
relied  upon  in  the  dilTerentiation  are,  in  order  of  importaiu-o,  the  nystii:- 
mus,  tho  bladder  disturbances,  and  the  volitional  tremor,  'i'he  tremuiii 
liysteria  is  not  volitional. 

!Mucli  more  {)uzzling,  lunvever,  are  tho  instances  of  pspudd-sHcrosr  * 
phiqiu's,  which  have  been  described  by  W'estphal.  French  writers  n'L'iiri 
them  as  instances  of  hysterical  tremor.  In  childi'on  the  condition  iiiav 
with  difliculty  be  separated  from  Fi  iedreicirs  ataxia. 

The />m/«rAs-/.s' is  unfavorable.  Ultimately,  the  jKitient,  if  not  ciinki 
oif  by  some  intercurrent  atfection,  becomes  bedridden. 

Treatment.  —  No  known  treatment  lias  any  inlluenc"on  the  lun."-- 
of  sclero.sis  of  the  brain.     Neither  the  iodides  nor  nu'rcury  have  tlu'  >li. 
est  elTect,  but  a  prolonged  course  of  nitrate  of  silver  nuiy  be  tried,  ai, . 
sonic  is  recommended. 


VII.    CHRONIC    DIFFUSE    MENINGO-ENCEPHALITIS 

(Dcmehtia  I'dnth/Ziin  :  Gi'iienil  Pare-us). 

Defluition. — A  chronic,  ])rogressivo  meiungo-enceplialitis  assori;!: 
with  ])sychieal  ami  motor  disturbances,  linally  leading  to  deuieiitiii : 
paralysis. 

Etiology. — Males  are  alfected  much  more  freijuently  than  U'm 
It  occurs  chielly  between  the  ages  of  thirty  and  tifty-live.     lieivdii};; 


TEM. 

rai)i(l  oscillation.  A 
r  to  tho  inoiitli.  Tiir 
iciul,  wliicli  sliako  ;i> 
isolcs  may  1h'  [urlVctiy 
L'  (iill(»\v,  tiviiiliiiiij.'  ai 
are  lyronounccd  sldwiy 
H!cnliiaU'cl.  Tliis  .-iiic- 
r)  Nysla<j;imi.'<,  a  iai>ii 
iilKirtant  syiiil>t<»iii. 

cases.      0|)ti<'   ali'oiihy 
es.     'riui  sphincters.  ;i- 

debility  is  not  iiiiciui!- 
A  the  tlisoase,  in  wliirii 
1)  is  common,  and  tin',- 
eneral  jiaresis. 
^'olitiiinal  tremor,  scai;-] 
symplom-gronp.     W  n 
.  of  the  logs.     l'ariil\-.-| 
•asionally  hysteria  may 
not  seen  until  near  ilm 
lolds  that  of  all  nrgiii!i. 
osis  in  its  early  stairt'-i- 
teria.     The  points  tu  n- 

importanco,  the  nysta: 

tremor.     The  tremor  i; 

I'os  of  pscuild-sclrrosr  ■• 
Frenidi  writers  n-a: 
llren  the  condition  iiiayj 

ia. 

'  patient,  if  not  eaiiU'l 

den. 

iitluenceon  the  pni.'r'-| 
mercury  liave  the  slii'ii 

er  uuiv  be  tried,  aiular-j 


-ENCEPHALITIS 

n-encepluilitis  assooiai-^j 
L'uding  to  dementia  ;'■ 

freipiently  than  i-n 
tifty-tive.     Ueredii}  ^^ 


rilUOXIC   DIFKL'SK   .MEXIXtio-RXCICPHALITLS. 


'.)•;: 


fiidiir  in  only  a  few  cases.  An  overwhelming  majority  of  the  cases  are  in 
iiiariied  peo])le.  Statistics  show  that  it  is  more  common  in  the  lower 
rlasses  of  society,  but  in  this  country  in  gciu'i'al  medical  pi'acticc  the  ilis- 
ra>i' is  certainly  more  common  in  the  well-to-do  (dasses.  An  important 
ureilisposing  cause  is  "  a  life  alisoriied  in  amliitions  projects  with  all  its 
-irniigest  mental  efforts,  its  long-sustained  an.xietics,  deferred  hopes,  and 
•tniining  expectation  "  (Mickic).  The  habits  of  life  so  fi'dpu'iitly  seen  in 
arlive  business  men  in  onr  large  cities,  and  well  e\pi'cssed  i)y  the  plii'a.s(! 
"burning  the  candle  at  both  ends,"  strongly  ))i'edisj)ose  lo  the  disease. 
Tlio  important  individual  factor  is  syphilis,  which  is  an  anteci'dcnt  in 
fri 111!  T"  to  0(1  per  cent  of  all  cases.  To  this  disease  dementia  paralytica 
aiui  talies  dorsalis  are  .so  (dctsidy  related  that  Fonrnii'r  de>criiies  them 
mi'ler  the  heading  /j's  Affi'd imiK  I'iir(is>/p/ii/i/ii/ni's.  His  i-cceiit  work, 
wiili  this  title,  is  full  of  interesting  details  gk'aned  fi'om  an  enormous  ex- 
lu'ricuee.  He  suggests  that  these  two  disonlers  may  be  not  nu'ridy  diverse 
rxpressions  of  one  and  the  same  morljid  entity,  but  that  they  possibly  nuiy 
bcdiie  ami  the  same  disease. 

Morbid  Anatomy. — The  essential  histological  changes  in  the  cere- 
iiial  c(irtex  are  tlius  summarized  l)y  Jievan  Lewis:  (1)  A  stage  of  inilam- 
iiiatory  change  in  the  tunica  adventitia  of  the  arteries  with  excessive  nn- 
flcar  proliferation,  profonnd  idiangi's  in  tlu'  vasculai-  (dianiuds,  and  trophic 
changes  indnce<l  in  the  tissues  around. 

(".')  A  stage  of  extraordinary  develo])nu'nt  of  the  lymph-connective 
system  of  the  brain,  witli  a  i)arallel  cU'generation  and  disappearance  of 
iiti'vc  elements  and  the  axis  cylinders  of  which  they  are  denuded. 

{'■>)  A  stage  of  general  tibrillatiou  with  shrinking  and  extivme  atro])liy 
of  tlic  parts  involved. 

'I'lie  macroscopical  chaniros  are  :  Increase  in  the  oerebro-spinal  lluid, 
iiileiiia  of  the  pia,  and  thickening  and  opacity  of  the  nu'iunges,  which  ai'e 
ailluTcnt  in  jilaces  <".nd  t(>ar  the  cortex  on  removal.  The  dura  is  sometimes 
tliickeiu'd,  and  pachymeningitis  ha'inorrhagica  inteiMia  may  be  j)resent. 

Tlio  convolutions  are  atrojiliied,  usnally  in  a  marked  degree,  and  in 
j  iiiii>c(|uence  the  !)rain  looks  small.  This  is  particularly  noticeable  in  the 
froiUal  and  jiarietal  regions.  On  section  it  cuts  with  lirmness.  In  ex- 
|tri'iiu'  cases  the  gray  nuitter  may  be  obscundy  outlined.  The  grade  of 
>ili'n)sis  varies  much  in  different  cases.  The  white  nuitter  nniy  be  tiiiner 
[in  I'onsisteiu'o,  but  it  does  not  show  sn(di  important  (diangcs.  'I'lie  ven- 
tricles are  dilatetl  ami  the  ependyma  extremtdy  granular.  In  addition, 
liiTe  are  freipiently  areas  of  softening  or  luiunorrhage  associated  with 
|tliroiiie  arterio-sclerosis. 

Spinal  cord,  ("hanges  are  ahuost  constantly  found,  usually  sclerosis 
jfif  the  posterior  columns,  either  alone  or,  more  commonly,  with  involve- 
liiuiit  of  the  lateral. 

Symptoms.  — ('/)  PrmlrdiiKd  SfiKjc.—'Vhh  is  of  variable  duration, 
[and  is  characterized  by  a  general  mental  state  which  linds  expression  in 


I 


>    '4' 


■  '     !' 


;i  •. 


'<■    't  >  f  If 


0(kS 


DISEASKS  OF  TIIK   NKUVOrs  SYSTEM. 


symptoTiis  trivial  iti  tlu'insclvos  hut.  iiii|i(ii'tiiiit  in  coiiiicction  witli  oilii.|\ 
liTitiibiiity,  iiiattt'Utioii  to  bnsiiu'ss  iinii)iiiitiii<,'  sonit'tiiiics  to  iiHiilTiMvin',. 
or  !i|)iitliy,  Hiul  somc'tiiiuts  n  cliiiiip'  in  cliiiractcr  niiirkcd  l)y  acts  uliiih 
may  astonish  the  friends  ami  rclativos  may  he  the  lirst  indic'Uions.  In- 
stead  of  apathy  or  iiidiirnrcnci'  there  may  he  an  extraordinary  (le:,Mvc  nf 
physical  and  nK^iitai  restlessness.  'I'he  patient  is  eontiniially  planniiiLr  uipI 
schemin<r,  or  may  launch  into  i-xtravajranees  and  speculation  of  the  wiMi.t 
character.  A  eommou  feature  at  this  jteriod  is  the  display  of  a'l  iiii- 
hoiiniled  eiroism.  lie  hoasts  of  his  personal  attainments,  his  |)ropeil\-,  his 
position  in  life,  or  of  his  wife  and  ehildren.  l-'ol lowing,'  these  feat ii res  hk; 
important  indications  of  moral  perversion,  manifested  in  olTences  uj;aiM-i 
dot;oiicy  or  the  law,  many  of  which  acts  have  about  them  a  suspicions 
efTrontery.  Forj^fctfulness  is  common,  and  may  he  shown  in  inattention  in 
business  details  and  in  tlie  minor  courtesies  (jf  life.  At  this  pei'ioil  ilicro 
may  bo  no  motor  pheiiomeiui.  The  onset  of  the  disease  is  usually  insiili- 
ous,  althout,di  cases  are  re[)oi'ted  in  which  epileptiform  (U' apopieciiforia 
seizures  were  the  lirst  symi)tonis.  Anion^f  the  early  motor  features  ;iiv 
tremor  of  tlie  tonij;u(!  and  lips  in  speakini;',  slowness  of  speech  and  Ir-i- 
tiuuT,  inequality  (tf  the  pu[)ils,  and  the  Arifyll-Uoliertson  i)Upil. 

{//)  Srroiif/  Sliiijc. — Tills  is  characterized  in  i)rief  by  mental  exaltaiii.n 
or  excitement  and  a  projrress  in  the  motor  symjjtoms.  "  The  intensity  nf 
the  excitement  is  often  extreme,  acute  maniacal  states  are  frcfpieiit ;  in- 
cessant restlessiu'ss,  ol)stinate  sleei)lessness,  noisy,  boisterotis  excitetiifiit, 
and  blind,  uncalcidatiiiLi;  violence  especially  characterize  siu-h  states" 
(fiCwis).  It  is  at  this  stage  that  tlie  delusion  of  graiuU'ur  becomes  niaikrl 
and  the  patient  believes  himself  to  be  possessed  of  countless  millions  or  to 
have  reached  the  most  exalted-sphere  {>ossii)le  in  profession  or  ocxnipalin;., 
'I'his  expansive  delirium,  as  it  is  called,  is,  however,  not  characteristic.  ;i> 
was  formerly  supposed,  of  paralytic  dementia.  IJesides,  it  ^\oV!^  not  always 
occur,  but  in  its  stead  there  may  be  marked  mehmcholia  w  liy[to(hiiii- 
driasis,  or,  in  other  instances,  alternate  attacks  of  delirium  and  dc|nv" 
sion. 

The  fades  has  a  peculiar  stolidity,  and  in  speaking  there  is  iiiarkcii 
trenuilousness  of  the  11  [>s  and  facial  muscles.  The  tongue  is  also  tivmu- 
loua,  ami  may  l)e  pn^ruded  with  ditMculty.  The  speech  is  slow,  iutor- 
riiptcd,  and  blurred.  Writing  becomes  diilicult  on  account  of  unsteaili- 
ness  of  the  liand.  The  subject  matter  of  the  patii'iit's  letters  gives  viilii- 
able  indications  of  the  nu'iital  condition.  In  many  instances  the  pujiilj 
are  nneciual,  irregidar,  sluggish,  sometimes  large.  Important  syniptonis 
in  this  stage  are  apoplectiform  seizures  aiul  paralysis.  There  may  \k 
slight  -syncopal  attacks  in  which  the  ])atient  turns  pale  and  may  fall. 
Some  of  these  are  petit  mal.  In  the  true  apo])lectiforni  seizure  tlic  [m- 
tient  falls  suddetdy,  becomes  unconscious,  the  limbs  are  relaxed,  the  faw' 
is  lliushed,  the  breathing  stertort)Us,  the  temperature  increased,  aiul  ileaiii 
may  occur.     The  epileptic  seizures  are  more  common  than  the  apoiikeii- 


('HIIONIC    DIIFISK   MKNINCO  KNCHIMIAI.ITIS. 


IM)!) 


eotion  with  rilhi'iv. 
lU'S  to  indilTiMi'iKv 
kcd  by  acts  wliiili 
t  iiKlicnUoiis.     Ill- 
uinliiuu'V  (IcLji'i't'  111' 
iiuiUy  |)luiiniiii:;iii«l 
itioii  of  tlu'  wiMi-t 
display  (if  a'l  nu- 
ts, Ids  property,  liis 
C  tlieso  foatiifi's  UK! 
ill  olTi'iu'cs  iiuMin-i 
,  tliein  a  siisiii(iiiii> 
,vn  ii>  iiiattfiitidii  m 
\t    this  period  ilinv 
use  is  usually  iii>i'i;- 
rill  or  apoplei'til'urm 
•   motor   realiires  iiiv 
i  of  siH'eeh  and  lu-i- 
son  i)iipil. 
jy  nietilal  exaltiitinu 
"  The  intensity  nf 
es  are  frc(iuont ;  in- 
listerous  cxciieiiirri;. 
terizo   siieh    states 
car  l)eeoniesm;u'kid 
nlless  iiiillion>  nr  tu 
.■ssion  or  oeeupatii'!.. 
Kit  eharaeteristir.  ;i5 
L's,  it  dues  not  always 
eholia  or  hypoi'li.m- 
eliriuni  and  lUinvv 

liiiU  thero  is  marktd 
hiiii-ne  is  also  trfiiui- 
Ipeech  is  slow,  iiitrr- 
jiiecount  of  nnste;iili- 
Ps  letters  gives  vahi- 
iiistancos  the  [mvilj 


fiiriii  and  may  oecur  early  in  tlie  disease.  A  (h'finite  aura  is  not  nneom- 
iiiiiii.  The  attack  nsiially  he^jjins  (»ii  one  side  and  may  not  spread.  There 
may  he  twitchiiiiis  either  in  the  facial  or  lirachial  musides.     'I'ypicid  .lack- 


iiiiaii  epilepsy  iiiiiy 


occur. 


In  a  case  whicli  died  recent  Iv  utulcr  mv  care 


these  sei/.ures  were  atiioiiLj   the  early  syniptoii 


iiid 


the   disease  was  re- 


janled   as  eereliral  syphilid 


!• 


iralysis,  either  nionopie^u-  or   hemiple^qc. 


;iliu 


ly  follow  tlii'se  e[iileptie  seizures,  or  may  come  on  with  ;^r(>at  suddenness 
M   this  staii'e  the   i^ail   hccotues   iiiipaircil.  the   patient 


transient. 


trips  readny,  lias  d 


illici 


iltv  in   .^'iiiiiij;  up  or  down  stairs,  and  the  walk  inav 


tiO 


lastie  or  oeeasionallv  tal)etic. 


his  paresis  may  ije  progressive 


knee-jerk  is  usually  increased.      IMadder    or  rectal  symptoms    gradually 
iJi'Vi'ldp.     'I'lie    patient  heeomi's  helpless,  hedridden,  and  completelv  de 


iiu'Mled,  and  unless  care  is  taken  mav  siilTer  from  hedsore 


1» 


catn  occurs 


111  exhaustion   or    from   some   intercurrent  airectidii.     The  ahsenee  of 


laiii  I'l'action  on  pressure  ii])oii  the  ulnar  nerve 


heliii 


id  the  ejliow 


(B 


lerna- 


ik  symptom)  is  a[iparently  not  of  any  special  value.  The  spinal-cord 
[••attires  of  dementia  paralytica  may  come  on  witli  or  precede  the  menial 
tt'oiihles;  in  80  per  cent  of  the  eases  they  follow  them.  There  are  cases 
ill  which  one  is  in  donht  for  a  time  whether  thi'  .symptoms  iiulieate  tabes 
••r  dementia  ])aralytica,  and  it  is  well  to  bear  in  mind  that  every  I'eiUiire 
'f  jiiv-;itaxic  ttibes  may  exist  in  the  early  stage  of  general  paresis. 

Diagnosis — The  recognition  of  the  disease  in  the  e;iflie-t  stage  is  ex- 
Triiiely  dillicult,  as  it  is  ofttii  imijcssible  to  decide  that  the  .-'ighl  altera- 
tbui  in  eoiidiiet  is  anything  more  than  one  of  the  mooils  or  phases  to 
wliicli  most  men  are  at  times  subject.  The  following  description  by  Fol- 
111  i>  an  admirable  presentation  t)f  the  diagnostic  eharacters  (d'  the  early 
'aire  of  the  disea,se :  "  It  -liould  arouse  snsjiicion  if,  for  instance,  a  strong, 


lii'aitii 


V  man,  in  or  near  the  prime  of  life,  distinctly  not  of  the  '  nerv 


ous, 


:.i'iii'iitic,  or  neurasthenic  type,  shows  .some  loss  oi  niterest  m  his  atrairs  or 
iii|iaired   faculty  of  attending  to  them;  if  he  becomes  varyingly  absent- 

nt.  negligent,  aptithetic,  inconsiderate,  and.  al- 


:,l!ii|cd 
imii^di 


lieeilli'ss 


1T( 


iiiililterei 


able  to  follow  his  routine  iluties,  his  ability  to  take  up  ne 

11 


w  won 


111)  matter  how  little,  diminished  ;  if  he  can  less  well  command  men 


ital 


■oVx'Ul 


lion  and  concentration,  conci'})tion,  perce})tion,  reliection,  judgment  ; 
if  here  is  an  unwonted  lack  of  initialiye,  iind  if  exertion  causes  unwonted 
iii'iital  and  ])hysical  fatigue;  if  the  emotions  art' inleiisilied  and  easily 
'iiaiige,  or  are  excited  readily  from  trilling  causes  ;  if  the  .sexual  instinct 

[  i>  not  reasonably  controlled  ;  if  the  liner  feelings  arc  even  slightly  blunted  ; 
if  the  person  in  question  regards  with  a  jdacid  apathy  his  own  acts  of 
i'ulilTereuce  and  irritability  and  their  conse(|uences,  and  especially  if  at 
•iiiii's  he  sees  himself  in  his  true  light  and  suddenly  fails  again  to  do  so; 
if  any  symptoms  of  cerebral  vaso-motor  distiirb;inces  are  noticed,  however 

I  vacate  or  variable." 

There  are  cases  of  c(M'ebral  syphilis  which  closely  simulate  dementia  para- 
ytieu.    'i'lie  mode  of  onset  is  important,  particularly  since  paralytic  symp- 


I 


070 


mSKASKS  OF   Tni']   N'KRVOUS  SYSTKM. 


t    ---^ 


St',' 


**i*}  i 

m 


T, 


4-4 


m,m 


tmii.-i  iirc  iisiiiilly  early  in  sy|iliilis.  'I'lic  alTcclioii  of  the  sporcli  aii'I  iMni.Mio 
is  lint  in'csciit.  Mpilciitic  seizures  are  more  eoimiioii  aini  imirc  lialili' to 
Ix'ciirtieal  (>v  .laeksoriiiin  in  cliai'aeter.  'I'Im'  expansive  delirinm  is  I'mv, 
W'iiile  syin|il(inis  of  fjfeiieral  paresis  are  not  coniinon  in  eoniieeiion  with 
lilt'  (levelo|)iiient  of  ,i;iiMiniatii  or  deliiiite  yiiiiiiiialoiis  met  ini^itis,  tin  rciui, 
on  the  oihci'  hand,  inslances  of  paresis  wliidi  follow  sypliililic  infcciion 
so  closely  that  an  etidloejieal  eolineetion  lietwccn  the  two  must  he  ai-kiKiwj. 
ed^ed.  J'ost  inortein  in  such  eases  there  may  lie  iiothiii;;  more  than  a 
{^oneriil  arterio-selerosis  ami  dilTiisc  ii)eiiiii<,'o-eneeplialitis,  which  may  |nv. 
yent  iiotliinir  distinctive,  bill  the  lesions,  nevertheless,  may  hi-  caiisdl  liv 
the  syphilitic  virus.  There  aro  certiiin  forms  of  lead  encephalopathy  uiiiih 
resemhlt'  geiionil  piifcsis,  and,  oonsiderini;'  the  associalion  of  plunihisin  uith 
arterio-selerosis.  it  is  ii'it  iinlikelv  that  the  anatomical  siih>tratiim  of  the 
disease  may  result  from  this  poison. 

Prognosis. — Tlu'  disease  rarely  ends  in  rccoV(>ry.  As  a  ride  the  \<\-u<^. 
n'!i^  is  slowly  downward  ami  the  case  terminates  in  a  few  years,  altli(/iii;ii 
it  is  occasionally  prolonged  ten  or  fifteen  years. 

Treatment.— 'i"he  only  hope  of  iiermanent  relief  is  in  tlio  cases  fellow, 
iin;  syphilis,  which  should  \w  placed  upon  larire  doses  of  iodide  of  putas- 
siiim,  Ciucfiil  niirsinc'  and  the  ordeilylifc  of  an  asylum  are  the  diilv 
nieasir.es  necssary  in  a  i,n'eat  majority  of  the  cases.  l''or  sleeplessness  ami 
the  I  pileptic  ;ei/.ures  liromiiles  may  he  nsed.  I'ldloniicd  remissions,  wliirji 
ar..(  not  unco'iunoii,  uro  often  erroneously  attribiiled  to  the  action  uf 
runiedifsi. 

VIM.    TUMORS    OF    THE    BRAIN. 

IMie  following  are  the  most  common  varieties  of  new  growths  with;!; 
the  ei'aniiiin  : 

(d)  Titlirrrh',  which  may  form  large  or  small  growths,  usually  mulliiik'. 
They  are  most  fre(|iient  early  in  life.  Three  fourths  of  the  cases  oi'iur 
uiulor  twenty,  and  ono  half  of  the  patients  are  under  ten  years  ef  .'iiro 
((iowers).  Of  VM)  ca,sos  of  tumor  in  jier.sons  under  nineteen  coliorti'i 
from  various  sources  by  Starr,  1.")'*  were  tubercle.  They  are  most  mum:- 
ous  ill  the  cerebellum  ami  about  the  base. 

(//)  Sj/j)/nlit)ii(i  is  most  commonly  found  in  the  liemispheres  nr  about 
the  pons.  The  tumors  are  superlicial,  attached  to  the  arteries  or  the  iik- 
ninges,  and  rarely  grow  to  a  large  size.     T'hey  imiy  be  !nulti[)le. 

{(■)  (I'limna  (Uid  Neuro(jU()ni<(. — These  vary  greatly  in  appearanc<'.  Tluv 
may  be  firm  ami  hard,  almost  like  an  ai'ca  of  sclerosis,  or  soft  ami  ven 
vascular.  'I'hey  jiersist  remarkably  for  many  years.  Klebs  has  cal: 
attention  to  the  occurrence  of  elements  in  them  not  unlike  ganglion  ri, 
Tumors  of  this  character  contain  "the  spinnen"  or  spider  cells;  cinii'in" 
spindle-shaped  cells  with  single  large  nuclei;  cells  like  the  ganglion-Cfllsj 
of  uerve-centres  with  nuclei  and  one  or  more  processes ;  ami  traii-liuvn'. 


TUMOUS  OF   TDK    lUtAlN. 


971 


nil  iimri'  liaMr  to 
•  <lclirimn  i-  riiiv, 
1  colilirflidll  wiili 
■1  iiijritis,  thiiviii!, 
yphilitic  iMfcrtiiin 

I  must  lie  ;irl\iiii\vl- 
hiii;:  iiiiiiH'  than  A 
i>,  which  iiiiiv  lire- 
iiiiiv  ht'  (MU.-fil  liy 
(■[)h;iln|)iitliy  wliicli 

II  (if  iihiniltisin  whii 
siih>lr;itiiiii  •'[  the 

As  ;i  MiU'  thciivn-. 
few  yours,  ullhm;^:ii 

^  in  the  cases  follow- 
of  iodiile  (if  li'iia-- 
svlum  iirc  the  "iih- 
>\.r  sleel)l«'ssiu'ssa;i't 
,.(!  rciuissioits.  wlii^ii 
d   to    the    iiclioii  uf 


;,  usiuilly  nuiltipW. 

of  tl>e  eases  ocvw: 
vv  ten  years  of  iiL'.' 

nineteen  eolloi'tfi 
ley  are  most  nuim.- 


iini;il-lik(^  llhres,  taperiiii,'  at  eadi  end,  which  residt  from  a  vitreniis  oi'  hya- 
liiii  transfoiination  <if  the  hir;,^e  s|iinine-c(lls. 

((/)  SdrriiiiKi  occurs  most  commonly  in  tlic  mcml  raucs  of  the  lirain 
aii'l  ill  tiie  |ions.  It  forms  some  uf  the  hir,L''csl  and  most  dilVuMh  inlil- 
tniiiii.i,'  lit  iiitrncranial  growths. 

('■)  ('iini/iiniKi  not  infrei|iieiitly  is  sccoiKhiry  to  cancer  in  mher  part-. 
ii  I-  sehhmi  primary.  Oceasioiially  cancerous  tumors  liave  liei  n  found  in 
symmetrical  parts  of  tlu'  liraiii. 

(  /')  Oilier  varieties  occur,  siicli  as  filji'oid  j^niwtlis,  whicli  usually 
develop  from  the  mi'mliraiu's  ;  Ijoiiy  tumors,  which  j:row  sometimes  from 
liie  fal.x,  ami  psauimoma  and  cholesteatoma.  I-'atty  tiunors  are  oecasioii- 
all)  found  on  tlie  corpus  calli>siim. 

(//)  I'l/s/s  occur  bctwetii  the  mciidd'aiu's  aiul  the  hraiii,  the  result  of 
Im  iiiorrha^'e  or  of  softi'iiini;.  l'oreiicc|tlialiis  is  a  seipu'iu'c  of  <'on;^-enital 
alinphy  or  t;f  ha'morrhaj,'e,  or  may  be  due  to  a  develo|)meutal  defect. 
lluiaiiil  cysts  will  he  referred  to  in  th  section  on  parasites.  .\ii  interest- 
ariety  of  the  cysts  is  that  which  i'(j|lows  severe  injury  to  the  skull 
life. 


Il)_'   V 


111  early  liU 

Symptoms.— (1)  General. — The  following  are  the  most  important: 
//w'«A/r/(r,  either  dull,  achiiiLr.^  :n;d.  (  out iiiiious,  or  sharp,  staltliiiiLT.  and  par- 
ii\y~iiial.  It  may  he  dilTused  over  the  entire  head  or  limited  to  the  hack 
Hi' fi'oiit.  In  tlu'  former  case  it  may  extend  down  the  neck,  and  in  the 
littler  he  acconipanied  with  iieui'al,i;ic  pains  in  the  fai'e.  Occasionally  the 
|i:iiii  may  be  very  localized  and  associated  with  tenderness  on  pressure. 

i)/i/ir  Xfurifis.- — This  occurs  in  four  liftlis  of  all  the  cases  ((iowers). 
1'  i-  usually  (louble,  but  oceasioiially  is  found  in  only  oiu'  eye.  A  urowth 
may  develop  slowly  and  attain  (lonsideralile  size  without  producing'  optic 
miiiiiis.  On  the  other  hand,  it  may  occur  with  a  very  small  tumor,  more 
idiiimonlv  in  a  trrowth  at  the  ba.se. 


11)11  fim/. 


This  is  a  common  feature,  and  with  headache  and  <ipti 


iK'iiritis  makes  up  the  characteristic  symiitom  e'roiip  of  cc'rehral  tiiiiuir. 
All  imi)ortaiit  ])oiiit  is  the  alisi'iiee  of  detinite  relation  to  the  meals.  It 
may  he  very  obstinate,  particularly  in  growths  uf  the  cerebellum  and  the 

["Ills. 

<!li'i/i>ii'ss. — This  is  often  an  early  symptom.  The  jiatieiit  complains 
iif  vertigo  on  rising  suddenly  or  on  turning  (piickly.  Mrnttil  Distttrlidncc. 
The  patient  may  act  in  an  odd,  unnatural  manner,  v..  there  maybe  stupor 
aii'i  heaviness.     The  jiatieiit  may  beconio  emotional  or  silly,  or  symptoms 


I'l'^^elllblilH 


;  hysteria  may  develop,      i 


iiiirii 


/.v/o/^s•,  either  iieiieral  and  resem- 


line 


true  opilep.sy  or  localized  (Jacksoniaii)  in  character. 
(•-')  Localizing:  Symptoms.— (")  Ci'iitraJ  Mofar  Amt. — The  synqitom.'? 
iiiv  either  irritative  or  ilestriietive  in  character.      Irritation   in  the  lower 


iin 


10 


1  may  produce  spasm  in  the  muscles  of  the  face,  in  the  angle  of  tl 
miiutli,  or  in  the  tongue.     The  sjiasm  with  tingling  maybe  strictly  lim- 
itL'i.1  to  one  muscle  group  before  e.\teiuliug  to  others,  and  this   Seguin 


A:-r 


[■n 


■l  I 


:M'J 


072 


DISKASKS   OF   TIIK    NKUVol'S   SYSTKM. 


terms  tliP  sii/ntil  si/m/i/niii.  'riic  niiiMIc  tliiid  (if  the  tiKilor  jirca  cuiitjiins 
tli('  ('('iitrcH  (MMilrtilliii^f  the  uriii,  iiinl  licro,  t(»(i,  the  spasm  may  Iiclmh  in 
till'  lini,'('rs,  ill  tlic  tliiimli,  in  the  muscles  of  tint  wrist,  or  in  the  sliunlilrr. 
Ill  tlie  upper  third  of  the  motur  areas  the  initatioii  may  proihiee  <p;i.iii 
he^Mliiiiii;,'  in  the  tnes,  in  the  aiikh'S,  (ir  in  the  iiiiiseh'S  ot"  the  le^;.  In 
many  itistatiees  the  patient  can  ileteriniiie  aeeiirately  the  pnini  of  uriiMn 
tjf  tlie  Spasm. and  there  are  impitrlant  sensory  distiirliaiiees,  siidi  as  nuinli. 
iiess  and  tiii<,dinir,  whieli  may  lie  felt  iirst  at  the  region  alTeeled. 

In  all  (iases  it  is  important  to  deli'riniiie,  (irst,  the  point  of  ori'jin.  the 
si'f/Hfil  si/iiiji/oiii  :  second,  the  order  or  march  of  the  spasm;  and  lliiiij. 
the  8iihse(pU!iit  condition  of  the  j)arts  Iirst  alTected,  whether  it  is  a  state  ef 
j)aresis  or  ana'sthesia. 

Destructive  lesions  in  the  motor  /one  cause  paralysis,  whiidi  is  ufiin 
prece(h'd  hy  local  convulsive  seizures;  there  may  lie  a  iiion(ipleu:ia.  as  (if 
the  leir.  iiiid  convulsive  sci/nres  in  the  arm.  often  due  to  irriiatioii  in  tlic-r 
centres,  'I'limors  in  the  iieiirhhorhood  id'  the  motor  area  may  cause  luciil- 
ize(l  spasms  and  siihse(pienlly,  as  the  centres  aio  invade(l  hy  the  i:iiiwtli, 
jiaralysis  occurs.  On  the  hd't  side,  (growths  in  the  tliird  frctiitiil  or  liroca's 
convohitioii  may  cause  motor  aphasia, 

(A)  I'rcfiiiilul  /tiyiiu/.—  'SvUhi'V  motor  nor  sensory  distiirhance  may 
he  present.  The  j^i'iicral  symptoms  are  often  well  marUeil.  Tlie  iih'-i 
stiikiiii;  featiiri' of  jj'rowtlis  in  this  reiiioii  is  meiiti  "  torpor  ami  L:iailn;il 
iiiiiiecility.      In  its  extension  downward  the  tumor  'nvolve  on  the  lii; 

side  tile  lowei'  fiMiilal  convolution  and  produce  ap..  ,  or  in  its  [irii.'iV" 
backward  clause  irritative  or  destructive  lesions  of  the  motor  area. 

(r)  'I'liniors  in  the  /x/ricfa-ocrijii/f//  Inhc  may  <,n'ow  to  lartre  size  uiili- 
ont  causiiiiif  any  symptoms,  '.''here  may  lie  word-hlindiiess  and  luiii'l- 
hlindiiess  when  the  anirular  iryrus  is  involved,  and  i)ara[)liasiii. 

{il)  Tumors  of  the  lu-cipiinl  luhr  produce  liomiaiiopia,  :ind  a  hilatcral 
lesion  may  produce  hlindiiess,  Tumors  in  this  ret,M(iii  on  tlie  left  htini- 
«jdiere  may  lie  associated  with  word-lilindiiess  and  niind-hliiidness. 

(f)  Tiinioi's  ill  the  /ciii/iordl  luhr  may  attain  a  hirfj;e  size  withoiii  pm- 
diiciiiii:  .symptorns.  In  their  ^n-owtli  they  involve  the  lower  motor  ceiitn-. 
On  the  li'ft  side  involvement  of  the  iirst  and  st'cond  iryri  may  lie  associated 
with  W(ird-<h'afriess. 

(_/■)  'I'umors  fjrowinjj;  in  the  neiizhborliood  of  the  //asal  f/fnit/lin  proiliirr 
lieniiplei>'ia  from  involveiiieiit  of  tlu'  iiiteinal  capsule.  Limited  <,n'owiii«  in 
cither  luicleius  of  the  corpus  striatum  do  not  necessarily  cause  paraly-iv 
Tumors  in  the  thalamus  opticus  may  also,  wdieti  small,  cause  no  syiiipinin-. 
hut  increasinjj:  they  may  involve  tlie  lihres  of  the  optic  radiation,  priiilin- 
iiig  hemianopia  and  .sometimes  hemiana'sthesia.  (irowths  in  this  situatinii 
lire  apt  to  cause  early  optic  neuritis,  and,  i,n'owing  into  the  tliinl  veniiiili'. 
nniy  cause  a  distention  of  the  lateral  ventricles.  In  fact,  pressure  symp- 
toms from  this  cause  and  paralysis  due  to  involvenu'nt  of  the  intiriuil 
capsule  are  the  chief  symptoms  of  tumor  in  and  about  these  ganglia. 


TITMORS   OF  TIIK    lUIAlN. 


978 


itor  arcii  ('niit;iin«' 
sill  iiiiiy  Im'v'iii  in 

r   ill    tllC  sliniiJiliT. 

ly  prdtliH'i'  -|i;i-iii 
s  of  the  \<''j.  Ill 
.'  jMiint  (if  uri;_'iii 
■cs.  siK'ii  as  iiiiiiili. 
lTc(a('(l. 

lint  of  oi'iirin.  lln' 
[liism  ;  iiiid  tliiiM, 
lier  it  is  a  .stair  of 

.sif",  wliicli  is  iifirii 

I110tl0|>l('J.Mil.  as  nf 

irritation  in  iln'-r 
'a  may  caiisc  |im;iI- 
Icd   liy  the  ui'oulli, 

frontal  or  I>n"-,r> 

,•  ilistiirliaiKT  iiiiiy 

larkfil.     'I'lu'  iii'-i 

torpor  and  uTaihini 

■|iviilvc  on  tlu'  K'ft 

,  or  in  its  progivss 

\otor  art'ii. 

to  larsic  si/.f  witli- 

niliu'ss   anil    iniu'l- 

pliasia. 

tia,  an<l  ii  Mlatml 
111   tlic   li'ft  lifiiii- 
bliniliit'ss. 
size  without  pi'ii- 
wcr  motor  ci'iitir-. 
may  hv  associatnl 

il  l/aHj/Jiii  pni'liii''-' 
,iiiiiti'd  jirowtlis  in 
ily  canst'  pal■aly^i^ 
luso  no  syniiiii'iii-. 
radiation,  pmiln'- 
tlis  in  tliissitiKiti"" 
till"  third  vontrirlr, 
ict,  pri'ssuro  syiiip- 
nt  of  the  imu'iial 
these  ganglia. 


(Irowths  ill  tlic  mr/iiirfi  i/inn/n'iii  nn'i/(/  arc  rarily  limilcil,  l»iit  nmst 
cDiiiiiioiilv  in\olvf  tlic  crura  ccrc'.iii  as  \mII.  (>ciilar  symptoms  arc 
iMiiikcd.  'I'lic  pupil  ictlcx  is  lost  a  id  there  i,>  iiysta;,'miis.  In  the  gradual 
i;niulli  the  third  nerve  is  involve,!  as  it  pa.sses  through  the  cms,  in  which 


motor  ociiii  paralysis  on  one  side  and  hemiplegiii  on  tl 


U! 


ni<c  there  will 

(itlicr,  il  coiiihiiiation  almost  characteristic  of  unilateral  cnis  disease. 

((/)   'riiniiirs  of  the  /nuts  and  iiiiihillu.     'i'hc  .symptoiiis  are  cliiitlv  tlioso 
(if  pressure  upon  the  nerves  emerging  in  this  region.      In  disease  of  iIh^ 


III-  the   nerves   mav 


iiivol 


veil   alone  or  with   the  tr.nct 


Of 


I.'   c.'ise.s 


;iii;il\zed   hv   Marv   I'litiiaiii  -lacolti,  there   were    l.'J   in   which   the  cranial 


lici'M'S  were  involved  alolie 


i;;  ii 


I  uliicli  IIh 


liml 


»s  Were  an'ciic( 


IIKl 


!i;  iM 


wiiicli  there  was  lu-miplegiu  and  involvement  of  the  nerves.  Tweiit v-t wo 
111'  (he  latter  had  what  is  known  as  alternate  paralysis — i.  e.,  iiuolvcmeiit 
iif  the  luTVes  on  oiiu  side  and  the  limbs  on  the  opposite  side.  In  four 
cases  there  were  no  motor  symptoms.  In  tuherciilosis  (or  syphilis)  u 
".'inwih  at  the  inferior  and  inner  aspects  of  tlu?  cms  mav  cause  parahsis 
nf  the  third  nerve  on  one  side,  and  of  tins  face,  hyjioglossal,  and  limhs  on 
tlu  opposite  (syndrome  of  Weher).  A  tumor  growing  in  the  lower  jiart 
nf  the  pons  usually  involves  the  sixth  nerve,  producing  internal  strahis- 
iiiii- ;  the  sevi'iith  nerve,  producing  facial  paralysis;  and  the  auditory 
iHTve,  causing  deafness.  Conjugat'  deviation  of  the  eyes  to  the  side 
nliliiisiie  that  on  which  there  is  facial  paralysis  also  occurs. 

Tiimois  of  the  iniditlht  may  involve  the  cranial  nerves  alone  or  cause 
in  MHiie  instances  a  coinhination  of  hetniplegia  with  paralysis  of  the  nerves. 
^il;lls  of  iiritalioii  in  the  ninth,  tenth,  and  eleventh  nerves  are  usually 
|in>fiit,  and  produce  difliculty  in  swallowing,  irregular  action  of  the  heart, 
irn'giilar  respiration,  vomiting,  and  sometimes  retraction  of  the  head  and 
lurk.  The  gait  may  be  unsteady  or,  if  there  is  pressure  on  the  cerebellum, 
;iia\ic.  Occasionally  there  arc  sensory  symptoms,  numbness,  and  tingling, 
Tiiw.u'd  the  end  convulsions  may  occur. 

Diagnosis. — From  the  general  symptoms  alone  tlie  existenci^  of 
luiiiiir  may  bt;  determiiUMJ,  for  the  combination  of  headaclie,  ojitic  neuri- 
tis and  vomiting  is  distinctive.  The  lo"alization  must  be  gathered  from 
tiic  consideration  of  the  symptoms  above  detailed.  Mistakes  are  most 
likely  to  occur  in  connection  with  ura'inia,  hystiiria,  and  general  paralysis; 
liiit  careful  c()nsideration  of  all  the  circumstances  of  the  ca.so  usually  en- 
alili-  the  practitioner  to  avoid  error. 

Prognosis. — Syphilitic  tumors  alone  are  amenable  to  treatment. 
I  nlHiciilous  growths  occasionally  cease  to  grow  and  become  calcified. 
Tile  gliomata  and  fibromata,  particularly  when  the  latter  grow  from  the 
iiicinliranes,  may  last  for  years.  I  have  described  a  case  of  small,  hard 
u'liimia,  in  which  the  Jack.sonian  cjiilepsy  persisted  for  fourteen  years. 
Ilughlings  Jackson  has  rujiorted  ca.ses  of  glioma  in  which  the  symptoms 
lasttil  for  over  ten  years.  The  more  rapidly  growing  sarcomata  usually 
prove  fatal  in  from  six  to  eighteen  months.     Death  may  be  sudden,  par- 


1)74 


DISEASES   OF  THE    NEIIVOL'S  SYSTEM. 


I       .    { 


■    i. 


'  :!,» 


tieiiliirly  in  cf^wths  near  the  nK'ilulla  ;  rnoiv  ooinriioiily  it  i,^  iluo  ti'  cnnia 
in  CDnsciiiiciifc  of  Lrriidual  increase  in  the  intracranial  pressure. 

Treatment.—  ('/)  ]iri/i,.i/. —  If  there  is  a  suspit'idn  (if  syphilis  the 
iodide  of  potassiimi  and  mercury  should  be  ,<riven.  Xowliere  do  we  sec 
more  brilliant  therapeutical  elfects  than  in  certain  cases  :)i  cerebral  Lrutis 
mata.  The  iodide  .should  be  given  in  increasing  doses.  In  tuliei'riileiH 
tumors  tlie  outlook  is  less  favorable,  tliough  instances  of  cui'e  are  repoi'iril, 
and  there  is  post-mortem  evidence  to  show  that  the  solitary  tubei'riil(,n; 
tumors  may  umlergo  (diangcs  and  Ix'come  obsolete.  A  geni'ral  tonic  irta'- 
ment  is  indicated  in  these  cases.  'I'he  lieadaclie  usually  demands  pr<iiii|it 
treatment.  'The  ioilide  of  jtotassium  in  full  doses  son;  'imes  givi'S  inarkti] 
relief.  An  ice-cap  for  the  head  or,  in  the  occi|)ital  lioadache,  the  appliia. 
tion  of  the  I'a'pudin  cautery  may  be  tried.  The  bromides  are  not  of  miiili 
use  in  the  headache  from  this  causi",  and,  as  the  last  resort,  morphia  iiiu-r 
be  given.      For  the  i  onvulsions  bromide  of  })ota,ssium  is  of  little  serviiv. 

{/))  Sinyiriil. — Tmnors  of  the  brain  liave  been  snccessfully  rcniovr,!  !., 
Macewen.  llorsley.  Keen,  and  others.  The  number  of  cases  for  operaiii,;;, 
however,  is  small.  Four  fifths  at  least  of  all  the  oases  are  pi'oliably  un- 
successful, or  of  such  a  nature  as  to  render  an  operation  fatal.  The  iii(i>t 
advantageous  cases  are  the  localized  tibroinata  growing  from  tl\e  dni'a  am] 
only  compressing  the  brain  sulistance,  as  in  Keen's  remarkable  case.  The 
safety  with  which  the  explonitoiT  operation  can  lie  nuidc  warrant-  it  in 
all  doubtful  cases.  For  all  the  receiu  details  and  cases  consult  Stan''' 
Brain  .Surgery  and  vol.  i  of  ('hi})ault"s  larger  work  (i'aris,  1S'.I4). 


pi 


IX.    INFLAMIViATION    OF    THE    BRAIN 

{Siiji/iiirdtiri    h'lifi  jihfilifis  ;    Ali.-icef-s), 

Etiology. — Suppuration  of  the  bnnn  substance  is  rarely  if  ever  pri- 
mary, liut  I'csults,  as  a  rule,  from  extension  of  inllammation  fi'oiii  in  i^ri- 
boring  ()arts  or  infection  from  a  distance  through  the  blood.  "^I'lii'  (|U(  .-ti' ; 
of  idiopathic  brain  abscess  need  scarcely  be  considered,  though  ocea-inn- 
ally  instances  occur  in  which  it  is  extremely  ditlicult  to  assign  a  eau-r 
There  are  three  important  etiological  factors  : 

(I)  Trauma.  Falls  n[)on  the  head  or  blows,  with  or  without  ;i!m:i- 
sioii  of  the  skin.  .More  commonly  it  follow.s  fracture  or  })unctiiii  : 
wounds.  In  this  grou]!  meningitis  is  frccpiently  associate  1  with  tl' 
abscess. 

(■•i)  Hy  far  the  most  important  infective  foci  ;ire  those  \  hicli  aii-'  ^ 
direct  extension  from  di.sease  of  the  middle  ear  or  of  the  nuistoiil  I'li- 
From  the  roof  of  the  nnistoid  antrum  the  infection  readily  passes  te  tin 
sigmo''(  sinus  and  induces  an  iid'ective  thrombosis.  In  other  instants th' 
dura  becomes  involved,  and  a  sub-dural  abscess  i.s  formed,  which  mi' 
readily  involve  the  arachnoid  or  the  pia  mater.     In  another  group  iii' 


njHiLLniLiuiHai 


/  it  is  due  t"  coma 

on  of  sy|iliilis  the 
Sowliero  do  wc  sec 
s  of  cc'rcliral  liuii;- 
'S.      Ill  tiilKTriilous 
f  <'Ui'e  iuv  rc[.orti'il, 
olitiiry  tubcrciiliius 
n'lU'ral  Idiiii'  Ivfiit- 
V  (U'liiands  pruiiiK 
■inu'S  givos  niarkiil 
L(lil('ll(.',  tlic  iipiilii-i- 
U's  are  not  of  inurii 
sort,  iiioriiliia  must 
s  of  littlo  scrvicr, 
.'ssfiillv  n'liKivfi!  !iy 
casi's  for  o|i('rarKiii, 
3S  arc  [U'olialily  im- 
in  fatal,      riu'  iii"-i 
J  from  till'  dura  ami 
uarkablo  case.    'I'ln' 
iiaiio  warrants  it  in 
uses  consult  Starr's 
iris,  1S',I4). 


is  rarely  if  over  jiri- 

latioii   from  lu-iidi- 

dod.     1"lic  ([iic-ti":! 

d,  though  occa-imi- 

to  assign  a  '■an-, 

1  or  witliout  iiiini- 

■tiirc    or    puni'tii'''-! 

v<ociatc  1    wiili  '''■' 

those  >  hicli  an-'-  >' 
)!'  the  mastoid  cil!-- 
readily  itassos  to  tfe 

other  iiislancr?ili'' 
formed,  which  imtv 

auother  gronii  tin 


IXn.AMMATloX    OF    TlIF,    liRAIX. 

intlammation  extends  along  the  lyiiijih  spaces  or  the  thromljoscd   w 
into  the  substance  of  the  bi'ain  and  causes  su[)|)iii'atii>n.     M 


'lO 


ins. 


iccweii  thinks 


that  without  local  areas  of  meningitis  the  infective  agents  may  be  canicd 
thnnigli  tlio  lymph  and  K'nod  (diannels  into  the  cerd     i,    iibstaiice.      In- 


fi'i'tiou  which  extends  from  the  roof 


he  mastoid  process   is  most  likciv 


to  he  followed  by  abscess  in  the  femporo-splieiioi''   I  l-^he,  wliile  infection 
extending  from  the  posterior  wall  causes  most  fretp  ■     tly  sinus  thrombosis 


;iii(l  cerebelliiV  ab.ice.vs 


;'))   In   septic   processes.      Abscess   of   the  brain   is  not  ofi 


en  touml  in 


iivami 


a.      In    nlceriitive    endocarditis    mull 


iplc    foci    of    suiiiiuiatioii    af( 


(.■oiiiiiion. 


iOcalized  bone  disease  and   suppuration    in  tlie  liver  are  occa- 


oiial  causes.     Certain  inllammations  in   the  liin 


particularly  bromdii- 


I'ctiisis,  wlii(di  was  j)resent  in  IT  of  oS  cases  of  these  so-called  "piilmonal 
I'cn'bral  iibsces.ses "  collected   bv    11.    '1'.    Williamson,  are  liable   to  be   fol- 


io wei 


1  by  abscess.     It  is  an  occasional  complication  of  em]i\ema. 


.\1 


)scess 


of  the  brain  may  follow  the  specilic  fevers.  I'ti'istowc  has  called  attention 
to  its  occiirreiicc  as  a  seipiel  of  intltieiiza.  The  largest  number  of  eases 
occur  between  the  tweiitielh  and  fortieth  years,  and  the  condition  is  more 
fivijiient  in  men  than  in  women. 

Morbid  Anatomy. —' The  abscess  maybe  solitary  or  multi[)Ic.  dif- 
fuse or  circumscril)ed.  In  the  acute,  rapidly  fatiil  cases  following  injury 
the -iippuriition  is  not  limitc(l ;  iuit  in  long-standing  cases  the  al»scess  is 
fiirliised  in  a  delinite  cansule,  whi(di  mav  have  a  thickness  of   fi'om  two  l(» 


live  niillimetr 


es.      1  he  pits   varies   much   in   appearance,  depeiidin::   upon 


the  aire  of  the  abs 


cess 


In  earlv  cases   it   mav  be   mixed    with   reddi>h 


li'lin's  and  softened  lu'ain  matter,  Init  in  the  solitary  encapsulated  absces.- 
ho  [Ills  is  distinctive,  having  a  greenish  tint,  an  acid  reaction,  and  a  pc' 
li.'ir  odor,  .sometimes  like  sulphiii'otted  1 

Ih 


(■11 


IVllroi,^'!!. 


he    btaiii   subst.-ilice 


irroiindine;  the  abscess  is  usuallv  (edematous  and   inldtrate( 


Tl 


le  size 


varies  from  tlnit  of  a  walnut  to  that  of  a  laroe  orange.  Therti  are  cases 
on  record  in  wliicli  the  cavity  litis  occupied  the  greater  portion  of  a  liemi- 
>|iliere.  Multiple  ub.scesscs  are  usually  -mall.  In  four  lifths  of  all  cases 
tlic  absc(\ss  is  solitary.  Suppuration  occui^-s  most  fre(pienily  in  tlie  eere- 
hrimi,  and  the  temporo-s[ilienoidal  lol)e  is  more  often  invidved  than  other 
parts.  The  cerebellum  is  the  next  iiujst  common  seal.  [);irticulaily  in  con- 
lu'ciion  witli  ear-diseas 


se, 


Symptoms. 


''ollowing  injury  (U^  oiieration  the  disease  may  run  an 
U'lile  course,  with  fever,  headache,  <lcliriuin.  vomiting,  and  rigors.  The 
symptoms  are  those  of  an  acute  meningo-eiicephalitis.  and  it  may  be  very 
ilillicidt  to  determine,  unless  there  are  localizing  syiin)toms,  whether  there  is 
ivally  suppurttion  in  the  brain  sul)staiice.  In  the  cases  following  ear  dis- 
ease the  symptoms  may  at  tirst  be  those  of  meninge.il  irritation,  '{'here 
may  ho  in  italiility,  restlessness,  severe  headache,  and  aggravated  I'arache. 
Other  striking  symptoms,  particularly  in  the  iiuu'e  [»rolongeil  cases,  are 
diowsiiiess,  slow  cerebration,  vomiting,  and  optic  neiirilis.     In  the  chronic 


\'<l 


070 


DISEASES  OF   T[IR    NERVOUS   SYSTEM. 


form  of  brain  abscess  wliicli  may  follow  injury,  otorrboni,  or  loi  al  IniiT 
trouble,  there  may  be  a  latent  pei'iod  ranging;  from  one  or  two  wciks  to 
several  months,  or  even  a  year  or  more.  In  the  "  silent  "  re<,n()ii>.  when 
the  aljscess  becomes  encapsulated  then-  may  be  no  sym])toms  wlmtcvir 
durinj;  the  latent  [u'l'iod.  Durinir  all  this  time  the  patient  may  be  luiijcr 
careful  observation  and  no  suspicion  be  arouscil  of  the  existence  of  siiii- 
})iiration.  Then  severe  hoadaidie,  voinitini:,  I'cvcr,  set  in,  peilmps  with 
a  chill.  An  Arab  was  admitted  to  my  wards  at  the  rnivcrsiiv  ll(i>. 
pital  in  a  condition  of  jirofoiiiul  amemia,  having,'  licen  picl\e(l  up  bv  lii^. 
police  in  the  street,  covered  wit,h  t)lo()(l.  There  was  a  snutli  Idealized  an^i 
of  dulness  in  the  tliird  and  fourth  interspaces  on  the  right  side  <'lnse  i,,  tin. 
sternum,  aiul  althouLrb  no  tuber(d(;  bacilli  were  fouiul,  it  was  thoiiirlit  to 
be  probably  a  localized  tuberculosis,  lie  recovered  rapidly  from  the  aiia'- 
mia,  and  within  three  months  was  strong  and  well.  A  few  days  In-fniv 
his  intcmh'd  discharge  be  begai\  to  comjilain  of  iK'adachc,  which  heramo 
aggravated.  He  had  vomiting,  fever,  and  gradually  increasing  coma.  A 
hirge,  solitary  encapsulated  abscess  was  found  in  the  parieto-occipital  ii'^iun 
of  the  left  hemisplicrc,  and  in  the  middle  lobe  of  the  right  lung  a  cinaiin- 
scribed  cavity,  jtrobably  bronchiectatic,  surrounded  by  fibroid  tissue  aiul 
containing  a  very  oll'cnsive  pus.  So,  too,  after  a  blow  upon  the  head  ma 
fracture  the  .sym|)toms  of  the  lesion  maybe  iransient,  and  months  after- 
ward cerebral  symptoms  of  the  most  aggravated  character  mtiy  develop. 

The  locali/t.tion  of  the  lesion  is  ofti'U  dillicult.  In  or  lU'ar  the  meter 
region  there  uuiy  be  convidsions  or  paralysis,  and  it  is  to  lie  reiiieiHl)eiv>i 
thai  an  absee.ss  in  the  temporo-spheiuiidal  lobe  may  com])rcss  the  jnuvr 
motor  (UMitres  and  prodiu'c  jiaralysis  of  the  arm  aiul  faeeand  on  the  left. quf 
cause  aphasia.  A  hirge  abscess  may  e.xist  in  the  frontal  lobe  without  caii." 
ing  paralysis,  but  in  these  cases  there  is  almost  always  some  mental  dull !(>.■;.<. 
In  the  temporo-sphenoidal  lobe,  the  common  seat,  there  may  hi'  iu>  fecaliz- 
ing  symptoms.  So  also  in  tiie  parieto-occii)ital  region  ;  though  here  early 
examination  may  lead  to  the  detection  of  hemiano[)ia.  In  abscess  ef  the 
cerebellum  vomiting  is  common.  If  the  miildle  lobe  is  affected  there  iiiiiv 
be  stagfrerini; — cerebellar  incoordination.  Localizinsr  svmptoms  in  \hc 
pons  and  otlier  parts  are  still  more  unci-rtain. 

Diagnosis. —In  the  acute  cases  there  is  rarely  any  doubt.  The  hi- 
tory  of  injury  followed  by  fever,  marked  cerebral  symptoms,  the  devi|ii|i- 
nient  of  optic  luuiritis  and  rigors,  delirium,  and  p«  'haps  paralysis,  iiiiikt 
the  diagnosis  certain.  In  chronic  ear-disease,  such  cerebral  synipteins  ;i; 
drowsiness  and  torpor,  with  irrcgidar  fever,  supervening  upon  the  ces>atinu 
of  a  discharge  should  excite  the  suspicion  of  abscess.  It  is  j)artieuhirly 
in  the  chronic  cases  that  diibculties  ari.se.  The  symptoms  «e.seiidile  tiin.<t 
of  tumor  of  the  brain;  indeed,  they  are  those  of  tumor  plus  fever.  In  a 
patient  with  a  history  of  traiuna  or  with  localized  lung  or  pleural  tnuihlf. 
who  for  weeks  or  months  has  had  slight  lieadacdie  or  dizziness,  the  oii.'^i'tuf 
a  rapid  fever,  intense  headache,  and  vomiting  point  strongly  to  iibscvi^s. 


CnROXir   ITYDROCEl'IIALUS. 


97 


Maor-won  lays  stress  upon  tlio  value  of  {)orenssioii  of  the  skull  as  an  aid  in 
iliiiuniiisis.  'Vhi'  note,  wliicli  is  uiiiforinly  dull,  becotni'S  much  more  res(»- 
iiiiiU  when  the  lateral  ventricles  are  distended  in  ci'ri'bellur  abscess  and  in 
Kiiiditions  in  wliirh  {ho  vena*  (ialciii  arc  compressed. 

It  is  not  always  easy  lo  determine  wlietlier  the  meninsres  are  involved 
ivitli  the  abscess.  Often  in  ear-disease  the  condition  is  that  of  meniiigo- 
.;rr|ilialitis.  I  have  already  referred  to  a  condition  sometimes  associated 
viih  car-disease,  which  may  simulate  (dosely  cerebral  nionintiitis  or  even 
aiisoess.  Indeed,  (Jowers  states  that  nnt  oidy  may  those  general  symptoms 
!.[irH(luced  by  ear-disease,  but  evendistinct  ojitic  neuritis. 

Treatment. — A  remarkable  advance  has  been  made  of  late  years  in 
;  aliiiLi'  with  tiiese  cases,  owing  to  tlie  iin|)iinity  with  wliicdi  the  Iirain  can 
r  i'\iilore<l.  In  ear-disease  free  discharge  of  the  iidlamtiialory  pi-n(hicts 
'•'n\i\.\  be  promoted  and  carefnl  disinfection  practised.  'I'lic  ti'catmenlof 
iiijurii'S  and  fractures  comes  within  tlie  scope  of  the  surireon.  'I'he  acute 
-inptoms,  smdi  as  finer,  headache,  and  delirium,  must  be  treateil  by  rest, 
„:,  iie-cap,  and,  if  necessary,  local  depletion.  In  all  eases,  when  a  rcason- 
;i!)le  suspicion  exists  of  the  occurrence  of  abscess,  the  tri'phiiu'  shoidd  bo 
Liiplied  and  the  brain  explored.     The  ca.ses  follo\viii<f  ear-disease,  in  which 


y  HUl) 


puration   is  iu  the  temporo-s[)henoidal  lobe  or  in  the  cerebellum, 


111-  the  most  favorable  (diances  of  i 


ecoverv. 


'I'he  localization  can  rarelv 


made  acenratelv  in  these  case.> 


and  til 


e  o])t'rator  uni 


St    I 


)c  ffuiikd  more 


iyfrt'iieral  anatomical  aird  patholotncal  knowledire.     Ii 


1  eases  o 


f  iniurv  the 


t:vp 


hiue  slioiild  be  a])plied  over  the  seat  of  the  blow  or  the  fracture.     I 


n 


i:ir 


-di'caso  the  supjmration  is  most  freqiu  nt  in  the  ti'mporo-sphem)idal 
•!ii' or  in  the  cerebellum,  and  the  operatii'ii  should  be  performed  at  the 

lints  most  accessible  to  these  reirion 
liiiirlit  almost  say  essential,  factor 
rmiial  su])]Miration  is  an  intelliirent  I 


And 


istiy.  a  most  impoi'tant,  one 


le  successful  treatment  of   iiitra- 
ujetiu'con  Wn'  part  of  the  siu;j<.'"ii 


'  the  w 


urk  and  works  of  William  Macuweii 


X.    CHRONIC    HYDROCEPHALUS. 


Definition.  —  A  condition,  conireuital  or  aeipiired,  in  \hiidi  thenMS 
i-i'i'iit  aeetimulati(Ui  (if  iluid  within  the  ventricles  of  the  brain. 

The  terui  hydrocephalus  has  also  been  applied  to  the  cdlh^  tin'   of  fliuil 

"'iweeu  the  cortex  of  the  brain  aiul  the  skull,  kiunvn  ii\   tin-  -''  ,ation  as 

I ''■'.' /(■/•// //.s'  or  //.  e.r  vaoio,  u  condition  common  in  cases  of  at    'pliy  of  the 

'-liii  substance,  and  perhaps  caused  also  by  iiK'nintreal  cysts.      A    true 

'fsy.  however,  of  the  aracluioid  sac  probably  does  not  occur. 

The  cases  may  be  divided  into  two  groiij)s,  coMgeuilai  or  infantile,  and 
W'liidary  or  accpiircd. 

(1|  Congenital  Hydrocephalus. — 'I'lie  eidarged  head  nuiy  obstnut 
l''''"ii';   more  freipiently  the  condition  is  noticed  some  time  after  birth. 


'.>78 


DISEASES  OF   THE   NERVOUS  SYSTEM. 


**■ 


'I'lic  causo  is  unknown.     It  has  occurred  in  several  members  of  tlic  smnc 
I'umily. 

Tlie  auatomicial  coiHliiion  in  tliese  cases  olTers  no  clew  to  the  niilnrciif 
the  trouhle.  'Plie  lateral  ventricles  are  enormously  distended,  but  \y 
cpeiidyma  is  usually  clear,  sometimes  a  little  thickcauM]  ami  <i;ranul;ir,  ;ii.l 
the  veins  lar;;e.  Tlie  (dioroid  plexuses  are  vascular,  soinetinuissclereiic.liii; 
often  natiiral-lookini,'.  The  tliiril  ventricle  is  enlarii^ed,  the  ai|ueuiict  i,f 
Sylvius  dilated,  and  the  J'oui'th  ventricle  may  he  distended.  'I'he  i|iiamiu 
ol"  fluid  may  reacii  s(>veral  litres.  It  is  lim|iid  and  coiit.ains  a  trace  di 
ailiumin  and  salts.  The  changes  in  eonse(|iien(!e  of  this  enormous  ven- 
tricular <listentioii  are  remarkable.  Thccerel)ra!  (!ortex  is  srreally  atretelie' 
and  over  the  middh'  rciriou  the  thickness  may  amount  to  no  moi'c  lliiiiin 
few  millimetres  without  a  tra(!e  of  the  suha  or  convolutions.  The  Kastl 
^aTiirlia  arc  llattened.  The  skull  eidarires,  and  the  cii-cumference  of  ihc 
head  of  a  I'hihl  of  three  or  four  years  may  reach  twenty-live  or  even  tlii:i\ 
inches.  Tht^  sutures  widen.  Wormian  Ijone  develop  in  them,  mimI  tin 
bones  of  the  craiuiim  beconu-  e\cee(lini;ly  thin.  The  veins  are  markeil  iir- 
neath  tlu;  skin.  A  lluctuation  wave  may  sometimes  he  ohtaineil,  and 
Kishei'V  brain  nnirmur  may  be  heard.  'l"he  orbital  plates  of  the  trnntul 
bone  are  depn^ssed,  causimj  exophthalmos,  so  that  the  eyeballs  eaniioi  ik 
covered  by  the  eyelids. 

C'onvulsioiis  may  occur.     The  rellexes  are  increased,  the  child  learii< 
to  walk   late,  and   ultimately   in  severe  cas(>s  the  leirs  become!   feeble  aini 
somctiuH's  spastic.     The  Tiienlal  condition  is  varial)le:  the  child  may  !»■ 
briirht.  'out,  as  a  rnlc.  there  is  some  firade  of  imix'cility.     TIk;  conLreiiitiil 
cases  usually  die  wiihin   the  lirst  four  or  live  years.     Th(>  process  iiiav  i 
arrested  and  the  patient  may  reach  adult  life.     Cases  of  this  sort  ;ii'e  i; 
very    uncommon.      Kveti    when   extreme,  the    mental    faculties    may    ■■ 
retained,  as  in    Uriudit's  celebi-ate(l  j)atient.  Cardinal,  who  lived  to  tlieuL' 
of  t  wenty-niiu',  and    whose  head  was  translucent  when  the  sun   was  >ii,  ■ 
in<i  behind  him.    Care  must  be  taken  not  to  mistake  the  rachitic  Inaill    j 
liyilroee|>halus. 

Miiiiinjilis  .scrnsn. — (Quincke  distiuiruishes  a    sovous  meiuti<:itis  fi'"'! 
ordinary    leptomeninjiitis   and  from  hydroci  ohalus.     The  all'e<'ti()ti  lUi 
come  on   acutely  in  childi'cn,   with   pain    in   the  lu'ad,  retraction  <if  i; 
tu'ck,   and   sisjrn-  of  iiu'reased    intra-cranial   ju'essure,   choked    disk,  sjnv 
pul>e,  I'tc.      Delirium,  c(ui\ulsions,  ami  local  paralyses  may  occur,     i'ei" 
is  absent.     In   other  instam-es  the  ons(>t   is    more    insidious,  tlu^  luui-' 
■more  chronic,  and   the  condition   is  mistaken   usually  for    brain   tinn  : 
Anatomically  a  niei\in,<i^itis  ventrieularis,  with  distention  of  the  veiitriei-j 
(acute  hydrocephalus)  with  n.  clear  exu(hite  is  found.     The  diaijno.-i:^  l'i'"iJ 
tiunor  is  very   ditlicult.     The   lumbar    p\iiu'[ure  may  be  made.     .\  H"  I 
with  a  specilio  f^ravity  of  l,(>t'''.  with  albujiun  above  2  per  1,001),  is siij.'i.'o>;-| 
ive  of  hydrocephalus  throUL''!)  blood  stasi.s. 

(2)  Acquired  Chronic  Hydrocephalus. —This  is  stated  to  be  occasiuiiailyj 


J   «..i  .     \m 


KM. 

lu'inbors  of  tlie  same 

olow  to  the  natiu'i'iif 
,•  (listiMuU'il,  hut  tlif 
ril  iiiiil  fj;riuuilai',  ;u.i 
lUftinK^^sclcri'Ui'Jiu; 

•0(>(!,   IIh!  iUllU'ilui't  i.f 

.>ii(l('d.  The  <iiiauui\ 
I  conbiinrt  u  irarc  i.f 
if  this  ('nonii<iii<  wn- 
rx  is  irniatlystri'trluM. 
int  to  no  luorc  tluiii  ;i 
ivolutions.  'I'liv  li;isil 
»  circuniferoiu'c  of  ihi' 
■  iilv-tivc  ort'vcii  iliivi} 
op  in  tlieni,  and  tin 
V.  veins  iU'f  nmrkcd  in- 
iiiHS  he  olttiiincd.  mA 
ill  phitcs  of  tin-  frniiUii 
tin;  cychallH  canma  u- 

Tiisi'd,  tlu'  cliiltl  li'iini-j 

[»crs  luM'onic  fi'fliK'  aini 

1,1,.;  ti\('  ehil<l  iiiav  I.' 

•ility.     'Hh!  fonu'fiiii  ii  I 

Tho  jirotn'ss  iiiav 

;  of  this  sort  aiv!i"-| 

iitul    faculties    may  :»■ 

I,  who  li\e(l  t<i  lln'M'.''' 
lien  the  sun  was  >\u:A 
e  the  niehitie,  head  I  ■  j 

L-ous  iiieninililis  fi'""' 
Is.  The  alVeetioii  iu:iv 
liead,  retract ii'ii  "f  lli-' 
]iv,  choked  disk,  slnw 
IscH  may  occur.  If^'f 
insidious,  the  ediiiv 
lially  for  brain  tn"""' 
Intion  of  the  vciitrirl- 

II.  The  dia<In^^i^f|■""lj 
liiav   be  nuide.     A  I.' 

2\m-  1,000,  is  .Mi;:L't'^i' 


CHRONIC   IIVDUOCHIMI.M.US. 


979 


primary  (idiopatliic) — that  i«  to  .say,  it  comes  on  .spontaneously  in  the 
ailiiit  witliout  observable  lesion.  Dean  Swift  is  said  to  have  died  of  livdro- 
{■(■|ihalus,  but  this  seems  very  uidikcly.  It  is  base(l  upon  the  ,-tatement 
that  "  Ih^  (.Mr.  Whiieuay)  opened  the  skull  and  found  much  walei'  in  llui 
lirani,"  a  condition   no  douiit  of  //.  r.r  riicim^  dne  to  the  wasliiii,f  associated 


with  his  proloULTc 


d  ill 


ne.ss  ami  paralvsis. 


In  nearlv  all  cases  there  iseilher 


a  tiiuior  at  the  base  of  the  brain  or  in  the  third  ventricle,  which  eomj)res.se.s 
liii'  veme  (Jal'  lli.  The  passaire  from  tlu>  third  to  the  fourth  ventr'cle  may 
lit'  rjdsed,  either  by  a  tumor  lu-  by  parasites.  More  rarely  the  foiameii  (d' 
ii:endic,  ihi'oimh   which   the  ventricles  communicate   with   the  eerehro- 


M 

s|iiiial   meiiiui^'es,  iH-conics  closed  by  menin^dti.- 

I'in 


Tl 


lese  eoiKiUioiis,  occur- 


ir  in  adults,  may  produce  the  most  extreme  hydrocephalus  without  any 


I'tilarizement  of  the  head.     Kven  wiieii  the  tumor  betdns  oarlv  in  lil 


IKM'O 


liiav 


be  n 


o  exiiansion  o 


f  tl 


Kill 


u  the  case  of  a  lmi'I  au'ed  sixteen,  hlim 


fi'eiii  her  third  year,  the  heail  was  not  unusually  lar,i,H\  the  ventricK'.s  were 
ciiermously  distended,  and  in  the  h'olamlic  rei,don  the  brain  substance  was 
oiilv  live  millimetres  in  thickness.      A  tumor  occunied  the  third  ventri(de. 


In  a  case  01  ciiolcstcatuma  ol  the  floor  o|  the  tlurd  ventricle,  in  whicli  llu; 
-yiii|itoms  persisted  at  intervals  for  eiirht  or  nine  years,  the  ventricles  were 
iiiiirinoiisly  distemU'd  witluuit  cnlarixement  of  the  skull,  in  nilier  in- 
slaiices  the  sutures  sej)arate  and  the  head  jfradiially  enlar<res. 

The  .symptonus  of  hydrocephalus  in  the  adult  are  curiously  variable. 
lu  the  lirst  ca.se  mentioned  there  were  earlv  heiidachcs  and  irradiial  blind- 
in>s ;  then  a  proloiiij^cd  period  in  whi(di  she  was  able  to  attend  to  her 
Headaches    aLraiii    siipervene<l,   the    i^ait    became   irrei,nilar  and 


stmlle.- 
■uiiiew 


h;it  ataxic.  Death  occurred  suddenly.  In  the  other  case  there 
wt'ic  prolonn(!(l  attacks  of  cnina  with  a  slow  pulse,  and  on  one  occasion  the 
|ialii'iit  remained  unconscious  for  more  than  thnc  months,  (iradiially 
essiiiif  optic  neuritis  without  focal i/iu.u;  symptoms,  headache,  and 
s  of  .somnoh'iice  or  coma  are  su^f,ij;estive  symptoms.     ('as( 


l»ni,LM 
.itlack 


are  rare 


as  a  re>u 


It  of 


meiiiiiiritis. 


Th 


ponueil   t( 


tl 


le 


po; 


le  only  instaiu'cs  I  have  seen  were  two  wliiel 
iterior   lueiiiiiLritis  of  (lee  and    P)arlow.  in   which 


with 


M, 


the  distention,  there  was  extensive  (dironie  pnrnleiit  epemlymitis. 
Treatment. — Very    little  can    he    done    to     relieve    hydrocephalus. 


•iiies    are    powerless    to    cause    the    alisorption    of  the  lluii 


M 


ore 


rational  is  the  system  of  arradual  compre.ssion,  with  or  without  the  with- 
'iraual  of  small  (piantities  of  the  lliiid.     The  <-ompression   may  be  made 


liv  means  of  broad  plasters,  so  applied  as  to  cross  each  other  on  the  vertex, 
and  another  may  be  placed  round  the  circumference. 

Of  late  years  f)uncture  of  the  ventriides,  an  operation  which  had  been 
fi'niii|  iiliiindoned,  has   been   revived,  but   when   pressure   symptoms  are  marked 
t^iiiiieke's  procedure  may  be  used.      He  recommends  puncture  of  the  sub- 
arachnoid sac  betweeen  the  third  and  the  fourth  lumbar  vortebra'.    At  this 
piiiiit   the  s[»iual  cord  cannot  be  touched.     The  a(lvantajj;es  are  a  slower 
lt't-1  to  be  occasieii;iiljH  ''^"'"^al  of  lluid  and  less  danger  <d'  collapse.     Browning  (William),  who 


'.HO 


DISEASES  OF  'I'lIE   NERVOrs  SYSTEM. 


m  r 


"/ 


liiis  ])nictisc'(l  tlio  mctliotl,  rccotmiu'tHls  tiie  use  of  u  siiiof)tli,  (inn.  aspi. 
mtiiig  needle,  .No.  o,  iiml  to  enter  between  tlu!  ttiinl  and  i'ourtli  IninlMi 
vertebrie,  a  little  to  one  s'uh'  of  tlie  median  line,  in  adidt ciises  the  (li'|itii 
insertecl  is  altont;  .">  centimetres ;  in  children  ^'-r)  eeiiliinetres.  The  ijiiim. 
tity  which  has  been  removed  at  u  sitting  is  from  one  to  one  and  a  li;ilf 
ounce.  It  has  boon  used  with  .siiccoss  in  tuberculous  meningitis  (ji.  ',i,;;i. 
and  is  certaiidy  worth  trying  as  a  means  of  relief  in  cases  of  greatly  in- 
creased l)rain  pressure. 


I 


1^.^ 


!    [ 


I  ?  a. 


V.   GENERAL   AND   FrNCTIOXAE    DISEASES. 

I.    ACUTE    DELIRIUM    '.nr/r.s   Mania). 

Definition. — Acute  delirium  running  a  rapidly  fatal  coiu'so,  witli 
slight  fever,  and  in  which  post  mortem  no  lesions  are  found  sidlieiciit  i. 
account  for  the  disease. 

Cases  are  Tej>orted  by  many  old  writ(.'rs  under  the  term  brain  fevrrnr 
phrenitis.  l>ell,  at  the  time  Superintendent  of  the  McLean  Asylum,  di- 
Bcribed  it  *  accurately  under  the  designation,  "  a  form  of  disease  resenihliiii: 
some  advanced  stages  of  mania  and  fever." 

'I'he  tlisease  nuiy  set  in  abruptly  or  be  ])receded  by  a  period  of  irrita- 
bility, restlessness,  and  insomnia.  The  nu'utal  symptoms  develoii  with 
rapidity  and  may  (piickly  reach  a,  grade  of  the  most  intense  frenzy.  Tluiv 
are  the  wildest  hallucinations  and  outbreaks  of  great  violence,  "i'lie  pa- 
tient talks  incessantly,  but  incoherently  and  unintelligibly.  No  sle('|i  i- 
obtaiiietl,  ami  at  last,  worn  out  with  the  intensity  of  the  muscular  iimv'- 
meuts,  the  patient  becomes  utterly  jtrostrated  and  assumes  the  siitiiij:  nr 
reeund)ent  posture.  Tlier'-  may  sometimes  be  delinite  salaam  movenuiit^, 
and  in  a  case  which  I  saw  at  Westphal's  clinic  tlu-  [)atient  iiu'essamly 
nuule  motions  as  if  working  a  [)ump  handle.  After  a  [leriod  of  intnisi' 
bodily  excitement,  lasting  for  from  twenty-four  to  thirty-six  hours  ni 
longer,  the  [latient  can  be  examined,  and  presents  the  conditions  wliirli 
Bell  described  as  typho-mania.  The  temj)eraturo  ranges  from  in;!'  to 
10-4°,  or  even  higher.  The  tongui!  is  dry,  the  pulse  ra])id  nnd  iVrltli', 
and  sometimes  there  are  seen  on  the  skin  bnlhe  and  pustuli's,  and  fn- 
quently  sores  fi'om  abrasion  and  sidf-inllicted  injurii's.  Toward  the  il"-'' 
or,  according  to  S])itzka,  even  during  the  development  of  the  disease  tlniv 
may  be  lucid  intervals.  There  may  be  jtetechia!  <tn  tlu'  skin,  and  nl'iiii 
there  is  marked  I'ongestion  of  the  face  and  extremities.  The  duration  "t 
the  disease  is  variable.  Very  acute  cases  may  tormiiuite  within  a  woik; 
others  j)ersist  for  two  or  even  three  weeks.     The  course  of  the  discasii' 


*  Amerieuii  Jouriml  of  Irisunity,  1849, 


;m. 


ACUTE    DELIUIUM. 


lt>^l 


smooth,  firm.  ;i>|ii. 

anil  foiu'lli  liiiiiliiir 
(lult  (sises  the  ili'|illi 
mcti'cs.     Tlic  iiiiaii- 

to  one  and  a  luiit 
nu'niu,i;itis  ((i.  ',).); i, 

cases  of  gi'c'iiily  in- 


DISK 


^iVRlt,^ 


I II I  a). 

ly  fiital  courso,  with 
c  found  siitliciont  tn 

:<  term  brain  frvcr  nr 
McLi'iUi  Asyium,  di- 
of  (UseuriC  rL'Semliliug 

by  a  period  of  irrita- 
nptoms  (levcloii  with 
ikMise  i'ri'uzy.    Tluif 
it  viok'nce.     'I'hf  1«- 
lii^nlily.     No  sli'r[i  i- 
.!iL'  muscular  iiiovi- 
isunu'S  tlie  silting  "f 
salaam  movcnuiits, 
patient  incessainly 
a  period  of  intciiH' 
thirty-six  hours  ur 
the  eondilions  wliiih 
anjres  from    l""i    t" 
rapid  nnd  fiH-Mt', 
id   pustules,  and  in- 
Toward  the  vl'-f 
it  of  the  disease  lliero 
the  skin,  and  "ft'" 
ics.     The  duration  "i 
inate  within  a  wock; 
urse  of  the  disfusi'!> 


aluiiist  uniforndy  falal.  The  amdotiiieal  eonditiou  is  praetieally  ne^ra- 
tivc,  or  at  any  rate  presents  ixitliiiiLC  distinctive.  Tlicrc  is  trrcat  venoM.s 
.'nrifenieid,  of  the  vesscds  of  the  meinn<,'i's  and  of  the  i^ray  cortex.  In 
I  cases  in  whieji  1  made  a  careful  micntscopic  cxaminiitinu  (d'  the  i:rav 
ittcr    tliere  were  jierivascular  exudation  and    leucocytes   in  tlie  lymph 


ni 


hi'Mths  and  perii^'anujliar  space 


In  tl 


le  inspec 


lion  of  fatal  cases  cd'  a<'Ute 


ili'jiriiim  cand'nl  examination  should  he  made  of  the  Innirs  and  ileum.  It 
.Imiild  he  liorne  in  nniid  that  in  a  niiijurity  of  the  cases  dyini.'  in  this 
iimiiiicr,  there  is  i'ni,MirircnH'nt  of  the  liases  (>['  the  luuirs  ore\en  deglutition 


piu'innoiiia. 

Tile  nature  of  tile  disease  is  (piitc  unknown.     Some  of  t lie  cases  sulc 
iri'st  acut(^  iid'ection.     S])it/.ka  thiid<s  that  it  is  due   to  an  anloclitliouons 
nerve  poison. 

Diagnosis. — There  are  several  diseases  which  may  pv'  'cnt  identical 
-vin|ili>iiis.  As  Hidl  remarks  in  his  paper,  the  first  ,i,dance  in  many  cases 
•iiir.i-'csts  typhoid  fever,  ]»artieularly  when  the  jiatient  is  seen  after  the  vio- 
lence of  the  mania  sulisidcs.  He  irivcs  two  instances  of  thiswhii  ii  wei'c  ad- 
;;ii!tcd  from  a  i,fenei'al  hospital.  Knlari^emeiit  of  the  spleen,  the  occur- 
niu't' of  sj)ots,  and  t hi' history  ixive  (dews  for  the  separation  of  the  cases; 
but  there  are  instances  in  which  it  is  at  lirst  im[)ossilde  to  deiddc.  More- 
nvrr,  ty[)hoid  fever  may  set  in  with  the  most  intense  dtdiriiini.  The  exist- 
tiice  of  fever  is  the  most  deceptive  symptom,  and  its  cdmhinaliun  with 
iilirium  and  dry  ton,i^uo  so  conunonly  means  typlmid  fever  tiiat  it  is  very 
iillicidt  to  avoid  error. 

.\ciite  })neiimonia  may  come  lui  with  vioieiit  maniacal  delirium  and  the 


I'Uliiio 


nary  symptoms  may  he  entirely  masked. 


Occasionally  acute  iiijeniia  sets  in  suddenly  with  iidense  mania,  and 
inilly  subsides  into  a  fatal  coma.  The  condition  of  the  ui'inc  and  the  ah- 
ciu'c  of  fi'ver  would  he  important  dia,n"nostic  features. 

The  character  of  the  didiriuin  is  (juite  diU'erent  from  that  n(  /um/ifi  i) 
'■'In.  It  may  lie  extremel}  dillieult  to  dilh'i'entiate  acut(^  dtdiiiuin  fnrm 
crtaiii  cases  of  cortical  nieninuntis  oc<Mirring  in  connection  with  pneii- 


inoiua  or  u 


IcerativD  endocarditis,  tuberculosis,  or  due   to  extension  froii 


ISC  ol    the  ear.      liiis  .sets  in  more  Ireipu-nlly  witli  a  chill,  and  lliei 


'tiy 


ih 


iimv  1 


ic  convulsions. 


Treatment. 


.veil   tlioiii 


h   bodily   prostration    is    a|it    t 


o    collie    on 


rlv  and   be  iirofinind,  I   would  not  hesitate  to  a<lvise,  in  the  case  of 


riiipii.-. 


1 
nian,  free  venesection.     It  is  not  at  a[l  improbalilc  that  some  (d'  ti 


liiiiny  eases  of  mania  in  whiidi  Henjaniin  Kiish  let  blood  with  sindi  beiielit 
')iliinuu'(l  to  this  (dass  of  alTections.  Coiisidcriiu:  its  remarkable  calniiiiLT 
iiitliiciicc  in  febrile  (Udirium,  the  cold  bath  or  the  cold  jiack  should  be  em- 
I'l'iU'd.  .Morphia  and  (diloroform  may  !)(>  administered  and  hyoscine  and 
till'  hromides  maybe  tried.  KralTt-Kliing  states  that  S(divetti  has  ob- 
"liuid  (rood  results  by  the  use  of  ergotin.  I'n fortunately,  as  usyhim  re- 
|"'i't.s  show,  the  disease  is  almost  uniformly  fatal. 


'■  -i. 


;iM 


!)82 


DISKASKS    OF   TIIH    NKIIVOUS  SYSTKM. 


'« 


,i>' 


J4J 


II.  PARALYSIS  AGITANS 

{I'arkiunou'.i  Dixidsc  ;  SluikiiKj  /'(i/m/). 

Definition.— A  clironic  utVcciinii  t,\'  ihc  iii'rvoii.sKysloin,  cliiiriictcii/.ril 
by  iiiiisculiir  wcakrit'ss,  ticiiiors,  mihI  ri.nidily. 

Etiology. — Men  nw.  nunv.  rrc((iu'iitly  all'cctcd  tliiin  women.  Il  raivly 
(KUMirs  miHcr  forty,  hut  iiistiiiicfs  liavn  liccii  rcportcfl  in  wliidi  IIic(liM;i>c 
l)(',i,fan  about  tla;  twentieth  year.  It  is  hy  no  means  an  iineoninioii  ailVc. 
tioii.  Direct  iiei'edity  is  rare,  hut  the  |ialieiits  iil'len  hidoiiiX  to  t'aiii'liis  in 
whieii  thei'e  are  other  nervous  aU'eeiioii.-.  .\nion;.;'  exeitiu^M'auses  mav  lie 
iiu'ntioiied  ex])osurt!  to  cold  and  wet,  and  husiiu'ss  worries  ami  an  actirs. 
In  sonu'  instances  tiu!  disea.s(^  lias  followed  directly  upon  sesei'c  iiiciital 
shock  or  trauma,  ('ase.s  liave  lieen  ih'sci'ihcd  after  the  s|peeitic  fevers. 
Muhiria  is  believed  l»y  somk;  to  be  an  inipoiianl  factor,  hut  of  this  thnvis 
no  satisfactory  evi(h'?M'e. 

Morbid  Anatomy.  —  Xo  eonstant  lesions  have  been  found.  The 
siniilai'ity  helweeii  certain  of  the  features  nf  Tarkinson's  disea.se  ami  ilmM' 
of  old  ago  suggest  that  the  all'oction  may  depend  upon  a  [U'emature  miiII- 
ity  of  certain  regions  of  tlu!  brain.  Our  organs  do  not  age  uiiiforiid\.  Init 
in  .some,  owing  to  her»'ditary  disposition,  the  process  may  Ije  nuirc  ra|iiil 
tiiaii  in  otiuM's.  "  I'arkiu.son's  disea.se  has  lu)  (diaracteristie  h'sions,  hut  mi 
the  other  luind  it  is  not  a  iHUirosis.  It  has  for  an  anatomical  basis  the 
lesions  of  cerel>ro-spiiial  senility,  and  which  oidy  diller  from  tho.se  ef  tnir 
senility  in  their  early  onset  aiul  greater  intensity."  (Duhief.)  'I'lic  im- 
portant changes  are  doubtless  in  the  <'erehral  corti'X. 

Symptoms. — 'I'Ih;  disease  begins  gradually,  usually  in  one  or  otlicr 
hand,  and  the  trenM)r  may  be  eithei-  constant  or  intermittent.  W  ith  ihi- 
may  he  as.;ociated  weakne.ss  or  stilTi:i'Ss.  At  lirst  tliesi'  .-symptoms  iiia\  \<r 
])"esent  oidy  after  exertion.  Altho'.igh  the  on.set  is  slow  aiul  gradual  ii. 
neai'ly  all  cast's,  there  are  instances  in  which  it  sets  in  abiaiptly  after  fiiL;li! 
or  trauma.  When  well  established  the  disease  is  very  characteristic  aiM 
the  diagnosis  can  he  made  at  a  glance.  The  bair  prominent  syui|iiian> 
are  iTenjiir,  weakne.ss,  rigid itv,  and  llu'  attitude. 

7'rciiKir. — Tliis  jnay  he  in  the  four  extremities  or  eonlined  to  haial-nr 
feet  ;  the  head  is  n(>t  so  comnuudy  alTeeted.  The  tri'tnor  is  usually  iiiarkiii 
in  the  hands,  and  tiie  thumb  and  forefinger  display  the  motion  mailc  in  Hi' 
act  of  rolling  a  pill.  At  the  wrist  there  are  movenu'nts  of  pronatinii  am: 
.supination,  ami  less  marked  of  iU.xion  and  extt-nsion.  The  uppcr-iinn 
mu.seles  are  rarely  involved.  In  the  legs  the  movement  is  most  eviilciil  ii' 
the  ankle-joint,  and  less  in  the  toes  than  in  the  lingers.  Shaking  nf  llu 
liead  is  le.ss  freipu'nt,  but  doe.s  occur,  aiul  is  usually  vertical,  not  retati'n 
The  rate  of  oscillation  is  al)()ut  five  j)er  second.  Any  emotion  exagginitf' 
the  movenu'nt.  The  attempt  at  a  voluntary  niovenu'iit  may  cherk  tin 
tr(!iiu)r  (the   [jatient  may  he  able  to   thread  a  needle),  but  it  returns  witli 


;m. 


PARALYSIS    AfllTANS. 


983 


vsUmm,  chamitrii/.iil 

II  wiiiiicii.  It  I'aivly 
in  whicli  tlic  iliMMM' 
in  uMcoiniiHUi  allVc- 
(clolil,'  til  i'aiii'lirs  ill 
•iliii;.^  cau-^cs  may  !»• 
pi'i'i'.'S  ap<l   an  .iriii-^. 

npon  si'Nci'i'  niciil;il 

llu'  siiccilic   t'lVci's. 

,  hilt  01   this  thcTL'  is 

'  hct'ii  t'tium!.  Tlio 
iTs  (liscasu  ami  tli'i-^f 

III  a  [ttviiiaturc  -iiiil- 
it  aj^c  imiftinnly.  Imt 
■;  may  he  imn'i'  ra|ii(l 
n-islic  lurtioiis.  Imt  nii 

anatomical  \)\[M<  tlio 
■r  from  those  of  tnii' 
(Diihiff.)     Till  nil- 

illy  ill  one  or  otlnr 
•milli'iit.  ■\Villi  till- 
symiitoms  may  W 
~h>\\  and  gradual  ii; 
aiiruptly  after  fii;:!it 
■V  clianicti'ristir,  ami 
romiiifiit  syiii|>tni"? 

conliiu'd  to  liaial-nr 
(ir  is  iisiiaily  mai'ki'i 

motion  made  in  llu 
its  of  pronatinii  ami 
.11.  'riie  ii|i)'rr-;ini; 
\t  is  most  e\  iili'iil  a! 
i-s.  Shaking  nf  llir 
rcrtieal,  not  roliitniy. 
emotion  exagiicvaU"' 
neiit  may  elierk  tln' 

l)ut  it  returiw  will: 


inci'i'.ised  intensity.  The  tn'inors  cease,  as  a  rule,  diii'ing  sleep,  hut  jicrsist 
ulu'ii  the  niuscles  iiro  iit  repose.  Tlie  writing  of  the  piitient  is  treninhnis 
iim!  zigzag. 

W'd/ri/rss. — Loss  of  power  is  present  in  all  cases,  and  may  occi.r  even 
liifei'i'  the  tremor,  hut  is  not  very  sti  iking,  as  tested  Ity  the  dynan.oineter, 
until  tlie  late  stages.  The  weakness  is  great<'st  where  the  tremor  is  most 
ilrvel(ipe(l.  The  nioveiiieiits,  too,  ari'  reinarkahly  slow.  There  is  rarely 
ruiiiplete  loss  of  power. 

Hiijidihl  may  early  he  cypressed  in  it  sh)wness  and  stilTiiess  in  the  vol- 
liiiiary  movements,  which  are  performed  with  some  elfort  and  diMiciilty, 
mill  all  the  iictions  of  the  patient  are  deliherate.  This  rigidity  is  in  all  the 
inii-:i'les.  and  leads  ulliniately  to  the  chara'  teristic 

Mlihiilr  (tinl  diiil.  -'V\\r  head  is  heiit  fnrward,tlie  hack  is  howed,an(l 
•lie  arms  are  held  away  from  the  l)ody  and  are  somewhat  Hexed  at  the 
illiiiw-joints.  'I'he  face  is  expressionless,  and  the  movements  of  the  lipH 
aiv -low.  The  eyehrows  ai'e  elevateil,  and  the  whole  expresion  i.s..iiniiiohile 
ir  iiia-k-like,  the  so-called  I'arkinsoirs  masi<.  The  voice,  as  pointed  out 
'v  l')ii/.zard,  is  apt  to  he  shrill  and  jiiping,  and  tlicre  is  often  a  hesitancy  in 
!i(:.Miiiiing  a  sentence;  then  the  wonls  are  uttered  with  rapidity,  as  if  the 
jiatieiit  was  in  a  hurry.  This  is  sometimes  in  striking  c<mtrast  to  the  sean- 
niiig  speech  of  insular  sclerosis.  The  lingers  are  llexcil  and  in  the  position 
.issiimed  when  the  hand  is  at  rest;  in  the  late  stages  they  cannot  he  ex- 
imiliMl.  Occasionally  there  is  overextension  of  the  terminal  phalanges. 
The  hand  is  usually  turned  toward  the  ulnar  side,  and  the  attitude  some- 
HJiat  reseinhles  that  cd'  advanced  cases  of  rheumatoid  ai'thritis.  In  the 
late  stages  there  aiX' <'outractiires  at  the  ellxiws,  knees,  and  ankhs.  The 
iiinvemeiits  of  the  patient  are  eharai'terized  hy  great  deliheration.  lie 
ii<('>  from  the  chair  slowly  in  the  stoo|ting  attitude,  with  the  head  proji-et- 
iii;'  fnrward.  In  atteni]»ting  to  walk  the  steps  are  short  and  hurried,  and. 
i-Trmisseau  remarks,  he  appears  to  he  running  after  his  centre  cd'  gravity. 
This  is  termed  festination  or  proj)ulsion.  in  contradistinction  to  a  peculiar 
irait  ohserved  when  the  jtatieiit  is  pulh'd  hackward,  when  he  makes  a  num- 
li'T  (if  steps  and  would  fall  over  if  not  prevented — retropulsioii. 

The  reflexes  are  iiornial  in  most  eases,  hut  in  a  few  they  are  exag- 
Lvrated. 

Of  sensory  distiirhances  Charcot  has  note(l  ahmirmal  alterations  in  the 
'(■niperatiire  sense.  The  patient  may  complain  of  siihjective  sensations  of 
lii'at,  either  general  or  local — a  phenomenon  which  may  he  present  on  uw. 
■:ilt'  only  and  associated  with  an  actual  iin'rease  of  the  surface  teiupera- 
tiiv,  as  iiiuidi  as  ('1°  V.  ((iowers).  In  other  instances,  patients  complain 
"fi'iild.  Localized  sweating  may  he  pi'i'seiit.  The  mental  condition  rarely 
■Ihiws  any  (dian^e. 

^ " rid f ions  in  llio  Si/u)pfoi»s. — The  tremor  may  lie  ahseiit,  hut  the 
n.L'itlity,  weakness,  and  attitude  are  suHicient  to  make  the  di;ignosis.  The 
'li^t'iise  may  he  hemiplegic  in  tdiaracter,  involving  only  one  si<ie  or  even 
"111'  limb.     Usually  these  are  but  stages  of  the  disease. 


■  i 


984 


DTSRASKS  OF  THE   NKRVOl'S  SYSTEM. 


Diagnosis.-  Ill  wfll-ilcvrlopcd  cusi's  tli(>  discuse  is  rcfoj^tiizcil  m  n 
flliUicc.  'I'lit'  atliliidc,  Ljiiit,  stilTncSfi,  !iii(l  iiiiisls-likc  cNprcssidii  ai'c  imini, 
III'  iis  miicli  iiiii»<»rt!iiic('  iis  tin-  (iscillaliniis,  ami  ii>iiilly  serve  to  s(|iai;Hc 
tlie  eases  from  senile*  and  (itlier  i'driiis  of  ti'eiiior.  disseminated  se|irii>i« 
develo|is  eai'liei".  and  is  eliarae'.erizeil  by  the  nystairnius,  and  tic  seaMiiiii;; 
spcceli,  and  does  nut  present  the  (tllihulf  so  constant  in  paralysis  airiliUh, 
The  heiniple^jfie  form  miirht  he  eonl'oiimleil  wiih  post-hennpleirie  tivnmr, 
l)nt  the  Instory,  the  mode  of  onsi't, and  the  greatly  ip'Teased  rellexes  \\iiul(| 
he  snilieient  to  (listin;j;insh  the  two.  'JMie  Parkinsoiuan  face  is  ol'  ^fnut 
importance  in  the  diatinosis  of  the  ohscure  and  anomalous  foi'ins. 

'I'he  disease  is  iiicui'alile.  I'erioils  of  improvement  may  ocenr.  l)iit  iln- 
tendency  is  for  the  all'eetion  to  proceed  projjro.ssively  (htwnward.  lli«;i 
slow,  dep'nerative  process  and  the  cases  last  for  years. 

Treatment. — There  is  mt  method  which  can  he  recommeiiilcd  ih 
satisfactoi'y  in  any  respect.  Arsenic,  opium,  and  hyoseyainia  may  lie  liin]. 
hut  tho  friends  of  the  patient  should  lie  told  frankly  that  the  disciiM-i- 
itieurahle,  and  that  not hinjf  can  he  done  except  to  attend  to  the  pliy.-ii  ;il 
comforts  of  the  [latient. 


K  I   >, 


i    , 


,     J   M    If 

"f.n  '" 


OTHiiii  Koif.Ms  or  Tkkmok. 

(n)  S'iiiip?r  Troiior. — 'I'his  is  occasionally  found  in  jiorsons  in  wIkuii  it 
is  impossible  to  assiifn  any  cause.  It  may  be  ti'ansient  or  persist  funm 
iiidelinite  time.  It  is  often  extremely  slight,  and  is  aggravated  by  all  caii-r- 
which  lower  the  vitality. 

(/;)  lli'rcilihivii  'rrriiKir. — ('.  L.  Dana  has  reported  remarkable  cn-cs , if 
hereditary  tremor.  It  occni;red  in  all  the  members  of  one  fannly.  uini 
beginning  in   infancy   continued   without  [irodueing  any  serious  cliaiiL"- 

{r)  Scin'lr  '/'rriiKir. — With  advancing  age  tri'inuloiisness  during  iiiii- 
eular  movements  isextri'mely  common,  but  is  rarely  .seen  under  .seM'iity. 
It  is  always  a  line  tremor,  which  begins  in  the  hands  and  often  exti'iids  t^ 
the  muscles  of  the  neck,  causing  slight  movement  of  the  head. 

{//)  '/'(i.ric  fri'iiior  is  seen  cliielly  as  an  I'U'ect  of  tobacco,  alcohol,  leail,  it 
mercury:  more  rarely  in  arsenical  or  opium  poisoiung.  Iii  elderlv  iiir;i 
who  smoke  much  it  may  be  entirely  due  to  the  tobacco.  One  of  the  coin- 
nionest  forms  of  this  is  the  alcoholic  tremor,  which  occurs  only  on  innvt- 
nient  and  has  eonsiderable  range.  Lead  trenn)r  will  bo  considercil  in 
.speaking  of  loud  j)oisnning,  of  M'liieh  it  constitutes  a  very  impertuiit 
symptom. 

{(')  Ifi/s/rn'raJ  fremor,  which  usually  oeeurs  under  circumstances  uliiiii 
make  the  diagnosis  easv,  will  be  considered  in  the  section  on  hvsteria. 


t.Ali,..^'^; 


KM. 


ACUTK   CllOKKA. 


ilS.") 


i  li  rocnjinizcil  ;it  ;i 
sprcssioii  arc  |iniiii. 
Ilv  sci'Vf  to  sf|iiinui> 
ssciiiinat.'il  srlcni-i. 
s,  1111(1  tl<'  sciiniiiii^' 
ill  |iiiriilysis  !ii:iijiii>. 

-llCllli|)lt'J,M<'   trrtlinr, 

•ciiscd  rcllfxcs  UdiiM 
iiiii    I'iicc  is  of  ^iviii 
loiis  forms. 
,  iiiiiy  occur.  Imt  \\v 
(lowiiwunl.     It  i.«  a 

lie  rccotiiiiicinliil  a- 
•vaiiiiii  may  he  Iricil. 
V  that  the  (liscusc  i- 
Ltoiul  to  tUo  physii:al 


II  persons  in  wIkhii  it 
-lent  or  persist  fur  an 
Lrravaled  by  all  raiiM- 

rciiiarkahU'  cur^i.'^  ><( 
of  one  family,  aihl 
my  serious  chaiiL'i'. 
usiiess  (liiriiii:  iiiib- 
secii  iindiT  scwnty. 
11(1  often  extends  lo 
he  head. 

•CO,  alcohol,  leail.  "r 

111!;.      In  elderlv  iiun 

One  of  the  i-m- 

)ccnrs  only  on  iimM- 

be  considered  in 

s  a  very    inipeitaiit 

circumstances  uiiiih 
tion  on  hysteria. 


III.    ACUTE   CHOREA 

tS_i/ili-ii/iiiiii'-i  C/iiinii ;  i)l.  \'iliis'.s  l)mtrr). 

Definition.— A   disease   cliietly   all'eetiiiL;'  eliildrcii,  characterized   hy 

iiTf;jidar,  iii\u|iintary  coiit rad i'Ui  of  the  iiui,^rlf<,  a  NarialiK-  amount  of 
|is\ihical  di-liii'liaiii-e.  and  a  iTiiiarkalde  lialdlily  to  acute  eiidipcarditis. 

we  shall  speak  lici'c  only  nf  Sydenham's  chorea.  Se idle  chorea,  chronic 
•liiirea,  the  iirchciiiiplc'^ic  and  po-tdicniiplci:ic  forius,  and  ili\  thiiiic  (diorea 
ii'r  liitally  diil'crciil  alVectioiis. 

Etiology.  —>V./'. — Of  ."i."i4  cases  whiih  I  lia\c  iinal\/ed  from  the 
riiil;id(dphia  liilirinary  for  I  )i-ca~cs  id'  the  Nervous  Sy.-ieiii,  >cventv-one 
per  cent  Were  in  females  and  twenty-nine  per  cent  in  males.  After  pii- 
lirily  the  percenta^'e  in  females  increases. 

Aiji'. — 'Pile  aire  incidence  in  :^•l^l  cases  was  as  follows:  in  the  lirst 
ijiradc,  ".'III  ;  ill  the  second  drcjide.  •JtS;  in  the  third  decade.  Id;  in  the 
fniirth  decade,  1  ;  ahovc  the  fourth  decade,  '.'.  in  the  cases  under  twenty 
viar>  the  following,'  is  the  aire  incidence  in  the  heinidecadcs :  In  the  lirst 
hiinidecade,  ;{:{  ;  in  the  second  liciiiidecade,  ItirS ;  in  the  third  liemi- 
'Ircade,  'iVi;  in  the  l'(p|irtli  licniidecade.  ')-l. 

Slntlmi. — While  the  disease  alTccts  (diildreii  (.fall  irraiKs  of  society,  it 
\i  iiiore  common  anioii;^  the  lower  (diisses. 

Hari\ — Chorea  is  rare  in  the  iie;,'ro,  and  is  alim.st  unknown  in  (he  na- 
tive races  of  this  continent. 

SnisDiiiil  /'//((/intis.  —  Morris  .1.  Lewis  has  analyzed  l:);  separate  atta(d<s 
with  reference  to  this  point,  'riirouirhoiit  I  >ccemlirr.  danuary.  and  l'\d)- 
r!iary  the  cases  increase.  There  is  a  fall  in  April,  a  rise  throUirh  .May  and 
■luly.  and  then  a  steady  fall  until  Octohcr.  The  cases  are  most  nuiuerou.s 
uiieii  the  mean  ndativc  humidity  and  barometric  ju'cssurc  arc  lo\^'. 

IHii'iiiiiitl ism. — .\  causal  ridationshi[)  hetwecn  rheumatism  and  (dioi'ea 
ImH  been  claimed  by  many  since  the  time  of  l')ri_ifht.  The  Kniz'li.-h  and 
li'i'iich  writers  maintain  the  closeness  of  this  eoniiectioti,  and  Koltci'  irocs 
-•  far  !i.s  to  regiii'd  the  disease  in  tdl  cases  as  a  manifestation  of  rheiima- 
;i"iii.  On  the  other  hand,  (iernian  authors,  as  a  rule,  regard  the  coiinec- 
tiHji  as  by  no  means  very  (dosi'.  Of  .'(."i-f  cases  which  I  have  analyzed,  in 
IV,')  per  cent  there  was  a  history  of  rheumatism  in  the  family.  In  ss 
'HM-.  l.'cS  per  cent,  there  was  a  history  of  articular  swidliiiir,  acute  or  .■-iil)- 
I'liie.  In  III)  cases  there  were  pains,  sometimes  descrilu'd  as  rheumatic, 
itnarious  jiarts,  l)ut  not  associated  with  joint  tiajiible.  If  we  reizard  all 
>iii'li  cases  as  rheumatic  and  add  them  to  those  with  manifest  articular 
'roulde,  the  percentaixe  is  raised  to  nearly  twenty-one. 

We  lind  two  o;ronps  of  cases  in  wliicdi  acute  arthritis  is  present  in 
dmrea.  In  oi;e,  t'.ie  arthritis  antedates  by  some  months  or  years  the  onset 
"f  the  chorea,  and  does  not  recur  before  or  dnriiiij  the  attack.  In  the 
"thci'  group,  the  chorea  sets  in  with  or  fidlows  immediately  upon  the  acute 


St 


980 


DISKASKS   OF  TIIH   XKIlVOl'S  SYSTHM. 


;:!i 


I     ! 


,1    > 

I 


h    h  'I 


iirlliritis.  In  souk?  instuiici'S  it  is  iiii|K»ssil)li'  to  drcidc  wlivilicr  tlic  jdin; 
Iroiililf  or  tli((  tiiovciiicnts  conic  lirst.  It,  is  (liMinilt  to  (iitlcrciiliaii'  t||, 
casus  of  irr('i.Mil;ir  piiiiis  wiilniiii  ilcliiiilc  joint  iiil'cciion.  It  is  |iiiili;ilil,. 
that,  niiiny  of  I  licni  arc  riicunialic,  and  yd  I  tldnls  ii  woidd  lie  a  mi-inki 
to  rc;:ai'd  as  siicji  all  cases  in  children  iti  which  then'  ai'c  complaints  df 
valine  pains  in  the  hones  or  mnselcs — so-called  ijrowini,'  pains.  I'  dmiili 
never  he  i'di'LTotteii,  however,  that  a  slight  ai'iicnlar  swcllini,^  nia\  he  tJ!. 
sole  nnmii'estation  of  rhenniati~in  in  a  child  so  slij^dit,  indeed  I'mt  tl,,. 
disease  may  he  entirely  overlonked.  The  statistics  of  the  Collective  In- 
vesli^'ation  Coniniittcc  of  the  Itrilish  Meilical  Association,  liased  np  w  ]:]<.> 
<'ases,  ixive  twenty-six  pei'  cent  of  antecedent  joint  alVcctioii,  and  if  \\\r 
cases  (d'  vauiie  pains  iielie\ci|  to  he  I'heninatic  are  addeil,  the  pcrcent.'iL''' 
is  raised  to  ihii'ty-tuo.  In  this  connli'y  rheuniatisin  is  not  so  cdninmn  in 
(diildreii  as  in  I-Iniilaiid.  Of  the  last  ill  ca>es  i>\'  the  Inlii'tiiai'y  srrio, 
alnio,>t  every  one  of  which  I  saw  personally,  and  in  which  the  ino>t  niiimti 
inquiries  were  made  ahont  rheuniatisni,  there  were  oidy  ■.'■"  cases  with 
articular  pains  or  swcllinuf.  and  in  only  H  had  there  iieeii  acute  iidlaiiiin.i- 
tory  rheuniatisin.  The  ipicstion  may  reasoiiahly  lie  asl<c(|,  Ho  these  ;ii- 
tii'ular  iiirectioiis  of  clioi-ea  hi'loiiLf  to  true  rheuniatisin '/  Are  they  im! 
analoiroiis  to  tlu'  joint  tri>ui)les  of  .-cailet  fever,  puerperal  fever,  ainl  i.'iin- 
orrhiea,  which  no  one  now  i-e;:ai'ils  as  truly  rheniuatic"/  They  ha\e  lini, 
spoken  of  Ity  i^'rciich  writeis  as  choreic  arthropathies. 

Jlcitrl-disKisf. —  Mudiicarditis  is  helie\ed  oy  some  writers  to  he  tin 
cause  of  the  disease.  The  particles  of  liluin  and  veifetalioiis  •Voiii  tli( 
valves  pass  as  ciiilioli  to  the  ccrchi'al  vessels.  (>ii  this  \'\i.\\\  \\''i<-h  we  shall 
discuss  later,  chorea  is  the  result  of  an  cinholic  process  occiiriini;'  in  tin 
I'oiir.se  of  ii  rlieiimatit'  endocarditis. 

I/it'ir/idiis  />/.^vY^s7'.s■.■ -Scarlet  fever  with  arthritic  inanifcstalioiis  iiiav 
ho  ii  ilirect  iinteeedenl.  It  may  he  nieiilioned  that  a  history  nf  this  di.-ca-r 
occurrcil  in  141  cases,  or  ahout  twcnlv-live  iier  cent.  Stiirires  state,- ilu!; 
ii  history  <d'  jin^vioiis  wlioopiim-coni:li  occurs  more  fre(|ucntlv  in  c||,,iiir 
than  in  othei'  children,  hut  I  lind  no  evidence  of  this  in  the  Inlii'iiiaiy 
records.  With  the  exe(^ption  of  rlu'iiinatic  fever,  there  is  no  inliiiiati' 
ri'liitioii.ship  hetween  clioi'ea  ami  the  acute  diseases  incident  to  childliiKMl. 
It  may  he  noted  in  contrast  to  this  that  the  so-called  canine  cluMva  i- 
u  common  .serpiel  of  distemper.  Choroii  has  hecii  known  to  develnji  n: 
tho  course  of  nn  ticute  pya'inia,  and  to  follow  gonorrh(ea  and  puerinrnl 
fevor. 

Kinnieutt  and  others  have  reported  cases  (jf  chorea  in  malari.al  frvi  r,-. 
hnt  the  ussociation  was  prohahly  uccide'iital,  not  <'ausal.  .Viueniia  i,-  h- 
often  an  antecedent  than  a  seiiucnco  of  chorea,  and  thouizh  ca.ses  deveii'ii 
in  (diildren  who  are  ana'tnic  and  in  poor  health,  this  is  Ijy  no  meatis  tla 
rule.     Chorea  may  devi'lop  in  (dilorotic  girls  at  piihertv. 

I'rrt/)/(fi/ri/. — (!liorca  may  occur  duriiiLT  pregnancy — most  often  diuiii.:: 
the  lirst  live  mouths.     It  is  muri;  common  in  a  lirst  iiregiuincy,  and  i.-  laa 


\l. 


At'L'TK  rilollKA. 


{)> 


ulivllwr  fill'  jdiiit 
()  ilitlVrciitiatr  tlif 
II.  It.  in  |ii'iili;ilili' 
,vnul«l  1)1'  a  iiii-t;iki' 
ai'f  ciiiiiiilaiiits  (if 
;  jiaiiis.  I'  'limiM 
•fllinj;'  iiia_\  lir  Ihi- 
it,  iiidci'd    t'lal  thii 

the    (  'ollcrtlVr   III- 

nil,  lia-rd  mi  11  41!'.' 
iTcctiiiM,  ami  if  ilif 
led,  the  pcrci'iila;'!' 
;  lint  so  ciillllllnli  in 

he  I  iilirtiiarv  m'Hcn 

•ll    till-    Mill;. I     lllilllltl' 

iiily  •.'."  .  ascs  wiili 
•n  acute  iiillaiiiiiiu- 
iskcd,  I>ii  liicsc  ar- 

;|ll  ?        Al'c    tllcv   Hot 

I'l'al  t'i'vcr,  and  L.'nn- 
'f     'I'lu'V  liavc  larii 

writers  \o  lie  tllr 
.U'tatiiiiis  'ViMii  tlir 
i'.;\v,  w  Ideh  vc  .dial! 
'ss  oi'C'iirriiig  in  tin' 

iianifi-tatiiiii-  may 

slery  (if  this  disea^t' 

Stiir^res  stales  tliai 

ijiieiitly  in  ehunir 

s   in    tlie    liiliriiiaiy 

(•re   is  nil  intiiiiaU' 

ideiil  to  cdiildlii""!. 

d   eatiine  (dmrea  i- 

lown    to  devejiiji  ii, 

Ilea  and   paeriieral 

I  ill  malarial  feviiv. 

Anu'mia  i-  \'- 

iiiiLdi   eases  drvrii'l' 

is  1)V  no  nieaii-  da 


in  uoiiien  over  twiMity-llve  years  of  n<^i'.  The  diseuse  i.s  iisimlly  severe, 
and  maniacal  sym|itoiiis  may  develdp.  Oeeasionally  it  ei.mes  on  after  an 
aliiiiiion  or  after  didivery  at  term. 

A  tendency  lo  the  disease  is  found  in  eeriain  families.  In  eii;lilv  casi'.s 
till' re  was  u  history  of  a  Macks  of  idmrca  in  ni  her  mem  lie  rs.  In  one  instance 
lintli  mother  and  ;;i'undmi  ther  had  iiceii  ulTecte(|.  IliLrh-strunjf,  excilalde, 
iirr\oiis  (diildreii  are  esjiecially  liahle  to  the  disease.  /'//'////  is  considered 
a  fivijiifiit.  cause.  l)iit  in  a  iafirc  majority  of  the  eases  no  (dose  coiincclioti 
(■\i-ls  hetween  the  fri;,dit  and  the  oll^(■t  of  t  lie  di>ea-c.  Oi'ca^ionalU  the 
ailaclv  I'tsinal  once.  .Menial  worry,  troiiMc,  a  siidileii  irrii  f,  or  a  .«cold- 
inL'  niay  apparently  he  the  e.vcitin;;-  cause.  'I'he  strain  of  nlunitinii,  par- 
liiiilarly  in  i;irls  diirin;,^  the  third  hemidecade,  is  a  nio.-t  important,  factor 
in  the  etioloLry  of  the  disease.  I?ri,i,'lit,  intelliireiit,  active-minded  nirls 
fnnii  tell  to  foiirtccii,  amliiiioiis  to  do  wdl  at  s(diool,  often  siimiilalcd 
ill  llieir  (dTorls  hy  teatdiers  and  parents,  form  a  lar^fe  eontiiiifeiil  of  tlio 
ia.-ie.~i  of  chorea  in  iiospital  and  private  jiraetice.  Stiirire.s  ha.s  called 
>liceial  Jltteiitioii  to  this  silniohnnnli'  (diol'eii  as  one  serious  evil  in  oiir 
iiiiHlfi'ii  iiicthiMl  (d'  forcc(l  cdiical  ion.  Iiiiildt  inn,  \\\\\v\\  ismciilioiieil  a.s 
an  c.\citin;j;  cause,  is  extrciiicly  rare,  and  does  not  appear  to  have  inlhi- 
iiic'd  the  onset  iu  a  siii;,de  ease  in  the  Iniirmary  records. 

The  di.sease  may  rapidly  follow  an  injury  or  a  slight  siiiLiical  opera- 
linn.  K'ellcx  irritation  was  Ixdicvcd  to  play  an  impoitaiil  rnlr  in  the 
ijisease,  parlicnlarly  the  presence  of  wdi'iiis  or  irenilal  irritation  ;  luit  I 
iiavc  met  wit  ll  no  instance  in  wliicdi  the  disease  could  lie  al  irihnied  to 
vitlier  (d'  these  causes.  Local  spasm,  particularly  of  the  face— -the  iiahit 
I'linica  of  .Mit(dudl — may  he  usso(dated  with  irritation  in  th"  iiostril.s 
and  adenoid  growths  in  the  vault  of  the  pharynx,  as  poiiucd  out  hy 
.laci'lii. 

ii  has  been  (duimed  by  Stevens  that  (iciihir  i/r/'nis  Vw  at  the  basis  of 
many  ca.ses  of  (dioi'ea.  and  that  with  the  correction  (d'  tliese  the  irregular 
iiMiveiiieiits  disappear.  The  invesiigatioiis  of  !)e  Sidnveinitz  show  that 
'"■ular  defe(ds  do  not  occur  in  greaicr  pinporl  ion  in  (dmreic  than  in  other 
liiildi'eii.  .\  majority  of  the  cases  in  u  liiili  operation  has  been  followed 
'i}  relief  have  been  instances  <if  ///•,  ImchI  'u-  general. 

Morbid  Anatomy  and  Pathology.  N"  (on-iant  h  sions  have 
Ihi'Ii  found  in  the  nervous  .system  in  .icute  (diorea.  N'asciilar  (dianges, 
Midi  as   hvaliiie   t  ransforinal  ion.  exudation  of  Iciii'ocvtcs,  minute   lueinor- 


lii.iLMs.  an 


d  throinltosis  of  the  smaller  arteries,  havi'  been  descrilied. 


i  Jidiolism  of  the  .snialler  cereijral  vessels  has  been  found,  as  might  lio 
^^x|H■l•^(•(l  in  ;i  di.seasie  with  whi(di  endocarditis  is  so  fri'(|Ui.'iitly  asscKdated  ; 
aiiii,  based  upon  this  fact.  Kirkes  and  others  have  sujipoited  what  is 
l^iieuii  as  the  embolic  theory  id'  the  disea.se.  Kndocarditis  is  by  far  the 
iiiii>I  freipient  lesion  in  Sydenhaiirs  chorea.  With  no  di.sease,  not  except- 
iiost  often  iliuiiiL'  ■  iiiLT  rheumatism,  is  it  .so  con.-tantly  ii.s.siudated.  I  have  eidlected  from 
nancy,  ami  1.- rai'i   ■   rweni  litcruturo  (to  duly,  iM'.ld)  tlu'  records  of  V-i  autopsies;  there  were 


S'" 


9S8 


I)Iseasp:s  of  tiik  nervous  systf-lm. 


(V2  with  ondociinlitis.*     'Plio  eiidociinlitis  is  usuiilly  of  tlu'  siiiijih'  viuiftv, 
but  the  ulcenitivc  form  has  ocoiisioiiallv  been  dcscrilii'd. 


We  arc  si  ill   far  frmii  a 


(phitKm  III    all   the   iii'dljifnis  coiiticctcil  uiih 


cliorca.     Uiifdi'tmiatcly,  the  word  has  liccii  used  to  cover  a  si-ries  df  tniuljv 
diverse  disorders  of  luoveiiu'iil.  s(»  that  there  are  still  exei'Ucnt  oKm  rvci. 


ho  hold  that  chorea  is  oidy  a  syiiiiitoiii,  and  is  not  to  be  re^'ardcd 


w 


etiological  unit, 


a-  ail 


lie  I 


hoj-ca  (if  cliildlinoil,  the  disease   which   S 


Mli'iiiiaiu 


dcscril)e(i,  ]iresents,  hnwevcr,  characteristics  so  unniistakabh!   that  ii  iiiii.>t 
be  rcLTarded  as  a  dclihile,  sidistantive  alTectioii.     \\v  cannot  discii.--^  fiillv. 


but  onlv  indicate  biiellv,  eertain  <if  the  theories  wliieh  liave  been  a<l 


Vaiircil 


witii  reijard  to  it 


he  iiKist   LMnci'ally  acce[)tetl  view  is  that  it  is  a  I'liu 


tidiial  brain  discrder  allVctiiii;  the  nei've-ceiitres  eontrdlliiiLT  the  iniiinr 
upparatiis,  an  instaliility  of  liie  nerve-cells,  broiii,dit  about,  mie  supiMiM^  hv 
liypc'eniia,  another  by  ana'niia,  a  third  ))y  psychical  inllueiiccs,  a  fiuntli 


ty  irritatKin,  centi'ic  or  pcri|ihe!i( 


Of  the  actual  nature  of  this  (h'r,'itii;( 


nieiit  we  kiuiw  iKitliinir,  ikh',  in<leed,  whcthei'  tlu'  changes  ai'c  p''iuiar\  ai 
the  residt  of  ;i  fai  llv  aetioii  nf  ihe  cdit 


leal  ceils  (ir  whether  I  le  iniimlx'S 
lire  si'coiidarily  disturbed  in  their  e<inrse  dnun  the  motor  path.  'I'lie  piv- 
doininancc  of  the  disease  in  fcmaU's,  and  its  onset  at  a  lime  when  ilu' 
ediicaiidii  of  the  brain  is  rapidly  devclopinjx,  are  etiolo<,Meal  facts  which 
Sturixes  has  tirixt'd  in  favdr  nf  the  \icw  that  eli  ;iea  is  an  expressiun  ..f 
fiiiicti(»nal  iiistaiiilily  <if  the  nerve-centres. 

'i'he  embolic  thcdi'y  dri;;iiially  advaiiceil  by  Kirlies  has  a  solid  lia.-is  i.f 
fact,  but  it  is  luit  cdmprchen.-ive  eiiduirh,  as  all  of  the  cases  eaniint  Ik; 
brouirht  within  its  liuuts.  'ricri'  are  instances  witiiout  OiUlocarditis  ami 
without,  so  far  as  can  be  asccrlai'H'd,  pln^'j^'ini,'  of  cerebral  ves.-els;  aii'I 
there  are  also  cases  wit ii  exleii.-ive  eiulocardil is  in  whi.'h  the  iiistole-ical 
examination  of  the  brain,  sci  far  as  embdlism  is  concerned,  was  neuaiivi'. 
]u  favor  of  tlu'  einlxilie  view  is  thtt  experimental  piiuluctidii  in  •iniuiaN  of 
I'lidrea  l>y  lidseiilhal,  and  later  ly  Mi  iiey,  by  injecUng  line  pai'ticles  iiiln 
the  cariilids  of  animals. 

Lately,  ;is  indeed  ini,udit  be  expected,  a  microhic  oriirin  has  been  smiirlit 
for,  and,  however  improbalile  sech  ,i  ihenry  looks  ai  lirst  .^iirht,  ihe  can' 
of  tetac.us  <fives  a  warrant,  at  least,  to  speculation  i.d  investiyatinu  in 
thi.' dircctidii.  \dtliin,:f  detiiiite  has  yet  been  deten  lined.  In  I'avnref 
this  view  it  has  been  ur;;ed,  as  it  is  imiiossible  to  relVr  Jk-  churca  In  einjo- 
cardiMs  or  the  endocarditis  in  a'l  cases  to  rheumati.-n.,  that  bdth  liavr 
their  origin  in  a  cdinnion  cause,  some  infectidus  aircnt,  which  is  capaMr 
al>d,  in  persdiis  predispuscd,  of  excitiuLf  articular  disi'ase.  ('a.<es  have  Ihiii 
reported  in  scarlet  b'vcr  with  arthritic  manifestations,  in  pueipeial  I'rur. 
a'..d  rlicnmatism,  also  after  <:d!iorrluea,  and  such  facts  ari'  siigu'estive  at 
least  of  tlu'  association  of  t'u  <lisease  with  iiif'-ctive  processes.  l'o.->ilily, 
118  lias  been  suggested  by  so.iii  writers,  ilie  jtaralytie  eonditioiis  ussoeiati'il 


Osier,  (Miiiri'ii  ami  (^hureifenii  .MTfclioiis,  1S()4. 


...___,,_.^' 


^ 


Acrrr,  ciiouka. 


OhJ) 


le  simple  variety,     ^B   ^' 


5   COlUiectril  uilh 

a  serie.s  of  Uitiilly 
;L't'll('iit  oliM'i'M'is 
)u  reganlcil  a-  un 
A'liicli  Svili'iihaiii 
u1)1l'  ihal  it  imi>t 
not  (^i.s(■u^>  fully, 
vr  hi'cu  aihaiirt'i 

tiiat  it  is  a  liiiif- 
•uUiiiiX  I  lie  iiKildl' 
t,  one  su|i]iiis(',>  by 
lliieii('(.'S,  a  I'ninlh 
(■  (it"  tliis  (li'1'aiii.'i'- 
s  art'  jii'iiiian  'iiil 
liior  I  le  iin|iul.«cs 
r  path.     'I'lic  [iiv- 

a  time  wlicii  tlu' 
)irieal  facts  which 
;  an  expression  nf 


las  a  sill  id  lia>is  i^f 

0  cases  cainiiil  hr 

e.ulociinlilis  aii'i 

iral  vcs.-ets ;  aii'l 

I    the    histdlnLlirul 

iicd,  was  ticuativf. 
tiiin  in  ■iiiinial-  nf 
ini'  particles  iiiln 

lias  '-ecu  .-(Uiu'ht 

rsl  ■  i.Ldit,  ilic  i-.i'v 

invc>li;j;-atinu  in 

icij.      In  favor  I  if 

11'  clidrca  til  ciiii'i- 

,,  that   hnth   li:ivc 

which   is  cai'iihlf 

Cases  have  lurli 

n  puerperal  fe\ti'. 

arc  sngiresli\e  a; 

„.(.sses.      I'o.-il'ly, 

fi  it  ions  iisstieiaii'u 


til  clinrea  may  be  anah)<jons  to  those  wliicli  occur  in  typhoid  and  cer- 


tain of  the  infections  disca'-cs.  On  the  nther  hand,  thci'c  ai'e  eonditimis 
cxirini(dy  dillicult  to  harnnini/c  with  this  view.  'I'lie  prnininent  psychical 
(■Iciiiriit  is  certainly  mie  of  the  nmst  serious  (ilijectiuns,  since  there  can  he 


110  ilnl 


eiiioiKin. 


d)t  that  ordinarv  tdiorca  niav  raoidlv  fullow  u  fri'dit  or  a  sudden 


Symptoms. — Three   irriiiips  of  cases  may  he  recognized  —  tlu'   mild, 
icvere,  and  maniacal  clnirca. 

Milt/    C/nircd. —  In    this    tlie    allVctidn    of    the    muscles   is  .sliglit.    tlio 

i     I  spccili   is  not  seriously  distnrhed,  and   the  o-eueral    health   not  impaired. 

I'lvahiiiitury  symptdins  are  shown  in  resihssiiess  and  inahilily  to  sit  still, 

ii  condition   well   (diaractci'izeil    liy   the  ti'rm  *•' llili:ctf 

(list 


here  are  emo- 


noiiai    disturoances,   siieh    as   cryiiio   sjiells,   or   sometimes    niohl-Ierrors. 
Till  re  may  l)e  pains   in   the   limhs  and    hcnihedic.      I  tiocsl  ivc  disturlianccs 


and  ana'inia  may  he  present.      .\  (di 

III) 


inp'  in  the  temjiei'ainent  is  freipiently 


deed,  and  a  (hiidle,  (piiet  child   may  heeome  cross  and    irrilahle.     After 
lluve  sym]>toms  have  persisted   for  a  week  or  more   liie  (diaracteristic  i 


viiliiiitarv  moveincnt.- 


II- 

rin,  and  are  often  first  noticed  at  the  tahle,  when 


tile  child  spills  a  tismhler  of  water  or  upsets  :i  plate,  'i'here  may  he  only 
awkwardness  or  sliirht  iiieoordination  of  voluntary  movements,  or  constant 
iriVLridar  cdonic  spasms.  The  jerky,  irreonlar  eharacter  of  the  movements 
ihlTerentiates  them  from  almost  every  other  disorder  of  motion,  in  the 
mild  eases  only  one  hand,  or  the  hand  and  fa.'c.  are  alTectcd,  and  it  may 
lint  spread  to  the  other  side. 

ill  the  second  grade,  th  .s^'/v/v /'o/vy/,  the  movements  hcconie  general 
iiiiil  the  ])atient  may  1h'  unahle  to  get  ahout  or  to  feed  oi'  undress  hersidf, 
nwiiiLr  to  the  constant,  ii'rcoular,  clonic  conti'aelions  of  the  vai'ions  muscle 


:'niii|is 


Ti 


le  siieech    IS  also  a 


ITcct 


cd.  and    lor  davs  the  chnd  niav  not  i»e 


al)h'  to  talk.     Often  with   the  onset  of  the  severer  symptoms  there  is  loss 
of  power  on  one  side  or  in  the  limh  most  atTccted. 

The  third  and   most  extreme  form,  the  so-ealled   mania'/al  (diorea,  or 
is   ti'ulv  a   terrihle  disease,  and   mav  devtdoi)  out  of  the 


'inrm   nisiiinciix. 


"I'dinary  form,     'i'he.sc  casi'S  are  more  eoiuinon  in  adult  women  and  may 
develop  during  )>regininey. 

lorea  heirins,  as  a  rule,  in  the  luiiuls  and  artus.  thi'?i  involves  the  faee. 


(' 


;i;;i 


1  suh.sequently  the  legs.     'I'he   movements  may  he  conlined  to  oi 


le  side 


— Ill  iiii(dn)rea.  I'lie  attack  hegins  oftene<t  on  the  right  side,  though  oc- 
>'asioiially  it  i.s  general  from  the  outset.  One  arm  and  the;  opposite  leg 
iiiity  lie  involve(l.  In  nearly  one  fourth  of  the  eases  speeidi  is  alTected  ; 
'vliiii  slight  this  is  only  an  einharra.ssmeiit  or  hesitancy,  hut  in  other  in- 
-taiires  it  Ijccome  *  an  incoherent  juir'.iie.  In  very  .severe  eases  the  (diild 
«ill  make  no  attempt  to  speak.  Tiic  inal)ility  is  in  articulation  rather 
tlian  in  ]ihotialion.      The  lips  and   tongue  are  eoneerned   in  the  defect. 

-    H  "I'i'iisionally  the  inspiratory  mnseles  are  involved,  even  when  the  speech  is 

Hut  at  all  utTeeted,  and  sohhing  ami  sighing  may  result.     I'uroxysms  of 


990 


DISKASF.S  OP  THE   NERVOUS   «YSTEM. 


paiiliiii;  ;iii(l   nf  hard   oxpiratioii   may  (icciir,  or  nild  soumls  iiiav  lie  tif,, 
diii'ctl.      As  a  rule  the  iiiovciiiciits  ccax'  duriti;.''  slfi'j>. 

A  i»r()iiiiiioiit  symptom  is  niusridar  woakiicss,  usually  no  tiuirc  tluui  ;■ 
(!(»nditioii  (if  piircsirf.  'I'iic  loss  of  [lowcr  is  slight;,  l)Ut  llic  wcakiK  ->  m;,, 
be  shown  l)y  ;ui  ctifi't'idcd  ircip  or  l)y  adraii-^fimr  of  tlu'  Ictr  or  liiii|iiiiM.  h. 
Jiis  orii,qnal  ac('(miit  Sydfiiham  refers  to  the  '•unst{'a<ly  muNcuinil- nf  .u,, 
(tf  t\\v  Iv'J-',  wliioii  th(!  palii'Ut  draffs.""  'I'hcre  may  lie  cxlrcmc  |iai'c«i>  uj'  . 
but  ffw  niovcmeiUs — tlic  paralylic  (du)ii'a  of 'I'odd.  <  (ccasidiialh  a  in,  ,ii 
paralysis  or  weakness  remains  after  the  attack. 

It  is  doul)tful  whetlier  choreic  spasms  exl^'iid  to  the  muscles  df  (.rL'aiiic 
life.  The  rapid  actimi  and  disturlicd  I'hyiiimnf  iln'  heart  present  iioi!ii!;_- 
peetdiar  to  tlic  disease,  iiiul  there  is  no  sup]inrt  I'or  the  view  that  iric'_'ui;ir 
contractions  occur  in  the  papillary  muscK'S. 

Heart  Symptoms. —  Xinrii/ir. — As  so  many  of  the  subjects  of  rli(.p.;i 
are  lu'rvous  i^irls,  it  is  nut  sur|irisinLr  th.at  a  cnminoii  symptom  is  ra|ii'liv 
aciii'.ir  heart.  Irreirulariiy,  however,  is  not  so  s]>ecial  a  featui'c  in  clierm 
as  rapiility.     The  |)atieuts  st'ldoin  complain  of  pain  about  the  heart. 

Ilifiiii'-  .]///riiiitrs.  —  With  ana'iiiia  and  debility,  not  uneomiMoii  assn- 
ciates  of  chni'i-a  in  the  third  ami  fnurth  week,  we  lind  a  coi'respdinliiiL' 
cardiac  condition.  The  impidse  is  dilTiise,  jierhajis  wavy  in  thin  cliilihv::. 
The  carotids  throb  visibly,  and  in  the  recumlieiit  postiir(>  there  u\-a\ '.« 
piilsation  in  the  cervical  veins.  <>n  auscidtatinn  a  sy-^tolic  luurinur  i- 
beard  at  the  base,  perhaps,  too.  at  the  aiiex,  soft  and  blowimr  in  (|nalitv. 

KidliK'nnlil IS.  -X^i  in  rheum.atism,  >o  iii  chorea,  acute  valvidiiis  rarciv 
gives  evidence  of  its  presence  by  symptouis.  It  mu.-t  lie  souirht.  and  rjii- 
ical  experience  has  shown  that  it  is  usually  associated  with  murnmrs  ;i! 
one  or  other  of  the  cardiac  oriiices. 

For  the  guidance  of  the  pi'actilioucr  the  followiuif  statements  may  lie 
made  : 

(1)    In  thin,  nervous  children  a  systolic  murmur  of  soft  (jiiality  is  i  y 
treuu'iy  common  at  tlu'  base,  particidarly  ;it  the  second  Kd't  co.^tal  cariihiuv. 
and  is  proi)ably  of  no  monii'iit. 

{'i)   A  systolic  murmur  of  maximutn   intensitv  at  the  apex,  ami  \\rx--\ 
also  alon,:^'  the  left  steiaial    mai'Liin.  is  not  uncommon  in  an;einii\  enfniili 
states,  and  does    not    necessai'ilv 


indicate    either   endocarditis  or  in-ulV; 


ciencv. 


C     \v-\n\\ 


(.'5)   A  murmur  of  maximum  intensity  at  apex,  with  romrb  'piality.  an 
transmitted   to  axilla  or  aiiirle  of  sca|)ida.  indicates  an  orixani 
the  rnitnil  valve,  and  is  usually  associated  with  signs  of  eidaruiinent  nf  tii^ 
heart. 

(4)  When  in  doubt  it   is  much  safer  to  trust  to  tiie  cvideme  "i  r\' 
ami  hand   than  to  that  of  the  ear.      if  the  apex  beat  is  in  the  normal  pesi-    |l 
tioii,  and  the  area  of  tliilness  m>t  im-reased  vertically  or  to  the  right  "f  tin 
.Bternutti,  there  is  ])robably  ^w  serious  valvular  disea.s<'. 

(5)  'I'he  endocarditis  of  chori-u  is  almost   invariably  of  the  simpk'  "■ 


,1^1,  .ji|)i  M!jm 


ACUTE  CHOREA. 


901 


iiuls  iii;iy  \)r  jirii 


stiitciiiciits  iiiav 


wariy  form,  ami  in  itself  is  not  <l!m<.'ontins ;  but  it  is  apt  to  loiul  to  tlioso 
sclrrotic  clia Hires  in  the  valve  wliicli  jirodiicc  incoiniirtciicy.  <>i'  14(1  pa- 
tjriils  oxaiiiiiii'd  luiirc  than  two  \cars  al'tci'  the  attack,*  I  Iniiiwi  ilic  iicart 
iiuuiiai  ill  .")  1  ;  in  l\  there  was  t'unel  iwiial  distiirliaiiee,  ami  ','t  presented 
«ii:ns  of  orixanie  heart-disease. 

((!)  I'ericafditis  is  an  occasional  eoinplicalion  of  chorea,  usuallv  in 
r;e(S  with  well-marked  rlieumatisni. 

Snisorj/  I  list  II  rliiiiircs. —  j'aiii  in  the  alTected  linihs  is  not  common. 
Occasionally  there  is  .soreness  on  jiressnre.  There  are  cases,  nsiiallv  of 
luiiiiehorea,  in  which  ]iain  in  the  liniiis  is  u  marked  svnipinin.  Weir 
Miichell  has  sjxiken  of  t liese  as //(/////W/ r/zo/'m.v.  'I'lie  pain  may  he  (piite 
iipart  from  any  ai'thiit  ic  coin[ilicati(ins.  'J'in;;'linir  .'Hid  pricking-  st'iisations 
aini  niimoiie>s  are  found  occa.-i<iii;dly.  ,\iKestlie.-ia  is  \ei'\  iiiiciiinriion. 
Ti  iider  jtoin's  alonj;  the  lines  of  emergiMU-e  of  the  spimd  nerves  or  along 
tlic  course  of  tlm  nerves  of  the  liinhs  are  rai't".  The  Fieiich  writers  have 
coinpjired  these  to  the  liysteroirenie  points  in  iiystt-ria,  and  have  also 
il'  -crilicd  ill  certain  eases  ovarian  teiuleriiess.  Headache  may  he  a  very 
tioiihlesoiiK^  sy ni|)toni. 

I'siji-liinil  ili.--linliit)iri'!i  are  eonunon,  tliouixli  in  a  majority  of  the  ('ase.s 
sliuiit  in  de^rt'e.  Irrilal^ility  of  temjier,  marked  wilfulness,  and  emotional 
iiiithreaks  may  indicate  a  eom])lete  clianp'  in  the  characler  of  the  child. 
There  is  deiicieiicy  iii  the  powers  of  enncentratidii,  the  nieninry  is  eii- 
IVehled,  and  the  aptitude  for  study  is  lost.  iJarely  there  is  proLjressive 
impairment  of  the  intellect  with  termination  in  actual  dementia.  .Vciite 
iinlaiieholia  has  bi'en  tleserihetl  (Kdes).  Hallucinations  of  siuht  and  liear- 
wvz  may  occur.  I'alients  may  hehave  in  an  odd  and  .-trantre  manner  and 
iln  ;dl  sorts  of  meanin,ulc.-s  acts,  liy  far  the  most  si'iioiis  manifestation  of 
this  eharaeter  is  the  maniacal  delirium,  o<'casionally  a^soeiated  with  the 
very  severe  eases— r/zo/vv/  iHsiinii'im.  I'sually  tin-  motor  disturhaiice  in 
these  eases  is  airirravated,  hut  it  has  bei'U  overlooked  and  patients  have 
ixH'ii  sent  to  an  asylum. 

'I'lie  psychical  eleiiu'iit  in  olioroa  is  apt  to  be  neirleeted  by  the  jiraeti- 
tiuiier.  It  is  always  a  .i(<Mi(l  plan  to  tell  the  parents  that  it  is  not  the 
muscles  alone  of  the  child  which  are  alTccteil,  but  that  tlie  ^'eneral  irrita- 
liility  and  change  of  disposition,  so  often  found,  really  form  part  of  the 
ilisease. 

'l"he  condition  of  the  rfjh'.rrs  in  ebore.a  is  usually  normal.  Sinkler 
iiwiili'  ob.servutions  at  the  I'hilailelphia  Inlirmary  in  oO  eases  with  the  fol- 
louinij  results:  In  '■»'<!  the  knee-jerk  was  normal,  in  i.")  it  was  diminished 
ill  (leLTfee,  and  in  I)  it  could  not  be  olttaiiied.  Trophic  lesions  rarely  occ'ir 
ill  chorea  unles.s,  as  some  writers  have  done,  we  reLMrd  the  joint  troubles 
us  arthropathies  oeeurrini:  in  the  course  of  a  cerehro-spinal  disea.^e. 

Freer  is  not,  as  a  rule,  present  in  clnn'ea  unless  complications  exist. 


of  the  siiiiph'  or 


*  Moiiogruj)li  oil  Chorcii,  181)4- 


It02 


DISEASES   OF  THE   XERVOT'S  SVSTEM. 


M 


will'' ' 


^'■"^Si 


'I'licre  iiKiv  lie  till'  most  intense  and  vidlcnl  movcnifnts  witlidut  am  rl- 
of  t('ni|i('i'alun'.  1  have  seen  in^'tanccs,  liowcvcr,  in  wiiicli  uitlioiit  a|  iiai- 
cntly  any  visccriil  or  articular  distiii'lianccs  there  was  slight  daih  |(  \i;-. 
II.  A.  Hare  states  tliat  in  monochorea  the  tempei-ature  on  the  alTcit,ii 
side  may  lie  elevated  ;  hut  this  is  not  an  invai'iahle  rule.  I''evcr  is  feiuiil 
with  an  acute  arthi'itis,  when  there  is  marked  cudoeai'diiis  or  iieiirai'iliii., 
thouirh  the  former  mav  certainlv  occur  with  little  if  aiiv  lise  in  teiii|ni';i- 
lure,  aiui  in  the  cases  of  maiuaeal  (diorca,  in  wlii(di  tlu^  fe\cr  luay  nuiu'i 
from  l(»-i°  to  Ki-r. 

('(iliiiirniis  Ajfrc/iiiiis'. — The  piirmentation,  wlii(di  is  !iot  uncoiunn.n.  i- 
due  to  thcarsi'uic.  ller|ies  zoster  occa.-ionally  occurs.  ( 'erta.iu  ski;:  cniji- 
tioiis,  usindly  reuariled  as  rhemmitic  in  (diaracter,  are  not  uneounnnn, 
Erythema  nodosum  has  been  described  and  I  have  si'cii  several  eases  with 
a  jiur|Mii'ic  urticaria.  There  may,  indeed,  be  the  inore  aii'ufavated  cdiaji- 
tion  of  rhc'imatic  j)Ui'|iura,  known  as  Sidiiudcin's  j/r/iosis  rZ/rintintlr,', 
Siihcutancons  liiirous  nodules,  which  have  been  iu)ted  hy  I'".ni;'li.-li  oli-ci\ii- 
in  many  eases  of  chorea,  associated  with  rheumatism,  are  extremely  lair 
in  this  country. 

Duration  and  Termination.  —  I^'om  eii^ht  to  ten  weeks  \<  \\ir 
average  duration  of  tin  attack  of  moderate  severity.  ('ase>  may  ln'  so  iiiilil 
as  to  get  well  in  tw(,  or  three  wi-eks ;  on  the  other  hand,  there  may  !i. 
found  at  every  clinic  for  diseases  of  the  nervous  system  cdioreic  palidi!- 
who  liave  been  tinder  treatment  for  three,  four,  or  own  six  iiiniiili-. 
Ch.'oiiic  (diorea  I'arely  follows  the  miuoi'  disease  whiidi  we  have  bnii  mi:- 
siderini;.  The  cases  described  under  this  desiirnation  in  cdnldrcii  ap' 
nsmdly  instances  of  cerebral  sclerosis  or  l*"riedrei(di's  iitaxia;  but  iHca- 
sionally  an  atta(d\  whii  h  has  come  on  in  the  ordinary  way  persist-  f^r 
numths  or  years,  and  recovery  ultimately  takes  place.  A  slight  irr;idc  I'f 
(diorea,  y)articid,irly  noticeable  under  excdti'tueiit,  may  persist  for  uimin  - 
in  nervous  (diildreii. 

The  tendency  of  (diorea  to  voeiir  has  1)oon  noticed  by  iill  writers  siii'v 
Sydenham  first  madt!  the  observation.  Of  410  cases  analyzeil  fortlii>  pur- 
pose,'>}()  had  one  attack,  llii  had  two  atta(d<s,  :5.">  three  atta(d<s,  in  four 
ilttacks.  \-l  live  atta(d\s,  and  :>  six  attacks.  The  recurrence  is  apt  I'l  '"■ 
Vernal.  Ilheiimatism  seems  to  favor  this  tendency  ;  of  (it)  cases  in  uiiirli 
till  re  were  three  or  more  attacks,  there  was  a  history  of  articular  dismsr 
in  11,  a  iiimdi  higher  percentage  tiian  in  cases  with  only  one  or  tun  at- 
tU(d\s.  The  occurrence  of  heart-disoase  has  been  thought  to  iiicii'asf  tlii> 
liability,  hut  I  think  it  is  tho  other  way — recurrences  toiid  to  induce tiiiln- 
carditis  and  valvular  disea.se. 

liecovery  is  the  rule  in  (diildren.  The  statistics  of  otit-patienfsMi'i>;iri- 
ments  are  not  favorable  for  determining  the  mortality.  .\  ndial^lc  i-'i- 
mate  is  that  of  the  Collective  Investigation  Committee  of  the  liiiu-:! 
Medical  Association,  in  which  'J  deaths  were  reported  among  C!'.*  i;i-f' 
about  two  pur  cunt. 


ACUTE  CIIOIIKA. 


993 


nthmit  any  rise 
1  witluiiu  iij  [iiir- 
i;l»t  daily  I'ivit. 
on  the  alTcrii'il 
I'\'vcr  is  I'luuid 
s  or  pi'vicanliti*, 
rise  ill  t(Mii|H'i':i- 
fcvtT  may  I'aiigo 

()1  unconininii,  i- 
crtain  skin  cnip- 
iiot  iiiicnnnnnii. 
i-viTal  ca^c-  with 

<r(r|';i\  iltcil  rdliill- 
(isis     fhl'HIHilli'''. 

Kiiglisli  (ib-fi'vcv- 
re  extronifly  ran' 

ton  weeks  is  tlir 
es  may  lie  mi  mii'l 
ml,  tluM'o  may  !»■ 
1  choreie  iKilii'iiti- 
even  six  iiiniillis. 
ve  have  lieen  cnu- 
in  chilli ren  are 

taxia;    hut  <"tii- 

way  persisls  for 

A  sliiiht  trra'le  of 

ersist  ftii"  meiitlis 

y  all  writers  simr 
vzed  fnrthi^  I'ur- 
|e  attacks,  |i»  f"ur 
■nco  is  ajit  i"  '"' 
i;o  cases  in  wlii'li 
f  articular  discast' 
v  Diu'  or  twii  lit- 
lit  to  inciease  tlii^ 
id  to  induce eiiilii- 
lt-uatientsMcpuri- 
A   relialilc  i'>ti- 
l.e  of   the  Uriti^li 
lauiung  \'-Vi  i-'i'»^'»' 


Tho  paralysis  rarely  persists.  Mental  dulnoss  may  ho  present  for  a 
time,  hut  usually  passes  away;  pernianont  iin[)airinoiit  of  the  niiiicl  i.s  au 
excf'|itional  .sor|U('noe. 

Diagnosis. — 'I'hcro  an*  few  diseases  which  )>roseiit  more  cliaractor- 
jjlii;  features,  and  in  a  majority  of  instances  the  nature  of  the  trouhle  is 
recoijnized  at  a  irlanco ;  hut  there  are  several  all'ections  in  children  wliich 
mav  simulate  and  he;  mistaken  for  it. 

((/)  Multiple!  and  dilTuso  ceri'hral  scderosis.  The  cas(>s  are  often  mis- 
;;ik('ii  for  ordinary  choiva,  and  have  heen  ilescribed  in  literature  as  iliorea 
sjiiis/irtt. 

There  are  douhtlcss  chronic  chan<:es  in   the  cortex.      As  a  rule,  tlie 

ii.uviiiients  are  readily  distin<rnishahlo  from  those  of  true  ehorea.  l)ut  the 

-iiiiiilation   is  sometimes   vei-y  close;  tho  onset   in    infancy,  the   impaired 

i!ii('lliirence,  increased   rellexes,  and   in   some    instances   risridity  and  the 

iinmic  course  of  the  disease,  separate  them  sharply  from  true  chorea. 

(■')    l''rieilrei(drs  ataxia.     Cases  of  thi 


■ilv  cl::ssed  as  chorea.     Tl 


s  wcU-idiaracterized  disease  wore 
le  shiw,  irrcirular,  incoordinate  movements, 


■  ic  -roliosis,  scanniiiL''  speech,  the   early   talipt's.  the  tiystairmus,  and   the 
family  <'haracter  of  the  iliscase  are  points   which  sIkuiKI   render  the  diair- 


n>is  easv. 


(' )    in   rare  cases  the  paralytic  form  of  clion^a  may  he  mi>takcn  for 
liii-my(ditis  or,  when  Ixith    Ici^s   are  alTccted.  for  paraplegia  of  spinal 
loriiriii;  hut  this  can  only  he  the  case  when  the  choi'cic  iiioveiiienis  are  very 
slight. 

(il)   Hysteria  may  simnlate  chorea  minor  mo<i  (doscly.and  unless  there 
larc  other  manifestations  it  may  he  impossihle  to  make  a  diagnosis.      .Most 
(iiiniiioiily,  however,  the  movements  in  the  so-called   hystci'ical  chorea  are 
Irlivtiiiuic  anil  ditl'cr  entirely  from  those  of  ordinary  idiorea. 

(r)   As  mentio?icd  above,  the  mental  symjitoiiis  in  maniacal  chorea  may 

jniask  the  true  nature  of  tho  disease  and   jiatients  iiave  even   heen  sent  to 

lu' asylum. 

Treatment.  —  .\hnornially  hriirht,  active-minded  children  holoiiirinj; 

I'm  families  with   pronounced    nc'irotic  taint   should   lie  carefully  watched 


frniii 


>"\\VV- 


he  ao;es  o'i  eiiihl  to  lifteeii  am 


I    not    allowed  to  overtax    their  mental 


■io  freipuMitly  in  children  of  this  da-s  docs  1^ 


le  alta<'k  ol  cliorea 
'iiitf  from  the  worrv  and  .stress  incident  to  school  cxaniinalions  that  the 
'"m|ietition  for  prizes  or  places  should  he  cm|iliaiically  i'orhidden. 

Til'  treat:nent  of  the  attack  consists  lar;rely  in  attention  to  hygienic 
fiiasures,  with  which  alone,  in  time,  a  majority  of  the  cases  recover.  I'ar- 
|t'iits  should  he  told  to  scan  L'^cntly  the  l'ault<  and  waywardiics-;  of  choreic 
iMi'cii.  The  ]isvchical  (dement,  stron,i.dy  developed  in  so  many  cases, 
lii'st  treated  hv  (|niet  and  seclusion.  The  child  should  ho  coiitinod  to 
the  recnmhent  posture  and  nu'utal  as  well  as  bodily  (piiet  enjoineil. 
Ill  pr'vato  jiractice  this  is  often  impossilde.  but  with  well-to-do  patients 
■11"  ili>easo  is  always  serious  enough  to  demand  the  assistan )f  a  skilled 


m 


f^r 


094 


DISEASES  OF  THE   NERVOUS  SYSTEM. 


•  1  -imuli 


nurso.  Toys  uml  dolls  should  not  lio  iillowod  lit  first,  for  tlio  clii' 
\)v  ki'iil  aiiiuscd  uitlioiit  cxcitfiiu'iit.  Tlio  rest  iilhiys  the  liy|»'r-i'.\iit|,l,j|. 
ity  and  rcdiici's  to  a  niiiiiiiiiiin  tlii-  possihility  of  (liiiiiiij^'i'  to  the  \;il\r  si  <.'- 
nif'iits  sliould  ciidocjirditis  exist.     'I'iiiio  and  airain  liavo  I  scni  v 


cry  scviTu 

(.•ases  which  had  rcsistiMJ  tri-atniciit  for  weeks  oiitsiih;  ii  hosjiital  lircnmc 
quiet  and  the  nioveineiits  8ub.sido  after  two  or  three  days  of  aljsohiu  ri',«; 
in  l)cd. 

The  child  should  be  kept  a|iart  front  other  chihlreii  atid,  if  |in«<il,i,, 
from  other  nienihcrs  of  the  family,  and  shouhl  see  only  those  |i(is(,i|. 
directly  coneerned  with  the  iiursin<i:  of  tlu,'  ease.  Thou^'h  irksonie  iiiul 
troulihsome  to  cai'ry  out,  this  is  an  iminu-taut  part  of  the  ti'calirc m.  In 
the  latter  period  of  liu'  disease  daily  rubbings  may  be  resorted  in  uiih 
trreat  benefit. 


The  medicinal   treatment  of  ihe  disease  is  unsatisfactorv 


Willi    tl 


exception  of  arsenic,  no  remedy  seems  to  liave  any  influence  in  cuii. 
trollinjr  tiie  progress  of  the  ail'ection.  Without  any  specilic  actioM.  u 
certainly  does  good  in  many  cases,  jirobaltly  l)y  improving  the  gciuial 
nutrition.  It  is  convi'iiiently  given  in  the  form  of  Fowler's  solution,  ;im! 
the  good  effects  are  rarely  .^icen  until  maximum  do.^es  are  taken,  li  iii;i\ 
be  given  as  .Martin  originally  advi.-cd  (!si;i);  he  began  "  with  live  iIihik 
and    increased  oiu'  di'op  every  day,  until  it  might  Ix'gin  to  disagree  \\i:ii 


the  stomach   or   bowel.- 


Wlieii  the  dose  of  fifteen  minims  is  reai' 


nuiy  be  continued  for  a  week,  and  then  again  increased,  if  necessary, 
dav   or  two,  until  ))hvsioh)"ieal  cfTeets  are  manifest.     On  tlie  o( 


iril,  It 


('V"rv 


ciirnij 


of  these  the  drug  sliould  l)e  stoj)ped   for  three  ov  four  days.     'I"he  pun! 
of  resumiiiir  the  administration  wiih  smaller  doses  is  rarely  neeessuv. 


tol 


erance  is  usu 


[illv  I'sfablished  and  wv  can  Ijeaiii  with  the  dose  w 


iii'ii 


child   was  taking   wIumi   the  .symjitoins  of  saturation   occurrec].      i 
freipiently  given  as  mucli  as  twenty-five  minims  three  times  a  thiy. 


■r(  II  a:,v 


ally  tlie  signs  of  saturation  are  trivial  hut  plain,  and  1  have  never 

ill  effects   from    the  large  doses,  l)ut   1   have   heard    reci-ntly   of  a  cUMofj 

arsenical  neuritis  due  to  the  administration  of  Fowler's  solution  in  cliiiniLl 

Of  other  medicines,  strychnine,  the  zi;ic  compounds,  nitrate  of 
bromide  of  potassium,  belladonna,  chloral,  and  especially  ciniicifug;i. 
been  reeommcndi'd,  and  mav  be  tried  in  obstinate  cases. 

I"'or  its  tctnic  effect  electricitv  is  sometimes  useful  ;  but  it  is  not   i 


•ilvir, 


Illt'iOl 


lir,> 


sarv  as  a  routine  treatmen 


t.     T 


le  (|Uestioii  of  irvmnasties  is  an  imiuiiiant 

lit  ,i'l 


one.      Farly  in  the  di.sease,  when  the  movi'inents  are  active,  it  is  ii 
visable  ;  Imt  during  convalesceiici'  ci'refully  graduated  exercises  arc  iii.j 
doui)tedlv  lieiieficial.      It  is  not  well,  however,  to  send  a  choreic  cliilil  t" 


school 


yvninasium,  as  the  stimulus  of  the  other  children  ami  the  cv 


meiit  of  the  romping,  violent  ))lay  is  very  pri'judicial. 

Other  points  in  treatment  may  be  mentioni'd.  It  is  important  to 
late  the  bowels  and  to  attend  carefully  to  the  digestive  fiinetioiis. 
the  anu'inia  so  often  present  })reparations  of  iron  are  indicated. 


n:'"' 


ACUTE  ClIOUHA. 


005 


■  tho  chilli  -liiiiiW 
(!  liyiit'i'-i'X'iUiliil- 
.  to  till"  valve  si;.'- 

I  HcrU  vcl'}   ,M\iir 

II  lidSpitill   iHCnlllr 

in  of  ubsoliiU'  iVfi 

■i\  and,  if  |i"v«ilil', 
;mly  tliosc  ii(i>tiu> 
oiifli  irksniiic  iiiiil 
tin-  trt'iitiii.  nt.  in 
JO  rt'St)rU'cl  U'  Willi 

jifiictory;  wiiU  tli- 
,•  iiilliicniH'  in  I'l'ii- 
,•  siH'i'ilif  action,  il 
troviiip  tlu'  •jyhvrA 
jwler's  sdlutinii,  u:.<l 

iuv  taken.  It  m;'} 
ran  "■  with  livf  'l''"!'- 
,oiu  to  (lisa.i:n'f  wrh 
niii\inis  i^  ivailuVi, ,; 
■a,  if  ni'C'ssary.  r\.rv 
On  tlic  (H'ciinvi.v 

.lays.     'Hu'  pradi'A'i 
is  rarely  ni't-'t'>>arv.H'^l 


ll>0  llnSL'    w 


Urli 


11  occurri'i 


tinio: 


11  I 


1.      1 
lav. 


r 


1  have  never 
rt'centlv   of 


!'(ii  iiiiv 


a  I  :!-'■ 


(I 


|r 


solutioti  in  cli"";!.! 


Ills,  niti-ato  o 


>\\y'U 


ally  eimie 


ifii^ii- 


u:r'Oi 


lil'S. 


;  Imt  it  IS  not   II'  '• 

4ics  is  an  inii"'ri'i!' 

active,  it  is  h"'  •"' 


Ited  exereiso; 
Il  11  choreic  t 


<  ari'  I'.iH 
hiia  I" 


lUren  J' 


uul  tl 


ic   <.' 


Xi'lUi 


In  the  severe  cases  with  incessant  movenienls,  sk^eplessncss,  dry  tongue, 
1111(1  ilclirinni,  the  important  iiulictition  is  to  procure  rest,  for  which  ptir- 
jMisr  clihjral  may  he  freely  ^Mveii,  and,  if  necessary,  morphia.  Chloroform 
iiiliiilatioii.i  may  he  neci'ssary  to  stibdiic  the  intensity  of  the  paroxysms, 
i.iit  ilie  high  rate  of  mortality  in  this  class  of  cases  illustrates  how  often 
iiur  iiest  endeavors  are  fi'uitless.  The  wet  pack  is  Sdinetinies  very  sooth- 
iiiL' and  should  l)e  tried.  As  these  patients  are  apt  to  sink  rapidly  into  u 
liiw  typhoid  state  with  heart  weakness,  ii  supporting  treatment  is  reciuired 
fniiii  the  outset. 

Cased  arc  found  now  and  then  wliich  drag  on  from  month  to  month 
without  getting  either  better  or  worse  and  resist  all  modes  of  treatment. 
Change  of  air  and  scene  is  somi'times  followed  by  rapid  impmsenient,  and 
ill  these  cases  the  treatment  by  ri-st  and  seclusion  should  alwavs  be  given  a 
fiill  trial. 

In  all  cases  care  shouhl  be  taketi  to  examine  the  nostrils,  and  glaring 
noular  defects  should  be  properly  corrected  either  by  glasses  or,  if  necea- 
siry,  by  operation. 

After  the  child  has  recovered  from  the  attack,  the  parents  sliouM  be 
wiinied  that  return  of  the  disease  is  by  lu)  means  infrecpient,  and  is  par- 
Uiularlv  liable  to  follow  overwork  at  school  or  debilitating  inlhieiices  of 
;inv  kind.  Tlicse  ri  hqjses  are  apt  to  occui-  in  the  spring.  Sydenham  ad- 
viM.ll  purging  in  order  to  j'reveiiL  the  vernal  recurrence  of  the  disease. 


IS   1 


mportant  ton:: 


stive  function^- 


m 


dicated. 


.*•'■  f 


:.-    i 


yiM5 


DISKASKS   OF   TIIH   NIORVOUS  SYS'I'KM. 


IV.    OTHER    AFFECTIONS    DESCRIBED    AS    CHOREA. 


t 

17  1 

'W 

V;>'| 

m 

^    i 

"  t^ 

{     ' 

inV 

} .    ' 

I    4       J 

^' 

h^  ^ 

ib 

'\}  ' 

,        J^ 

f 

) 

-■  ( 

I  \ 

j  i 

■f 

[  !• 

'  (*■ 

1  -j^  ^ 

s^' 

■  r 

i'-W 

t' 

{(')  Chorea  Major;  Pandemic  Chorea.— 'riic  cnninioii  niinic,  St.  \  itu-'s 
•  lance,  iipplicil  to  cliDrcii  liiis  ('(hiil'  to  us  from  tlic  niidillc  a^ris.  when 
imdcr  tlie  inlliK'iMH'  ol'  ri'litrioiis  t\'rvor  tlicrc  \vcn>  cpidfiiiics  cliiirartirizi.il 
l»y  <,M'i'at  ('xcitctiiciit,  t^csticiilatiotis,  and  daiioiii;:^  l""or  tlic  rcli(.|' nl' tlif<c 
.•;yiiiptoins,  wlicii  excessive,  pilj^n'iniap's  were  made,  and  in  tlic  ii'lu'iiish 
pi'oviiice.s,  partieidarly  to  the  Cliapel  of  St.  N'itns  in  Zebern.  K|ii(ieiiiii.s 
of  this  sort  iia\e  oeenrn>d  also  diiriiiir  tiiis  century,  and  descri|)tioii>  df 
them  amoiii;  the  early  settK'rs  in  Kentucky  liave  been  <iiven  hv  Icibcit-on 
and  VandeU.  It  was  unfortunate  lliat  Sy(h'iiluim  aii|)li(>d  tiie  term  rlidiva 
to  an  alTection  in  ciiihiren  totally  distinct  from  tlii.s  chorea  major,  wiiirji 
is  in   reality  an  hysterical  manifestation  under  the  inlluenee  of  rtligiims 


excitement. 


{/>)  Habit  Spasm  (Habit  Chorea);  Convulsive  Tic  (of  il 


rciwii 


'I' 


W( 


)  ^n'oups  of  cases  may  be  recoiiiii/.ed  under  the  dcsi;i:r,atioii  i 


if  hal.iit 


[iinl 
ami 


spasm — one  in  which  there  are  simply  localized  spasmodic  movements, 
the  other  in  wliieli,  in  addition  to  this,  there  are  explosive  utteraiire.s 
psychical  symptoms,  a  I'ondition  to  which   l-'rciich  writer.s  have  given  tlu- 
name  /if  cdiiriilsif. 
( 1 )   IIkIiH  Sj)(ts)n.- 


'I'his  is  foiiiul  chiellv  in  childhood,  most  frriiiiintlv 


in  jrirls  from  seven  t.>  fourteen  years  of  ',vj,v  (Mitclu'll).     in.  il.- 


-Illl|.k'«l 


form  there  is  a  sudden,  (lui 


cK  CO 


ntraction  of  certain  of  the  facial  tiiiis 


such  as  rapiil  winkini;  or  drawini:  of  the  mouth  to  one  side,  or  the  inrk 
mn.scles  arc  involved  and   there  are  unilateral   movements  of   the  licad. 


The  head  is  <fiven  a  sudden,  (piick  shake,  and  at  the  .same  time  ilir  ivi> 
wink.  A  not  infrequent  form  is  the  shruir.irinir  of  one  shoiddi  r.  Tin' 
f^rimace  oi-  movement  is  re|)eated  at  irri'ixular  intervals,  and  is  uiikIi  ai:,i:iii- 
vated  by  emotion.  A  short  inspiratory  snilV  is  not  an  uncommnii  symp- 
tom. The  cases  are  found  most  frecjuently  in  children  who  ar( 
sorts 
encv  to  Uv'urotic  disordtMv 


>iit 


or  who  have  been  ;rrowi 


ntj  rajiiilly,  or  who  have  inherited  a  teml- 
lied  to  or  as.sociated  with  this  arc  sninc  df 
the  curious  ti'icks  of  (.'hildren.  A  boy  at  my  clinics  was  in  the  haliil  evtiv 
few  mouuMits  of  puttin.uj  the  middle  finirer  into  the  mouth,  bitim:  it.  ami 
at  the  same  time  pressing  his  mtse  with  the  forefinger.  Hartley  Cok'- 
ridge  is  said  to  have  had  a  sonu'what  similar  trick,  only  he  bit  In- arm. 
in  all  these  ca.ses  the  hal)its  of  the  child  should  be  examined  carefully. tlie 
noso  and  vault  of  the  pharynx  thoroughly  in.spected,  and  the  eyes  aci  uiaiilv 


OTllKIl  AFFKCTIONS    DHSriUnill)    AS  ClIOHKA. 


t>!>7 


As  a  rule  the  cniiditiiHi  is  traiisifiit,  and  al'tcr  pcrsistiii;:  fur  a  fc 


w 


.S   CHOREA. 


tlic  lanal  iiiiis'li'^ 


i|in 


ll! 


lis  or  Idiiufcr  <,'ra(iiially  tlisa|t|K'afs.    Occasioiially  a  local  si)asm  ]H'rsists 
iw  iii'hiiii:  of  till'  cvcliils,  or  the  I'arial  LTiiiiai't'. 

I  .')  Tic  (  iinrnlsif  [(lillfs  ilv  hi  'I'ttiivillrs.  nisvnsr). — 'I'liis  r('niarkal)lo 
itli.iioii,  often  iiiistalxcn  for  cliorca,  more  frf((iK'iitly  for  liaMl  spasm, 
-  icillv  a  psvi'liosis  allit'(|   to  hysteria,  tlionjxh  in  eerlain  of  its  aspects  it 


llie  features  of   iiioiioliiania.      'I'iie   disease   hcLMl 


IS,  as  a  rule,  iii  voiiii},' 


IIIIU 


rcu,  oeeiirriui:  as  early  as  the  sixth   ycai',  tiiouiih  it  may  ih'\elop  alter 


HlliertV. 


here    IS   usui 


a  mar 


kedl 


V  neurotic  faniilv  hisiorv. 


and  is  miidi  aL'.irra- 
|n  uncommon  .-mii|i- 
who  are  "•  "lit  I't 
inherited  a  tcinl- 
|th  this  are  sniuc  ni 
in  the  hahii  fvtiy 
,uth,  bitintr  it,  ami 
i-r.     Hartley 
„dy  he  Ini   1m~  iinii.  ■     (,,, 

iiied  .'arefully.tiH'B.i 
ll  the  eyes  acciiniulv 


-Dccial  features  of  the  complaint  are: 

\ii)  Involnntarv  muscular  movements,  usually  alTci'tin;:  the  facial  or 
lirachial  muscles,  liiit  in  a^'ifi'avated  cases  all  the  mus(des  of  the  liody  may 
In' iiivolveil  and  the  movements  may  ho  extremidy  irre;j:ular  and  violent. 

(/.)  ]''.\plosive  utterances,  which  may  resemble  a  hark  or  an  inarticulate 
irv.  A  word  heard  may  be  mimicked  at  once  and  repeated  (tver  and  over 
;iL'aiii,  usually  with  the  involuntary  movements.  To  this  the  term  crhi)- 
klid  has  been  applie(l.  A  much  more  distressiiii:  disiiirhance  in  thoso 
i;i-i('s  is  c(i/ir(ilii/i(i,  or  the  use  of  bad  lan,iruai;e.  A  child  of  ei,i.dil  or  ten 
inav  shock  its  mother  and  friends  by  constantly  nsiiijf  the  word  t/tniiu 
ttiit'ii  makiuLr  flic  involuntary  movements,  or  by  uttering  all  sorts  of  ob- 
iirtu'  words.     Occasionally  actions  are  mimiid\ed — rr/iid-nicsis. 

{<■)  Associated  with  some  of  tlie.so  cases  are  ciiri()U.s  mental  disturh- 
ama's;  the  patient  becomes  the  subject  of  a  form  of  obsession  or  a  lixed 
ili'a.  1  was  consulted  recently  al)out  a  younir  .ii'ii'l  in  whom  the  spasms 
uvrc  very  sliirht,  amoniitiiiii  only  to  twitchimf  of  the  eyes  and  sli^rht  .j<'rk- 
iiiL'of  the  shoulder,  but  who  had  a  most  pronounced  ixraile  of  the  fixed  idea 
kiKiwii  us  (irif/niiiiiiiinn'ii.  Almost  every  action,  even  the  most  trillinii, 
was  prcTcded  by  the  eoiintiuij:  of  a  certain  number  <'f  ii.Lnires.  Before  sho 
went  to  bod  slio  had  to  taj)  her  heel  upon  the  side  of  the  bedstead  a  eer- 
t;iiti  iiiimber  of  times;  before  drinkinir  the  tiimliler  had  to  be  rotated 
'ii'lit  or  ten  times,  and  then  when  set  down  airain  the  same  act  was  re- 
i"atii|.  IV'fore  openiiiijf  the  door  a  certain  nnmlier  of  knocks  had  to  be 
.ivfii.  'I'he  irreatest  dillieiilty  was  ex]>erienccd  in  jjfettinif  her  to  !)riish 
I'!' hair,  as  it  took  her  so  Ion<j  to  count  the  necessary  number  of  tiiiuros 
ii't'ui'e  she  heiran.  in  other  cases  the  lixed  idea  takes  the  form  of  the  im- 
'il-c  to  touch  objects,  or  it  is  u  lixed  idea  about  words — onomatomaina. 
Ar(irdiii<r  to  (iiiinon,  who  lias  written  an  exhaustive  article  upon  it  in 
;i('  Ihciioiiiiaire  Kucycloi)e(li(pU',  the  proirnosis  is  bad. 

The  disease  is  well  marked  and  readily  distinu'uishcd  from  ordinary 
tlioiva.  'I'he  niovomonts  have  a  largor  raiiire  and  are  explosive  in  (diarac- 
''tr.  Tourotle  regards  the  coprolalia  as  tlu^  most  distinctive  feature  of  the 
'iisi'asr. 

Saltatoric  Spasm  {LafttJi  ;  Miirinrliil  .-  .Ixi^pcrs). — 11aml)i'rLrcr  has 
t'^L'ribod  a  disease  in  whii'h  when  the  jiatieut  attempted  to  stand  there 
"iTo  strong  contractions  in  the  leg  muscles,  which  caused  a  jumping  or 


()(»8 


DFSKASKS  OK   TlIK    NKItVOl'S  SVSTHM. 


,*?iK 


w- 


H|iriii;.nii<;  iiKtiidii.  'I'iiis  occurs  oiilv  w  lifii  the  |i;iticiit  iiltoiiipts  to  .-i.iiui. 
The  atlVctioii  liaa  occurred  in  Itoth  men  and  women,  more  frequently  in  tlip 
former,  ami  tlie  .-ulijccts  liii\e  ii>iially  shown  marked  iieuroiic  temh  ii.  h 
In  many  eases  the  condition  has  iieen  transitory;  in  others  it  ha- in- 
sisted for  years.  Ilemarlxalile  alVeetions  similar  to  this  in  certain  |Miiiit.s 
occur  as  a  sort  of  endemic  neurosis.  One  of  the  most  strikinj,' <d'  Ihcsi' 
occurs  auioiiif  the  "  iuin|iin;:  !■  Vcnchmen  "  of  .Maine  and  Canada.  .\- ilc- 
scribed  liy  j'canl  and  'I'lioruton,  the  subjects  are  liable  on  any  sudden  ciiki. 
tioii  to  jum|)  \iolciitly  and  utter  a  loud  cry  or  sound,  and  will  obc\  luiv 
command  or  imitate  any  action  without  re^'ar<l  toils  nature.  The  inn- 
dition  of  echolalia  is  present  in  u  nuirked  de^Mve.  'i'he  "  jum])in^  "  piv- 
vaiis  in  ceitain  I'atnilitvs. 

A  very  sinular  disease  prevails  in  parts  of  IJussia  and  in  .Tavii,  where  it  i. 
known  by  the  luinu's  (d"  myriacdnt  and  latah,  the  chief  feat'.ire  uf  whit  h  ; 
linmicry  l»y  the  patient  (d"  everything'  he  sees  or  bears. 

{i/}  Chronic  Chorea  {lhii,liii(idii)i\-<  Clinrrii). — .\u  alTeition  chai.H  i. 
ize(l  by  irrci^ular  moveineuts,  disturl)ance  of  speech,  ami  j.M'adual  demciiti;i 
It  is  fri'(|Uently  hereditary.  The  disease  has  no  conneclioii  with  Sydciiliain' 
(diorea,  and  it  is  uid'ortuiiate  that  the  term  was  applied  to  it.  It  wa-il 
scribe(l  by  Iluntiiiffdon.  (d'  INuiieroy.  ( Hdo,  at  the  time  a  practitioner  mi 
Lonj;  Island,  ami  he '.m  in  three  bi'ief  parai;i'aphs  the  salient  poiiiI>  in 
eoniu'ctioii  with  the  disease — namely,  the  hereditary  nature,  the  asMi'ia- 
tioii  with  psycdiical  troubles,  ami  the  late  onset — between  the  tbirtielh  ;iii(| 
fortieth  years.  'J'lie  disease  seems  common  in  this  country,  and  luiiiiv 
cases  have  been  reported  by  Clarence  Kin^',  Sinkler,  and  others.*  I  lime 
seen  it  in  two  Marylaiul  families  within  the  past  two  years,  rndcrtlir 
term  chronic  (diorea  may  l.'c  j:rouped  the  lu'ivditarv  form  and  lin' 
cases  which  come  on  witlutut  family  disposition,  either  at  middk' lilV  nr. 
more  couimonly,  in  the  ajied — senile  (du>rea.  It  is  doiil)tful  whether  llir 
cases  in  children  with  (diroidc  choreifoi'ui  moveinent<,  often  with  inciiliil 
weakness  and  spastic  condition  of  the  le<fs,  should  tro  into  this  cate^roiv. 

The  hereditary  character  of  the  disease  is  very  strikinir.and  it  has  liivii 
traceil  throu<di  four  or  live  m-iu'rat ions.  Iluutinirdoirs  fathi'r  aiul  Liriiml- 
father,  also  physicians,  had  treated  the  disease  in  the  family  whiidi  luilr- 
scrilied.  An  identical  atlVetioii  occurs  without  any  hereditary  dispo.-itinii, 
The  af?e  of  onset  is  late,  rarely  b(d'ore  the  thirtieth  or  the  thirty-liftli  ycir. 

The  syin])toms  are  very  (diaractcristic.  The  irrefxular  nH)vemeiils  niv 
usually  first  seen  in  the  hands,  aiul  the  patient  has  slight  ditliculty  in  lui- 
forminfi  delicate  nmni])ulation.s  or  in  writinji.  When  well  establishcil  tin' 
movenu'iits  are  disorderly,  irrejinlar,  incot'irdinato  rather  than  choreic,  mid 
have  not  the  sharp,  brus(pie  motion  of  Sydenham'.s  chorea.  In  the  I'li"' 
there  are  slow,  involuntary  j;rimaces.  In  a  well-developed  ease  the  i;;iil  i^ 
irrej^ular,  swaying,  and  somewhat  like  that  of  a  drunken  man.    The  siiwli 


For  complete  literature,  see  lluet,  ile  la  Choree  Chrouique,  Paris,  1889. 


'I'^^v 


KM. 

it  attonipts  to  i-i.iml 
iiin-  t'ri'inu'titly  in  tlu' 
iit'iiniiic  It'iiili'iiiic-. 
in   oiliiTs  it   liii«  |n'r- 
tliis  ill    certain  imiiils 

nst    ^tnkill;4  of    tinsr 

and  Ciimiilii.  A-  ik'- 
k'  oil  any  smltli'ii  iiiin- 
11(1,  iiii<l  will  olit\  iiiiy 
its  natiirt'.  'I'lu-  run- 
The  '*  juiiipiii;:;"  ihv- 

,11(1  ill  .lava,  wluTc  it  i> 
iff  ffiitiiro  of  wliicli  U 

cs. 

,11  alTcction  chariutcr- 
and  <rra(lual<U'niiiitia. 
.(•lion  with  Sydcnliam'- 
plied  to  it.     It  ua^il.- 
time  u  iiraetitioiK  roll 
IS  the  salient  |)oiiH>  in 
ry  nature,  the  assd-iu- 
tweeii  the  thirtidli  ;ii;'l 
lis  country,  and    nmiiv 
•,  and  others.*     1  luivc 
two  years.     riuUTtln' 
litary    i'oi'in    and    ili' 
ther  at   iiiiddh'  life  .t, 
d.ml.tfiil  whether  the 
it<.  often  with  mental 
.(.  into  this  (■ate.ircry. 
iikin,-r,and  it  ha^-  i'^.u 
il,,irs  father  and  j:iana- 
llie  family  which  IumIi- 
liei'e(litary  dispo^itieii. 
I„r  the  thirty-liftli  uar. 
rejiular  inovemcnt-  :"'' 
sli^dit  ditViculty  in  I'ir- 
,.n  well  estahlislu'l  '1"' 
ither  than  ehoreie.  iiinl 
s  chorea.     In  tlu   fair 
i-loped  case  the  uait  i> 
ken  man.    The  si'wl' 


INFAN'TII-K  CO.WLLSIOXS. 


Oi»l) 


[oiiique,  Paris,  1889. 


is  -low  and  dilViciilt,  flic  syllahle.s  arc  liadly  jironouiicod  ami  indistijict.  hiit 
iio!  dcliiiitely  staccato.  The  mental  Impairiiieiit  leads  linally  to  demciilia. 
\ Cry  few  post-mortems  have  itceii  made.  No  characteristic  lesimis  have 
111  I  11  found.  Atrophy  of  the  (  itividiition-,  idiroiiic  mcniiiL'o-eiiccphalitis, 
and  vascular  (diaiiL'cs  have  usually  heeii  pn  -cut.  the  cmiditinii*  which  one 
wwmM  expect  to  liiid  in  a  chronic  dementia.  'I'liese  existed  in  an  aiitupsy 
wliiidi  I  iiad  on  one  of  my  cases.  Oppeiiheim  ami  lloppe  liave  desciihed 
in  'WO  case.-  .1  miliary  disseminateil  encephalitis  <d'  the  cortical  and  suh- 
cn;  cal  reui'iiis,  particularly  nf  the  im>tiir  zone.  The  allVciiijn  is  evi- 
(Iciiily  a  iiciiro-ile^eiierative  disorder,  and  ha-  no  coiiiicctidii  with  the 
siiiiple  clinrca  of  cliildhoud. 

('■)  Rhythmic  or  Hysterical  Chorea. This  is  readily  reco,i:iii/ed  hy  the 
iii\ihmical  idiaraeter  of  the  movements.  It  m.'iyatfect  the  muscles  of  the 
iilHiiiineu,  prodiiciii!.'  the  salaam  coiiviilsidii.  uv  iiivolvi'  the  steriio-mastoid, 
|inilucin^f  a  rhythmical  movement  of  the  head,  nr  the  psoas,  or  any  group 
nf  muscles.      In  its  drilerly  rhythm  it  reseiiihlcs  the  canine  chorea. 

V.    INFANTILE    CONVULSIONS    i/yiamp.i,,). 

roiiviilsive  seizures  similar  to  those  of  epilcp-v  are  not  iiifre(|uent  in 
cliildreii  ,(iid  in  adults.  The  lit  may  indeed  he  identical  with  epilepsy, 
fmiii  wlii(di  the  condition  dill'ers  in  that  when  the  cause  is  removed  there 
i-  no  tendency  for  the  lit,-  to  recur.  <  )ccasi(iiiall\.  however,  the  convul- 
^i(lll-  in  children  continue  and  develop  into  true  epilepsy. 

Etiology.  .\  conviiNioii  in  a  chiM  may  he  due  to  many  causes,  all 
iif  uhich  lead  to  an  iiiistahle  condition  lA'  ilie  ner\c-ceiitres,  jiermittiiiir  <»f 
Mnldeii,  excessive  and  temporary  nervous  di-charges.  'i'ho  follow  in^;'  are 
tile  most  important  of  them  : 

( 1)  Dehility.  resultinu  usually  from  Lrastro-intestinal  (listurhaiice.  Con- 
viil.-iniis  fre(|iiently  supervene  toward  the  clo^e  of  an  attack  of  .eiitero- 
ii)liti  and  recur,  sometimes  pi'ovini:  '.ital.  .Morris  .1.  Lewi.-  has  slmwn 
tli.c  the  death  rate  in  (diildicn  from  eclampsia  rises  steadily  with  that  nf 
r,i>ir()-intcstinal  dl.-;ordci's. 

(v')  IV'ri[»lieral  irritation,  hciititidii  al'>ne  is  rarely  :i  caiis{>  of  cniivul- 
sions.  hut  is  (d'ton  one  i>\'  several  factors  in  a  1'eehle,  unhealthy  infant. 
Tile  LM'eatest  mortality  from  conviiNiiuis  is  durini;-  the  first  six  months,  lie- 
fiiiT  the  teeth  really  cut  throuirh  the  irums.  Other  irritative  causes  are 
llie  iiverloadinjj;  of  the  stoma(di  with  indiirestihle  food,  it  has  heen  siitj- 
L'l'sii'd  that  some  of  these  eases  are  toxic,  owinir  to  the  nhsor|>tioii  of  poi- 
HiMious  ptomaines.  Worms,  to  which  convulsions  are  so  freipieiitly  attrih- 
ii'eil.  prohahly  have  little  inlliience.  Anioiiir  other  sources  possihle  arc 
phimosis  and  otitis. 

(;!)  Riid\ets.  The  ohservation  of  Sir  William  .leiiner  ujion  I  he  assoeia- 
tiot!  of  rickets  and  convulsions  has  hoen  amjily  confirmed.  The  spasms 
may  lie  laryngeal,  the  su-called  child-crowing,  which,  though  convulsive  in 


lOlM) 


DISKASKS  OK  TlIK   NKUVolS  SYSTKM. 


PI'  ^■'■' 


I 


B     {  n; 


'■'m 


,H^ 


I  t 


1 


ra '''' 


iiiitinf,  i-aii  sfiircfly  lie  coiisiilrnMl  witli  (rlaiiiiisiii.  Tlir  iiilliiciicc  i<\'  UiIm 
('(tiiililiiiM  is  iiinrc  a|i|)iin'iit  in  Kiirn|)(>  tliaii  in  this  cniiiiii'v,  alllioii^rh 
rirkcts  is  a  rMmiiiMii  tli^ca^i'.  iiarticiilarlv  aiiinii;,'  ilic  (((lorcil  |ic(>|)|(., 
Spasms,  loi'iij  or  ^■^•■iici'al,  in  lickcls  arc  |irul»al»|y  assncialcil  wiili  ihr  idn- 
(litioii  III'  (Icliility  and  inalnnliilinn  and  witli  cranin-taltcs. 

(4)  l'"f\fr.  In  yonnj,'  cliildrcn  ihi-  tmst't.  dt'  tiic  intVctions  ilisca-is  i< 
frcijiii'iiilN  uiili  I'linvnisiitns,  wliicli  id'lm  take  the  |>lai'<'  nl'  a  chill  in  ilic 
atliilt.  It  is  nnt  known  npon  wluit  they  (l('|nnd.  Scarlcl  IVvfr,  niia.-li>. 
lUtd  itnciiMionia  ai'c  most  (d'tcn  inffcdt'd  l)y  ('(invulsidiis. 

(.*»)  ( 'un;.''('st ion  ol' till'  brain.  That  cxtn'mc  (•n;ior;^('mcnl  of  the  IiI.mmI. 
vessels  may  prodnc'c  convnlsions  is  shown  l>y  their  <>eea>ional  ocnirniiiv 
in  .-icscre  w  hoo|iin;_f-t'onjfh,  Iml  their  rarily  in  this  disease  reiillv  iinli- 
eates  how  small  a  part  nieehanieal  eonj,'estioii  plays  in  the  prodiniiuii 
ol"  lils. 

((i)  Severe  eonvnlsioiis  usher  in  or  accompany  many  of  the  serioii>  i|j«. 
cases  (if  the  iier\ous  system  in  children.  In  more  than  lifty  per  cent  nf 
the  cases  of  iiifanliie  heniiplci^ia  the  allVctioii  follows  severe  con\  id-inn^. 
They  less  freipiently  preced*'  a  spinal  paralysis.  They  neenr  with  nieiiiii- 
jritis,  tulierculoiis  or  simple,  and  with  tnnnirs  and  other  lc>ion>  of  tin- 
brain. 

And,  lastly,  convulsions  may  (m'ciii'  inimedialely  after  liirth  ;ind  pci'- 
sist  for  weeks  or  months.  In  such  instances  there  has  prohahly  hciii 
iiKMiiiiu'eal  lia'tnorrhairc  or  serious  injury  Id  the  cortex. 

The  must  important  cpu'stion  is  the  relation  of  convulsions  in  chiMrfU 
to  true  epilepsy.  In  (iowers's  li^^ures  of  1, }."»()  cases  of  epilepsy,  the  attack^ 
bej^an  in  jsti  duriiiLT  the  lii'st  three  years  of  life.  Of  -lUd  cases  of  epil()i«v 
ill  eiiildreii  which  I  havi' analyzed,  in  jsT  the  tits  hei^an  within  the  lirst 
three  years.  Of  the  total  list  the  <ireatest  niunher,  1-1,  was  in  the  lirst 
year.  In  nearly  all  thesi-  instances  there  was  no  interruption  in  the  lon- 
viilsioiis.  That  convulsions  in  early  iid'ancy  are  lu'cessarily  followed  iiy 
('pile|)sy  in  after  life  is  certaiidy  a  mistake. 

Symptoms. — The  attack  may  come  iii  suddenly  without  any  wAm- 
\uii;  niori'  commonly  it  is  preceded  by  a  stai^eof  restlessness,  accoMipaiiiril 
by  twitchintr  and  pei'haps  irrindiii",' of  the  t"eth.  It  is  rarely  so  complrti' 
in  its  Kta.iJfes  as  true  epilepsy.  The  spasm  beirins  usually  in  tln'  IimihIs, 
most  commoidy  in  the  ri^'ht  hand.  The  eves  are  fixed  and  stariiii,' or  ire 
rolled  up.  The  body  becomes  slitT  and  breathini!:  is  suspended  for  ;i 
moment  or  two  by  tonic  spasm  of  the  res[)iratory  mus(des,  in  conse(|iiriiii' 
of  wliieli  the  face  becomes  cotiffcstod.  ("loiiie  eonviilsions  follow,  the  cvis 
are  rolled  about,  the  hands  and  arms  twitch,  or  are  (lexed  an<l  extemliil  in 
rhythmical  movements,  tlu'  facie  is  contorted,  and  the  head  is  retriii'tdi 
The  attack  >ifradually  subsides  aiul  the  child  sleeps  or  passes  into  a  slate  iif 
Btupor.  Followinij:  indiirestion  the  attack  may  be  sin>rle,  but  in  rickct- miuI 
intestinal  disorders  it  is  apt  to  ))e  repeated.  Sometinu's  the  attack-  fol- 
low each  other  witli  great  rapidity,  so  that  the  child  never  rouses  bui  lii'.'; 


^^fm 


M. 


INFANTIM",   (■|^N•V^^^-I(»^S. 


l(Mll 


,('  illlllU'lK't'  III  tills 
(•(illlltIV,  illllniii;:li 
ic    rnlol'cil     |MM|i|c, 

lilted   W  ill)  llu'  lull- 

ICS. 

iifcrlidiis  (lisciiscs  is 
[•^•  til'  a  cliill  ill  till' 
iirlt't  t'l'vcr,  nil  ;i>li>, 

•liU'lit  nf   the  111 1- 

CllSlullill    Ol'rill'i'riii'i' 

disease    reallv   imli- 
in  the  iiruduriinii 

IV  iif  tlie  serinii-  di-- 
III   lit'tv   per  ei'iil  of 

M'\ere  euiiVliUinii-. 
y  (leenr  witli  iinpiii- 

(itlicr   ie^idll.s  111'  ill, 

after  liirtli  iiii'l  |mt- 
lias   |)i'()l)al)lv   linii 

\  ulsioiis  in  rliililtvii 
r|iile|isy,  tlie  attiiik- 
W  cuses  (if  epilrl'-v 
i^aii  within  tin  IliM 
M,  was  in  tlir  lirsl 
riMiplinn  ill  lln'  ''"H- 
■essarily  fnlliiwnl  i'v 

without   an>  "arn- 

sness,  acriiiii|i;iiii''il 

rarely  so  eoiii|ililt' 

-ualiy   in   the  iiamls. 

(i  and  slariii.ir  "i" '"'' 
is   sns|»endeii    fur  ;i 

^(•les,  in  conseiiiii'iiiv 

/ions  follow,  the  evis 
xed  and  extemli'ii  i" 
e  liead  is  reifaitnl. 
lasses  into  a  slatr  nf 
e,  hut  ill  rickrt-  :in4 
lines  tlie  atlaelv-  f"'- 
[levur  I'ousos  hiil  lii'-'- 


111  a  deep  eonui.  If  the  eonvulsion  has  lueii  liinitrd  rhielly  to  one  sid») 
lilt  le  may  lie  sli;.'lit  pare>is  after  recovery,  or  in  instaiiees  .in  w  hieh  tiu' 
KihMilsioi.ri  iislier  in  infantile  lieiniple;:ia,  when  the  child  arouses  one  sido 
h  .  iiiiiplelely  paraly/ed.  hiirin;,'  the  lit  the  temperature  is  oficii  raised. 
|i.  :iili  rarely  occurs  fnuii  the  con\  ul>ioii  itself,  except  in  dcliililnlcd  chil- 
.livii  or  when  the  attacks  redir  with  ;,M'eat  fre(|Uency.  In  the  so-ealled 
liwli'oceplialoid  state  in  coniieclinii  with  protracted  diarrluea  convulsions 
iiiii^  clo^c  I  he  scene. 

Diagnosis.  -ComiiiL,'  on  when  Ihesuliject  is  in  full  luallh.  the  !'t- 
liirk  is  pmhahly  iliu'  eillier  to  overloaded  stomach,  to  some  peripheral 
iniiatioii,  or  occasionally  to  trauma.  Settiiii,'  in  wilh  h!;,di  IVvci'  and 
Miiiiiliii^f,  it  may  indicate  the  oii>ct  of  an  I'xanlhem,  or  occasionally  he  the 
|iiiiiiary  symptom  of  eiicephalilis,  or  wh:itever  the  eoiidition  is  which 
iiii-rs  infanlilc  hcmiplcLiia.  When  the  attack  is  assoeiiitid  wilh  dchility 
ami  with  rieki'ls  the  diaiiiiosis  is  easily  maile.  'i'he  carp<ipedal  spasms 
ami  pseiulo-paralytic  riiiidity  which  are  often  associated  with  rickets, 
iji  \  ii'iisnius  sliidiiliis,  and  the  hydroccplialoid  state  are  usually  contiiicd 
:n  I  he  h;iiii|s  iiiid  anus  and  are  intcrmillcnt  ami  u>ually  tonic  The  coii- 
'.iil-ious  associated  with  tumor  or  which  follow  iiifaulil"  hiiiiiple^iii  aro 
uMially  at  first  .laeksoiiiaii  in  character.  After  the  second  year  convulsivi! 
M'i/.iires  which  come  on  irre;:ularly  without  apparent  <'aiise  and  recur 
while  till!  child  is  apparently  in  good  he.ilth  are  likely  to  prove  true  epi- 
Ifpsy. 

Prognosis. — ('onvulsious  play  an  important  ])ait  in  infantile  mor- 
tiility.  Ill  .Morris  ,).  Li'wis's  tahle  of  deaths  in  children  under  ten,  S',"i  per 
nut  Were  ascrihed  to  com  uL-ions.  \\'est  states  that  ■-.>•.'•'"."»  per  cent  of 
iJiMlhs  under  one  year  ar*'  caused  hy  convulsions,  luit  this  is  too  hie|i  an 
I'stiiiiate  for  this  country.  In  chronic  diarrluea  convulsions  are  usually 
of  ill  omen.  Those  ushering  in  fevers  are  rarely  serious,  and  the  same 
limy  he  said  of  the  fits  associated  with  indigestion  and  peripheral  iriita- 
iiiiii. 

Treatment.  —  Kvery  source  of  irritation  should  he  removed.  Ifas- 
-ni'iaied  with  iiidigestihle  food,  a  prompt  emetic  should  he  given,  followed 
tiv  nil  enema.  The  teeth  should  he  examiiieil,  and  if  the  gum  is  swollen, 
Imt.  and  tense,  it  may  he  lanced;  hut  never  if  it  look>  normal.  When 
■ii'i'ii  at  lirst,  if  the  paroxysm  is  severe,  no  time  should  he  lost  hv  giving 
a  Imt  hath,  hut  chloroform  should  he  given  at  once, and  repeated  if  iieces- 
•ary.  .\  child  is  so  readily  put  under  chloroform  and  with  such  a  small 
||iiiuitity  that  this  precediire  is  ipiite  harmless  ami  saves  much  valuahle 
tiiiif.  The  practice  is  almost  universal  of  putting  the  child  into  a  warm 
liatli,  and  if  there  is  fever  the  head  may  he  douched  with  cold  water.  The 
ti'inperature  of  the  hath  should  not  he  ahovo  9r)°  or  OC".  The  very  hot 
Itatli  is  not  siiitahle,  jiarticularly  if  the  Ills  are  diu;  to  indigestion,  .\fter 
till'  attack  an  ice-cap  may  he  placed  upon  the  head.  If  there  is  miii-li  irri- 
tahiliiy,  particularly  in  rickets  and   in  sevoru  diurrluL'a,  siiiall  dosus  of 


''  It; 


lori2 


DISEASES  ()!•'   TIIK    XKI{V(»rs  SYSTEM. 


n|iiiim  will  lie  fiiiiml  clliciiciuus.  When  tin'  (•(iiiviiNiinis  rcciir  aftri-  ihr. 
cliiM  cHiiics  iVdiii  iiinlcr  llic  iiilliiciirc  of  clilurdl'di'in  it  is  licst  to  \>\:,,r  \\ 
r;i|iiiilv  mi'liT  tlic  iiilliiciifc  (if  ip|iiiiiii.  wliidi  may  lie  lmvcii  as  iikh  i  hia 
Iiv|»(Hl('i'iiiically,  ill  doses  i.f  fmiii  one  tweiity-liftli  toone  thirtieth  of  a  Liiin 
f  ir  a  eh i  1(1  of  one  year.  Otiier  remedies  I'eeoiii mended  are  chloral  iiy  cih mu, 
in  tive-irrain  doses,  aiw]  nitrite  of  amyl.  After  the  attack  lias  |iass(i|  tlic 
iirouiidcs  are  iisefiil,  of  which  live  to  ciLdil  irraiiis  ma\  he  lmm'H  in  a  (l,i\  tn 

li'ecufi'int:  eon\  Ill-ions,  |iariiciilarly   if  they  coiim- en 


;i  ehiKl   a    vear  o 


uithoul  special  eanse,  should  receive  the  most  thoroiiLrh  and  cai'efiil  feat. 
meiit  with  Id'omiihs.  When  iissociat(Ml  with  riekels  the  treiitnu"  'miili! 
be  diiveliul  to  improving  the  general  toiiditioii. 


VI.   EPILEPSY. 


"'.      IT,     HI 
»#     ft 

.Jill  '!  >A'W 


^1  ^'  ||g| 


-* 

rm 

. 

m 

'J 

M 

Definition.  —  An  alTection  of  the  nervous  system  characterized  ],\ 
iit(a(d<s  of  iinconscioiisness.  wiili  or  without  convulsions. 

The  I  raiisient  loss  itf  conseioiisness  without  convulsive  seizures  is  kiinuii 
l\^  /ii/i/  mill  :  the  loss  of  consciousness  with  Lrclieral  convulsive  seizi.n-  i« 
kiiiiwii  as  ///'////^  iihil.  Localized  con\ulsioiis.  occiirrini;'  usually  wiiiimr 
loss  of  consciousness,  are  kiioun  as  c|iile|itifoi'iii,  or  more  fre<jUeiill\  a,> 
Jacksoiiian  orco'lical  e|iile|isy. 

Etiology.  -   .1,'/''.      In  a  larire  proportion  of  all  cases  the  disease  hei;iii- 
l)efore  piihcrty.      Of  the  l.ir.i)  eases  oliserved  hy  (iowers,  in  •J",'"."  llie  di-e;i«r 
lieiraii  licfore  the  t-Mitli  year,  and  llii'ce  fourths  of  th.'  cases  iieiraii  liefei-, 
the  twentieth  year.     Of  .|tlii  ca>es  of  epilepsy  in   children  which   1    ha 
aiialyze(|  *  the  aire  of  onset  in.-l'ii  was  as  follows:    l''ir>t   \car.  M;  >,•  i.i.i 
year,  tl',*;   third  year,  .'i I  ;   fourth   year.  'i\\  fifth  year,   II  ;  sixth  year.  1>: 
seventh  \car.  I'.t ;  ei.Lditli  year.  ■.'•'! ;  ninth  vear,  11  :  tenth  year.  "..'I  ;  elevnr' 
year.  11  ;  twelfth  year,  I's  ;  thirteenth  year.  l.">:  fomtccnth  year.  ".'1  :  !' 
tecnth  year.  :!t.      .VrraiiLTcd    in   hemidecades   the   tit;iires  are  as   folJeH-: 
l''roiii  the  iii'st  to  the  fifth  year,  ■.'■.'!! ;   !'r.,in  the  fifth  to  the  tenth  year,  li'l; 
from   the   tenth   to  the   lifteenth   year,  !».").     The-e   ti.i^urcN  illiistnite  in  a 
strikiiii:  manner  the  early  onset  of  the  disease  in  a  laiyc  |U'oporlion  ol'  ti 
cases.     It   is  Well  always  to  he  suspicious  of  epilepsy  dexclopini;  in  i!.' 
adult,  for  in  a  majority  (d'  siudi  cases  the  convulsions  are  due   to  a   le'ii: 
lesion. 

Sr.r.  —  \()  s|)e(-ial  inlliiciice  appears  ti»  lie  discovcralde  in  this  rehiiie: 
eertaiidy  not  in  children.  Of  VX.\  cases  in  my  tallies,  •.':>■.'  uci'c  male-  ;!' 
•jii:!  were  females,  showiniT  a  slight  predominance  of  the  iiiali'  sex.  All- 
jniherty  nn(|Ue8tiotiahly,  if  u  largi?  luuiiher  of  case.s  iirc  taken,  the  h'mI'- 


*  Three  Inini1r(>ii  .iiid  nine  cases  friiin  i  lie  reeeids  rnmi  the  I'hiiiiilel|iliiii  Infinn.ivv  ' 

Pisr.'isrs  (if  tlie  Nervelis  System,   l'2ll  ease>   lit   llie  I'lhvyii  Ilist  it  ut  ieti  fnr  p'relilc-ii  'I   ii  . 

Cliililreii.  ami  '^7i  from  the  reeord.s  of  my  iieuruhigitiul  clinic  al  Ihu  Johns  Ihi'Mi 
LIu.s|iital, 


I. 


EPri.KPSV. 


vm 


]]<  rociir  after  tlio 
is  best  to  iil;.(  r  it 

trivi'M    as  llKH  plliil 

tliirtictli  nt'a  I'l-iiii 
!■  chldi-ai  liy  ciii mil, 
ai'k  lias  |ia-.-r(l  tln' 
(•  i.MV('n  in  a  (l;i\  In 
Iv  ir  tlii'V  ciiiiic  nil 
;iii(l  cari'ful  tivat. 
V  troalim"      'h'IiM 


1  cliaractcriziil    liv 

ii'  st'iziiri'S  is  kimuti 
iiviilsivo  scizi.n-  i« 
iiLT  usually  withiiii! 
moiv  fiH'<|tieiitly  ;i.- 

cs  the  disease  lir-'i::- 
s,  ill  J'^^  iIk'  <li-c;hr 
(•uses   lieLTaii  liiti'fi 
Mrcu  wliieli    1    lia.i 
st  year.  M  ;  scmiihI 
1 ;  :  ^i\tli  year.  1>; 
vear,  ••J".  ;  elevrn!'i 
11th  year,  'l\  ;  lit- 
are   as  fellMU.: 
he  teiilli  year.  l"l; 
ires  illustrate  in  ;i 
lirmiortiiiii  111'  '1' 

(leVel<>|iillt,'    ill    'i 
illV  due   to  a   lerai 

lie   ill    thi>i  relali"" 

.>;',•.'  were   iiiale<  ;ii"' 

le  male  sex.      \l' 

re  taken,  tiie  i:  :i   ■ 

il.i.lclpliiii  Infinii.iiyf  ' 
tloii  fnr  I''.>clil(-iiiin'l("l 
ill    lllL'    Jelms  II.t''il 


ir( 
tl 


are  in  oxf'osrt.     The  fijjiifes  of  Sievekiiiir  ami   Keviiolds  show  that  the  dis 
fiiM'  is  rather  more  |tivvaleiil  in  females  than  in  males. 

//r/v"//7//.— Mni'h  stivss  ha.s  heen  laid  ii|ioii  this  iiy  many  aiitiiuis  as  an 
iiiiMui'taiit  predisiiosiiiL;' e;uise,  ami  the  stat  isties  collected  irive  fr<>ni  nine  to 
o\i'r  forty  per  cent,  (inwers  i^ives  thirty-live  per  eeiii  for  his  cases,  wiiieli 
li;i\e  special  value  apart  from  other  statistics  emiiraciiiL''  lar;j:e  numhers 
(if  epileptic-;  in  that  they  wci'e  collected  liy  him  in  his  own  practice^ 
111  oiir  li;:;ures  :•  Mppeav.s  to  play  a  minor  /v/'A .  in  the  Intirmary  li.st 
tlure  wure  oiilv  ;!I  cases  in  which  there  was  a  liisldiy  (  f  marke  1  neurotic 
t;iiiit,  and  only  three  in  whiidi  the  mother  hersi'lf  had  lieeii  epileptic  hi 
the  Mlwyn  eases,  as  miufht  he  expected,  the  pereentaire  is  lai'iicr.  Of  tlio 
IJi;  there  was  in  '.i'i  a  faiiiily  history  of  nervous  deranLrt'iiu'iit  of  some  sort, 
cillier  paralysis,  epilepsy,  marked  hysteria,  or  in.-anity.  It  i-  iiiterestin<^ 
tiMiote  that  ill  thisLn'oiip,  in  v'icli  the  ipicstion  of  heredity  is  carid'nlly 
liMiked  into,  there  wci'c  only  two  in  wlii'di  the  mother  had  had  ejiilcpsy, 
ami  not  one  in  which  the  father  had  heen  all'cclcd.  Indeed.  1  wa.-  not  a 
litlle  surprised  to  tiiid  in  the  list  of  my  cases  that  hereditary  inlluencei* 
plaved  so  small  a  part.  1  lia\e  heard  this  opinion  e\pre>sed  liy  certain 
Fieiieh  phvsieians,  notably  .Marie,  who  in  writiiiij:  al.-o  iipdii  the  (jiiolioii 
lakes  stronjf  ^'rounds  a.irainst  heredity  ;'s  an  important  factor  in  epile|i-y. 

While,  tlu'ii,  it  may  he  said  that  direct  inheritance  i>  comparalivcly  iin- 
I'oinmon,  the  children  of  neurotic  families  in  which  iieihaleia,  insanity, 
and  hysteria  prevail  are  more  liable  to  fall  vielim  in  the  disease. 

('hrniiir  iilroliiilisiii  ill  the  parents  is  rcLfardi'd  tiy  many  as  a  potent  pre- 
ili>p(isin<i:  factor  in  the  production  of  e|iilepsy.  Kidieverria  lias  analy/ed 
"li'.' cases  bearinif  upon  this  point  and  divided  them  iiiln  tliree  classe-:,  of 
ui.  'h  ■.'.">;■  cases  could  be  traced  directly  to  alcdhol  as  a  cause  ;  i".'(;  cases 
ill  wlii(di  then'  were  associated  conditions,  such  as  syphilis  and  traiima- 
ti-iii;  l<s;i  cases  in  whi(di  tlu'  alcoholism  was  proiiably  the  roiilt  id"  the 
epilepsy.  l"'i,a"ures  e(pially  stronir  are  iri veil  iiy  .\lartiii.*  who  found  in  l."tO 
iii-aiie  epileptics  S!)  with  a  marked  history  of  parental  iiitciiipeiancc.  (If 
ilie  rjii  l:^lwyii  cases,  in  whi(  h  the  family  lii,-tor\  on  thi-  point  was  care- 
fiillv  investigated,  a  dellnite  statement   was   found    in   oii'v  four  of   the 

SjipltiJis. — This  in  tin  parents  is  probablv  les<  a  predisposiiiLr  than  an 
aetiial  cause  cd'  epilep,-y.  which  is  the  direct  oiiteoine  of  local  cerclii'al 
iiiaiiifestatioiis.  'i'lu-re  is  no  ri-ason  for  reeoirniziiif  a  special  form  of 
syphilitie  epilepsy.  On  the  other  hand,  convulsive  seizures  due  to  acipiircd 
•;ypliiliti('  disease  of  the  brain  are  very  common. 

Mriilitil. — Severe  epileptic  coiiMiNioiis  may  occur  in  steady  dri;ikers. 


'  M' ox(.'itiii<!:  (\'nises  fright  is  iKdieved  to  be  in 


ipdrtaiit. 


but  is  les>  M>.  I 


111- 


iiid<,  tliati  is  iismdly  stateil.     Trauma  is  present  in  a  I'crtain  nimilier  of 
uiee.s.     An  important  group  deiieiids  ujioii  a  local  di.sease  of  the  bruin 


*  Animli's  M(5dicales  l'.>>yeliologi(iuis,  1879. 


1004 


DISEASES  OF  THE   NERVOl'S  SYSTEM. 


I 


exist iiiji:  from  cliildlHind.  MS  wcii  in  the  j)nst-licirii|ilci:ic  cpilcpsv.     (Ir,.;i. 

sidllillly   CiL-CS    folliiW    tlu'    illt'cctioUS    fcVlTS.        MllsHirliatinll     has    lu'Cll    >t;ilrii 

to  Ik'  a  s[ii'cial  cansc,  hut  its  iiithiciicc  is  pnilialtly  (ivciTalcd.  A  I;ii'::o 
ffroup  (if  I'luiviilsivc  seizures  allieil  to  e)iih'|isy  are  (hie  to  some  toxic  aui m, 
as  ill  iea(l-|)oisoiiiiiif  and  in  iiraMiiia.  tireal  stress  was  laid  ii|ion  i'  |l,  \ 
ciiiises,  such  as  (h'lititioii  and  worms,  llie  irritation  of  a  eieatrix.  some  b  ■ ;,; 
ailVet ion,  such  as  adherent  |)re|iuce.  or  a  toreiirii  iuxly  in  the  ear  or  I'm 
nose,  in  iiiany  of  tiiese  eases  the  tits  cease  alter  tlie  reino\al  of  the  ciui^c. 
so  tiiat.  tliere  can  he  no  (|Uest  ion  of  the  association  hetweeii  the  twd.  In 
others  the  attacks  persist,  (iciiuiiie  eases  of  rellex  e|iiie)isy  are,  I  1m  In  \i. 
rare.  A  reinarkahle  instance  of  it  occurred  at  the  rhila(lcl|iliia  liilirii,;ir\ 
for  I  )isca>(>  of  the  Nervous  .System  ill  the  ease  of  a  man  with  a  testis  in  lin 
injriiinal  canal,  pr"s>iire  iipoii  which  wdiild  cause  a  typical  tit.  Ifeiiio'.iil  (,| 
the  orii'aii  was  followed  hy  cuiv. 

Mpilepsy  has  hecii  thoiiiiht  to  he  associalc(l  with  distiirlianct'  of  :!, 
liearl's  action,  and  some  have  spoken  i>\'  a  speci;il  cardiac  epilepsy,  p;ii 
ticularly  ill  >  ascs  in  which  there  is  palpili'tion  ov  slowiii<f  of  the  aiHi.i 
prior  to  the  onset,  l-ipii'pli.'  seizures  may  occur  durin;^  the  passaii'e  of  a 
•lall-stoiie  or  occasioiiall)  thirinuf  the  removal  of  pleuritic  fluid.  IndiL:v<- 
tioii  and  i^astric  tr.>iihi.  -  are  extremely  eomiiuui  in  epile|isy,  and  in  iii:iii\ 
instances  the  eatinir  "f  itidiirestihie  articles  m-'-ius  to  precipitate  an  all.i'  L. 

All  ath  Mipt  to  associate  irciiuine  epilcp->   with  eye-strain   has  siiriiaily 
failed. 

Syiuptoms.  -( 1)  Grand  Mai.— I'rccedin'r  tlif  fits  there  is  iisuall\  ;i 

localized  seii-atioii.  kiiouii  as  an  mint,  in  some  part  of  the  hody.  'I'ln- 
may  hexiiiiatic  in  which  the  feeliii;:  comes  froiii  wrfinf  particular  n  ' 
in  the  peiipherv,  as  from  the.fin«rer  or  hand,  or  is  a  sensation  felt  in  \\v 
stomach  or  ahoiit  the  heart.  'I'he  peripheral  sensations  preeediiijx  tlu  li; 
arc  of  sjfi'eat  value,  particularly  those  in  which  the  aura  alw.ays  occurs  in  ,i 
definite  rcLrion,  as  in  oiie  liiiL'er  or  toe.  It  r-  the  e(|iiivalent  of  the  .-iL'n:i 
sym|itoiii  in  a  lit  fnuii  a  hraiii  liiiiior.  The  varieties  of  these  .seiisati'i  - 
lire  iiuiiieroiis.  The  e|)i<:astric  .sensations  are  most  common.  In.tJH'.-'  li^ 
patient  complains  of  an  uneasy  sensation  in  the  epij^astrium  or  distre-  ii 
the  intestines,  or  the  sensation  may  not  he  unlike  that  of  heart-hurii  :im  ; 
may  lie  as.sociatcd  with  palpitation.  Tlie<e  groups  are  someliincs  kici 
lis  luieiimoirastric  aura'  or  waniiiiiis. 

Of  psychical  aura'  one  of  the  most  common,  as  deserihed  hy  llujflihni:- 
Jaekson,  is  the  vasrue,  dreamy  statis  a  sensation  of  straiuieness  or  ^i>\w- 
tijiies  of  terror.  The  aura  may  he  a,ss()eiate(i  with  special  senses,  of  wliiih 
the  visual  arc  the  most  common.  consistiuLr  of  flushes  of  liirlit  or  scii-:i 
tions  of  color;  less  eommoidy,  distinct  ohjects  are  seen.  The  aiidii"i' 
iiura-  consist  of  noises  in  the  ear,  odd  sounds,  ii'.usieal  tunes,  or  oeeasioiiall) 
voices.  Olfactory  and  {.gustatory  aiine,  unplea.sant  tastes  and  odors,  .li- 
ra re. 

Oec'usiuiiallv  the  (it  mav  he  preceded  not  hy  an  aura,  hut  hy  ccnui 


■  I'     lll  1,1^"  "1 


EPILKI'SV. 


ItKI 


i'|iilc'l>sy.  0' i:i- 
1  has  lu't'li  slalni 
fiTalrd.      A  liiriio 

SOUR'  liixii'  iiLii  III, 
;  laid  U|Hin  ivllix 
•icutrix,  sdiiio  linal 

in  tin-  t'iir  or  ilic 
iioval  ol"  ihf  caiix', 

U'Cll    tlu'     two.       Ill 

■|isy  ai'i'.  I  Ik'Iii  vc. 
i(l('l|iliiii  liiliniiarv 
with  ;i  tostis  in  llic 
'A  tit.    Ki'iiioMil  (if 

ilisturbaiH'c  of  the 
•iliac  (■itiU'j)s_v.  par- 
ainil  of  tin'  art  It'll 
ni:  tlic  iiassa.i:<'  "f  ;i 
lie  tluid.  ln'li'jv<- 
K'|)>y,  and  in  nianv 
•I'cipitat''  iiti  iitta'  k. 
-.strain  lui^  siirnully 

.rt  tliiTi'  is  iiHuall\  ;i 
(.f  tin-  li"dy.     'Hii- 
|iartii'nlar  nv  '  ' 
fosation  1'flt    in     '' 
s  jircci'dinj,'  tlif  li;  _ 
always  occurs  in  ;i 
iilcnt  of  the  si-iKil 
f  these  sensation- 
ninn.     In  tlic-   ''  • 
riuni  or  distre.->  m 
nf  hcart-hnrn  iin'l 
sometimes  kn'iui, 

ri!>ed  1a  Hu<ihliit-'- 
iran'jeiicss  or  soinr- 
■ial  sei\ses.  of  whi'li 
'S  of  li.illit  <"■  '^''""' 
;eell.  The  a\nlil"n 
tun'S,  or  occasionally 
isti's  ami   odors,  .n- 

aura,  hut  by  <'C'i"'i" 


I 


nidvemeiits ;  tin' jiatient  may  turn  roniul  rapidly  or  run  witli  jrreat  speed 
fur  a  few  minutes,  the  so-calle<l  epilepsia  procursiva.  In  oin-  of  the  KUv\ii 
(Ums  the  lad  stood  on  his  toes  ami  twirled  with  extraordinary  i-apidity,  so 
tlial  his  features  were  s<'arci'ly  recoj^nizahle.  \\  the  on.-et  of  thr  attack 
tile  patient  nniy  give  a  loud  scream  or  yell,  the  so-called  epileptic  cry. 
Tlic  patient  drops  as  if  shot,  making'  in»  elVort  to  ;rnar(|  the  Call.  In 
(•iiiisei|Uencc  of  this,  epileptics  fre(piently  injure  themsehts,  ciitlin;,'  tin? 
face  or  head  or  hurninj^  themscUes.  In  the  attack,  as  dc-crilied  hv 
llijipocratcs,  "  the  patient  loses  his  speech  and  chokes,  aii'l  i'naui  issues 
IriPiii  the  nmiith,  the  tei'th  are  tixed,  the  hands  are  contracted,  the  eyes 
(li'iorted,  he  heconu's  inseiisilile,  and  in  soun'  cases  the  howels  arc  alTected, 
Aim]  theses  symptoms  occiii' sometinu'S  on  the  left  side,  sometimes  nu  the 
ri;jiil,  and  sonu'tiines  on  hoth."  'i'he  til  may  he  ilocrilied  in  three 
-iM'/i'S : 

((t)  luin'i'  S/ifi.'iii). — The  hea<l  is  drawn  hack  or  to  the  ri^dit,  ai<d  the 
jaws  are  fixed.  The  hands  are  clim  lied  and  the  le;:s  evtendcd.  This 
'Ml;:'-  contraction  alfccts  the  nms<'K's  of  the  chest,  so  tjuit  lopiratioii 
i>  impeded  and  the  initial  pallnrnf  the  face  cliamres  tn  a  dii-ky  or  li\  id 
line.  The  muscles  of  the  two  sides  are  iiiie(|liall_\  all'cctcd,  so  that 
the  head  and  neck  are  rotated  or  the  spine  is  twisted.  'I'hc  feet  are 
extended  and  the  knees  and  hip-joint  arc  flexed.  The  arms  arc  usually 
tlr\i(l  at  the  elliows.  the  hand  at  the  wii>l,  and  the  liiiu'ei's  are  tiuhlly 
liii.ched    ill   the  palm.     This  stag*'    la-^ts  onl\    a  few   .scionds,  ami    ihcn 

(//)  C/iniir  sf(ii/r  hegins.  The  miiscnlai'  contractions  heioiiie  inler- 
iiiiltent;  at  first  tremulous  or  vilii'at"ry,  they  gradually  lieeonic  im>n' 
rapid  and  the  limits  are  jerked  and  tns.^ed  .'lixpiit  \  iuliiitU .  The  miis- 
'Ics  ')f  the  tii'i'  ari'  ill  constant  clonic  spasm,  the  eyes  roll,  tin-  eyelids 
ale  opelieil  and  closed  convulsively.  The  movements  of  the  muscles 
if  the  jaw  arc  very  forcihie  and  strong,  and  it  i-  at  this  time  that  the 
imiuue  is  apt  to  he  caught  hettveeti  the  teeth  and  lacerated.  The  cvan- 
">i-.  marked  at  the  end  of  ih'  tunic  stage,  gradually  Ic-- cun.  .\  frothy 
siliva,  which  may  he  'Icod-staiiied,  cm  a|>c^  from  the  niuuth.  i'he  fa'ces 
and  urine  may  he  di.scharged  involuntarily.  The  diiratinii  <>(  this  stage  is 
variahle.  It  rarely  lasts  more  than  one  or  tw..  minutes.  The  e.iiiti-ac- 
liiiiis  heeome  less  \  ioleiit  and  the  patient  gratliially  sink-  intu  the  ciui- 
illlioli  of 

('■)  i'lniui.  The  hreathing  is  noisy  or  even  stertorous,  the  fa-'  eon- 
i.'r-!ed,  hut  no  longer  intensely  I'yanotii'.  The  linihs  are  rdaxeil  and  the 
nil  inseioiisiiess  is  prcd'oiind.  .\fler  a  varialile  time  tlie  patieiii  can  In- 
ai'iii-eij,  hut  if  icft  aloiie  he  sleeps  fur  some  hour-  and  then  awakes,  eom- 
I'la  ning  (uily  of  slight  headache  or  mental  eiinfu>i<>n. 

In  sonu'  ca.ses  one  attack  follnw  -  the  other  with  great  rapidity  and  eoii- 
^'■iiiisue.ss  is  lint  regained.  This  is  termed  the  .yfnfiis  '■fii/rp/ifus,  an  ox- 
C'l'tioiial  condition,  ill  which  llie  patient  may  die  ot  exhaustion  consequent 


I  >, 


h 


m 


loon 


I)Isi:asi;s  of  the  XERvors  system. 


upon  till'  rcpi'iitcil  iiltiii'ks.  In  il  tlic  tt'iiiiu'ratiin'  is  usually  cli'v.ihMl. 
Al'tur  the  iittiU'k  ihv  ivlloxi's  arc  soiiiftiiiifs  aliscnt ;  iiKirc  riv(|iu'iitl\  ilu.y 
iii'c  iiicrcasci!  and  tlii'  ankle  clomis  can  iisniiHy  Ix'  olitaiiicd. 

Tim  stale  di"  the  urine  is  vi:rialile,  pai'tieularly  as  re^ninls  the  >'<\\,\^, 
'Pile  (jiiantity  is  usually  iiieivased  al'ler  the  attaek,  and  alhuineii  is  imi  in- 
l'ro(|iieiitly  presi'iit. 

/'os/-i/ii/r/i/ir  sjimpfomx  are  (»f  jrreat  iiiiportaiiee.  'I"he  patient  mav  Ic 
in  a  traiiee-like  eouditiitii,  in  v.liieh  he  peri'nrnis  aetions  (d'  which  >\\\\>v. 
<|iiently  he  has  no  recollcctinii.  M  n'c  serious  are  the  attacks  of  niaiiiii.  in 
which  the  patient  is  ol'lcii  danii'eroii  ■!  and  sonictinics  hninicidal.  it  is  \\vV\ 
liy  i.n)od  authorities  that  an  outlu'cak  (d'  mania  may  In-  snlistituted  t'cr  ilic 
lit.  And,  lastly,  the  mental  condilion  (d'  an  epileptic  patii'iit  is  cd'tcu  mtj. 
ously  impaired,  and  prol'ound  did'ccts  are  comnioii. 

I*araly,;is,  whiidi  rarely  I'ollows  tlu'  epilejitic  lit,  is  usually  heinipli-ii 
iiml  transient. 

Sli^llt  distiirl)anees  of  s)H'c(di  also  jiuiy  occur;  in  soiue  instances  fmiiiv 
of  sensory  aphakia. 

The  attacks  may  occur  at  iiiLrlit.  ami  a  person  may  lie  epileptic  l'..r 
years  witlmul  kiiowinLT  it.  .\s  'I'l'oussi  aii  tndy  I'cmarks,  when  a  p.r-un 
tells  us  that  in  the  iiii;lit  he  has  incont  iiicni'c  of  urine  an<l  awakes  in  liu 
niornini,'  with  headacdie  and  mental  confusion,  ami  conijilains  (d'  ditliciiltv 
in  spceidi  owin;^  to  the  fact  that  he  has  liitten  his  toiiixue ;  if,  also,  tliciv 
are  oil  the  skin  of  the  face  and  iie(  k  piiipnric  sjiots,  the  prohahility  is  viry 
stroiiLT  indeed  that   he  is  sul)ject   to  iioetiirnal  epilepsy. 

(".')  Petit  Mai.— 'I'his  is  epilep.y  without  the  convulsions.  The  aliink 
consists  of  transient  uncons<'ioiisiiess,  whi(di  may  come  on  at  any  tiiiir, 
accninpanied  or  una<'conipaiiie(i  hy  a  fecliii<f  (d"  faintiie.ss  and  virtii:". 
Suddenly,  for  example,  at  the  dinner  table,  the  suliject  stops  talkiiiL' :iiiil 
oatinjr,  the  eyes  hecium^  lived,  and  the  fai'c  sliirhtly  jialc  Anythinir  wliirh 
may  have  heeii  in  the  hand  is  ii>iially  dropped.  In  a  moment  or  two  iim. 
.«ciousness  is  r"<fained  and  the  patii'iit  resumes  conversation  as  if  iiotliiiii: 
liad  happeiieil.  In  other  instances  there  is  slijfht  ineoliereney  or  tin  |i;i- 
tieiit  perforins  some  almost  autunatic  action.  lie  mav  licji'in  to  iiu'lir>- 
liim>clf  and  on  ret ii miliar  to  consciousness  lind  that  he  has  piirtiall\  di- 
rohed.  In  other  attacks  the  patient  may  fall  without  convulsive  seiziin- 
\  ilelinite  aura  is  rare.  Thou;jjh  transient,  uiicoiiscioiisiiess  and  ^ddiliiir- 
are  the  most  constant  nianifestctioiis  of  y;r///  imil  :  there  an-  manyi'iiir 
e(|iiivalent  manifestations,  smdi  as  sudden  jerkin^'s  in  the  liin()S,  siclkii 
treini>r,  or  a  siidd"ii  visual  sensation,  (lowers  mentions  no  'ess  th,;ii  se\rii- 
teeii  dilTerent  manifestations  of  /ir/if  nitil. 


After  the  attack  the  patient  may  lie  dazed  for  a  ft' 


w 


s  and   I'll'- 


f^ 


orin  certain  aiitiuiiatic  action^ 


whiid 


1  tnav  seem  to  he  vo 


lit    iiial.     A.>^ 


IIICll- 


tioiied,  utulressinjr  is  a  common  atdinn,  hut  all  s(»rts  <»f  odd  i.ctions  iu;i\  1" 
performed,  .some  of  wliiidi  are  awkward  or  even  .serious.  One  (d'  '\\  pii- 
tieiits  after  an  attack   was  in  the  liahit  uf  tearing  anything  he  ''ouM  la} 


EPILEPSY. 


1007 


usiiiilly  ('lis.iUil 
•(■  riv(HU'iitl\  tlu'v 
.■(1. 

'(•<iiinls  the  ^"YuU, 
ill)iiiiu'ii  is  Hut  iii- 

'lu'  piilit'iit  may  lie 

IS   of    Wllicll    SUllM'- 

tarks  oi'  luiinia.  in 
iiiiidai.  It  is  lirld 
sulistiliilftl  fi'i'  ilic 
ilit'iil  is  (il'tt'ii  M  ri- 

usually  hniiiiilr.'ii 

nu'  iiistaiHH's  l'iiriii> 

ay  1)0  t'pilt'ptii'  fur 
rks,  wlu'ii  a  pci-dii 
and  awakes  in  llu 
ii;;lains  of  (lilliciilly 
><HU' ;  if,  also,  tlirrc 
I'  proliahility  is  \rr, 

Isioiis.     'I'licalta.k 
(■  oil   at   any  tnn'-. 
itncss  aii<l    vd'ii.L"'- 
t   sto|ts  talkiiiL'  ami 
.     Anythin,!:  wlii'li 
lonit'iit  or  two  ini;- 
sation  as  if  notlmiL' 
ihcrfHcy  ov  till'  |';i- 
ly  ln'^rin  to  unilrt'>s 
V  has  partially  'li- 
oiiviilsivc  sci/iir'  V 
lu'ss  and  jriddiiM- 
Vi'  arc  iHU'iy   I'lur 
tin-  linii)r»,  f.i'Mt" 
no  'I'ss  th,;n  si'\<'ii- 

\v  s'  s  ami  i'li'- 

olit  -);ial.  As  iiu'ii- 
odd  i.ciion-'  n:i'  >" 

MIS.     One  of     !^  !'■'• 


liaiids  on,  particularly  books.  Violent  actions  have  hccn  conunittcd  and 
a>-iidt.s  made,  frci|ucnlly  Lnviiii,''  ri>c  to  ipiestioiis  which  come  liefore  tlm 
(•(Piirts.  'I'liis  condition  has  Ih'i'Ii  termed  ma>kcd  epilepsy,  or  ijnhpsia 
laii'dta. 

in  a  MiajoritN  of  the  cases  of  priit  nutJ  c()nvidsions  tiiuilly  occur,  at 
tii-l  sli^dit,  hut  ultimately  ihv  i/niii'/  inal  heconies  well  ileveloped,  and  tho 
attacks  may  then  alternate. 

(:i)  Jacksonian  Epilepsy. — 'I'his  is  also  known  as  cortical,  symptomatic, 
111'  |iartial  cpili-psy.  It  is  distin^niishe(I  fi'om  the  ordinary  epik'|)sy  hy  the 
important  fact  that  consciousness  is  retaiiu'd.  The  atta(d<s  ai'e  usually  tho 
rt'sidt  of  irritative  lesions  in  the  mot(tr  zone,  thoUL;h  t  here  arc  prohahly 
also  s 'usory  »M|uivale!it- of  this  nu)tor  form,  in  a  typical  .itta(d\  the  spa-ui 
lifiins  in  a  limited  muscle  ^'roup  of  the  face,  arm,  or  'ei;.  The  zyi,nimati() 
iniisides,  for  instance,  or  the  thiimh  may  twitidi,  or  the  toes  may  lirst  ho 
moved,  i'rior  to  ihc  twitchini,'  the  jiaticiit  may  feel  a  .sensati(»n  of 
iiiiinhnoss  or  tinjjlin^  in  the  part  alVectcd.  The  spasm  extends  and  may 
iiivolvo  tho  inusck's  of  one  limi»  only  or  of  tho  face.  The  patient  i.s 
niiisciou.s  thnjU'diout  anil  watches,  often  with  interest,  the   march  of  tho 


spasm. 


The  onset   mav  he  slow,  and   there  mav  ))e  time,  a>   in   a   cas 


lia\r   \\ 


ported,   for   the   patient,   to   jilacc  a   |)illow  on  tl 


e  Wlllcjl  1 
ic  lliiof,  >o  as  to  lie 
a'*  couifortahle  as  pos>ii)le  durini;'  the  atta(d\.  The  spasm-s  may  he  htcal- 
izcil  for  year.s,  hut  there  is  a  <ircat  risk  that  the  partial  e|)ilepsy  may 
I  I  lime  ijenoral.     Tlu mlition  is  diu',  as  a  rule,  to  an   irritative  lesioji 


I'l 


th(^  motor  zone.      Thus  of   107  cases  analvzed  h\    liolaiid,  lli 


ere  Were 


is  of  tumor,  'l\  instaiK'cs  of  inllammatory  softeuinir,  14  instances  of 
ai'iile  aiul  chronic  inenin<j;itis,  and  S  cases  of  trauma,  'i'he  remaiintii^ 
instancies   were   due    to  ha'i.iorrhaii'c  or  ahscess,  or  were    assoc-ated   with 


.siierosis  cerclti'i.  I  wo  other  conilitions  may  l>e  inentioneil,  whicli  niay 
i;m-e  typical  .lacksoiiian  ej)ile|)sy  — munely,  nra'inia  and  proi:-rc.~sivc  pa- 
I'aiysis  of  the  insane.  A  considcrahle  numher  of  tiic  cases  of  .lackso- 
iiian epilepsy  are  found  iii  children  followiiiLr  hciniplcLiia,  the  so-called 
liii-t-lu'iuipleiric  epilepsy.  The  convulsions  usually  hcirin  on  the  alTected 
siile,  either  in   the  arm   or   lcl.^  and   the   lit    mav  lie  iinilatrral   and   wilh- 


111     loss     of      COnscioUSUC: 


■-'rn'ral 


ritimatclv    thev    hccome    nmrc    severe    and 


Diagnosis.  -  1  n  major  epilepsy  the  suddenness  of  the  attaek,  tho 
aiiiiipt  loss  of  consciousness,  the  order  of  the  tonic  and  clonii'  >p;'-tn.  atid 
itii'  relii.Kiition  of  the  sphiuctei's  at  the  lieiuhi  of  tic  atta'k  are  di~Mii  tivo 
fi'.tiiire.-t.     Th(!  convulsive  seizures  due  to  ura'inia  are  epileptic  in  (MiaracttT 


ain 


usually  readily  roco^^ni/cl   hy  the  existence  of  jrreatly  increased  t.o! 


>i<iii  and  the  condition  of  the  urine.  I'raetically  in  yoiiiur  adults  iiystoria 
iMiiscs  tho  <;roiitost  dithculty,  and  may  closely  simulate  true  epilepsy.  'I'Ih^ 
fiillnwin,!^  talile   from  (lowei's'.s  work   draws  idcarlv  the  (  hief  diircrences 


ivthing  ho  '-ouM  i;i^  ■  '"i^\oen  tliem 


1)1- 


m !  .1  I'- 


ll ii    Ji.-  ^' 

u  <W  «  \' 

14  »  '^ 


/      .(<'■ 

'<     '{      ,* 


1008 


DISKASDS  OF  TIIK   NKRVOl'S  SYSTKM. 


ElMLKI'TIC. 


IlYMTKItOIl). 


A|)|iiir<'nl  ('.•iiisi- iKiiii',  Crnniidn. 

Wiir'iiiii,' ;  any.   Imt    csiiciiiilly    iiiiilal-    |ial|iiliil  ioti.    rnalaix',   I'lmliin^'.  Ijj. 

I      I'l'jil  of  I'liij^aslric  mini'.  liitiT:il  fnnt  luira. 

Onset !  always  sudilcii.  uI'Iimi  irrailiial. 

Scrrani i  at  linnet.  ilmiui;  ('oiirsi'. 

C'onvul.sidU i'ij,'iilily   I'ciIIhwimI    l.y  ••  jci'k-    I'i^'iility  oi' "stiaiv'^'linir."  tlii-i.uim; 

in^;,"  rarely  ri;:iility  almu'.  ,      almut  of  iimlis  cir  ln'ail.  aiilnn;; 

of  liai'k. 


Bitini; :  liiMniic. 


Micturition . 
I)('fi'c;iti(in  .. 
Talkinu'... 
Duration  .  . 


fi'('<|U('nl. 

(icciisidnal. 

never. 

II  few  ininules. 


J{esiraint  necessary ..' to  prevent  iiecjdent. 
Tt'riuinatioii ■  siionluncous. 


lips.   Iiiinds.  or  other  people  uimI 

tliint;s. 
never, 
never. 

IreijUelil. 

more  tlian  ti-n  niinnti's.orteii  nni'  h 

loii;,'er. 
to  cont  roj  \  iojenec. 
.spouianeoiis    or    induced    (water, 

ulc). 


Kt'ciin  iiiLT  <'l>ilt'|'lic  sci/.tircs  in  m   iicrsoti  (ivcr  tliiflv    who   has  imt  liail 
providiis  attiicks  is  always  sii<,f,ocsti\('  id'  priranii'  (iiscasc.     .Xccnrdino-  1,1  || 
C  Wooil,  whiisc  ()|)iiiiini    is   sii|)|i(ii'tc(l   iiy  that  <d'    P'otiniicf,  in    iiiiic  caM- 
out  nf  tell  tlic  condilioii  is  liiic  to  syphilis. 

J'r/if  iihil  must  hi'  (listiuotiislu'il  I'foiu  attai'ks  of  syncope,  and  the  \er- 
tij^o  oi'  .MctiiiTc's  dist'aso,  of  ;i  cardiac  lesion,  and  of  iiidiifcstioii.  In  tl,e-e 
cases  there  is  noaetiia!  loss  (d' eonseiousinv-s,  which  forms  a  eiiafaetefi^tir 
tliouirh  not  ati  iuvariahle  feature  (d'  jx/if  iiKtl. 

.laeksonian  epilepsy  has  feattii'es  .so  distinctive  iind  peculiitr  that  it  is 
at  once  recoo-nizcii.  It  is  hy  no  means  easy,  however,  always  to  deter- 
mine upon  what  the  spasm  depends.  Irritation  in  the  motor  cetitivs 
niiiy  he  due  to  a  lifeat  \ariety'of  causes,  amoiio'  which  tumors  and  local- 
ized inenino'o-eiu-ephalitis  are  the  most  fre(pieiit ;  hut  it  must  not  lie 
f()i',i,'otten  that  in  ura'tuia-  localized  (  pilepsy  may  occur.  'I'lu'  most  t\]ii- 
cid  Jiicksoiiiaii  spasms  also  are  not  inffe([uent  in  giMieral  paresis  of  ilie 
insiimi. 

Prognosis. — This  may  he  triven  to-day  in  the  woi'ds  of  ]Ii|)pocrMte<: 
"'riie  pi'ouiiosis  in  epilepsy  is  iiufavcu'ahlc  when  tht-  disease  is  conireiiilal. 
and  when  it  endures  to  matdiood,  and  when  it  oci-ufs  in  a  ^'f(»wn  person 
without  atiy  previotis  eatise.  .  .  .  'I'lu'  cufe  may  he  altemi)te(l  '".  yoiuiL' 
persons,  hut  not  in  old." 

I )eath  during  the  tit  farely  occurs,  hut  it  Jiitiy  happen  if  tlio  paticn: 
falls  into  the  water  or  if  the  tit  eonu-s  on  whih'  he  is  eatiiiir-  Uceusionallv 
the  tits  .seem  to  stop  spoiitaue(tiisly.  This  is  particularly  the  case  in  tin' 
epilepsy  in  idiildreii  whi(di  has  followed  the  conviilsiotis  of  t(  ethinir  1"' "I 
the  fevers.  I"''re<pu'ncy  of  the  attacks  and  marked  inetilal  disliirhaiicc  aiv 
uiifavoraitle  inilications.  Hereditary  predispositimi  is  apparently  of  110 
Dfonu'iit  ill  the  |ir(»,j;uosis.  The  outlook  is  heller  in  males  than  in  feiii:ile-. 
The  jKwt-hi'iuipk'gic  epih'[).sy  is  nirely  arrested.     Uf  the  cases  cumin.'  'ii 


KIMI.KI'SY, 


lOOU 


KKoin. 


lilUo.    cliiikiii-'.  lii- 
ini. 


ujr^'lintr."  till'  « ill'.' 
IS  (ir  lu'iid,  iiriliiiiu 

otluT   jif'iiiic  mill 


Mil 


rlict". 

Ill-     iiidili't'il    (Willi  r. 


Ill  iniults,  tliosc  (liU!  in  sypliilis  iHid  In  local  alTcctidns  of  the  In'aiii  allow  ;i 
lilt,'  ravoraltlc  proj^misis. 

Treatment.  — ^'''//r/vr/. — In  llic  cas,'  nf  rliildrm  till'  |ianiits  should 
hi'  iiiailr  to  uii(li'r,-taii(l  I'l'diii  llir  oiit<i't  lliat  rpili  |i-y  in  llic  ^I'val  ma  jority  of 
ra-  -  is  an  inciirablf  alVfilidH,  ^o  thai  the  di-ca.-i'  iiiav  iiitcrrci'c  as  littli-  us 
|iii~-ilih'  with  the  (.'(hK^itioii  of  tlic  cliiM.  'I'hr  suhjcris  lu'cd  linn  l)iil  Uirid 
tri'i'iiiH'nt.  Induli,f('iici' iiiid  yifldiiii:  to  caprircs  and  uiiinis  arc  followed 
liv  ucaUciiinM;  of  llic  nioi'al  control,  whiih  i-  x)  ncccs.-ai'v  in  these  cases. 
The  disease  (h)es  not  in<'a|iacilatc  ;i  |ii'i-.-iin  fni' all  (Miii|iation.      It  is  nnich 


rttcr   for  e|iilejilics   to    have    sonic   dclinitc    pni'snit.      '{"here   ai'c    many 
i>t;iiiccs  in  which  lliey  Ikivc  hecii   |iei'sons  of  extraordinary  mental  and 
luileNiirit'ii  iiiurh      H   liiiijilv  viLjor  ;  as,  for  example,  .Inliiis  Ca'sar  and    Napoleon.     One  of  the 

-I   distres>inir   featnrcs   in   epilepsy  is   llie  ;;radiial    mental   im|)aii'mcnt 


who  has  not  lui'l 

According;'  t"  H- 

ier,  in   nine  ca-i'- 

eo|H',  and  the  \<v- 
<restion.  In  thr-i' 
us  a  characlt'i'i-lir 

.eenliar  that  it  i- 
'.  always  to  del.T- 
le  niotor  eelitro 
tumors  and  l'»al- 
It  it.  mnst  ni.t  I"' 
.  'I'lu'  ni'ist  i\|M- 
ral   paresis  of  i1h' 

Is  of  llipiioerait-^; 
lease   is  eontreiiital. 

in  a  iri'own  p«  r-'"; 
llcmptcd   '"'  yoiiii.' 

Ln  if  the  [taii'ii: 
lini:.  Oeeiision;illv 
llv  till'  case  in  III'' 
Is  of  teethiii.i;  '"'"'' 
ial  distiirlmner  ai' 
apparently  of  n" 
|es  Ihait  in  fenul'-- 
le  eases  coming   'H 


iiiii 


«lii'  h 


follows  in  a  certain  niimher  of 


such   patients   hecdnic  ex- 


trcir.ely  irritaiilc  or  show  si^ns  of  violence  they  should  he  placed  iiiuler 
Miprrv  isioii  in  an  asylum.  Marriaire  should  he  forliiddeii  to  epih'ptics. 
PiirinLT  the  attack  a  cork  or  hit  of  riihlier  .-lionld  he  jilaccd  hetwcen  tin; 
ii'clli  and  the  clot hi'S  should    he   louseiied.      The   patient    should    lie   in  the 


ivrlll 


llt'CI 


iheiit   po.stiire.      As    the  attack    usually 


iiassc.-^   oi 


with  rapidity,  n( 


id  treatment  is  neeessarv,  hut  in  cases  in  which  tlu'  convulsion  is  pro- 
iHiip'd  a  few  whiiVs  of  chloroform  or  nitrite  of  amyl  or  a  hypodermic  of 
:M|iiarter  of  ii  L;'r.iin  of  morphia  may  he  i:i\eii. 

Ilirh'lii-. — The  old  authors  laiil  ^reat  stress  upon  rci:'ime;i  iu  epilepsy. 
The  important  point  is  to  i:;i\e  the  jiatient  a  li;j:hl  diet  at  lixed  hours, 
ami  on  lu)  aeeoiini  lo  permit  ovcrloadiiiLT  of  the  stomach.  .Meat  should 
!mi|  he  i,nven   more  than   once  a  dav.     'I' 


lerc  are  cases  in  wlii(Ti  anim 


.i"ii|   seems   iiiPirioi^ 


A   St 


net    veL,fela!iic   iIk 


I    has   I 


M'eii    wai'mi\   recom- 


tii( 


tided.     The   p.-iiii'iit    -hoiilT    tml 


o    sleep   until    the    completion    of 


;asiric  diirc-tnui. 


McifiiiiKi/.-  The  hromides  are    I 


le  only  nnncdies  whieji  Ikhc  a  .>]ie( 


.111 


nee  upon  the  disease,      r.ilhcr  tli;'  sodium  or  potas.-iiim   salt    may 


lat 


1)0 


iw'ii.     Sodium  hroinide  is  prohahly  le>s  irritating' and  is  li<'tter  horiie  for 
It    niav  hi'   Lriveii    in   milk,  in   whii  h    it    is  searci'lv  tasted. 


I  imiL;'  |)erioi 


P 

111  all  instances  the  dilution  should  he  considerahle.      In  ailnlts   it   is  well 

::iken  in   .soda  water   or    in   some   mineral    water.     The   do-e   for  an  adult 


•iiM  1 


)('  irom  liali  a  iiracmu   in  a   (traeimi  aiiu  a  iiall  diiilv. 


As  ,s 


eeum 


I'l'i'i'iiiiuends,  it  is  often  hest  to  uive  hut  a  r-inirle  do.^e  dail\.  ahoiit  four  to 
-ix  Ikmm's  before,  the  attai'ks  art"  most  likely  to  oeeiir.  T'or  in>lance,  in 
the  eas(>  of  noetnriial  ejiile|isy  a  drachm  should   he  driven  an  hour  or  t 


wo 


;il'ti' the  evenitiii;  meal.  If  the  attac'k  oceiirs  early  in  the  morniiiir,  tlio 
|i:itii'tit  sliould  take  a,  full  (hise  when  he  awakes.  When  '/]\ru  three  times 
nl.-iyit  is  lu'st  ifiven  after  meals.  Mach  case  should  he  carefully  studie(l  to 
'I'teniiiiK^  Iiow  nimdi  bromide  should  he  u>vi].     'I'he  individual  sn.secpti- 

l'ilit\ 


P 
varies  tind  some  patients  re<piire  more  than  others,     l-'ortunately, 


il'heii  take  the  drii^'  well  and  stand  proportionately  laryer  doses  than 
U4 


loii) 


DISRASKS  OF  TIIF.   NKRVOUS  SVSTKM. 


'f    7 


adults.  SatiiiMlioti  is  indicated  l>y  certain  iiti|ilca>ant  ctTccts,  pnrficn- 
larlv  dr;)\vsiiu'ss,  iiii'iital  tnr|)(ir,  and  ^z'astric  ami  cardiac  disti'css.  Lus^nf 
palate  ivlk'x  is  one  of  the  earliest  indications  that  tiie  system  is  nmlii'  the 
iiilluencc  of  the  liromides,  and  is  a  condition  wliicli  should  iw  attiiiiu  i!.  \ 
very  uupleasant  feature  is  the  di'Velopimnt  id'  acne,  which,  however,  i-  n,, 
indication  of  hromism.  Sei;fuin  states  that  the  tendency  to  this  is  iiiii,  h 
diininisii((l  l»y  yivin^f  tlie  drii^'  lai'gely  ililntcd  in  alUaline  waters  an  I  ;ii| 
niiiiisterinj:  from  tiriu'  to  lime  full  doses  of  arsenic.  'l"o  lie  elVccluai  ih,. 
treatment  should  he  continued  for  a  proloni^^ed  peiiod  and  tin-  casis 
should  he  incessantly  watchcil  in  order  to  i)revent  hronusm.  'I'lie  iiuMJi. 
(dne  should  he  continued  for  at  least  two  yeai's  after  the  cessation  of  tju' 
fits;  indeed,  Se;^uin  recommends  that  the  re(lnction  of  the  hronndcs  shouM 
not  l)e  he;^un  until  the  patient  has  hceii  three  years  without  any  iiiani- 
fcHtations.  Written  directions  should  lie  yiveii  to  the  mother  or  to  the 
friends  of  the  patient,  anil  he  shoidd  not  himself  he  held  responsihlc  fur 
till'  administralion  of  the  medicine.  A  l)ook  should  he  ])roviiled  in  wliirh 
the  daily  nuinhcr  of  attacks  and  the  amount  id'  medicine  taken  shoidij  ln' 
noted.  The  addition  of  l)elladonna  to  the  hromide  is  warmly  ncDiii- 
mended  iiv  IMack,  of  ( Jlas'fow. 


imoni;  other  niiiu'dies  which  have  Ix'cn  recomnn 


nded 


;is  conirolliii;' 


itr.i- 


e[)il(!psy  uro  cldoi'al,  eannahis  indica,  /.in<',  iMtro<f|y(H'rin,and  horax.  N 
^dycerin  is  sometimes  advanta<^eous  in  jicllt  imiK  hut  is  not  of  much  serv- 
ice in  the  nuijor  form.  To  he  beiielicial  it  nni>t  he  <,nven  in  full  doses, 
from  two  to  five  nuninis  of  the  one  per  cent  solution,  and  increased 
iiidil  the  physiological  ctTects  are  |»roduced.  Counter-irritation  is  rarely 
advisalile.  When  the  aura  is  very  dcliinte  and  constaid,  in  its  onset,  ;is 
from  the  hand  or  from  the  toe,  a  hlistcr  ahoiil  ihc  part  or  a  lii^atuiv 
tij^htly  applied  may  stop  the  oncoiniiiLf  tit.  In  children,  eare  shoiilil  lie 
taken  that  tlun'e  is  lu)  source  of  pei'iph.'ial  irritation.  In  hoy.s,  adiicretit 
|)re[)Ui'e  nniy  oeciasionally  l)e  the  cause.  The  irritation  of  t(>etirm,Lr.  the 
prosence  of  worms,  and,  foreign  iiodies  in  the  eai's  oi-  no.se  liave  been 
eiateil  with  enileittie  sei/ure.s. 


assD- 


The  subjects  of  a  chronic  and,  in   nn)st  cases,  a  ho[)clessly  in 


curaiiii' 


disease,  e[iileptii'  patients  foi-m  no  small  portion  of  the  nid'ortnnate  virtiiiis 
of  eh.arlatans  and  i|iiacks.  who  prc>crii)e  to-day,  as  in  the  lime(d"  the  fa.tlier 
of  medicine,  "  purilieations  and  spells  and  other  illilieral  practices  of  like 


Lind 


SiinjicitL-An  Jacksonian  epil'.'psy  the  jjropriety  (jf  surj;ical  iiiti'i- 
feronee  is  universally  <rranted.  It  is  rpu'stionahle,  however,  wdietlierin  t!.i' 
epile|)sy  followine^  hemiplefj;ia,  considering!-  the  anatonucal  coi\ditioii,  it  ;< 
lik(dy  to  be  of  any  benelit.  in  idiopalhic  epilepsy,  when  the  lit  starts  in 
a  certain  region — the  thumb,  for  instance — and  the  sii^nial  syinptotn  is  in- 
variable, the  centre  controlling^  this  part  may  bi'  rennivod.  This  prociMlur.' 
has  been  practised  by  Maiujwon,  Ilorsley,  Keen,  and  others,  but  time  aleii' 
can  dettu'mino  its  valiu'.  The  truuniatie  ej)ilepsy,  in  whiidi  the  lit  folloW; 
fracture,  is  much  more  hopeful. 


Mir.RAlNK. 


loll 


rlTccIs,  piirticn- 
(listrcss.  l,oS'<(»f 
>tciii  is  niuliT  llic 
1,1  l...iitli\i""'l.    A 

ell,  llO'.Vt'ViT.  i<  IM 

^  to  this  is  iiiiirli 
lu'  watrrs  aiul  ad- 
I'o  be  ctYi'itiiai  tlif 

l)(l     iUul      tlu'     ••ilS(S 

misiii.  'IMic  iiuMli- 
ic  ct'ssatiiiii  lii  tiif 
he  !)nniiiili'S  Au<\M 
viihiiuL  any  "linii- 

IC     lllDtllC'V   111'    1"   til'' 

icld  rcsiuitisililr  fur 

■  iiniviiU'tl  ill  \^1'>''1' 

no  taken  slunild  ln' 

is   warmly  rccnin- 

'lulfil  as  coiitroUin;,' 
i,anill»(>rax.    Niti'"- 
ri  not  of  iiuirli  siTv- 
rrivcn    in  full  <^'-''^ 
tion,  and    iii(n'UH''il 
-irritation  is  raivly 
taiit  in  its  onset,  as 
part  or  a  li.i^iitiin' 
Ircn,  care  shoiil.l  !«■ 
11  liovs,  adlu'iriil 


Ii 


ion  o 
nose 


f  teetirnvi.  tin 
have  been  assi 


lio[»clessly  incur 
unfortunate  vi 


ulil 


ctllllS 


lime  of  the  f;i,tl 


H'V 


:ral  praetiees  ( 


if  lik.' 


Iv  <» 


f   snri:iea 


1   intiT- 


Ivever,  whether  in 


[h 


li.-ul  condition.  It  i>J|i 
hen  the  lit  start-  m 

Lnial  svinptoin  i~ '"' 

Led.    This  pro 


t.liei-s.  I) 


at  tune 


■iliir.' 
iilmw ' 


'I'he  op(>ratinTi,  prr  sr,  appears  in  seme  eases  to  have  a  curative  edeet. 
Thus  of  r»(>  eases  of  trephitiirii,'  for  epilepsy  in  wiiicli  notliiiiiriihiioriiial  was 
fiiiiiid  to  account  for  the  syiii|>toins,  '••."»  were  reported  as  cured  uml  IS  us  iin- 
|ir(i\ed.*  Tlu-  operations  have  not  been  always  on  tlu' skull,  and  White 
has  roljecled  an  intcrestitiLr  series  in  wliirh  various  siiririi'al  procedures 
iiiivr  ln'cii  resorted  to,  often  with  ciirati\t'  cU'ert,  siirh  us  liLTatioiiof  tiie 
.IIP  it  id  artery,  cast'-ation,  tracheotomy,  excision  of  the  sii[icrior  cervical 
i;aii,ulia,  incision  of  the  scalp,  circumcision,  etc. 


VII.   MIGRAINE  (Ifcmicraiiia;  Sirh-  Ihadnrlu-). 

Definition.  —  \  paroxysmal  iilTection  characterized  by  severe  head- 
u'lii',  usually  unilateral,  and  often  associated  with  disorders  of  vision. 

Etiology. — The  disease  is  fre(|iieiitly  here(liiary  aiel  has  occurred 
tliriiii,i,di  several  generations.  Women  and  the  members  of  neurotic  f.'Mii- 
liis  lire  most  fre(|iienfly  attacked.  It  is  an  alTcetioii  from  which  many  .is- 
liiiL^uished  men  have  siitrereil  and  have  left  on  record  an  ai-coiiiit  (d"  the  dis- 
ease, nottibly  the  astrom)mer  Airy.  Kdward  Liveiiiij''s  work  is  the  staiidar<l 
iiiitliurity  upon  which  most  of  the  subse(|Ueiit  articles  have  been  based.  A 
L'Miity  or  rheumatic  taint  is  jiresent  in  many  instances.  Siiikler  has  called 
'[K'eial  attention  to  the  fre(|uency  of  rellex  causes.  .Mi,t.M'aiiie  has  Ioiilt  heen 
known  to  be  associated  with  uterine  and  menstrual  disorders.  .Many  of 
the  lieada(dies  from  eye-strain  are  of  the  hemicranial  type.  Uriinton  refers 
tocarios  of  the  teeth  as  a  cause  of  these  headaches,  even  when  not  associ- 
;iti'(l  with  toothache.  Cases  have  been  descrilied  in  connection  with  ade- 
imiil  j.q'()\vths  in  the  pharynx,  and  particularly  with  abnormal  conditions 
'4'  the  nose,  ^fany  of  tlu>  .ittacks  (»f  severe  headaclies  in  idiildrcii  are  of 
this  tiature,  and  the  eyes  and  nostrils  should  be  (>xamiiie(l  with  vawM  care. 
SJiikler  refers  to  a  case  in  a  child  of  two  years,  and  (iowcrs  states  that  a 
;!iir(l  of  all  the  cases  be;rin  between  the  fifth  and  tenth  years  of  aire.  The 
ilirt'ct  inlluences  inducing  the  attack  are  very  varied.  Powerful  emoticuis 
"fall  sorts  are  the  most  jiotent.  Mental  or  bodily  fatiirne,  diLTcstive  dis- 
t'lrhanees,  or  the  eating  of  s(uiie  particular  article  of  food  may  be  I'ollowi'd 
ly  the  headache.  The  pantxysmal  cliaracler  is  one  of  the  most  sti'iking 
f'litiires,  ami  the  attacks  may  recur  on  the  same  day  every  week,  every 
'"I'tnight,  or  every  month. 

Symptoms. — Premonitory  signs  are  present  in  many  cases,  and  the 
«tieiit  can  tell  when  an  atta(d<  is  coming  on.      Keinarkable  prodromata 

uv  been  described,  i)articularly  in  connection  with  visi(>n.  ,\pparitioiis 
"liiy  a|)pear — visions  of  animals,  such  as  mice,  dogs,  etc.     Transient  he- 

iiiiiiipia  or  scotoma  may  be  ))resent.  In  other  instances  there  is  spas- 
Ndie  action  of  the  j)upil  on  the  atfected  side,  Avhi<di  dilates  and  contracts 


■hich  the  lit  lulli'«>B  M.  WiUiam  Wiiite,  Ciinitivo  ElTects  of  Opcralieiis^xr  tse,  Annals  vi  Surgery,  1891. 


1012 


niSKASKS  ()!•  Till-;   NKItVolS  SYSTKM. 


of.r 


i''::i'»i'i,  ■<•!»■ 


ultcniiitcly,  till'  cniulitiiiii  known  mm  ////>/>'/\.  Frcijiiciitly  the  di^itiirlpiiiico 
(»r  \isinn  is  only  a  lilurrin;.',  nr  llicrr  urc  luills  of  li^jlit,  or  /i;.'Zii,i,'  liiu-.  i.r 
llic  so-ciillrl   t'ortiliciilioii  s|M(li-;i  (triclmpsiii),  wliicli   ni:iy  In-  ilhiiniiiMinj 

willl   ^fdl'^Tlins   Cdliil'S.        I  )i-I  lirllMlirc-;  nf    llic  nllicl"  SlMKlS  illT   fJirc.        Niillili. 

lu'ss  lit'  till' ton;:u»' ami  fiicc  ami  (irrationally  nf  tlir  liami  may  occur  with 
iintrliiii:.  Mon-  rarrly  tlnTc  arc  cramps  or  .-iia-ms  in  Ilic  mnsdrs  of  tin- 
iilTcilnl  .-iilc.  'ri'aii.-iciil  aphasia  has  also  liccn  notifl.  Sonic  patimts 
show  markcil  p-\i|iicii!  ili^tiii'liancc,  oil  lici"  cvritcmmt  or,  more  cominunlv^ 
mental  confusion  oi'  irirat  ilcprcs.-ion.  Di/./incss  occiii's  in  some  ■  a-i , 
The  henilarlie  follows  a  short  lime  after  the  proilromal  syniptonir  Inni 
iippeareil.  It  is  eiiniiilati\e  anil  e\pan>ilc  in  character,  licLrinninL'  ,i^  n 
|ociili/c(|  small  spot,  which  i-  irciierally  con>tain'  cither  on  the  temple  or 
fon  head  or  in  the  e\cliall.  It  is  ii-ually  de.  i  rilpcd  as  of  a  pcnctr;iliii;.', 
hharp,  horinjf  character.  At  lii>t  nriilalei'.il,  it  j:radually  spreatis  and  in- 
vol\i  s  the  side  of  the  head,  som,t inies  the  nee|\,  and  the  pains  iiia\  ji.i" 
into  the  arm.  In  ot  her  cases  Itoth  -ides  urc  all'cctcd.  Nansca  and  Munii- 
intX  ai'c  common  symploiiis.  If  t  he  attack  coims  on  when  the  >toniar||  |. 
fidl,  \oiiiitin;j  usually  i/ives  relief.  \'aso-niotor  symploms  may  he  pn- 
ent.  'I'hc  face,  for  instance,  may  he  pale,  ami  there  may  he  a  tii;,iLi  ; 
dillVrenec  hetwecn  the  two  sides.  Snh-eipicntI v  the  face  and  ear  an  lli- 
alVeetid  >ide  may  liceonie  a  hnrninu''  reil  from  the  va-o-di!alor  iidliniir.-. 
'['he  puUe  may  he  .-low.  The  tcmpoi'al  ai'tery  on  the  all'ectcd  sid  •  nia\  I. 
lirm  and  hard,  and  in  a  condition  of  artcrio-sderosis  — a  fact,  which  hi 
heen  conlirnied  anatomically  hy  Thoma.  I''ew  alTcctions  are  more  prn- 
Iratint:  than  mii,M'ainc,  and  dnrin;,'  the  paroxysm  the  patieid  may  siani!; 
h.'  alile  til  rai-~e  the  head  from  the  [liljow.  The  slijflitcst  noise  or  lij! 
ii,i:;,'ra\alis  t  he  eoiulii  ion. 

The  dura!  ion  of  the  entire  at t,icl\  is  variahle.     The  severer  forms  ii>ii;ill 
incap.Mcitate  the  person  for  at  least  thrc,' days.      In  other  instances  the  r:;- 
tire  attack  i-  over  in  a  day.     Thedise;i-c  rccui's  for  years,  anil  in  eases  wiHi 
a  marked  hcr.'diinry  tendency  may  pei'  i>t  throughout  life      In  women  p 
iitlacks  often  cea.se  after  the  climacteric,  and   in  mi  n  after  the  a^^'  of  ill' 
'I'wo  of  the  i;i'i'atest   siitVerei's  I   have  known,  who  had   recnrrinj,'  an;i  v 
every  few  weeks  from  early  hoyhood,  now  have  complete  freedom. 

The  nature  of  the  di.-ea-e  is  unknown.  Liseinif's  view,  that  it  i-  ; 
nerve  .-lorm  or  form  of  perioilic  discharjfc  from  certain  sensorv  centre- ;i:,: 
is  related  to  epilepsy,  has  fouml  much  favor.  .Vei'ordinLj  to  this  view,  i' 
is  the  sensory  eipiivaleiit  of  a  t  rue  epilept  ie  atta(d\.  Mollcndorf,  I.athiitii. 
ami  others  rci^ard  it  as  a  vaso-motor  neurosis,  and  hold  that  the  r;i:. 
symptoms  are  due  to  \aso-constrictor  !;nd  the  later  symptom,-  to  va-e-ihii- 
till'  inllueuces.  The  fact  of  the  development  of  aricrio-selcrosis  in  li. 
arteiT's  of  the  alTeeted  side  is  a  point  of  interest  liearin*^  upon  this  \i("'. 

Treatment.— The  patient  is  fully  uware  of  tlu*  causes  which  piviii:- 
tate  an  attack.  .Xvoidanee  of  cxcilenu'iit,  I'eufuliirity  in  the  nu'al-.  i  ■ 
inodurutiuu  in  diet  arc  important  rulos.     The  troatnioiit  should  bo  dii'oiMi 


tul^. 


;m. 


NKUUAIidlA. 


loi:: 


illy  111"  (lisitiirliiiiicp 
t,  or  /i^'/iiij  liiir-.  iir 
iiijiv  lif  illimiiiuitiil 
cs  iirr  I'Mi'i'.     Niriiili- 

IIIkI  llliiy  nfclll  A  nil 
II  ihc  iinisclcs  n|  \\\r 
Led.  St)iiir  |i:iliiiit- 
nr,  more  rniiiliiiinly, 
iciirs  ill  sniiii'  'ii-;!'. 
miiil  symiititiii-  li;i\ 
IcliT,  lii'.ixilinilrj  ;i-  :i 
KT    fill    tin-    ti'lll|ilr    Hi' 

:is  ol"  ii  iiciictraliiiL'. 

Ililllv   S|il'l'lllls   llll'l    ill- 

,1  tli(>  imiiis  mii\  jU" 
NiUiscii  im«l  \niiiii- 
1  ulii'ii  tilt'  sloiiiii'li  1- 
ii|,t,.iii-  may  '"■  I"'- 
■  vv  iiiav   tu'  a   iiiM'ki'l 
1"  I'iicc  ami  car  '<\\  lli'' 
jHo-ililator  ii.llmiir.-. 
,.  ulVcctctl  sit'  •  m;i\  !• 
,,sis — !i  fart-  wh'u'li  111- 
.(•tioiiH  arc  more  ini- 
liiiticiit  may  >r:w<r\\ 
i"-|ilcsL  noise  or  liL'1.' 


tdwiinl  Mic  rcinoval  of  llic  conijilions  iipoii  wliidi  tlic  attai'ks  »1c|m'I1(1.  In 
rliililrcii  tnmli  may  lie  done  liy  walelifulness  ami  eare  on  ilu-  pai'l  of  the 
iiiotJier  in  rei,'iil,itiiiir  the  howels  ami  watehin:.'  the  diri  of  the  ehiM. 
Kirors  of  refraction  shoidii  he  adju-itcd.  <Mi  mi  iireninii  .-hnidd  -m  li  etiil- 
ijn  II  he  allo\vc(|  to  e(iiii|icte  in  scIiomI  f(ir  prizes.  A  [iruldiejed  cciiirse  of 
hi.'mides  somcliiiies  |iro\es  siieces>riil.  If  aiuemia  is  |iie-eiit.  ii(  II  niid 
;ii-enii' .>hoiili|  he  j.d\eii.  \\  hi'ii  the  arterial  teiiMnn  is  iiierea-ed  a  cuinsc 
(if  nil  ro;;lyecriii  may  he  tried.  Not  too  much,  ImueNer,  should  he  ev|ieet- 
(■(I  of  the  |>ri\e?ili\e  trealiiiciit  of  nii;rraine.  It  mii-t  he  eciid'c»-c d  that  in 
a  \"ry  larL'c  |iroporliuii  of  the  eases  the  licadi>.'hes  rccnr  in  spite  of  all  we 
can  do.  Durini:  the  paroxysm  the  patient  should  he  kept  in  hei|  and  ah- 
siiliitcly 'liiict.      If  the  pnticiit    feels  fjiint   and   naiiseatcti,  a  small  cup  <<[ 

li<ii.  slroMi;  cdlTi r   twenty   drops  (,|'  (■hliiri.l'iirin   irivc  relief.     ( 'neiiidiis 

iiidiea  is  prohiihly  the  most  satishietnry  remrdy.  SeLriiin  reeunmiciids  ii 
|irn|oii<fcd  cuiirse  (d'  the  t\v\\'j;.  .\iitip\rin,  antifehriii,  and  phciiacetiii 
liine  hccn  nimli  iiM'd  of  hite.  \\  hen  iriveii  early,  at  the  very  «iiit«ct  of  the 
|iaro\ysni,  tln-y  iire  soiuetiines  elV(cli\c.     'I'hc  duMv<  uhieli   lia\e  hrcii  rc- 

iiiiiiiieiided    (if  aiilifeliriii   ,iiid   aiitipyrin   ai fteii   dan,i,''eroiis,  and   I    have 

Seen  in  a  case  of  migraine  unpleasant   collapse  symptoms   f(ilh>\v  a  twenty 
live-LM'ain  dose  of  aniipyrin  wl.itdi  the   patient  had  taken  mi   her  own  re 
.-poii-ihility.      Smaller,   rcpc-iicd   ihises  are   more  satisfaetnry.      (>f  dther 
niuedies,  caireinc.  in  llvc-i^rain  doses  of  the  citrate,  niiv  vomica,  ami  eri_'ot 
liavi'    heeii    nu'oniineiided.      Mleetrieity   docs    not    a]i|iear    to    he   of    tniich 
.<ervieo. 

VIII.    NEURALGIA. 


severer  forms  ii-iiialu 
ilicr  instances  the  rii- 

ii-s,  and  in  cases  witli 
it  life.      In  women  il^ 

after  the  iXiH'  of  lif' 
lad   reciirrinj,'  alia '^■ 
,hte  freedom. 
,_;'s  view,  that,  it  i-  ■ 
lin  scnsorv  eentri-  a'- 
inliiiii  to  this  viiu.it 

M.iileiidorf,  Lalliaiii. 
d    hold    that   the  rarlv 
svnuitoms  to  va-'-'liii-l 
arn'rio-selerosis  m  >.. 
irin^f  npon  this  \i''^*' 
,.  eauses  which  pivruv 
rity  in    the   nioal^.  .n ' 

lent  should  lu;  dn"  -i  1 


Definition.  —  A  painful  alTcction  of  the  nerves,  dill-  citiier  to  fiinc- 
limial  disliirhance  nf  their  central  or  perijilicral  e\tremities  (ir  to  neuritis 
ill  I  heir  course. 

Etiology.  Meinliers  of  neuropathic  families  are  most  suhjeei  tu  the 
disease.  It  all'eets  women  more  than  men.  Children  are  rarely  attacked. 
•  •f  all  eauses,  dehility  is  the  most  freipieiit.  It  is  dftcii  the  lirst  indication 
iif  iiii  enfeehled  nervous  svsteni.  'The  various  forms  of  ameniia  are  I're- 
||Uriil|y  asM(»eiate(l  with  neiiralir'a.  it  may  he  a  prominent  fealme  at  the 
"ii~et  (if  certain  acute  diseases,  particularly  typhoid  fever.  .Malaria  i>  he- 
licved  to  !)(•  ii  potent  cause,  hut  it  has  mit  heeii  shown  that  iiciiral^ria  is 
iiKire  frequent  in  malarial  districts,  and  the  error  has  prohahly  arisen  from 
ri'pinlin^r  [leriodieity  as  a  special  manifestation  of  paliidi.-iu.  It  oceasion- 
ally  occurs  in  malarial  cachexia.  Kxp.osure  to  cold  is  a  caii-e  in  vo-y  siis- 
•'i'|iti'ii<,  persons.  Kollex  irritation,  particularly  from  carioii<  teeth,  may  in- 
'liice  juaira-fjiii  of  the  fifth  nerve.  Tlu'  disoa.se  occurs  .vdiiictinies  in 
rlii'iir.  itism,  <jjout,  lead  |)(ii,sonin<;,  and  diahetes. 

Syiliptoxns.  —  Before  the  onset  of  the  pain  there   may  he  uneasy  sen 
siitiiiiis,  soinetiines  tingling  in  the  ]iart  which  will  he  atTeete(l.     'I'lie  pain 


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Photographic 

Sciences 
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1014 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


>k  I  i'  > 


&>''■■( 

1'/'' 


I'! 


nf ' 


is  localized  to  a  certain  group  or  division  of  nerves,  usurdly  affecting  one 
side.  Tlie  pain  is  not  constant,  but  paroxysmal,  and  is  described  as  stiib- 
l)ing,  burning,  or  darting  in  v^'luiracter.  Tbe  sicin  may  be  exquisitely  toi  • 
der  in  tbe  alfected  region,  2>iirticularly  in  (;ertain  points  along  the  course 
of  tlie  nerve,  the  so-called  tender  points.  Movements,  as  a  rule,  are  jiaiu- 
ful.  Trophic  and  vaso-motor  changes  may  accompany  the  paroxysm;  ila' 
skin  may  be  cool,  and  subserpiently  hot  and  burning,  occasiomiUy  bicul 
oedema  or  erythema  oc(nirs.  !More  remarkable  still  are  the  changes  in  the 
hair,  which  may  become  blanched  (canities),  or  even  fall  out.  Fortunate- 
ly, such  alterations  are  rare.  Twitchings  of  the  muscles,  or  evi'ii  sj>a.<ni>, 
may  be  present  during  the  paroxysm,  xifter  lasting  a  variable  time; — tidin 
a  few  minutes  to  many  hours — the  attack  subsides.  Recurrence  may  he 
at  definite  intervals — every  day  at  tlie  sanu;  hour,  or  at  intervals  of  two, 
three,  or  even  seven  days.  Occasioiudly  the  })aroxysms  develop  only  at 
tlie  catamenia.  This  periodicity  is  quite  as  marked  in  non-malarial  as  in 
malarial  regions. 

Clinical  Varieties,  depending  on  the  Nerve  Groups  affected.— (l)  Tri- 
facial Xcu  rah/ iic ;  Tic  Douloarcn.r  ;  Proxopalcjia. — All  the  l)ran(;iics  aiv 
rarely  involved  together.  The  oidithalmic  is  most  often  alfected,  hut  in 
severe  attacks  the  pains,  though  more  intense  in  one  division,  radiate  (ivtr 
the  other  branches.  At  the  outset  there  may  be  hyperajsthesia  of  the  skin 
and  sensitiveness  of  tlu;  mucous  membrane.  Pressure  is  painful  at  tlip 
points  of  emergence  of  the  nerve  trunk,  and  where  the  nerves  enter  tlic 
muscles.  Sometimes  in  addition,  as  Trousseau  pointed  out,  there  arc 
pains  at  the  occipital  protuberance  and  in  the  upper  cervical  spines. 
When  the  ophthalmic  division  is  atfec^ted  the  eye  may  Aveep  and  the  con- 
junctiva? are  injected  and  i)ainfiil.  In  the  upper  maxillary  division  tb'rf 
is  a  tender  jjoint  where  the  nerve  losives  the  infraorbital  canal,  and  tlic 
pain  is  specially  marked  along  the  upper  teeth.  In  the  lower  branelics, 
wlii(!)i  are  more  frecpiently  involved,  there  are  painful  points  along  the 
auriculo-temporal  nerve  and  the  pain  radiates  in  the  region  of  tlie  ear 
along  the  lower  jaw  and  teeth.  The  movements  of  niasti(!ation  and  speak- 
ing may  be  painful.  Salivation  is  not  uncommQji.  Herpes  may  oeeiir 
about  the  eye  or  the  lips.  In  protracted  cases  there  may  be  atroi)!iy  or 
induration  of  the  skin.  Some  of  the  forms  of  facial  neuralgia  are  of 
frightful  intensity  and  the  recurring  attacks  render  the  patient's  lifi' 
almost  insupportable. 

{'i)  Cervico-occipital  neurahjia  involves  the  posterior  branches  of  tlio 
first  four  cervical  nerves,  particularly  the  inferior  occipital,  at  the  enuT- 
gence  of  which  there  is  a  painful  point  about  half-way  between  the  niastoiil 
process  and  the  first  cervical  vertebra.  It  may  be  caused  by  cold,  aiii 
these  nerves  are  often  aifected  in  cervical  caries. 

(3)  Cervico-brachial  neurali/in  involves  the  sensory  nerves  of  tlio 
brachial  plexus,  particularly  in  the  cubital  division.  When  the  (drcuiullos 
nerve  is  involved  the  pain  is  in  the  deltoid.     The  pain  is  most  comiiioiily 


NEURALGIA. 


1015 


liiUy  iiffe(!tin,fr  one 
(lesci'ilK'd  as  -tub 
bo  exquisitely  ti'i  • 
s  along  the  cdurst' 
IS  a  rule,  iiro  jiaiii- 
the  paroxysm ;  thy 
,  occasionally  li";il 
the  changes  in  the 
11  out.     Fortuiuik'- 
es,  or  I'ven  spasiii^ 
ariahle  time— inmi 
llccurrence  may  lie 
[it  intervals  of  two,    | 
ins  develop  only  at 
I  non-malarial  as  in 

!  affected. -(1)  'l''>- 

dl  the  hranchesaiv 

iften  alTected,  hut  in 

livisioii,  radiate  ewr 

iwsthesia  of  the  skin 

ire  is  painful  al  ilif 

the  nerves  enter  the 

linted  out,  there  are 

iper  cervical  siiiius. 

y  weep  and  the  con 

fXillary  division  tl-."ir 

■hltal  canal,  and  iti' 

the  lower  hraiiehes. 

ful  points  along  the 

le  region  of  the  eiir 

lastication  and  speak- 

Herpes  may  <»ceur 

Ire  may  bo  atrophy  or 

lial  neuralgia  are  nf 

,r   the   patient's  lit'' 

lorior  branches  of  tl'^' 
]-cipital,  at  the  finer- 
between  the  mustenl 
caused  by  cold,  au'l 

isory  nerves  of  t''^' 
When  the  (nreamtk'S 


liu  is  most  commt 


)IllV 


about  the  shoulder  and  down  the  course  of  the  ylnar  nerve.  There  i.^ 
usually  a  marked  tender  ])oint  upon  this  nerve  at  the  el))o\v.  IMiis  form 
rarely  follows  cold,  hut  more  fretjueiitly  results  from  rheumatic  affections 
(if  the  joints,  and  trauma. 

([)  ]\'('ur(ihii(i.  (if  flic  plirour  nerve  \»  V'AYo.  It  is  sometim(>s  found  in 
jileiirisy  and  in  j)erieanlitis.  The  pain  is  chiefly  at  the  lower  ]iart  of  the 
'herax  on  a  lir.e  with  the  insertion  of  the  diaphragm,  and  here  may  he 
jiamful  points  on  deei)  i)ressure.  Full  inspiration  is  ])ainful,  and  there  is 
great  sensitiveness  on  coughiiig  or  in  the  performance  of  any  movement 
by  which  the  diaphragm  is  suddetdy  depressed. 

(."))  Intercostal  Neurdhjia. — Next  to  the  tie  (/oHioiiren.r  this  is  the 
most  important  form.  It  is  most  frequent  in  wonu-n  and  very  common 
in  hysteria  and  aiuemia.  ^Phc  pain  in  caries  and  aneurism  is  felt  in  the  in- 
tercostal nerves.  They  are  also  the  seat  of  the  intense  })ain  in  inllammation 
(if  the  pleura.  The  pain  is  oftc^n  constant  aiul  exaggerated  by  movements. 
Pleurodynia  is  supposed  by  some  to  be  local  intercostal  neuralgia,  con- 
lined  to  one  s})ot,  usually  along  the  course  or  at  the  exit  of  tlu'  nerves. 
IIer])es  zoster  or  zona  occurs  with  the  most  aggravated  form  of  intercostal 
neuralgia.  The  ])ain  usually  ])rece(les  the  eruption,  win  di  consists  of  a 
series  of  pearly  vesicdes,  whicdi  take  two  or  three  days  to  develop  and 
irradiially  disappear.  The  eruption  may  occur  without  nnu'li  pain.  The 
most  distressing  feature  in  the  com])1aint  is  the  persistenc(!  in  the  pain 
after  the  eruption  has  su])sided.  The  eruption  and  the  neuralgia  are  in 
reality  numifestations  of  neuritis.  Changes  have  been  found  in  the  nerves 
;iik1  in  the  ganglia  of  the  posterior  roots.  The  pain  of  zona  may  jjorsist 
iiidelinitely,  and  it  has  been  known  to  lu'  so  intractable  that  in  despair  the 
Iierson  has  committed  suicide. 

((!)  Lumbar  Xearalfiia. — The  alTected  nerves  are  the  posterior  fibres 
(if  the  lumbar  plexus,  particularly  the  ilio-scrotal  brancdi.  The  pain  is  in 
the  region  of  the  iliac  crest,  along  the  inguinal  canal,  in  the  s]iermatic 
eiird,  and  in  the  scrotum  or  labium  majus.  The  affection  known  as  irri- 
tiiltle  testis,  probably  a  neuralgia  of  this  nerve,  may  be  very  severe  and 
deeoinpanied  ])y  syncopal  sens.itions. 

(7)  Cocciidynia. — This  is  regarded  as  a  neuralgia  .if  the  coccygeal 
iilexus.  It  is  most  common  in  wonu'ii,  and  is  aggravated  liy  the  sitting 
I'ostiire.  It  is  very  intractable,  and  may  necessitate  the  removal  of  the 
(iiecyx,  an  operation,  however,  \vhi(di  is  not  always  successful.  .\euralgia.s 
ef  the  nerves  of  the  leg  have  already  been  considered. 

(S)  jYeni'ah/ins  of  the  Xerves  of  the  Feet. 

Painful  Heel. — Both  in  women  and  men  there  may  be  about  the  heel 
^I'Vcre  pains  which  interfere  seriously  with  walking — the  pododynia  of 
^.  1).  dross.  There  may  be  little  or  no  swelling,  no  discoloration,  atid  no 
I  iitToetion  of  the  joints. 

Plantar  Xcnralgin. — This  is  often  associated  with  a  definite  neuritis, 
Uuch  as  follows  typhoid  fever,  and  has  been  seen  in  an  aggravated  form 


I 


1016 


DTSEASICS   OF   THE   NERVOUS  SYSTEM. 


ii!  ciiissoii  disease  (llii<flics).     The  pain  may  be  limited  to  the  tips  of  tlic 
toes  or  to  the  Ijall  of    the  ^nv.it    toe.     Niimbiies.s,  tinj^ling,  and    hv|i(M 
a^sthesia  (»r  sweating  may  oeeiir  wilii   it,.      Koilouing  the  eoUl-bath  tii-i; 
meiit  in  typlioid  fever  it  is  not  uncommon  for  patients  to  (.'omplain  of 
great  sensitiveness  in  the  toes. 

.)/r/a/Ki's(f/iji((. —  Mort(jn's  (Tlioinas  (!.)  -'painful  afre(!tion  of  tlie  I'.iiii'ii 
metatarso-pliaiangeal  articulation"  is  a  ])eeiiliar  and  very  trying  disorder, 
seen  mo.-t  frecjuenlly  in  women,  and  usually  in  one  foot.  Morton  regard. 
it  as  due  to  a  pincdiiiig  of  the  metatarsal  nerve.  'J'he  disea.se  rarely  g(.'is 
well  ■.vitluiut  operation. 

Hriilhroi)ulid(jia. — Under  this  tprin  Weir  Mitchell  de.scribed  !i  con- 
dilion  wliicli  is  associattid  with  great  piun  in  the  heel  or  in  t'.e  sole  of  tin' 
foot,  with  vas(;ular  changes,  either  an  acute  hyperauniaor  cyanosis.  Soiii" 
of  the  cases  should  un(piesiionably  he  regarded  as  Haynaud'.s  disease. 

('.))  I'iscrrai  yi'nr(ihji((><. — 'i"he  more  ini])ortant  of  theses  have  ahrad; 
been  referred  to  in  conn"(!tion  with  the  cardiac;  and  the  gastric  neu loses 
They  are  nu)st  frequent  in  women,  and  are  constant  accoiupaninu'nts  of  ncii 
rastheuia  and  hysteria.  The  ]iains  are  most  conunon  in  the  pcdvic  regidi!, 
particularly  about  the  ovaries.  Nephralgia  is  of  gi'cat  interest,  for,  as  Ims 
already  been  mentioned,  the  symptoms  nuiy  closely  simulate  those  of  stone. 

Treatment. — Causes  of  ndlex  irritation  should  be  carefully  removed. 
The  neuralgia,  as  a  rule,  recurs  unless  the  general  health  improves;.-.) 
that  tonic  and  hygienic  measures  of  all  sorts  should  be  employed.  Often 
a  change  of  air  or  surroundings  will  relieve  a  severe  neuralgia.  1  Imvr 
known  obstinate  cases  to  be  cured  by  a  i)rolonged  residence  in  the  moiuit- 
aius,  with  an  out-of-door  life  and  ]ileiity  of  exercise.  A  strict  veg(d.;il)le 
diet  will  sometimes  ielieve  the  neuralgia  (u-  headache  of  u  gouty  pci'snii. 
Of  general  remedies,  iron  is  often  a-specific  in  the  ca.ses  associated  with 
chlorosis  and  anu'inia.  Ar.senic,  too,  is  very  beneficiid  in  these  form.-,  nini 
should  be  given  in  ascending  doses.  The  value  of  ((uiniue  has  been  nuieli 
overrati'd.  It  probably  has  no  nuire  iiilluenee  than  any  other  bitter  toide, 
except  in  the  rare  instances  in  which  the  neuralgia  is  definitely  associatcii 
with  malaiial  ]ioisouiiig.  .Strychnine,  cod-liver  ()il,  iind  phosphorus  aiv 
also  iulvautageous.  Of  remedies  for  the  pain,  the  new  analgesics  shoiilii 
first  be  tried — antipyrin,  antifebrin,  and  phenacetin — for  they  are  sonic- 
times  of  ser\ice.  Morphia  shoidd  be  given  with  great  caution,  and  oidy 
after  other  remedies  hiive  been  tried  in  vain.  On  no  consideration  shoiilii 
the  patient  be  allowed  to  use  the  hypodermic  syringe,  (iehsc  niiiitii  i^ 
highly  recommended.  Of  nervine  stimulants,  valerian  and  etlier,  wliicii 
often  act  well  together,  nuiy  be  given.  Alcohol  is  a  valuable  thoiidi 
dangerous  remedy,  and  should  not  be  ordered  for  women.  In  the  trifa- 
cial neuralgia  nitro-glycerin  in  large  doses  may  be  tried.  Aconitiii  in 
doses  of  from  one  two-hundredth  to  one  one-luindred-and-fiftieth  of  a 
grain  nuiy  be  tried.  In  gouty  and  rheumatic  subjects  cannabis  itidicv 
and  ciniicifutra  are  recommended  with  the  lithium  salts. 


(1. 


PROFESSIONAL  SPASMS;   OCCUPATION   NEUROSES. 


loi: 


to  the  tips  of  111 
^ling,  iu\(l    hy|H'i- 
lu>  fold-batli  tiiat- 
its  to  coiiiplaiii  uf 

'Ction  of  tlu!  t'nmtli 
'i-y  trying  (lir^<inlcr, 
t.  Morton  n\:^ai'iU 
(liscasf  rarely  t^'cls 

II   (Icsnribe'l  a  i'"ii- 
>r  ill  t'.e  soU'  of  lilt' 
,  or  cyanosis.    Some 
!\aii<rs  (liseaso. 
■  tlu'sc  have  alvomly 
;ho  •'■astric  noiiros(',<. 
»ini)anini('iitsof  mn 
ii\  tlic  {it'lvic.  rc.uiiin, 
.  interest,  for,  as  lia.s 
uilate  those  of  t^tmu'. 
)o  earef  ully  reniovctl. 
health  improves;  .-i 
be  employed.     Ofun 
n  luniraltria.     1  liiiv 
denee  in  the  iiii'iint- 
A  strict  vegotiiblo 
10  of  a  gouty  person, 
cases  assoeiateil  wilh 
1  in  these  forms,  am! 
inine  has  been  iiuuh 
ly  other  bitter  Unnr. 
definitely  associiitnl 
and  phosphorus  uiv 
•  w  analgesics  sliouM 
for  they  are  senn- 
it caution,  and  only 
consideration  sheuM 
lingc.     (.ielsemimn  i^ 
m  and  oth.er,  Avlii<li 
a   valuable  tluHidi 
l-omen.     In  the  trif;i- 
tried.     Aeoniiia  in 
redand-nftieth  of  :i 
ccts  cannabis  iiulioJ 
Us. 


Of  local  applieatioiis,  the  thermo-cauterv  is  invalualile,  [larticiilarly  in 
zona  and  the  more  chronic!  forms  of  neuralgia.  Aciipiiiicfuix!  may  bo 
used,  or  a([ua[)iinctiiro,  the  injection  of  dislillcd  water  heiieatli  the  skin, 
("iiloroform  liniment,  camphor  and  chloral,  menthol,  the  oleates  of  nmr- 
pliia,  atropia,  and  1  eiladoiiiia  used  with  lanolin  may  be  trii'd.  l''reezin;r 
(ivir  the  tender  j)oint  with  ether  s[)ray  is  sometimes  snecessriil.  The  coii- 
tiimous  current  may  be  used.  The  siiouges  should  be  warm,;iiid  llie  posi- 
tive pole  should  be  placed  near  the  seat  of  tlu'  pnin.  The  strength  of  the 
current  should  be  such  as  to  cause  a  slight  (iiigling  or  buriiiiig,  but  not 
pain. 

'I'ho  surgical  treatment  of  intractable  nenralgia cmbi'aces  nerve  stretch- 
ing and  excision.  The  latter  is  the  most  satisfactory,  but  too  often  the 
pain  returns. 


IX.  PROFESSIONAL  SPASMS;  OCCUPATION    NEUROSES. 

The  continuous  and  excessive  use  of  the  muscles  in  performing  a  cert^iin 
movement  may  be  followed  by  an  irregular,  inv(dunlary  spasm  or  cramp, 
which  may  completely  cdieck  the  performance  of  thv  action.  'I'hc  condi- 
is  found    most  frequently  in  writers,  hence  the  term    writer's  (!ranip 


tKin 
i>r  sc 


rivener's  palsy;  but  it  is  also  c 


omnion  in  luaiio  and  violm  ol 


i.y 


ers  an( 


in  telegraph  oiterators.     The  sjiasms  occur  in  many  other  persons,  such  as 
milkmaids,  Aveavers,  and  cigarette-rollers. 

•rami),  which  is  miicdi  more  fre- 


4 


fori 


itei 


most  comni 

qiient  in  men  than  in  women.  Of  75  cases  of  impaired  writing  power  re- 
]iorted  l)y  Poore,  all  of  the  instances  of  undoubted  writer's  cramp  were  in 
men.  ^lorris  J.  Lewis  states  that  in  this  country,  in  the  telegrapher's 
cramp,  women,  who  are  employed  a  great  deal  in  telegraphy,  are  much 
less  frequently  alTected  (only  4  out  of  -io  cases).  Persons  of  a  nervous 
U'liip.; anient  are  more  liable  to  the  disease.  Occasionally  it  follows  slight 
injury. 

(h)wers  states  that  in  a  majority  of  the  cases  a  faulty  method  of  writing 
lirts  been  eiii})loyed,  using  eitlu'r  the  little  linger  or  (he  wrist  as  the  fixed 
point  Persons  who  write  from  the  middle  of  the  forearm  or  from  the 
I'lhow  are  rarely  aflfeoted. 

No  anatomical  (dianges  have  been  found.  The  most  reasonable  ex- 
planation of  the  disease  is  that  it  results  from  a  deranged  action  of  the 
lUTve  centres  presiding  over  the  muscular  movements  involved  in  the  act 
'jf  writing,  a  condition  which  h..;s  been  termed  irritable  weakness.  "  The 
wliication  of  centres  wdiich  may  be  widely  se])arated  from  each  other  for 
tlu!  performance  of  any  delicate  movement  is  mainly  accomplished  by  less- 
ening the  lines  of  resistance  between  th^^m,  so  that  the  movjment,  which 
was  at  first  produced  by  a  considerable  mental  effort,  is  at  last  executed 
iilniDst  unconsciously.     If,  therefore,  through  prolonged  excitation,  this 


*■  »:        I 


I  ^    1 


1018 


DISEASES  OP  THE  NERVOUS  SYSTEM. 


'ii' 


lessened  resistance  be  curried  too  far,  there  is  an  increase  and  irropular 
discliarjfe  of  nerve  enertfy,  which  gives  rise  to  spasm  and  disordered  nidvc- 
ment.  Ac(!or(lin,L(  to  tills  view,  the  muscular  weakness  is  explained  hv  nii 
impairnu'ut  of  nutrition  accompanying  that  of  function,  and  the  (liiniii- 
ished  faradi(;  excitahility  l»y  the  nutritional  disturbance  dest'cndiug  tlie 
motor  nerves."     (<iay.) 

Symptoms. — Tiiese  may  be  described  under  five  heads  (Lewis). 

(a)  Cnimj)  or  SpasDi. — This  is  often  an  early  symptom  and  most  com- 
monly aif(H'ts  the  foi'clinger  and  tiiumb  ;  or  there  may  beacombiiu'd  luovo- 
ment  of  fiexion  and  adduction  of  the  thumb,  so  tiiat  the  pen  may  b'-  twisted 
from  the  grasp  and  thrown  to  some  distance.  Weir  Mitchell  has  descrilMMl 
H  loek-spasm,  in  which  the  fingers  become  so  firmly  'ontri'.cted  u])oii  the 
pen  that  it  cannot  l)e  removed. 

{!))  Pan'sis  and  Panfh/sis. — This  may  occur  with  the  spasm  or  aKnic. 
The  patient  feels  a  sense  of  weakness  and  (l(!bility  in  the  muscles  of  the 
hand  and  arm  and  holds  the  pen  feebly.  Yet  in  these  circumstances  tlu' 
grasp  of  the  hand  may  be  strong  and  there  may  be  no  paralysis  for  onli- 
nary  acts. 

(c)  Tremor. — This  is  most  commonly  seen  in  the  forefinger  and  may 
be  a  premoiutory  symjjtom  of  atrophy.  It  is  not  an  important  symptom, 
and  is  rarely  sutHcient  to  produce  disability. 

{d)  Pain. — Aliuormal  sensations,  jiarticularly  a  tired  feeling  in  the 
muscles,  are  very  cionstantly  present.  Actual  pain  is  rare,  but  there  may 
be  irregular  shooting  pains  in  the  arm.  Numbness  or  soreness  may  exist. 
If,  as  sometimes  happens,  a  subacute  neuritis  develops,  there  may  be  jiuin 
over  the  nerves  and  numbn(\ss  or  tingling  in  the  fingers. 

{p)  VaKOiiinfor  I>ixliirh(n)cei<. — These  may  occur  in  severe  cases.  There 
may  be  hypenvsthesia.  Occasionally  t-he  skin  becomes  glossy,  or  there  is 
a  condition  of  local  asphyxia  resembling  chilblains.  In  attempting  tn 
write,  the  hand  and  arm  may  become  fiushed  and  hot  and  the  veins  increased 
insize.  Early  in  the  disease  the  electrical  reactions  are  normal,  but  in  ad- 
vanced cases  there  may  l)c  diminution  of  faradie  and  sometimes  increase 
in  the  galvanic  irritaV)ility. 

Diagnosis. — A  well-marked  case  of  -writer's  cramp  or  i)alsy  could 
scarcely  be  mistaken  for  any  other  afi'ection.  Care  must  be  taken  to  ex- 
clude the  existence  of  any  cerebro-spinal  disease,  such  as  progressive  imis- 
cnlar  atrophy  or  hemiplegia.  The  physician  is  sometimes  consulted  by 
nervous  persons  who  fancy  they  are  becoming  subject  to  the  disease  and 
complain  of  stiffness  or  weakness  without  displaying  any  characteristic 
features. 

Prognosis. — The  course  of  the  disease  is  usually  chronic.  If  taken 
in  time  and  if  the  hand  is  allowed  perfect  rest,  the  condition  may  im- 
prove rapidly,  but  too  often  there  is  a  strong  tendency  to  recurrence.  The 
patient  may  learn  to  write  with  the  left  hand,  but  this  also  may  after  !> 
time  be  attacked. 


TETANY. 


1019 


.se  and  ivrc;.Milar 
(lisonlcivd  iikivc- 
t'XplaiiuMl  liy  iiii 
1,  and   till'  ilimiii-      a 
e  (li'sr(.'iiiliiii:'  till' 

['ads  (Lewis), 
itu  iind  most  cdin- 
iU'oiidiiiu'd  iiiovo- 
lenniayl''  twisted 
■lu'U  lias  dcscrilif(l 
lutnH'U'd  upon  tlic 

,he  spasm  or  alone. 

he  musclos  of  tlu- 

.  circ'unistanccs  tlio 

paralysis  for  onli- 

orefingor  and  may 
[iiportant  symptom, 

tired  fooling  in  the 

rare,  but.  thort'  niii\ 

soreness  nniy  exist. 

,  there  may  bo  ]»:iin 

s. 

severe  eases.  'I'Iktc 
glossy,  or  there  is 
In  attempting  to 

1  tho  veins  iiicrciisfd 

normal,  l)ut  in  ad- 

sometimes  increase 

lamp  or  palsy  could 
List  be  taken  to  ex- 


as  pr 


niirossivc  niiis- 


.'timos  eonsultctl  1'}' 
to  the  disease  and 
any  charaetcristic 

ehronie.  If  takon 
1  condition  may  im- 
J  to  roourronce.  'Hi'' 
ihis  also  may  after  i> 


Treatment. — Various  prophylactic  measures  have  boon  advised.  As 
mentioned,  it  is  important  tiiat  a  proper  metiiod  of  writing  be  aih)[)ted. 
(iiiwers  suggests  that  if  all  persons  wrote  from  the  shoulder  writer's  eraiii]) 
would  ])raotieally  not  occur.  Various  (k'vices  luivo  been  invented  for  re- 
]i(ving  the  fatigue,  but  none  of  them  are  very  satisfactory.  The  use  of  the 
tyjic-writer  has  diminished  very  much  the  freipuncy  of  scrivener's  })alsy. 
ilest  is  essential.  No  measures  are  of  value  without  this.  .Massage  and 
iiiainpulation,  when  combined  with  systematic  gymnastics,  givc!  tiic  liest 
results.  I'ooro  recommends  the  galvanic  current  applied  to  the  musclos, 
which  are  at  the  same  time  rhythmically  exiTcised. 

'I'he  nutrition  of  the  patients  is  ajjt  to  In'  nmch  im])aired,  and  cod-liver 
oil,  strychnia,  and  other  tonics  will  be  found  advantageou.s.  Local  iijipli- 
catious  are  of  little  benefit.  Tenotomy  and  nerve-stretching  have  been 
abandoned. 

X.  TETANY. 

Definition.  — An  affection  characterized  I)y  jioculiar  bilateral  tonic 
spa.snis,  either  paroxysmal  or  continued,  of  the  extremities. 

Etiology. — 'IMio  disease  occurs  under  very  dilTerent  conditions,  of 
which  the  fo.    wing  may  be  recognized  : 

{(i)  J^pideii  c  tetany,  also  known  as  rheumatic  tetany.  In  certain 
parts  of  the  coniinent  of  Europe  the  disea.se  has  jirevailed  widely,  particu- 
larly in  the  winter  season.  Von  Jaksch,  who  has  described  an  epidemic 
form  occurring  in  young  men  of  the  ^vorking  classes,  sometimes  with 
,-liirlit  fever,  regards  the  disease  as  infectious.  .  This  form  is  acute,  lasting 
only  two  or  three  weeks  and  rarely  proving  fatal. 

(/))  A  nnijority  of  the  cases  are  found  in  association  witli  debility  fol- 
lowing lactation  and  chronic  diarrho'a,  or  in  the  malnutrition  of  rickets. 
From  its  occurrence  in  nursing  wouien  Trousseau  called  it  nur-se's  con- 
traelure.  It  may  also  occur  during  pregnancy.  It  has  boon  found  as  a 
tcf|uenee  of  the  acute  fevers,  and  in  some  typhoid  ei)idoniics  many  cases 
ii:ive  occurred. 

{(■)  Tetany  may  follow  removal  of  the  thyroid  gland.  Thirteen  cases, 
for  example,  followed  seventy-eight  operations  on  enlarged  thyroid  in  JJill- 
mth's  clinic,  Jind  six  of  them  proved  fatal.  James  Stewart  has  reported 
im  instance  in  which  with  the  tetany  there  were  symptoms  of  myxcedema, 
and  no  trace  of  the  thyroid  gland.  Kemoval  of  the  thyroid  in  dogs  is  fol- 
lowed by  tetany. 

((/)  And,  lastly,  there  is  a  form  of  tetany  which  is  associated  with  dila- 
tation of  the  stomach,  particularly  after  the  organ  has  been  washed  out. 

On  this  continent  true  tetany  is  an  extremely  rare  disease.  Cirinith 
lias  collected  73  cases,  among  which,  however,  cases  of  carpo-])odal  s^iasm 
aiv  included. 

The  nature  of  the  disease  is  unknown  ;  certain  forms  depend  undoubt- 
ttlly  ou  loss  of  the  function  of  the  thyroid  gland. 


:.'.;j^'-i 


1020 


DISEASES  OK   TIIK   NEllVOl'S   SVSTKM. 


hit   •   , 
i    , 


Symptoms.  —  In  eases  .'issnciiitod  with  geiKTal  dchility  or  in  cliildivn 
with  ricki'ts  tiio  s{iii.si;i  is  limited  to  the  hands  and  feet,  'i'lic  linj^aTs  mv 
bent  lit  the  nietacarpo-[)hahiiip'al  joint,  exteiuh-d  at  the  terihiiial  joints. 
pressed  eh)sc  togetlic,  and  tiie  thiinil)  is  I'oiitracted  in  tlie  jialni  of  the 


hand.     Tlie  ui'ist  is  Hexed,  llie  (lliows  are  hcnt,  and 


anus  are  rdjiicd 


liaiiM 

over  the  eliest.  In  the  h)wer  liiidis  the  feel  arc  e\ten(h'(l  and  the  t(»cs  ml- 
dueted.  The  muscles  of  the  face  ami  neck  ari'  less  eoniinoidy  invohid. 
bi't  in  si'Vere  eases  there  may  be  trisiiius,  and  the  angles  of  the  moutli  aro 
drawn  out.  'I'he  skin  of  the  hands  and  feet  is  sometimes  tense  and  (I'dcni- 
atous.  'I'he  spasms  are  usually  paroxysnnd  and  last  for  a  vai'ial)l('  liinc. 
In  children  the  attack  nuiy  pass  otf  in  a,  few  hours.  In  some  of  the 
.severer  (dironic  eases  in  adidts  the  stiiTness  and  contracture  nniy  eoiitiiuu' 
or  even  increase  for  many  days,  and  the  atta(d<  may  last  as  long  as  \\\i, 
weeks.  In  the  acute  cases  the  temperature  may  he  eU-vated  and  the  piilso 
quickened.  In  tin*  severe  ])aroxysms  there  may  he  invtilvement  of  iho 
nnisclcs  of  the  hack  and  of  the  thorax,  inducing  dysjnuea  and  cyaiie>i.-. 
Certain  additional  features,  valuable  in  diagnosis,  are  j)resent. 

Trousseau's  symjjtom  :  "  80  long  as  the  attack  is  not  over,  the  paroxvsms 
may  Ijc  i'e[)i'oduced  at  will.  This  is  ed'ected  by  simply  compressing  the 
utrected  parts,  either  in  the  direction  of  tlieir  ]irincij)al  nerve  truid<.s  uy 
over  their  blood-vessels,  so  as  to  imiiede  the  venous  or  arterial  circnlatinn." 

Chovestek's  symptom  is  shown  in  the  remarkable  increase  in  the  iiic- 
chaiucal  excitability  of  the  motor  nerves.  A  slight  ta]i,  for  exam[»lo,  in 
the  course  of  the  facial  nerve  will  throw  the  muscles  to  whi(di  it  is  dis- 
tributed into  active  contraction.  Erb  has  shown  that  the  electrical  irrita- 
bility of  the  nerves  is  also  greatly  increased,  and  Ilofrnann  has  deiiuiii- 
strated  the  heightened  excitabilitv  of  the  sensorv  nerves,  the  sli<:litest 
pressure  oti  which  msiy  cause  para'sthesia  in  the  region  of  distribution. 

Diagnosis. — The  disease  is  readily  recognized.  It  is  a  mistake  to 
call  instances  of  carpo-pedal  spasm  of  children  true  tetany.  It  is  coni- 
mon  to  find  in  rickety  children  or  in  cases  of  severe  gastro-intestin:d 
catarrh  a  transient  spasm  of  the  fingers  or  even  of  the  arms.  I5y  inaiiv 
authors  these  are  considered  cases  of  inild  tetany,  and  there  are  all  grailt'? 
in  rickety  children  between  the  siinj)le  carpo-]iedal  spasm  and  the  con- 
dition in  which  the  four  extremities  are  involved  ;  but  it  is  well,  I  tliiiik, 
to  linut  the  term  tclany  to  the  severer  alTection. 

With  true  tetanus  the  disease  is  scarcely  ever  confounded,  as  the  inm- 
mencement  of  the  spasm  in  the  extremities,  the  attitude  of  the  luuids, 
and  the  etiological  factors  are  very  different.  Hysterical  contracture?  aiv 
usually  unilateral. 

Treatment. — In  the  case  of  children  the  condition  with  which  the 
tetany  is  associated  should  be  treated.  Baths  and  cold  sponging  arc  rec- 
ommended a)id  often  relieve  the  spasm  as  promptly  as  in  child-crouiiij:. 
Bromide  of  potassium  may  be  tried.  In  severe  cases  chloroform  inhala- 
tions may  be  given.     Massage,  electricity,  and  the  spinal  ice-bag  have  also 


iiYSTr':uiA. 


loiil 


1 II  used  witli  siiocoss.     Oasos,  liowevor,  inay  resist,  all  treatniciit,  ami  the 

!j(i;isiiis  recur  for  many  yiars.  The  tliyi'diii  extraet  sIkhiIiI  lie  ti'icil.  (lott* 
.striii  I'cjiorls  relii'l'  in  a  case  of  loii^-  slam'.iiiLr,  and  IJrainwi'll  fe|iiirts  (Uit! 
iM^i'  of  operative  tetany  and  oni'  nf  the  iili(i[ia'hi<:  form  siieeessfidly  ti'ealitl 
ill  this  way. 


re    (jastro-intestiiKil 


XI.    HYSTERIA. 

Definition. — A  state  in  which   ideas  control  the  body  and  ])roduee 

niniliiij  changes  in  its  functions  (Mrdiius). 

Etiology. — 'IMie  alTectioii  is  most  common  in  women,  ami  usuallv  ap- 
pears first  al)out  thi^  tinii'  rA'  [)id)erty.  Iiut  tlie  manifestations  mav  conlinnc! 
Miilil  tlie  menopause,  or  even  until  old  age.  Men  and  hoys,  however,  are 
by  no  means  exempt,  and  of  late  years  hystei'ia,  in  the  male  has  at tracted 
iinich  attention.  It  oeeur.s  in  all  races,  l)nt  is  mmdi  inoi'e  pi'evaleiit,  par- 
tiriilarly  in  its  severi'r  forniH,  in  incmlters  of  the  Latin  lij'r.  In  this 
iduntry  the  nulder  grades  are  (;onimon,  hut  tliogra\cr  forms  arc  rare  in 
(■(iinparisoii  with  the  frecpiency  with  which  they  are  seen  in  i''rance. 

Of  prt'disposing-  causes,  two  an'  imi)ortant — heredity  and  education. 
The  f(»rmcr  aets  by  endowing  the  child  with  a  luobik',  ahn.ormally  sensi- 
tive nervons  organization.  We  see  eases  most  frecpiently  in  families  with 
marked  neuro])athie  tendencies,  the  niend)ers  of  which  have  sullered  from 
iii'Ui'oses  of  vai'ions  sorts.  Kducatioii  at  home  too  often  fails  to  inculcate 
liiiliits  of  self-eontrol.  A  child  grows  to  girlhood  with  an  entirely  errone- 
ous idea  of  lier  relations  to  others,  and  a(  customed  to  \\:\\v  every  whim 
((nitilied  and  abundant  .sympathy  lavished  on  every  woe,  however  trilling, 
she  reaches  womaidiood  with  a  moi'al  oi'ganizatiou  unlitted  to  withstand 
the  cares  and  worries  of  (ivery-day  life.  At  school,  hi'tweeii  tln'  ages  of 
twelve  and  fifteen,  the  most  important  period  in  her  life,  when  the  vital 
energies  are  altsorhed  in  tlie  rapid  development  of  the  body,  she  is  often 
(•nininung  for  examinations  and  cooped  in  close  school-rooms  for  six  or 
eight  hours  daily.  The  result  too  frequently  is  an  active,  bright  mind  in 
111!  enfeebled  body,  ill  aihipted  to  subserve  the  functions  for  which  it  was 
fraiiieil,  easily  disordered,  and  prone  to  react  abnorinally  to  the  ordinary 
stimuli  of  life.  Among  the  nH)i'e  direct  intluences  are  emotions  of  vai'ious 
kinds,  fright  oi'casionally,  nion^  frefjuently  love  affairs,  grief,  and  domestic 
wurries.  Physical  causes  less  often  bring  on  hysterical  outbreaks,  but  they 
nmy  follow  directly  u]ion  an  injury  or  develop  during  the  convalescenco 
t'l'iini  an  acute  illness  or  be  associated  with  disease  of  the  generative  organs. 
The  name  In/sfcn'a  indicates  how  important  was  believed  to  be  the  part 
jiliiycd  by  the  uterus  in  the  causation  of  the  disease.  Opinions  ditfer  a 
ffdod  ileal  on  this  question,  but  undoubtedly  in  many  eases  there  are  ova- 
rian and  uterine  disorders  the  rectilication  of  which  sometimes  enrcs  the 
ilis(  ase.  Sexual  excess,  particularly  nuisturbation,  is  an  important  factor, 
both  in  girls  and  boys. 


.^^■i^ 


it'*''  J_ 


1(122 


DISEASES  Or<^  THE  NERVOUS  SYSTEM. 


TiTM 


Ill's    t'' 

IV  vi 


Symptoms.  -A  uscrul  division  Ik  into  the  convulsive  and  non-coti- 
vulsivo  viiric'ties. 

Convulsive  Hysteria.— (")  Minor  Forms. — 'i'hc  attack  most  coniiiunilv 
follows  cnii/lioiial  distiirliaMcc.  it  may  set  in  suddenly  or  be  jircccdcil  liv 
yyinploins,  called  i)y  the  laity  "  liysterical,"  siicii  as  laii^liinL,'  and  crvinir 
altornatcly,  or  a  sensation  of  eoiislriclion  in  the  neck,  or  of  a  liall  i  i.-iiiL.'  in 
tilt)  tliroat — till!  (j/a/jitK  /ii/.s/rn'c/is.  Sonu'tiiiU'S,  j)recodiiij;  the  eoiiMiMvr 
niovenients,  there  may  be  paiid'nl  se'nsations  ar'isini,'  from  tiie  i)elvi(  ,  ali. 
doMiinal,  or  tlioraeic  re;^ioiis.  i"'roni  the  description  these  sensations 
resemlile  aura\  'I'liey  become  more  intense  with  the  risin^if  sensation  ef 
claukiiif,'  in  the  neck  and  dillicnlty  in  j^'ettinf?  l»reatli,  and  tlie  patient  I'nlls 
into  a  inoro  or  less  violent  convnision.  Jt  will  be  noticed  that  the  fall  is 
not  sudden,  as  in  epilepsy,  but  the  subject  falls,  as  a  rule,  easily,  ol'icn 
pickiii}^  a  soft  sjiot,  like  a  sofa  or  an  easy  chair,  and  in  the  niovenients 
apparently  cxiTcises  care  to  do  herself  no  injury.  Yet  at  the  same  titne 
she  ajipeai's  to  lie  quite  unconscious.  The  niovenients  aw  clonie  nml 
disorderly,  consistinif  of  to-and-fro  inotion  of  the  trunk  or  pelvic  mus- 
cles, and  the  head  and  arms  are  thrown  about  in  an  irre^nilar  manner. 
The  paroxysm  after  a  few  minutes  slowly  subsides,  then  the  patient 
becomes  emotional,  iind  <.(radiially  regains  consciousness.  When  (|ncs- 
tioned  the  patient  may  coiii'esri  to  liavinj^  some  knowledj^e  of  the  events 
wdiicdi  have  taken  place,  but,  as  a  rule,  has  no  accurate  ret'ollcction.  Dur- 
ing the  attack  the  abdomen  may  be  nincli  distenilcd  with  flatus,  and  siili- 
r-  11'  Mtly  a  large  amount  of  ck-ar  urine  may  be  passed.  'I'liese  attinks 
\  reatly  in  character.     There  iiiav  be  scarcely  any  movements  of  the 

iiiii  .rt,  but  after  a  nerve  storm  the  patient  sinks  into  a  torpid,  semi-uiuen- 
scions  condition,  from  which  she  is  roused  with  great  difficulty.  In  sniue 
cases  from  this  state  the  patient  passes' into  a  condition  of  catale])sy. 

(b)  Major  Forms  ;  /fi/sfero-fpil('j)s}/. — This  condition  has  been  speeiiilly 
studied  by  Chanuit  and  his  pupils.  Typical  instances  passing  through  the 
various  jihases  are  very  rare  in  this  country.  The  attack  is  initiateil  liv 
certain  prodromata,  chiefly  minor  hysterical  manifestations,  either  foolish 
or  unseemly  behavior,  excitement,  sometimes  dysi])eptic  symptoms  with 
tympanites,  or  fretiuent  micturition.  Areas  of  hypernesthesia  may  at  this 
time  he  marked,  the  so-called  hysterogenic  spots  so  elaborately  descriltcil 
by  TJichet.  These  are  usually  symmetrical  and  situated  over  the  iipin'r 
dorsal  vertebra,  and  in  front  in  a  series  of  symmetrically  placed  spots  on 
the  chest  and  abdomen,  the  most  marked  being  those  in  the  ingiiiiiiil 
regions  over  the  ovaries.  Painful  sensations  or  a  feeling  of  oppression 
and  a  f/Ioliiis  rising  in  the  throat  may  be  complained  of  prior  to  the  eiiset 
of  the  convulsion,  which,  according  to  French  writers,  has  four  distimt 
stages:  (I)  Epilcptoid  condition,  which  closely  simulates  a  true  epileptic 
attack  with  tonic  spasm  (often  leading  to  opisthotonos),  grinding  of  tlic 
teeth,  congestion  of  the  face,  followed  by  clonic  convulsions,  gnidtial 
relaxation,  and  coma.     This  attack  lasts  rather  longer  than  a  true  cpi- 


IIYSTKIIIA. 


lO^.'J 


*'0  and  tioii-oon- 

IIKist  (■(illlllinlily 
r  lie  prcccilfil  l)y 
liiii!^  and  crviii;; 
if  ii  l)iill  li.-iii.u'  in 
(r  the  conMiUivi' 
ru  the  iiflvii  ,  ;ili- 

thc'sc    soiisiitions 

sillj^    SCllSiltinll   (if 

1  tlio  piitii'iil  falls 
.'(I  thiit  till'  full  is 
rule,  eiisily,  tiftcii 
u  the  movements 
at  the  ssune  tiinu 
ts  are  eU)iU''  ainl 
\k  or  pelvic  iniis- 
irregnlar  uiaiiiirr. 
then   the    patioit 
CSS.      When  >\w<- 
odgo  of  the  events 
■ccolleetinii.     Dur- 
ith  flatus,  and  suh- 
[.(1.     These  attarks 
movements  of  the 
orpid,  semi-nncim- 
ieulty.     In  some 
of  eatalei'sy. 
\  hasheen  specially 
lassing  throujih  tlic 
ack  is  initiated  I'V 
ions,  either  foclisli 
ic  symptoms  with 
ithesia  may  at  this 
ahorately  descrilml 
id  over  the  uppiT 
ly  placed  spots  on 
se  in  the  intrninal 
ding  of  oppression 
f  prior  to  the  ensH 
!,  has  four  distinct 
tes  a  true  epilcftK' 
5),  grinding  of  tlif 
aivulsions,  gra(huil 
■r  than  a  true  ipi 


Icptic  attack,  (y)  Succeeding  this  is  a  |ierio(l  wliiidi  Charcot  has  termed 
rlmriiism,  in  wliiidi  tiiere  is  an  emotional  dis|day  and  a  remarkahii^  sei'ies 
of  (toiitortiiins  or  of  catalc|itic  poses.  (:i)  'I'licn  in  typical  eases  there  is 
a  stage  in  \vhi(di  tiie  patient  assumes  ci'rtaiii  attitudes  expressive  of  tho 
vaiioiis  passions — ecstasy,  fear,  heatitnde,  or  I'rolism.  (4)  l-'inally  con- 
sciousness returns  ami  the  patient  enters  iijion  a  stage  in  wliiidi  she  may 
display  very  varied  symptoms,  idiielly  manifestations  of  a  delirium  w  ith 
tlic  most  extraordinary  haliiieinations.  Visions  are  seen,  voices  heard, 
and  conversations  held  with  imaginary  ])ersons.  in  this  stage  patietds 
will  relate  with  the  utmost  sok'mnity  imaginary  events,  and  make  ex- 
traordinary and  serious  (diafges  against  individuals.  'I'liis  sometimes  gives 
11  grave  aspect  to  these  seizures,  for  not  only  will  the  patient  at  this  sUigo 
liKike  aiul  helieve  the  statements,  hut  wlu'ii  n'Covery  is  complete  the  hal- 
lucination sometimes  ])ersists.  We  siddoin  sec  in  this  country  attacks 
having  this  orderly  se((uence.  Much  more  commoidy  the  convidsiotis 
sacc(?ed  ea(di  other  at  intervals  for  several  days  in  succession.  Here  is  a 
striking  dill'erence  hetweeii  hystero-cpilei)sy  and  true  e[iile|isy.  In  the 
latter  the  status  epilej)ticns,  if  persistent,  is  always  serious,  a.ssociateil 
with  fever,  aiul  t'retjui'ntly  fatal,  while  in  hystcro-cpilepsy  atta(d\s  may 
recur  for  days  without  special  danger  to  life.  After  an  attack  of  hystcro- 
cpilepsy  the  patient  may  sink  into  a  state  of  trance  or  lethargy,  in  wliicii 
she  may  remain  for  days. 

Non-convulsive^  Forms. — So  coni])lex  and  varied  is  the  clinical  ])icture 
of  hysteria  that  variiais  manifestations  are  hest  consi<lered  according  to 
the  systems  which  are  involved. 

(1)  Disorders  of  Motion. — {(/)  Pdraii/srs. — 'i'hcse  may  be  honii})legic, 
|iara])legic,  or  luonoplegic.  Ilysti-ricai  diplegia  is  extremely  rare.  'Che 
paralysis  either  sets  in  ahru]»tly  or  gradually,  ami  may  take  weeks  to  attain 
its  fall  development.  Then'  is  no  liipr  or  f (inn  of  or(/(iiiir  pardii/sis  icliicli 
may  not  he  simuhited  in  Jii/.s/eria.  According  to  Weir  Mit(diell,  the  hemi- 
plegias arc  most  frefpient  in  the  ratio  of  four  on  the  left  to  one  on  the 
ri<,dit  side.  The  face  is  not  affected  ;  the  ne(  k  nuiy  he  involved,  but  the 
li'jf  sutfers  most.  Sensation  is  either  lessened  or  lost  on  the  affected  side. 
The  hysterical  paraplegia  is  more  common  than  hemiplegia.  The  loss  of 
power  is  not  absolute;  the  legs  can  usually  he  nu)ved,  hut  do  not  support 
the  [)aticnt.  The  reflexes  may  he  increased,  though  the  knee-jerk  is  often 
iiornuil.  A  spurious  ankle  clonus  may  sometinu'S  be  jiresent.  The  feet 
lU'o  usually  extended  aiul  turned  inward  in  the  e(piino-variis  position.  The 
imiselos  do  not  waste  and  the  electrical  reactions  arc  normal.  Other  niani- 
fi'stations,  such  as  paralysis  of  the  bladder  or  aphonia,  are  usually  associ- 
atci]  with  the  hysterical  paraplegia.  Hysterical  monoplegias  may  lie  facial, 
I'l'iu'al,  or  brachial.  A  condition  of  ataxia  sometimes  occurs  with  paresis. 
Thy  incoordination  may  be  a  marked  feaiare,  and  there  are  usually  sen- 
sory manifestations. 

{I))    Contractures  and   Spasms. — An   extraordinary  variety  of  spas- 


102  ^ 


niSEASES   OF  THE   NEItVOUS  SYSTEM. 


.•I  ) 

f 

i'.'i  •• 


!*  i 


'V, 


it- 


iiMidic  iilTi'ciiiiim  oi'diiN  i?i  liystcriii,  <if  wliirh  the  most  ('(iiiiiiinti  iirc  (Ik 
rdllouiii;^:  The  livslcriciil  (■(iiilnictiircs  may  iittiick  aliimsl  any  irr(iii|i  ct 
vtiliiiilary  iiiiisclfs  and  In'  dl"  the  lii'rMi|ili\L''i(',  paraplcu'ii',  i>v  iiiuii(i|ili':.'ic 
iypii.  Tlicy  may  rimic  mi  sudtlcnly  or  slowly,  juTsist  lor  iiioiitlis  or  Mar,^ 
and  di>a|»|i('ar  rapidly.  'I'lic  contrachirc  is  most  comnionly  seen  in  ih, 
arm,  wliirli  is  llcxcil  at  tlic  clliow  and  wrist,  and  the  linizcrs  ti,irlillv  ^Mas|i 
till'  tliundt  in  liic  ]>alni  ol'  the  hand  ;  more  rarely  the  terminal  |ilialani,'('- 
are  liyperextended  as  inatlntosis.  It  may  occur  in  one  oi'  in  iiolli  Iil:s 
more  comnionly  tlu^  t'orme:.  The  aid\li'  clonus  is  ]>resent  ;  the  I'im.i  i- 
llivtM'ted  and  the  t.oes  are  str<;n,i;ly  lleved.  'I'liesc*  casi's  may  he  mi.-takdi 
for  lateral  sclerosis  jind  the  dillienlty  in  diajrnosis  may  really  lie  very  LTi'eiit. 
Tlui  spastic  trait  is  very  typical,  and  with  the  exairp'i'atcd  knee-jei'k  ami 
atd<]>!  eloiius  the  pictiin;  ic.iy  he  cliaraeteristie.  In  ISlK  1  rre(|iiciitlv 
showed  siieii  a  case  al  the  Montreal  (ieneral  Hospital  as  a  typical  e\an][ilc 
of  latci'al  sclerosis.  The  cunditioii  )iersisled  tor  more  than  ei;:-htceii  iii<iiitli> 
and  then  disappeared  completely.  Other  forms  of  contracture  may  he  in 
the  muscles  of  the  liip,  shoulder,  or  neck  ;  more  rarely  in  those  of  the  ja\v,< 
— hysti'rical  trismus — or  in  the  toiii^iie.  Ifemarkahle  indeed  aw  the  lecul 
ooiitraeturcs  in  the  diaplira,t(m  and  ahdoininal  muscles,  pivMlucinir  a  pliiiii- 
t.om  tiimoi',  in  which  Just  !■  w  and  in  the  neii;iih(ii"ho(id  of  the  iimlnliciis 
is  a  lii'in,  apparently  solid  j^iowth.  According  to  (iowers,  this  is  produced 
by  relaxation  of  tiie  recti  and  a  spasmodic  contraction  of  the  diaphrairin. 
together  witii  inilati<in  of  the  intestines  with  pis  and  an  archinjf  for\v;u(l 
of  the  verti  hral  column.  They  arc  apt  to  occur  in  niiddle-a.i^'ed  wdiiini 
ahout  the  menopause,  and  ai'e  freipn-ntly  associated  with  the  symptoiiis  nf 
spurious  ])reL(i)ancy — psfiiiln-ciii'sis.  The  resemhiance  to  a  tumor  may  W 
strikiiif^,  ant'  i  liave  known  skilful  dia,i,Miosticiaiis  to  be  deceived.  Tlir 
only  safejjjnard  is  to  hi;  found  in  complete  amvstliesia,  wlien  the  tiinidi 
entirely  disai)peurs.  Some  years  a<>o  I  went  by  chance  into  the  operatinir- 
rooiti  of  a  hospital  and  found  a  jiatient  on  the  tal)K>  under  chloroform  ami 
the  suri^eon  prepai'ed  to  perform  ovariotomy.  The  tumor,  liowever,  hiui 
compieti'ly  disappeared  with  full  anaesthesia.  Mi*^cliell  lias  veporteil  ;in 
instance  of  a  pluintoui  tumor  in  the  left  i)ec'toral  region  just  above  thr 
breast,  which  was  tender,  hard,  and  dense. 

Clonic  sjHtsins  are  more  common  in  hysteria  in  tliis  country  tliiin 
contractures.  The  following,' are  the  importaid.  forms  :  lilnitliiiiii'  hijslir- 
icnl  tipasin.  This,  unfortunately,  is  sometimes  known  as  rliythmic  elmivn 
or  hysterical  chorea.  The  movements  may  be  <if  {he  arm,  either  tlixioii 
and  extension,  or,  nmre  rarely,  pronation  and  supiiuition.  Clonic  contrac- 
tions of  the  sterno-cleido-mastoid  or  of  the  muscles  of  the  jaws  or  of  the 
rotatory  muscles  of  the  head  may  jn'oduce  rhythmic  movements  of  tluw 
parts.  The  spasm  may  be  in  one  or  both  psoas  muscles,  lifting  the  Ic^r  in 
a  rhythmic!  manner  eight  or  ten  times  in  a  minute.  In  other  inst;iii<H'S 
tlie  muscles  of  the  trunk  are  aCfected,  and  every  few  moments  there  i'^  ;i 
bowins;  movement — salaam  convulsions — or  the  mnscles  of  tlie  back  iiwy 


IIVSTKIJIA. 


IdlT) 


onnnnon  itrc  tlic 
lost  iiiiy  irrimp  'I 
ic,  or  iiinii(p|iliL'ii> 
•  iiioiit lis  di'  \(';ir.-, 
iioiily  siH'ii  in  111. 
iirci's  tijrlilly  '^\-a~\i 
•riiiiii:il  |ilialniiL,'('- 
ic  (tr  in   liolli   I'"-''' 
t'SC'iil ;  (Ih'  I'diil  i> 

niiiv  111'  iiiist;ik(ii 
[■nllv  !»■  very  LTrrat. 
tc(l   kiH'c-jcrk  ;iiiil 

ISl'.t  1  l'rci|iM'nlly 
^  U  ty|iir;il  t'\;itii|ilr 
111  I'iii-lilccti  itii'iillis 
tnicluri'  iiKiy  In'  in 
II  tlidsc  (if  tlir  jaws 

luU'cd    nVC   tlu'  Incill 

])V(i(liiciii^'  a  pliaii- 
()(1  ol'  the  Ullllii!irll< 
■rs,  this  is  jti'iiihircil 
1  ol"  the  (li:iiilira,;;iii. 
an  archiii.U  t'drwaid 
|ni(ltlk'-a^v(l  women 
the  syniptoiiis  nf 
to  a  tiunor  may  lii' 
)(>  (U'ccivcil.     'I  li'' 
,-\vlicii  till'  luiniir 
uilo  tilt!  opera tiiii:- 
'V  ohlorofonii  ami 
mor,  lH)\v('Vir.  h:i<l 
1  lias  Tt'iiortiil  iiii 
ion  just  abovi'  thf 

tliis  ronniry  tlian 

ninjilniii''  hijsh'r- 

IS  rhytlunic  rliomi 

arm,"  fit  Inn-  lU'xion 

m.     Clonic  coiilnH- 
the  jaws  or  "f  tlio 

iiownionts  of  llu'?e 
s,  lil'tin.ij;  the  1''^'  '» 
In  other  instaiurs 
noiiu'iits  tlu'iv  i~  !i 
3s  of  the  back  muv 


cniitrac',  causini,'  stron.ir  arcliini,'  of  the  vertebral  eolimin  ami  retraction 
(if  the  head.  These  leoveiiieiits  may  often  alternate,  as  in  a  case  in  my 
wards,  in  wliii  h  tiic  ,iatieiil  mi  line  day-^  liad  i'e:,Milar  >alaam  convid-ioiis, 
whil(!  on  wet  days  the  rliylhmic  spasm  was  in  the  mnsclcs  of  the  back  and 
iKi'k.  Miti'liel!  has  described  a  rotatory  spasm  in  which  the  patient  ro- 
laied  involiintarily.  usually  to  the  left.  .More  iinnsiial  cases  are  those  in 
which  the  coiiti'aclioiis  closely  simulale  pai'amyoeloiiiis  miilliplex.  Ifvs- 
trrical  athetosis  is  a  rare  form  of  spasm.  'I'ri'inur  may  be  a  pure  hvstei'ical 
iiiaiiil'i'station,  occmiiiiLr  either  alone  or  with  paralysis  and  eoiiti'aetiire. 
It  most  commonly  involves  the  iiamls  and  arms;  more  rarely  the  liead 
iind  lei^s.  The  movements  are  small  and  (piick.  in  the  type  AVv/'//^  tho 
iniuor  may  or  may  not.  persist  dni'inif  re|iose,  l)iit  it  is  increased  or  pro- 
voked by  volitional  movements.  N'olitioiial  or  intentional  tri'iiior  may  ex- 
isl.  simnlatiiiif  closely  tlu'  movements  of  insular  S(derosis.  Hii/./.ard  states 
lliat  many  instanei's  of  this  disease  in  young  ^drls  art!  mistaken  for  hystei'ia. 

(v*)  Disorders  of  Sensation. — Ainnstlwuui  i.s  mo.st  coin  nion,  ami  usually 
coiitiiied  to  Olio  hair  of  tiie  body.  It  may  not  be  noticed  ''V  the  iiatieiit. 
I'Mially  it  is  aecurately  limited  to  the  middle  line  and  ii.  .olves  tho  uineoiis 
Mirfaees  and  deeiier  parts,  'i'lie  conjunctiva,  however,  i.-  ofti'ii  spared. 
Tliei'e  iiiiiy  1)0  lioniianopia.  This  symptom  may  come  on  slowly  or  follow 
acdiivulsive  atbick.  Sometimes  the  vai'ious  seii.sations  are  dissoi'iated  and 
llicana'sthesia  may  be  only  to  pain  and  to  touch.  The  skin  of  the  alTected 
-iili'  i  usually  pale  and  cool,  and  a  pin-j)rick  may  not  be  followed  bv  blood. 
With  the  loss  of  feeling  tiiere  may  be  loss  of  muscular  power.  Curious 
tnipliie  elumgos  may  bo  prosoiit,  as  in  an  intero.sting  case  of  Weir  Mitcli- 
\\\'<.  in  which  there  was  unilateral  swelling  of  the  hemipU'gic  side. 

A  phoiiomenon  to  wdiicli  much  attention  has  been  paid  is  that  of  trans- 
tVrciice.  lU' metallotherapy,  tho  application  of  certain  metals,  the  ainvs- 
thi'sia  or  analgesia  can  bo  transferred  to  the  other  side  of  the  body.  It 
lias  been  shown,  howovor,  iiMit  this  phonoinonoii  may  be  caused  by  tho 
tli'ctro-magnot  and  by  wood  and  various  other  agents,  and  is  probably 
iiitirely  a  niontal  eifect.  The  subject  has  no  [)raetical  importance,  but  it 
iviiiaiiis  an  interesting  and  instructive  chapti-r  in  (iallic  medical  history. 

/fi//)e)'(Pst/u'sia. — ineroascd  sonsitivonoss  and  ])ains  occur  in  various 
parts  of  the  body.  One  of  the  most  froquont  complaints  is  of  pain  in  tho 
iii'iid,  usually  over  tho  sagittal  suture,  less  fre(|nontly  in  the  occiput.  This 
i>  (li'scribod  as  agonizing,  ami  is  compared  to  the  driving  of  a  nail  into  the 
part;  lioneo  tho  name  rldi'tis  /ii/sffrin/s.  Neuralgias  are  common.  Ily- 
piTa'sthetie  areas,  the  hysterogenic  points,  exist  on  the  skin  of  the  thorax 
iiml  abdomen,  pressure  upon  wh'ch  may  cause  minor  manifestations  or 
t'vcii  a  convulsive  attack.  Increased  sensitiveness  exists  in  the  ovarian 
ivirimi,  but  is  not  peculiar  to  hysteria.  Pain  in  the  back  is  an  almost  c(jn- 
>t:iiii  complaint  of  hysterical  jtatients.  The  sensitiveness  may  be  limited 
t»  certain  spinous  processes,  or  it  may  be  ditTuse.  In  hysterical  women 
the  pains  in  the  abdomen  may  simulate  those  of  gastralgia  and  of  gastric 
05 


|1: 


102G 


DISEASES  OF  THE   NERVOUS  SYSTEM. 


fi   I 


'f« 


ulpcr,  or  tl.'.>  condition  may  l)o  almost  icU'ntical  with  that  of  jx'viiMnitjs; 
more  rart'ly  tlio  abdominal  pains  closely  resemble  those  of  appendix  iii-r,i>c, 

Spci'idI  Si'iinrs. — Disturljaiices  of  taste  a!id  smell  are  not  iiiicun;iiinii 
and  may  c use  a  <?ood  deal  of  distress.  Of  ocidar  sym[)toms,  reliii.il  hv- 
])era>sthesia  is  the  most  common,  and  the  patients  always  prefer  to  Ix-  in  u 
darkened  room.  Ketraction  of  the  field  of  vision  is  common  and  iisiialiv 
follows  a  convulsive  seizure.  It  may  ]iersist  for  years.  The  color  |ii!c.ji. 
tion  may  lie  normal  even  with  complete  ana'sthesia,  and  in  this  coiuitiv 
tiie  achromatopsia  does  not  seem  to  be  nearly  so  common  an  hysti'ric;il 
manifestation  as  in  Kiiro])e.  Hysterical  deafness  may  be  complete  iiiiii 
may  alternate  or  come  on  at  the  same  time  with  hysterical  l)linili!(\-s. 
Hysterical  amaurosis  may  oeciir  in  children.  One  must  carefully  di>tiii- 
s^jnish  between  fimctional  loss  of  power  and  simulation. 

(.'5)  Visceral  Manifestations. —  licxpirdlDrii  AppardtHs. — Of  disturli- 
iinces  in  the  respiratory  rhythm,  the  most  fre(|uent,  |)erhaps,  is  an  exiiLrircni- 
tion  of  the  deeper  breath,  which  is  taken  normally  every  fifth  or  sixth 
inspiration,  or  there  may  be  a  "catchinj^"  bri'athiny;,  such  as  is  seen  wlitii 
cold  water  is  poured  over  a  person.  Hysterical  dys])n(ea  is  readily  nrdi;. 
nized,  as  there  is  no  s[)ecial  distress  and  the  pulse  is  usually  normal.  1 
have  met  with  a  remai'kable  ease  followintf  trauma  in  which  the  rcspiia- 
tions  ro.se  above  one  hundreil  and  thirty  in  the  minute.  Amoiiji:  Iiii'viil'i'iiI 
nnuufestation.s  aphonia  is  the  most  freipient  and  may  persist  for  innntlis 
or  even  years  without  other  special  symptoms  of  the  disease.  Spa-m  nf 
tile  muscles  may  occur  with  violent  inspiratory  ell'orts  and  ,s>:ri'at  distns-;, 
tuul  may  even  lead  to  cyanosis.  Hiccough,  or  sounds  re.stMnl)linjjf  it.  iniiv  1k' 
present  for  weeks  or  months  at  a  time.  Ainonir  the  most  reiuarkiilijc  nf 
the  respiratory  manifestations  are  the  hysterical  cries.  These  may  itiiiiiic 
the  sounds  produced  by  animals,  sirch  as  barkiiiir,  mewinfi,  or  ,i;i'iiiitiii,i;, 
and  in  France  epidemics  of  them  have  been  repeatedly  observed.  Kxtraor- 
dinary  cries  may  be  produced,  either  inspiratory  or  expiratory.  I  saw 
at  Waifiier's  clinic  at  Leipsi(!  a  girl  of  thirteen  or  fourteen,  who  had  fur 
many  weeks  given  utterance  to  ii  remarkable  inspiratory  cry  somewjiut  like 
the  whoo})  of  wliooping-cough,  but  so  intense  that  it  was  heard  at  a  Inin' 
distance.  It  was  inces.sant,  and  tho  girl  was  Avorn  to  a  skeleton.  .\ttaik< 
of  gaping,  yawning,  and  sneezing  may  idso  occur. 

The  hysterical  cough  is  a  frecpient  sym])tom,  ])articularly  in    yoiiii:' 
girls.     It  may  occur  in  paroxysms,  but  is  often  a  dry,  persistent,  iTeakinirj 
cough,  extrenu'Iy  monotonous  and  un{)lea.sant  to  hear.     Sir  Aiulriw  Chirk 
hiis  called  attention  to  a  loud,  barking  cough  {ri/iiofw.r  hchcfica)  oirurriiiL'l 
about  the  time  of  puberty,  ehielly  in  hoys  belonging  to  neurotic  tainilic 
The  atta(d\s,  which  last  about  a  minute,  recur  freipiently. 

There  is  a  jx'culiar  form  of  lia'ino()tysis  which  may  l)e  very  (liccptivil 
and  lead  to  the  diagnosis  of  pulmonary  disorder.s.     AVagner  desniiiis  \\w 
sputum  as  a  i)ale-red  fluid — not  so  bright  in  color  as  in  ordiiuiry  liaiii"p 
tysis,  and  on  settling  jiresents  a  ri'ddish-brown  sediment.     It  contains  par 
tides  of  food,  pavement  epithelium,  red  corpuscles,  and  microcucciJ"! 


IIYSTKUIA. 


1U2) 


it  of  ]H'vii.initis; 

i>  not  luicoMniii'ii 
)t(inis,  rotinal  liy. 
,  pri't'er  to  I"-  in  i 
mon  iintl  u-ual!;, 
Tlie  color  |ir!v.  ).- 
il  ill   this  (M.uiilr;. 
iiion  iin  hysuii'-:;' 
bo  coin|iK'i''  ai\ii 
stericiil  bliiuliuvs. 
st  carefully  disliu- 

„/„,s.._()t'  .li>uirl.- 
iips,  isiin  oxiiLi-.iri'ni- 
vcM-y  liftU  or  sixth 

lu'h  iis  i>^  ^*^'''"  ^^'^'^'^ 
ii'ii  is  readily  ivcd;:- 

usually  unnual.  1 
.  which  the  ivsjiini- 
:  Amon^'  l!n'yi\,iH'al 
f  persist  for  uiontlis 

disease.     Spa-^ui  nf 


am 


esi 


I  great  distiv 
mhliuir  it.  miiy 


most  rema 


•kal) 


111 


Thesi'  may   nimn'' 

liewin.ii,  or  oTuiitiiiL'. 

)l)served.    FAtnidV- 


'Xitiratory. 


1   <:iw 


irteen,  who  hail 


rv  crv  soniew 


liut  lik'' 


was 
a  ske 


heard  at  a  l<m;; 


letou. 


Att;ii'k> 


lirticularly  in 


voun:' 


tent,  cr.xikinii 
Andrew  Clark  j 


persis 
Sir 
I-  Jirho/irn)  ocrur 


■riiii.' 


lo  neii 
iillv. 


rotic  fai'iUH^ 


liav 


,•  he  very  il''''» 


P' 


iw 


aii' 
in 


iii'r  descrilH'S  u 
ordinary  laHU" 

it.     It  contain>l'; 

and  inicroeuco 


1, 1'l.' 


ndi'vliiulrieal  or  ciliated  epitheliiiin.     It  jtrohaljly  conies  from  th(>  inoutli 
(ir  |iliaryi!X. 

hiijrslirc  Si/.s/rm. — Disturbed    or   depraved    apjx'tite,    dyspcpsiii,    and 

;ra>tric  pains  are  common  in  hysterical  ])atii'nts.     The  ])atient   may  have 

(litliculty  in  swallowinif  tlic  food,  apparently  from  spusni  of  the  <j:ul!et. 

Tin  re  are  instances  in  whicli  the  food  seems  to  be  expelled  before  it  reaches 

the  stomach.     In  other  cases  there  is  incessant  uasririuiJ:.     In  the  hysterical 

viiiiiilini,'  the  f>iod  is  regnr^ntated  without  much  eifort  and  without  nausea. 

Tlii>  feature  may  jiersist  for  years  without  fi;reat  disturbance  of  nutriticni. 

Tlic  most  strik'nij  and  remarkable  digestive  disturbance  in  hysteria  is  the 

itiKiri'.riii  nrrrosd  described  l)y  Sir  William  (iiill.    ''To  call  it  loss  of  a]»pe- 

tit( — anorexia — but  feebly  characterizes  tiie  symittom.     li    is   rather  an 

annihilation  of  a[)petite,  so  complete  ttiat  it  seems  in  some  cases  impossible 

fvcr  to  eat  again.     Out  of  it  grows  an  antagonism  to  f(»(id  which  results 

at  lastand  in  its  worst  forms  in  spasm  on  theap|troach  of  food,  and  :his  in 

turn  gives  rise  to  some  of  those  remarkal)le  cases  of  survival  for  long  pei'iods 

without  food  "  (.Mitchell).    As  this  goes  on  there  may  be  an  extreme  degree 

iif  niiiscular  restlessness,  so  that  the  ])atients  wander  about  until  e\liausted. 

This  feature  has  not  been  ju'esent  in  the  cast-s  which  liave  come  under 

my  oliservation.     Nothing  more  pitiable  is  to  be  seen   in  practice  than  an 

advanced  case   of   this  sort.     It  is  usually  in  a  young  girl,  sometimes  as 

early  as  the  eleven'"    or  twelfth,  more  commonly  lu'tween  tiu'  lifteeiitli  and 

tucntieth  years.     The  emaciation  is  frightful,  and   scarcely  exct'cded    i>y 

that  of  cancer  of  the  (esophagus.    The  patient  (inally  t-.ikes  to  i)cd,  and  in 

fvtrcme  cases  lies  upon  one  side  witii  tiie  thighs  and  legs  Hexed,  and   con 

iiactures  may  occur.     Food  is  either  not  talvcn  at  all  or  only  upon  urgent 

inM)[iulsion.     The  shin  becomes  wasted,  dry,  and  covered  with  bran-like 

•lulcs.     No  food  may  be  taken  for  several  weeks  at  a  iinie.  and  attempts  to 

iVi'il  may  be  followed  by  severe  s[)asms.     Although  the  condition  looks  so 

planning,  these  cases,  when  removed    from  their  home  surroundings  and 

t'vaied  by  Weir  Mitciieirs  method,  sometimes  I'ccover  in  a    remarkable 

way.      Death,    however,   may    follow   with   extreme  emaciation.        In    a 

fatal  case  recently  under  my  care  the  girl  weigned  only  forty-nine  |iounds. 

No  Ifsions  were  found  post  mortem. 

Aniong  intestinal  symptoms  tlatulency  is  one  of  .■  most  distressing, 
:in(l  i<  usually  associated  with  the  condition  of  jteristaltic  unrest  (Kuss- 
iiiaul).  Fi^xpient  discharges  of  fa'ces  may  be  due  to  distui'baiice  in  either 
ilif  small  or  large  !;owel.  An  obstinate  form  of  diarrluea  is  found  in  some 
liystt'i'ieal  patients,  which  ])roves  very  intractable  and  is  associated  espe- 
'ially  with  tlie  taking  of  food.  It  .seems  an  aggravated  form  of  tlie  loose- 
'>iss  (if  bowels  to  winch  so  many  nervous  ])eople  ari'  subject  on  emotion 
I'l'  till  li'iidency  which  some  have  to  diai'rh<ea  immediately  after  eating.  An 
'iitinly  different  form  is  that  produced  by  what  Mitchell  calls  the  irrital)le 
[■■"•tinn,  ill  wlii(;li  scybala  are  passed  friMpieiitly  during  the  day,  sometimes 
h*itli  grout  violence.     Constipatittn  is  more  frequent,  however,  and  may  bo 


1U28 


DISEASES  OF  THE   NERVOUS  SYSTEM. 


'4' 

mm 


(liio  to  ii  loss  of  pnwor  in  the  muscles  of  tlio  bowol,  or  in  the  abdomiiuil 
iimsck's.  In  extreme  cases  the  bowels  niuy  not  be  moved  for  two  or  three 
weeks,  leudiiifi;  to  great  accnnmlation  of  fieees.  Other  disturbances  are 
ano-spasm  or  intense  pain  in  the  rectum  apart  from  any  iissure. 

Cardio-rd.sciiJar. — IJapid  action  of  the  heart  on  the  slightest  eiiiii,ii,ii. 
with  or  without  the  subjective  sensation  of  pali)itation,  is  often  a  ,<(auve 
of  great  distress.  A  slow  pulse  is  less  frecjuent.  J'ains  al)out  the  hemt 
may  simulate  angina,  the  so-called  hysterical  or  ijscudo-angina,  whiiii  ha- 
already  been  considered.  Flushes  in  "arious  parts  are  among  the  iu(i>t 
common  sympto!!!-j      Sweating  occasionally  occurs. 

Among  the  more  remarkable  vaso-motor  pheiu)mena  are  the  s(i-i;illii| 
stigmata  or  liaMuorrhages  in  the  skin,  such  as  were  present  in  the  celr- 
l)nited  case  of  fiouise  Lateau.  In  many  cases  these  are  undoiiliteillv 
fraudulent,  but  if,  as  appears  credible,  such  bleeding  may  exist  in  ihi 
iiypnotic  traiu'e,  tliere  seems  no  reason  to  doubt  its  occurrence  in  the 
trance  of  ])roh)nge(l  religious  ecstasy. 

Joint  Affections. — To  Sir  IJeujamin  lirodie  and  Sir  James  I*ai:et  w  ■ 
owe  the  recognition  of  these  extraordinary  manifestations  of  liv.-teiia. 
Perhaps  no  single  atfection  has  brought  more  discredit  upon  the  prot'es- 
sion,  for  the  cases  are  very  refractory,  and  tinally  fall  into  the  hamls  (4  a 
charlatan  or  faith-healer,  under  whose  touch  the  disease  nuty  disapiiearat 
once.  Usually  it  atfects  the  knee  or  the  hip,  aiul  may  follow  a  tiilliii;' 
injury.  The  joint  is  usually  fixed,  sensitive,  and  swollen.  The  surfaee 
nuiy  be  cool,  but  sonu^times  the  local  temi)erature  is  increased.  To  thi' 
touch  it  is  very  sensitive  aiul  movement  causes  great  pain.  In  pniiiaeteil 
cases  the  muscles  about  the  joint  are  somewhat  Avasted,  and  in  eiiii«e- 
((ueiu'e  it  looks  larger.  The  pains  are  often  nocturnal,  at  which  time  th' 
local  temperature  nuiy  he  much  increased.  While,  as  a  rule,  neuroniiiiietie 
joints  yield  to  ])r()per  management,  there  are  int"resting  instances  in  tlio 
literature  in  which  organic  change  has  succeeded  the  functional  distuili-l 
ance.  In  the  remarkable  case  reported  in  Weir  ^litcheirs  lectures,  flio 
hysterical  features  were  pronouiu'cd,  and,  on  account  of  the  clinniirirv. 
the  disease  of  the  knee-joint  was  considered  organic  by  such  an  autlieiitvi 
as  Billroth.  Saiuls  found  the  joint  surfaces  normal,  and  the  tliii  kenii!,'| 
to  be  due  to  inllammatory  products  outside  the  capsule. 

Intermittent  liydrarthrosis  may  be  a  manifestation  of  hysteria,  oeciir 
ling  in  the  knee  or  other  joints,  sometimes  with  transient  paresis. 

Mi'iihd  Si/iiijif(i)iis. — The  psychical  condition  of  an  hysterical  ])iiiit'i:tj 
is  always  abnoruud,  and  the  disease  occupies  the  ill-defined  territniv  ln-j 
tween  sanity  and  insanity.  In  a  large  number  of  cases  the  patients  ;iw| 
really  insane,  jtarticularly  in  the  perversion  witnessed  in  the  moral  splHit'-l 
Not  the  slightest  depeiulence  can  be  placed  upon  their  siatenieiits.  ;i 
they  will  for  months  or  years  deceive  friends,  relatives,  and  itliysiriaiil 
This  appears  to  result  ])artly.  but  not  wholly,  from  a  morbid  eravini:  l' 
sympathy.     It  is  really  due  to  an  entire  unhinging  of  the  moral  nature. 


T 


I. 


IIYSTEIIIA, 


1(>!2!» 


ill  the  iibdinn'mal 
111  for  two  or  ilmr 
r  disturbani'v:.  iiin 
('  iissuro. 

slightest  emiuioii. 
I,  iri  often  !i  MiuiTi' 
us  iihout  the  lu'un 
(-ungiiui,  wliirh  hvf 
•c  among  the  must 

la  avo  the  so-r:ilK'il 
present  In  the  «vK'- 
m  are  undoul'trdly 
it  may  exist  in  llu' 
ri  oeeiirrenee  in  tlif 

Sir  Jami's  I'a.irft  \\v 
■stations  of   h\>ti'n;i.  | 
ilit  xn^on  the  vrotVs- 
into  the  hands  of  a 
:iise  may  disaiijuar  at 
may  foUow  a  trilling' 
wollen.     The  surrarr 
[s  increased    T"  >'"■ 
^,ain.     In  prutiactr.l 
^ii'd,  and  in  consi'- 
al,  at  whitdi  tiiui'  \W 
a  rule,  neuroiuiiuHie 
■sting  instances  in  the 
,0  functional  dlstud)- 
it(dudrsle<'tun'S.tlio| 
lit  of  the  cdivniiiritv. 
liy  such  an  authority  I 
Al,and  the  thirkoiiin;,'! 

nle. 

on  of  hysteria,  oooiir- 

nsieut  paresis. 

an  hysterical  paiii'"t| 
l-defined  tervit(ivyl'i-[ 

ises  the  patii'iits  :iM 
d  in  the  moral  spluiv.] 

their  statements,  amli 
stives,  and  rhysimmj 

a  morbid  cravniL'  1'"] 
of  the  munil  Mm- 


Hysterical  patients  may  become  insane  and  display  persistent  hallii- 
fiiiations  and  delirium,  alternating  perhaps  with  emotional  outbursts  of 
;in  aggravated  character.  For  weeks  or  months  they  may  be  conlined  to 
lii'd.  entirely  olilivious  to  their  surroundings,  with  a  delirium  which  may 
^inlulate  that  of  delirium  tremens,  iiarticularly  in  being  associated  with 
Idutlisome  and  unpleasant  animals.  The  nutrition  may  be  nuiintaincd, 
!iut  in  these  cases  there  is  always  a  very  heavy,  foul  breath.  With  seclu- 
-inn  and  care  recovery  usually  takes  })lace  within  three  or  four  months. 
At  the  onset  of  these  attacks  and  during  convalescence  thi  patieuls  tmisi 
lie  ince.ssantly  watched,  as  a  suicidal  tendency  is  by  no  means  uncoium(»n. 
1  liave  been  accustomed  to  speak  of  this  condition  as  the  .-/<i/iis  liijslcricii.s. 
Of  hysterical  manifestations  in  the  higher  centres  that  of  trance  is  tiic 
most  remarkable.  This  may  develop  si)ontaneously  witliout  any  convul- 
sive .seizure,  but  more  frequently,  in  this  country  at  least,  it  follows  liys- 
tcroid  athicks.  Catalei).sy,  a  condition  in  which  the  limbs  are  plastic  aid 
remain  in  any  i)osition  in  which  they  are  placed,  may  be  present. 

77/6'  MclahoUsni  in  Ifi/sicrifi. — 'IMie  studies  of  (lilies  de  la  Ton  ret  te 
anil  Cathelineaii,  under  Charcot's  direction,  have  shown  that  in  the  ordi- 
nary forms  of  hysteria  the  urine  does  not  show  quantitative  or  qualitative 
changes,  but  in  the  severe  tyjx's,  characterized  by  convulsions,  etc.,  there 
are  important  modilications  :  reduction  in  the  urates  and  phosidiati's  ;  the 
ratio  of  the  earthy  to  the  alkaline  phosphates,  normally  1:1},  is  I:-,;,  or 
>\vn  1  : 1.  The  urim^  is  also  reduced  in  amount.  They  think  that  these 
ilianges  might  sometimes  serve  to  diil'erentiate  convulsive  hysteria  from 
i'pilc])sy,  in  which  there  is  always  an  increase  in  the  solid  constituents 
lifter  a  seizure. 

Ifi/sfrn'cal  Ftnrr. — In  hysteria  the  temperature,  as  a  riili",  is  normal. 
The  cases  with  fever  may  l)e  grouped  as  follows:  {a)  Instances  in  whicii 
the  fever  is  the  sole  manifestation.  These  are  rare,  but  I  have  .seen  at 
linst  two  cases  in  Avhich  the  chronic  course,  the  retention  of  the  nutrition, 
and  the  entirely  negative  condition  of  the  organs  left  no  other  diagnosis 
!"i-^sih|('.  Til  ;i  case  recently  under  obsci'vation  the  pi.tieiit  has  had  for  four 
III' live  years  an  afternoon  i'isc  of  tem])erature.  reac.'iing  usually  to  lH'i'  or 
i  ">'.  She  was  well  nourished  and  presented  no  pronounced  hystci'ical 
rviiiptoui;^  but  there  was  a  marked  neurotic  history  on  oiu  side  and  a  form 
"f  interrupted  sighing  resjiiration  so  often  seen  in  hysteria. 

(/')  Cases  of  hysterical  fever  with  spui'ious  local  manireitatioiis.  'i'hese 
lire  Very  troublesome  and  deceptive  cases.  Tlie  patient  may  lie  suddenly 
iiiken  ill  with  pain  in  various  regions  and  (devation  of  temperature.  The 
I'li-ie  may  simulate  meningitis.  There  may  be  pain  in  tlie  head,  vomiting, 
I'lntraeted  ]iupils,  iind  retraction  of  the  neck — symptoms  whieji  may  per- 
yk  fur  weeks — and  some  anomalous  manifestation  during  convalescence 
may  alone  indicate  to  the  physician  that  he  has  had  to  deal  with  a  case  of 
')'^ti'ri;i,  and  has  not,  as  he  perlia[)S  llattered  liimsidf,  cure(l  a  case  of  nu'ii- 
|in:,'iti.s.     >[ary   Putnam  Jacobi,  in  a  recent  articde  on    hysterical   fever, 


t-|! 


1030 


DISKASHS  OF   TIIK   NERVOUS   HVSTKM. 


HilEli 


m 


mcMilions  a  case  in  the  serviee  of  (,'oniil  \vlii(!h  was  admitted  with  (]vsjiii,p;^ 
slioht  cyanosis,  and  a  teniperatiire  of  d'.f  C.  Tlic  condition  2)rove(l  i(]  In; 
hysterical.  Tliero  is  also  an  hysterical  i)seudo-j)hthisis  with  i)aiii  in  iIk; 
chest,  slight  fever,  and  the  expectoration  of  a  blood-stained  nuiciis.  '['\^^. 
cases  of  hysterical  peritonitis  may  also  show  fever. 

{(•)  Ili/sfrriatl  lliiprrpyrc.ria. — It  is  a  suggestive  fact  that  the  cases  of 
l)aradoxical  temperatures  reported  of  late  years,  in  which  the  thernioinctcr 
has  registered  11"^°  to  1^0''  or  more,  have  been  in  women.  l''i'aii(l  \\;y^ 
been  practised  in  some  of  these,  but  others  have  to  be  accejited,  tlmiii,'!! 
their  explanation  is  impossible  under  our  known  laws.  Jacobi  has  n- 
cently  reported  a  case  in  which  the  temperature  rose  to  148"  F.  ((i.r,")  C), 
The  Omaha  case,  in  which  the  temperature  was  recorded  at  170°  V.,  Ims, 
I  am  informed  on  good  authority,  proved  a  fraud. 

Diagnosis. — In(|uiry  into  the  occnrrence  of  previous  manifestations 
and  the  mental  conditions  may  give  im[)ortant  information,  'i'hesc  (|iiis- 
tions,  as  a  rule,  should  not  be  asked  the  niother,  who  of  all  others  is  least 
likely  to  give  satisfactory  information  about  the  patient's  condition.  Tlic 
occurrence  of  the  globus  hystericus,  of  emotional  attacks,  of  wee|)ini:  ami 
crying,  are  always  suggestive.  The  2)oints  of  dilTerence  l)etween  th«'  cuii- 
vulsivc  attacks  aiul  true  ei)ilepsy  were  referred  to  in  their  (lescri|iti(iii. 
and  as  a  rule  little  dilticulty  is  experienced  in  distinguishing  between  the 
two  coiulitions.  The  liy.sterical  paralyses  are  very  variable  and  a  [it.  tn  lu' 
associated  with  ana'sthesia.  The  contractures  may  at  times  be  very  de'ep- 
tive,  but  the  occurrence  of  areas  of  ana'sthesia,  of  retraction  of  the  visual 
field,  and  the  development  of  minor  hysterical  manifestations,  give  valua- 
ble indications.  The  contractures  disapjiear  under  full  anaesthesia.  S|ie- 
cial  care  must  be  taken  not  to  confound  the  spastic  i)araplegia  of  hysieriu 
with  lateral  sclerosis. 

The  visceral  manifestations  are  usually  recognized  without  much  ililll- 
culty.  The  practitioner  has  constantly  to  bear  in  mind  the  strong  teinl- 
(!ncy  in  hysterical  patients  to  jiractise  deception. 

Treatment. — The  ])rophyla.:is  in  hysteria  maybe  gathered  from  tlio 
remarks  on  the  relation  of  education  to  the  disease.  The  siu*cessful  trnit- 
ment  of  hysteria  demands  (jualities  possessed  by  few  physicians.  Tlic  lin-t 
element  is  a  due  appreciation  of  the  nature  of  the  disease  on  the  |iait  ef 
the  physician  and  friends.  It  is  pitiable  to  think  of  the  misery  wliuli  li;is 
been  intlicted  on  these  unhappy  victims  by  the  harsh  and  unjust  tivul- 
ment  which  has  resi  Ited  from  false  viinvs  of  the  nature  of  the  tiniililc; 
(Ml  the  other  hand,  worry  and  ill-health,  often  the  wrecking  of  mini. 
body,  and  estate,  are  entailed  upon  the  near  relatives  in  the  mirsin^' iil;i 
protracted  case  of  hysteria,  'i'he  minor  mainfestations,  attacks  nf  tin' 
t'apors,  the  crying  and  weeping  spells,  are  not  of  much  momeiil  ami 
rarely  rc(|nire  treatnu'ut.  The  physical  condition  should  be  caivriillv 
looked  into  and  the  mode  of  life  regulated  so  as  to  insure  system  aini 
order  in  everything.  A  congcjiial  occupation  offers  the  best  renn  'ly  l^r 
many  of  these  numifestations.     Any  functional  disturbance  shouhi  Ih' at- 


WT~ 


HYSTERIA. 


1031 


lhI  with  (ly>i>iiii';i, 
;ion  provi'il  in  1»l' 
with  piiin  ill  the 
lod  mucus.    'I'lw 

tluit  tlic  cases  of 
tlio  tlicrniiiiiu'tt'r 

men.  Fnuul  has 
iiccoptcil,  thoiijih 

;.     .Jiicoln  lias  IV- 

U8°  F.  (('..rr.  t'.). 

edatnu°  F.,  has, 

nis  miinifostiilimis 
;i(m.     Tliosi"  ([iK's- 

iill  othi'fs  is  least 
's  coiuUtioti.  Thi' 
:s,  of  wec'iiiiiu'  ami 
.  between  tliv  rdii- 
1  tlieir  descriplinii, 
ishinjl  hetwcHMi  the 
iihle  and  apt  td  U' 
:imes  l)e  vefv  devp- 
letion  of  tlie  visual 
taticms,  irive  valua- 
l  iuiivstliesia.     Spc- 

raplegia  of  liysinia 

without  much  ililVi- 
ul  tlie  stroll,--  Mi'l- 

|e  ,<rathered  frnm  tli'' 
riie  succcssfid  tivat- 
hysicians.    Th.'  iii>' 
L.J.^o  on  tlie  part  <'f 
he  misery  wlii'li  ha- 
Ih  and  un.jusi  nvai- 
lure  of  the  tnmhli'-. 
\vre('l<in.t!;  <>f  mii'.'l- 
hi  the  nursin;:'"fa 
i,„)s,  attael<s  cf  tli'' 
Iniueh  moment   auw 
Ishould   be  eaivfullv 
I)  insure  system  ami 
the  best  remedy  f'^r ! 
•liuuee  shouhi  ht-at- 


ttnded  to  and  a  conrso  of  tonics  jircseribed.     Special  uttontion  should  lie 
paid  to  the  action  o;  the  bowels. 

N'alerian  and  asafo'tida  are  often  of  service.  For  the  pains  in  various 
parts,  jiarticnlarly  in  the  ba'-k,  the  thermo-cautery  and  static  electricity 
will  be  found  invaluable.  Morphia  should  be  withhe.d.  In  the  convulsive 
seizures,  particularly  in  the  minor  forms,  it  is  often  best,  after  settliiif^  the 
patient  comfortably,  to  leave  her.  When  she  conies  to,  and  linds  her- 
self alone  and  without  sympathy,  the  attacks  are  less  likely  to  lie  repeated. 
There  is,  as  a  rule,  no  cure  for  the  hysterical  manifestations  of  women, 
otherwise  in  good  health,  who  are,  as  ^[itchell  says,  "fat  and  ruddy,  with 
s<mnd  orjians  aiul  i^ood  appetites,  but  ever  complain  of  ])ains  and  aches, 
and  ever  lialilu  on  the  least  emotional  disturbaiu-e  to  exiiibit  a  ([uaint 
variety  of  hysterical  phenomena." 

'I'o  treat  hysteria  as  a  physical  disorder  is,  after  all,  radically  wroni^. 

It  is  essentially  a  mental  and  emotional  aiutmaly,  and  the  important  ele- 

lueiit  in  the  treatment  is  moral  control.     At  home,  surrounded  bv  lovinj; 

relatives  who  misinterpret  entirely  the  symptoms  and  have  no  appreciation 

(if  the  nature  of  the  di'-:oase,  the  severer  forms  of  hysteria  can  rarely  be 

ciirt'd.     The  necessary  control  is  irniiossilile ;  hence  the  special  value  of 

the  method  introduced  by  Weir  Mitchell,  which  is  particularly  applicable 

to  the  advanced  cases  which  have  become  chronic  and  bedridden.     The 

treatment  consists  in  isolation,  rest,  diet,  massa<ji:e,  and  electricity.     Sejia- 

ratioii  from  friends  and  sym])athetic  relatives  must  l)e  absolute,  and  can 

rarely,  if  ever,  be  obtained  in  the  individuars  home.    An  essential  element 

in  the  treatment  is  an  intelliircnt  nurse.     No  small  share  of  the  success 

which  has  attended  the  author  of  this  plan  has  been  due  to  the  fai't  that 

lie  has  persistently  chosen  as  his  allies  bri<j;ht,  intelligent  won  - ".     The 

details  of  the  ])lan  are  as  follows:  The  }iatient  is  confined  to  bed  and  not 

allowed  to  get  iiji,  nor,  at  first,  in  aggravated  cases,  to  read,  write,  or  even 

to  feed  herself.     Massage  is  used  daily,  at  first  for  twenty  minutes  or  half 

an  hour,  suhseqnently  for  a  longer  pi-riod.     It  is  essential  as  a  substitute 

for  exercise.     The  induction  current  is  applied  to  the  various  muscles  and 

to  the  sjiine.    Its  use,  however,  is  not  so  essential  as  that  of  massage.    The 

lift  may  at  first  he  entirely  of  milk,  four  ounces  every  two  hours.     It  is 

•letter  to  give  skimmed  milk,  and  it  may  be  diluted  with  soda  water  or 

liarli^'  water  and,  if  necessary,  jiejitonized.     After  a  week  or  leu  days  tlu' 

iliei  may  be  increased,  the  amount  of  milk  still  lieing  kept  u}).     A  chop 

may  be  given  at  midday,  a  cup  of  colfec  or  cocoa  with  toast  or  bread  and 

laitter  or  a  biscuit  with  the  milk.     The  patients  usually  fatten  rapidly  as 

the  solid  food  is  added,  and  with  the  gain  there  is,  as  a  rule,  a  diminution 

'•r  cessation  of  the  nervous  symptoms.     The  milk  is  the  essential  element 

ill  the  diet,  and  is  itself  amply  sutticient. 

The  remarkalile  residts  obtained  by  this  method  are  now  universally 
reeoguized.  The  plan  is  more  applicable  to  the  lean  than  to  fat,  flabby 
liysterical  patients.     Xot  only  is  it  suitable  for  the  more  obstinate  vurie- 


■L  l:] 


1(;32 


DISEASES  OF  THE   NERVOL'S  SYSTEM. 


ties  of  hysteria  with  hodily  iiiiiiiifi'statioiis,  hut  in  the  cases  with  iiiciiiul 
symptoms  the  seckisiou  ami  separation  from  rehitives  and  friends  arc  |iar- 
ticulariy  advantageous.  In  tlie  liystericai  voniilinj;  Deljove's  mctlidil  of 
forced  feedinjf  may  he  used  witli  henetit.  l-'or  tiie  innnmerahle  niiiinr 
manifestations  of  liysteria  and  for  tlie  simidalioiis  the  indications  for  li'mt- 
ment  are  usually  clear.  Of  late,  hy[)notism  has  heen  extensively  used  in 
the  ti'catnu'iiv  of  liysteria.  Occasionally  in  cases  of  hysterical  contractions 
or  paralysis  it  is  of  Ijcnefit,  hut  any  one  who  has  seci\  the  (h^velopmcnt  dl' 
this  nu'thod  as  practised  at  j)rcscnt  in  France  must  feel  tiiat  it  is  a  twd- 
edgcd  swoi-d  and  that  the  constant  repetition  in  the  same  patient  is  fnuiulit 
with  danger,  in  the  cases  which  we  have  tried  here  the  success  has  not 
been  nuirked. 

XII.   NEURASTHENIA. 


Definition. — A  comlition  of  weakness  or  exhaustion  of  the  nervims 
system. 

The  term,  invented  hy  Beard,  covers  an  ill-dellned,  motley  grou|i  of 
symptoms,  which  may  he  either  general  and  the  expression  of  di-ranp- 
ment  of  the  entire  system,  or  local,  limited  to  certain  organs;  lience  the 
terms  cerebral,  spinal,  cardiac,  and  gastric  neurasthenia.  In  certain  re- 
spects it  is  the  physical  counterpart  of  insanity.  As  the  essential  featinr 
in  the  latter  condition  is  the  abnormal  res[)onse  to  stimuli,  froin  within  nr 
without,  n[)on  the  higher  centres  })residing  over  the  miiul,  so  neurastheiii;! 
appears  to  be  the  expression  of  a  morbid,  unhealthy  reaction  to  stimuli 
acting  on  the  nervous  centres  which  ])reside  over  the  functions  of  orgmiir 
life.  No  hard  and  fast  line  can  be  drawn  l)etween  neurasthenia  and  ici- 
tain  mental  states,  particularly  hysteria  and  hypocliondria. 

Etiology. — Although  the  causes  are  apparently  varied,  they  may  lie 
grouped  as  hereditary  and  acfpiircd. 

(ii)  JlcrcdUavji. — We  do  iu)t  all  start  in  life  with  the  same  amount  df 
nerve  capital.  Parents  who  have  been  the  sul)jects  of  nervous  complaints 
or  of  mental  troubles  transmit  to  their  children  an  organization  wliirli 
is  defective  in  what,  for  want  of  a  better  term,  we  must  call  "  nerve  fDiir." 
Such  individuals  start  handicap])ed,  and  furnish  a  considerable  j)ro])(uiiiiii 
of  our  neurasthenic  ]iatients.  So  long  as  they  are  content  to  transact  a 
moderate  business  with  their  life  cajjital,  all  may  go  well,  but  there  is  no 
reserve,  and  in  the  enuM'gencies  which  constantly  arise  in  the  exigcmics 
of  modern  life  these  snndl  capitalists  go  under  and  come  to  us  as  liaiik- 
rupts. 

{(>)  Jci/iiircfl. — The  functions,  though  perverted  most  readily  in  pi'i- 
sons  who  have  inlieritcd  a  feeble  organization,  may  also  be  damagnl  liv 
exercise  which  is  excessive  in  ])roportion  to  the  strength — i.  e.,  by  striiin. 
The  cares  and  anxieties  attendatit  ujwn  the  gaining  of  a  livelihood  iimy 
be  borne  without  distress,  but  in  many  persons  the  strain  becomes  cmtsj- 


NEURASTHKNIA. 


1033 


isos  witli  mental 
1  I'l'li'iids  arc  par- 
love's  iiR'tl\iiil  iif 
iinnenihU'  iiiinnr 
cations  I'or  ircat- 
tcMisivoly  u^i'^l  ill 
rical  (•oiitnictiniis 
0  devolopiiH'ii!  iif 
that  it  is  a  twd- 
|)ati(.'nt  is  i'niiiulit 
e  success  has  nut 


:)u  of  the  nervous 

,  motley  'ynniy  nf 
•ssion  of  (leran.ize- 
)rgans;  hence  the 
a.     In  certain  iv- 
e  essential  featuiv 
.ili,  from  witiiiu  ^r 
pd,  so  nenrastlu'iiia 
.'action  to  stimuli 
actions  of  or.iraiiii' 
[•asthenia  ami  I'lr- 
ia. 
iried,  they  may  Ik' 

le  same  amount  nf 
lervous  comi)laiiit> 
o-anization  whicli 

^  ^ 

call  "nerve  fonc." 
leraltle  proiiortimi 

ntent  to  traii-arl  a 

L'U,  but  there  is  u" 

in   the  exi,treiii'i('^ 

)me  to  us  as  liaiik- 

lost  readily  in  |h'1'- 
so  be  damajivil  liy 
(l,_i.  e.,  by  strain. 
a  livelihood  iiiny 
liiu  becomes  I'Xfi'Sj- 


ivo  and  is  first  manifested  as  irorri/.  The  individual  loses  the  distinction 
lift  ween  e-seutials  and  uon-esscutia'.s,  trilles  cause  annoyance,  and  tiie 
entire  organism  reacts  with  unnecessary  readiness  to  slight  stimuli,  and  is 
ill  a  state  which  the  older  writers  called  irritable  weakness.  Jf  such  a 
condition  be  taken  early  aim  the  ])atient  given  rest,  the  balance  is  (juickly 
restored.  In  this  group  nniy  be  placed  a  largit  ])roportion  of  the  neuras- 
tlit'iiics  whicli  we  see  in  this  country,  particularly  among  Inisiness  men. 
Oilier  causes  more  subtle,  yet  potent,  and  less  easily  dealt  with,  arc  the 
worries  attendant  u})on  love  ali'airs,  religious  doubts,  and  the  sexual  ])as- 
sidU. 

Symptoms. — Tht'se  are  extremely  varied,  and  may  be  general  or 
Idealized;  more  often  a  combination  of  both.  The  appearance  of  the 
patient  is  suggestive,  sometimes  characteristic,  but  ditlicult  to  describe. 
Jidss  of  weight  and  slight  ana'mia  may  be  present.  'IMie  i)hvsical  debilitv 
may  reach  a  high  grade  and  the  ])atient  may  be  confined  to  bed.  Men- 
tally the  jiatients  are  usually  low-spirited  and  despondent,  in  women  fre- 
([lu'iitly  eniotional. 

The  local  symptoms  may  dominate  the  situation,  in  which  case  the 
cliiucal  picture  is  of  the  so-called  cerebral  or  spinal  neurasthenia.  Other 
local  fovms  are  cardio-vascnlar,  gastric,  and  sexual. 

In  the  cerebral  form  the  symptoms  are  chielly  connected  with  an 
inability  to  perform  the  ordinary  mental  work.  Thus  a  row  of  figures 
cannot  l)e  correctly  added,  the  dictation  or  the  writing  of  a  few  letters  is  a 
source  of  the  greati'st  worry,  the  transaction  of  ])etty  details  in  business  is 
a  painful  effort,  and  there  is  loss  of  ])ower  of  fixed  attention.  "With  this 
coiulition  there  nniy  be  no  headache,  the  appetite  may  be  good,  and  the 
patient  may  sleep  Avell.  As  a  rule,  however,  there  are  sensations  of  fulness 
and  weight  or  Hushes,  if  not  actual  hea<lache.  Sleeplessness  is  a  frt'(|Uent 
loiicomitant,  and  may  be  the  first  manifestation.  Some  of  these  jiatients 
arc  good-tem])ere(l  and  cheerful,  but  a  majority  are  moody,  irritable,  and 
depressed.*  The  special  senses  nniy  be  disturbed,  particularly  visiou.  An 
aching  or  weariness  of  the  eyoballs  after  reading  a  few  minutes  or  flashes 
cf  light  are  common  symptoms.  A  ditTcrcnce  lictwccn  the  pupils  may  bo 
present. 

When  the  spiiuil  .'<j/i)i/)/(i))is  jiredominate — spinal  irritation  or  spinal 
neurasthenia — in  addition  to  many  of  the  features  just  mcntioiu'd,  the 
patients  complain  of  weariness  on  the  li'ast  exertion,  of  weakness,  pain  in 
tile  hacdc,  and  of  aching  jiains  in  the  legs.  There  may  lie  spots  of  lo<'al 
temlerness  on  the  spine.  Occasionally  there  may  be  disturbances  of  sen- 
sat  inii,  particularly  a  feeling  of  nund)ness  and  tingling,  and  the  reflexes 
may  be  increased.  The  aching  \mn  in  t^he  back  t)r  in  the  back  of  the 
iii'ck  is  the  most  constant  complaint  in  thes(!  cases.     In  women  it  is  often 

*  I'or  an  oxliaustivo  coiisidoratinii  of  the  mental  syioptoins  of  iiennistlu'iiiii,  see  the 
'•^li.iiiuclv  Lecture,  hv  t'owles.    IJdstou  Meilieal  and  Sui^'ii'al  Journal.  lH()t. 


l(>:{4 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


If  I,; 


(!■  ■'•:  , 


impossible)  to  say  wliother  tins  coiulitioii  is  ono  of  iiourasthcuia  or  livs- 

teria. 

Ill  otliiT  rasos  tlio  cardio-rascidnr  symptoms  are  the  most  distress  in;.', 
and  may  occur  with  only  sli<fht  distiirhaiico  of  the  cerchro-spinal  functidiis, 
thoiiffli  the  conditions  may  be  cond)ined.  Palpitation  of  tlie  heart,  irrc^^n- 
hir  and  very  rapid  action,  and  pains  in  the  cardiac  re<i;ion  are  the  iiidst 
common  symptoms.  The  slightest  excitement  nniy  be  followed  by  in- 
creased action  of  the  lieart,  and  the  patients  frequently  have  the  idea  that 
they  sulTer  from  serious  disease  of  this  organ. 

\'aso-niotor  disturliances  constitute  a  special  feature  of  many  cases. 
Flushes  of  heat  and  transient  hyperaemia  of  the  skin  may  be  very  distress- 
ing symptoms.  Profuse  sweating  may  occur,  either  local  or  general,  and 
sometimes  nocturiud.  The  pulse  nuiy  show  interesting  features,  owln;,' 
to  the  extreme  relaxation  of  the  perij)lieral  arterioles.  The  arterial  tliidli- 
bing  may  be  everywhere  visible,  almost  as  much  as  in  aortic  insutliciciu  v. 
The  pulse,  too,  may  under  thes(!  circumstances  have  u  somewhat  water- 
hammer  ([uality.  The  capillary  pulse  may  be  seen  in  the  nails,  on  tiie 
lips,  or  on  the  margins  of  a  line  drawn  upon  the  forehead,  and  I  hav(>  on 
several  occasions  seen  ])ulsation  in  the  veins  of  the  back  of  the  hand. 
A  characteristic  symptom  in  some  cases  is  the  tln'obbiHfj  aorta.  This 
"preternatural  pulsation  in  epigastrium,"  as  Allan  Burns  calls  it,  may  l)e 
extremely  forcible  and  suggest  the  existence  of  abdominal  aneurism.  The 
subjective  sensations  associated  with  it  nuiy  be  very  unpleasant,  particu- 
larly when  the  stomach  is  empty. 

The  general  features  of  gastro-intestinal  neurasthenia  have  l)ecn  dealt 
with  under  the  sec^tion  of  nervous  dyspepsia.  The  connection  of  these 
cases  Avith  dilatation  of  the  stonuich,  lloating  kidney,  and  the  condilimi 
which  Glenard  calls  cnfcrojt/o.sis  has  already  been  mentioned. 

Sexual  neurasthenia  is  a  condition  in  which  there  is  an  iri'itable  weak- 
ness of  the  sexual  organs  manifested  by  nocturnal  emissions,  uiuisual  de- 
pression after  intercourse,  and  often  by  a  distressing  dread  of  impotence. 
The  mental  condition  of  these  })atients  is  most  pitiable,  and  they  fall  an 
easy  prey  to  quacks  and  charlatans  of  all  kinds. 

In  all  forms  of  neurasthenia  the  condition  of  the  urine  is  imjioi'tanf. 
Many  cases  are  complicated  with  the  symptoms  of  the  condition  known 
as  litluvmia,  and  so  marked  nniy  this  be  that  some  have  indeed  made  a 
special  form  of  litha'inic  neurasthenia.  .  Polyuria  may  be  ])resent,  but  k 
more  common  in  hysteria.  "With  disturbed  digestion  the  urates  and  oxa- 
hites  may  l)e  in  excess. 

The  (dtif/iiosis  is  readily  made.  Tt  is  sometimes  dittlcult  to  distinguish 
the  cases  from  hysteria,  and  this  is  not  surjirising,  as  we  cannot  abviiys 
diiferentiate  the  two  conditions.  Neurasthenia  occurs  (duelly  in  men;  in 
fact,  it  is  in  many  ways  in  them  the  ecpiivaleut  of  hysteria. 


T 


istlieuia  or  Ins- 


TIIH  TRAUMATIC  NEUROSES.  1035 

XIII.    THE  TRAUMATIC   NEUROSES 

{Raihiuy   liiain   (iiul    lidiliniij   Sjn'iir;   TraHnKtIic    I/i/.strrin). 

Definition.  —  A  morhid  coiKlieion  t'i)lIo\viii^  shock  wliidi  iircsciits  tlic 
svniptoms  of  lu'iinistlu'iiiii  or  liyrttcriii  or  of  Ijotli.  'riiccoiKlitioii  is  known 
as  "niilway  brain  "  and  "  railway  spine." 

Kfichst'ii  rct^anU'd  tlic  condition  as  the  result  of  inflainmation  of  the 
iiienin;.;es  and  cord,  and  {.fave  it  the  name  r  dlwuy  s})ine.  Walton  and 
.1.  .1.  I'ntnam,  of  Ho.ston,  were  the  first  to  recognize  the  hysterical  natnre 
(if  many  of  the  cases,* and  to  Westphal's  pupils  we  owe  the  name  trainnatic 
neurosis. 

Etiology. — The  condition  follows  an  a<'cident,  often  in  a  railway 
liain,  in  which  injury  has  been  sustaint'd,  or  succeeds  a  shock  or  concus- 
sion, from  which  the  patient  nuiy  api)arently  not  have  sulTered  in  his  l)ody. 
A  man  may  api)ear  perfectly  well  for  several  days,  or  even  a  week  or 
more,  and  then  develop  the  symptoms  of  the  neurosis.  Bodily  shock 
or  commission  is  not  necessary,  'i'ho  alTection  may  follow  a  profound 
mental  imi)ressi()n  •,  thus,  an  engine  driver  ran  over  a  child,  and  received 
tliereby  a  very  severe  shock,  subsequent  to  which  the  most  pronounced 
symptoms  of  neurasthenia  developed.  Severe  mi'utal  strain  cond)ined  with 
lindily  exposure  may  cause  it,  as  in  a  case  of  a  naval  otlicer  who  was 
wrei'ked  in  a  violent  storm  and  exposed  for  nu)re  than  a  day  in  the  rifj:- 
i;ing  before  he  was  rescued.  A  slight  blow,  a  fall  from  a  carriage  or  on 
the  stairs  nniy  sutfice. 

Symptoms. — The  cases  may  be  divided  into  three  groups :  simple 
neurasthenia,  cases  with  nuirked  hysterical  manifestations,  and  cases  with 
severe  symptoms  indicating  or  simulating  organic  disease. 

{(i)  Siinjile  Tranmaiic  Xcurasthpnia. — 'J'he  lirst  sym2)toms  usually  dc- 
vclo])  a  few  weeks  after  the  accident,  which  may  or  may  not  have  been 
associated  with  an  actual  trauma.  The  i)atient  complains  of  headache 
and  tired  feelings.  He  is  slee])less  and  linds  himself  unable  to  concentrate 
Ills  attention  properly  upon  his  work.  A  condition  of  nci'vous  irritability 
ili'veloi)s,  which  may  have  a  host  of  trivial  manifestations,  and  the  entire 
mental  attitude  of  the  person  nniy  for  a  time  l)e  changed,  lit' dwells  con- 
stantly upon  his  condition,  gets  very  despondent  and  low-spii'itcd,  and  in 
extreme  cases  melancholia  nniy  develop.  lie  nuiy  complain  of  nninl)ness 
ami  tingling  in  the  extremities,  and  in  some  cases  of  niiich  pain  in  the 
liark.  The  bodily  functions  nniy  be  well  performed,  though  siudi  patients 
UMially  have,  f(»r  a  time  at  least,  disturbed  digestion  and  loss  in  weight. 
The  physical  examination  may  be  entirely  negative.  1'he  reflexes  are 
slightly  increased,  as  in  ordinary  neurasthenia.  The  ])upils  nniy  l)e  un- 
t'i|iuil  ;  the  cardio-vascular  changes  already  descriljcd  in  neurasthenia  nniy 
lie  present  in  a  nuirked  degree.     According  as  the  synipt(>ms  are  more 

*  See  La  Xcurastlii'iiii',  par  li.  Uouverol,  I'aris,  18!)1. 


i 


:.     .  t,   I. 


lO.'lO 


DISKASKS  OF  TUK  XKIIVOUS  SYSTEM. 


Hpiiial  or  mow  ('crchral,  tlic  coiKlitioii  is  known  as  niihvuy  brain  or  railway 
Hjiiiif. 

(•.')  f'f/srs  irilli  Marked  //i/s/rrinil  Frahnrs. — Followiiitf  an  injiirv  of 
anv  sort,  iifiirastiicnic  syni|itoius,  lii<(>  tliosct  di'scrilicd  al)ovc,  may  (i('V('|c.|i, 
and  in  addition  symptoms  vcj^ardcd  as  cliarat'tcristic  of  liystcria.  The 
omntioiial  clcnicnt  is  prominent,  and  tlicre  is  hnt  siiij;iit  control  over  tlic 
tVolin;^'s.  'I'lic  patients  have  licadaclu',  l)a<'ka(du',  and  vcrtij^o.  A  violent 
tremor  may  he  present,  and  indeed  eonstitntes  the  nu)st,  strikin<i  featnre  ef 
tlie  ease.  I  have  ri'cently  seen  an  enj;ineer  who  developed  suhse(pient  to 
an  aeeidi'nt  a  series  of  nervous  ])henonu'na,  Ijut  the  most  iinirked  featiM'o 
wa-i  an  exeessivi'  tremor  of  the  entire  body,  which  was  sjieeially  manifest 
during  emotional  excitement.  The  most  )trononnce(l  hysterical  symptoms 
are  the  sensory  distnrhanees.  As  lirst  noted  by  Putnam  and  Walton, 
hemiana'sthesiu  may  ooeur  as  a  sequence  of  trannnitism.  This  is  a 
common  symptom  in  France,  l)nt  rare  in  England  and  in  this  count rv. 
Achromatopsia  nniy  exist  on  the  ana'stlietic  side.  A  .secoiul,  more  com- 
mon, maiufestation  is  limitation  of  the  held  of  vision,  similar  to  that 
whi(di  occurs  in  hysteria. 

Remarkable  disturbances  nuiy  develop  in  some  f)f  these  cases.  A  few 
months  ago  1  saw  a  man  who  had  been  struck  by  an  electric  ear,  avIkiso 
chief  symptom  was  an  extraordinary  increase  in  the  number  of  respiru- 
tions.  lie  was  a  stout,  powerfully  built  man,  and  presenteil  ])ractically  mi 
other  symptfun  than  dys[)no'a  of  the  most  extreme  grade.  At  the  time  of 
observation  his  respirations  wei'c  over  VM)  ])er  minute,  and  he  stated  that 
they  had  been  counted  at  over  X'A). 

(;>)  Cases  i)i  which  (he  Sjiniplonis  saf/j/csf  Orr/aiiic  Disoasp  of  fl/r 
Brain  and  Cin'd. — As  a  result  of  spimd  concussion,  without  fracture  or 
external  injury,  there  may  subsef|uent1y  develop  symptoms  suggestive  nf 
organic*  disease,  which  may  come  on  rapidly  or  at  a  late  date.  In  a  case 
reported  by  lieyden  the  symptoms  following  the  concussion  were  at  lirst 
slight  and  the  patient  was  regarded  as  a  simulator,  l)nt  finally  the  comli- 
tion  became  aggravated  and  death  resulted.  'I'ho  ])ost-mortem  showed  a 
chronic  pachymeningitis,  which  had  doubtless  resulted  from  the  accident. 
'I'ho  cases  in  this  group  about  which  there  is  so  niucli  discussion  are  those 
which  disj)lav  marked  sensorv  and  motor  chauires.  Followinfj  an  accident 
in  which  the  patient  has  not  received  extenud  injury  a  conditio"n  of  ex- 
citement may  develop  within  a  week  or  ten  days ;  he  complains  of  lieatl- 
ache  and  backa(die,  and  on  examiiuition  sensory  disturbances  are  foumi. 
either  hemianivsthesia  or  areas  on  the  skin  in  which  the  sensation  is  nnich 
beiuimbed  ;  or  painful  and  tactile  imju'cssions  may  1)e  distinctly  felt  in 
certain  regions,  and  the  tem|)erature  sense  is  absent.  The  distributinn 
may  l)e  bilateral  and  symmetrical  in  limited  regions  or  liemii)legic  in  tyiic. 
Limitation  of  the  field  of  vision  is  usually  marked  in  the.se  cases,  and  tlicio 
may  l)e  disturbance  of  the  .senses  of  taste  and  smell.  'J'he  superficial  iv- 
flexes  nniy  be  diminished ;  usually  the  deep  reflexes  are  exaggerated.    The 


TIIH  TUAl'MATIC   NKl'KOSKS. 


]o;57 


»riiii\  or  riiilwiiy 

>^  iiii  injury  of 
,',  iii;iy  tlt'V('|o|i, 
hysteria.     Tlic 
oiilrol  dvci'  till' 
ijfo.     A  vinlciit 
ikiiifi  i'ciitinv  III' 
il  siil)sr(|(U'iil  to 
iiiiirkt'd  ft'iiturc 
I'ciiilly  iiiiinii'csl 
'I'iciil  Hyiui'tiiiMS 
n  iind   Waltdu, 
sm,     Tliis   is  a 
in  this  country, 
■ond,  more  com- 
similar  to  th;it 

.i;o  oases.  A  few 
L'ctrie  car,  ■wliusc 
inbcr  of  rcspini- 
(id  practically  im 
At  the  tiiHf  (if 
1(1  he  statt'il  thai 

Discdsr    (if  till' 
.out  fracture  nr 

s  su<;"u'cstive  of 
ate.  In  a  easr 
ion  were  at  lirst 

ally  the  comli- 
)rteni  showeil  a 
oni  the  accident, 
ussion  are  those 
,-infi  an  accidtiit 
•onditidn  of  e^- 
nplains  of  hea'l- 
mces  are  foinni- 
'usation  is  nunh 

istinetly  felt  in 

'he  distributieii 
niiplejiic  in  typr. 

cases,  and  there 
le  superiicial  rc- 
:aggerated.    'I'lie 


pupils  may  he  unerpud  ;  tlii'  motor  distiirhanccs  arc  variable.  The  Frciieh 
writers  dcscrilu' cases  cd'  monoplegia  with  or  without  contnicturc,  symp- 
iiiins  upon  whieh  (  harcot  Ihvh  great  stress  as  a  manifestation  of  profound 
hysteria.  'Phe  coudtination  of  sensory  disturbances — ana'stlu'siu  or  liypcr- 
iesthesia — with  paralysis,  jK'.rticidarly  if  moiioplegic,  and  the  occurrence  of 
eontraetiires  without  atrophy  and  witii  normal  electrical  reactions,  nuiy  be 
reganled  as  distinetive  of  hysteria. 

In  rare  cases  following  trauma  and  succeeding  to  symptoms  which  may 
have  been  regarded  as  neurasthenic  or  hysterical,  there  are  organic  changes 
which  may  jtrove  fatal.  That  this  .secpieiu'e  occurs  is  demonstrated  clearly 
by  recent  post-mortem  examinations.  The  features  upon  which  the 
greatest  reliance  can  be  placed  as  indicating  orgaiue  cliange  are  optic; 
atrophy,  bladder  symi)tom.s,  jjarticularly  in  combination  with  tremor, 
paresis,  and  exaggerated  rcllexes. 

The  anatonucal  changes  in  this  condition  have  not  been  very  dctiiute. 
When  death  follows  spinal  concussion  within  a  few  days  there  nuiy  be  no 
ap))arent  lesion,  but  in  some  instances  the  l)rain  or  conl  has  shown  punc- 
tiform  luemorrhagcs.  Edes  lias  reporteil  four  cases  in  wlinh  a  gradual 
degeneration  in  the  pyramidal  tracts  followed  concussion  or  injury  of  the 
spine;  but  in  all  these  cases  there  was  marked  tremor  and  the  spinal 
symptoms  developed  early  or  followed  immediately  upon  the  accident. 
I'ost-mortems  upon  cases  in  which  organic  lesions  have  supervened  upon 
a  traumatic  neurosis  are  extremely  rare.  Bernhardt  rcjiorts  an  instance 
(if  a  man,  aged  thirty-three,  who  in  1)S8(!  received  a  kick  from  a  honse 
on  the  epigastrium  and  subsecpiently  developed  the  8ym])t()m-complex  of 
neurasthenia  and  hysteria  with  attacks  of  vertigo  and  great  psychical  de- 
pression. He  afterward  had  more  marked  mental  symptoms  and  attacks 
of  unconsciousness.  He  committed  suicide  and  the  brain  and  cord  showed 
a  beginning  multiple  sclerosis  in  the  white  nuitter,  which  was  possibly 
associated  with  an  advanced  grade  of  arterio-sclerosis.  In  a  second  case 
a  man,  aged  forty-two,  received  a  shock  in  a  railway  accident  in  duly, 
1SS4:.  He  Avas  rendered  unconscious  and  had  a  slight  injury  in  the  but- 
toi'k  region.  In  a  few  weeks  symptoms  of  traumatic  neurosis  developed, 
liarticularly  great  de])ression  of  spirits,  with  headache  and  sensory  disturb- 
aiiees  in  the  feet  and  hands.  Tremor  and  great  weakness  were  com- 
plained of  when  he  attempted  to  work.  There  was  no  increase  in  the 
rcllexes.  The  case  was  regarded  as  an  instance  of  simulation  and  a  defect 
ill  objective  symi)toms  favored  this  view.  Subscipsciitly  this  judgment 
was  reversed,  but  he  did  not  improve,  lie  died  in  January,  1SS9,  with 
symptoms  of  cardiac  dyspna'a.  Macroscopically  the  brain  and  cord  i\\)- 
jieared  normal.  There  was  extreme  arterio-sclerosis,  ])articularly  of  the 
vessels  of  the  brain  and  cord.  In  the  latter  there  were  scattered  areas  of 
degeneration  in  the  white  substance,  and  degeneration  in  the  sympathetic 
ganglia. 

I  have  entered  somewhat  fully  into  this  question  because  of  its  extreme 


ions 


DISKASES  OK  THE   NKHVOl'S  SYSTEM. 


i 

i 

1 

1 

Sti 


im|)f)rtiiii(;i'  iiiid  on  iicfoimt  <>(  llic  piiiicity  dl'  llic  oliscrviitioiis  ii|M)ri  (ii-cs 
wliich  liavi!  .siil)si'(|iiontly  (ievclopt'd  syniptnms  of  or<,'imic  (liscasc.  K\;iiii. 
|»lcs  of  it  ui'c  cxtn-nuly  rmr.  So  far  as  I  know  no  case  wiili  aiito|isy  Iiils 
lict'ii  rcportt'tl  ill  tlii;;  rounlry,  nor  have  1  seen  an  instance'  in  wliidi  ihc 
clinical  I'catnrcs  [)oinU'tl  to  an  organii;  iliscusu  wliicli  hail  followed  upnii  u 
traniinitic  nciii'osis. 

Diagnosis.  --A  condition  of  fri<,dit  and  fxcitcnicnt  followiiif;  an  acci- 
dent  may  persist,  for  days  or  cvi'ii  wct'ks,  and  then  >,'radnally  pass  awiiy. 
Tiic  symptoms  of  nenrastlicnia  or  of  hysteria  wiiich  snl»se(|nently  de\i  Idp 
present  nothin;^  pecnliar  and  are  identical  with  those  which  occur  iiii.|,r 
other  circumstances.  Caro  must  he  taken  to  avoid  simulati<tn,  and,  :i>  in 
these  cases  the  condition  is  lari.'cly  sulijcctive,  this  is  sometimes  extreim  Iv 
ditlicult.  In  a  careful  examination  a  simulator  will  often  reveal  hini-ilt' 
hy  exa^f,ij;eration  of  certain  symptoms,  particidarly  sensitiveness  of  ihr 
spine,  and  hy  increasing;  voluntarily  the  rcllexes.  It  nuiy  refpiire  a  caivfiil 
stiuly  of  the  ease  to  determine  whether  tlu^  individual  is  honestly  suireriiii; 
from  the  symjitoms  of  whitdi  he  complains.  A  still  more  important  {|ii(s- 
tion  in  these  cases  is,  Has  the  jiatient  orj^anic  disease':'  'Die  syniptmiis 
f^iven  under  the  first  two  gronps  of  cases  may  exist  in  a  marked  dcLrivr 
and  nuiy  persist  for  several  years  without  the  siij^htest  evidence  of  orLranic 
ehan<j;e.  It  mnst  bo  noted  that  in  the  two  aut(»psies  above  reft'rred  to  llic 
])atii'nts  were  the  subjects  of  extreme  arterio-s(derosis,  with  wliicdi,  in  ,ill 
jirobability,  the  areas  of  multiple  sclerosis  were  associated.  Iletniana'silic- 
sia,  limitation  of  the  field  of  vision,  monople<fia  with  eontraeture,  may  all 
be  present  as  hysterical  manifestations,  from  which  recovery  may  be  cuiii- 
plete.  In  our  present  knowled<,'e  the  diajrnosis  of  an  orj^anic  lesion  sliuiilil 
be  limited  to  those  eases  in  which  o[)tic  atrophy,  bladder  troubles,  and  sIlHis 
of  sclerosis  of  the  cord  are  well  marked— indications  either  of  ilegenciatinii 
of  the  lateral  columns  or  of  multiple  sclerosis. 

Prognosis. — A  majority  of  jtatients  with  traumatic  hysteria  recover. 
In  railway  cases,  so  long  as  litigation  is  })ending  and  the  patient  is  in  the 
hands  of  lawyers  the  symptoms  usually  persist.  Settlement  is  often  tin.' 
starting  point  of  a  speedy  and  perfect  recovery.  I  have  known  return  to 
health  after  the  jiersistence  of  the  most  aggravati^l  symjitoms  with  coni- 
])lete  disability  of  from  three  to  five  years'  duration.  On  the  other  haiul. 
there  are  a  few  cases  in  wliiidi  the  symjitoms  persist  even  after  the  lili,i;a- 
tion  has  been  closed  ;  the  jiatient  goc'j  from  bad  to  worse  and  psyclioscs 
develop,  such  as  nudancholia,  dementia,  or  occasionally  progressive  ])ai(-i>. 
And,  lastly,  in  extrcmiely  rare  cases,  organic  lesions  may  develop  as  a 
serpience  of  the  traumatic  neurosis. 

The  function  of  the  physician  acting  as  medical  expert  in  these  ca^es 
consists  in  detormiiung  (a)  the  ex..-<cence  of  actual  di.sease,  and  (b)  its  '  'ku- 
atiter,  whether  simple  neurasthenia,  severe  hysteria,  or  an  organic  loinn. 
The  outlook  for  ultimate  recovery  is  good  except  in  cases  Avhich  present  the 
more  serious  symptoms  above  mentioned.     Xevortheless,  it  must  be  Imiiir' 


OTIIKIl   FdllMS  OF   I  TNCTIONAL   I'AIIAI-VSIS. 


lit;!!) 


nUA  Upon  <;i,-:(is 
lisi'iist'.  K\aiii- 
kilh  autopsy  has 
ci'  in  wliiili  ilii' 

I'dlloWCll   Ull'ili  ;i 

)llo\vinji  iin  arii- 
niilly   liasrt  away. 
■(pu'utly  (lc\ilo|i 
ich  occur  iiimIit 
latioM,  anil,  as  in 
'tiuH'.s  cxtrciiuly 
II   reveal  hiiii-i'ir 
■iitivciu's.s  of   I  111' 
rccpiiiv  a  careful 
Honestly  sulTeriui,' 
'■  iiiipovtant  i|in's- 
'     The  syinptoiiis 
a  marked  deirnr 
idencc  of  oruaiiir 
ive  referred  in  llu' 
with  whieh,  in  all 
il.     Ileuuana.-ila- 
ntraciuro,  may  all 
very  uniy  be  cdin- 
anie  lesion  should 
rouhU'S,  and  sIlMiS 
lev  of  degeneralinu 

hysteria  recover, 
b  patient  is  in  the 
Inent  is  often  tlu' 
known  return  tu 
iptonis  with  c'liii- 
1  the  other  liaiul, 
I  after  the  litipi- 
■se  and  psyi'li^^i'^ 
irogressive  i)arcsis. 
may  devehjp  as  :i 

liert  in  these  cases 

k  and  (/>)  its  "'uu'- 

Ln  organic  le-ioH' 

which  present  ilif 

it  must  be  h'-na' 


in  mind  tiial  traumatic  hysteria  is  one  of  the  most  inlrac.'talde  alVeclioi 
uhich  we  are  called  npoii  to  treat. 


IS 


Treatment  of  Neurasthenia.  M 


my    paticiils  cdiiie  under  our 


(are  a  generation  too  late  for  satisfaclory  treatment,  and  it  may  lie  impos- 
.-ilile  to  resiori'  the  exhausted  capital.  In  other  instances,  the  recovery 
takes  place  rapiilly,  the  patient  remains  well   for  a  few  mmitlis  or  a  vear, 


an 


d  then  overwork,  or  even  the  ordinary  wear  and  tear  of  life,  again   pn 


trates  him.    Other  persons  drift  into  a  condition  of  chronic  invalidism  or 
slaves  to  morphia  or  chloral.      In  the  case  td'  hiisiticss  or  profc: 


hrcome 


Sll) 


nal  nu'ii,  in  whom  the  condition  (levelo|)s  as  a  result  of  overwork  or 
everstndy,  it  may  he  suflicieut  to  enjoin  ahsolnte  rest  with  »diange  of  scene 
and  diet.  A  trip  alii'oail,  with  a  residence  for  a  month  or  two  in  Switzer- 
land, or,  if  there  are  symptoms  nf  nervous  <|yspepsia,  a  residence  at  one  ni' 
the  Spas,  will  usually  prove  snllicient.  'I'he  excitement  of  the  large  cities 
ahroad  should  he  avoided.  Metier  still  for  these  cases,  if  they  carry  it  out, 
is  a  life  in  the  woods  or  on  the  plains.  'I'ln'ee  months  of  tent-life  in  the 
Adirondacks  or  the  same  length  of  time  in  the  h'ocky  Miamtains  will 
sniiietimes  cure  tlu^  most  marked  cases  of  this  kind.  Such  a  plan  is  not, 
Imwever,  within  the  circnnistances  of  all.  In  a  mmdi  larger  class,  includ- 
ing a  large  projiortion  of  neurasthenic  wouu'ii,  a  .systematic  Weir  .Mitchell 
treatjnent  rigidly  carried  out  should  be  tried  (see  hysteria),  l-'oi'  obstinate 
and  protracted  cases,  ])articnlarly  if  eond)ined  with  the  (diloral  or  morphia 
liabit,  no  other  |)lan  is  so  satisfactory.  The  treatment  of  the  gastric  and 
intestinal  symptoms  so  important  in  this  condition  has  ali'cady  l)een  coii- 
siilered.  In  milder  grades  of  the  condition  massage  alone  will  be  found 
very  usefni.  For  the  irregular  i)ains,  particularly  in  the  back  and  neck, 
tlie  thernn)-cauterv  is  iiivalual)le.     Medicines  are  of  little  avail.    Strv(diiua 


ni  Inl 


doses  is  often  bi'iiefleial.      For  the  relief  of  sleeplessi 


U'ss  ail  J 


)OSSl 


ble 


measures  should  bo  resorted  to  ])efore  the  employment  of  drugs. 


XIV.  OTHER  FORMS  OF  FUNCTIONAL  PARALYSIS. 

T.  Peuioimcai.  Pakalvsis. 

1  liave  already  referred  to  tlie  remarkable  periodicid  paralysis  of  the 
niidar  muscles,  which  may  recur  at  intervals  for  many  years.  There  is  a 
fiH'iii  of  periodical  paralysis  involving  the  general  musides,  which  may 
recur  with  great  regularity,  and  which  is  also  a  "  family  "  atVection.  In 
West[)hars  case,  a  l)oy  of  twelve,  the  attacks  l)egan  in  the  eighth  year,  and 
It  lii'st  recurred  every  four  or  six  weeks,  and  lasted  from  a  few  hours  to 
t«M  days.  Cioldflam*  has  described  a  family  in  which  twelve  inend)ers 
vvw  alfected  Avith  this  disease,  the  liereditv  being  through  the  mother. 

»  Zeitschrift  fUr  klinisehu  Modicin,  15d.  xix,  18'J1. 


1040 


DISEASES  OF  THE   NERVOUS  SYSTEM. 


II 


m 


Consot  liiis  also  met  witli  ii  family  in  wliicii  the  niotlicr  and  fonr  cliil 
were  attai'kcil.  Tlii'  (liscasc  occnrs  in  yoiitii,  and  tlu'  tiMuk'ncy  t<j 
atta('I\s  diininisiics  witii  ajxc. 

Tiu'  clinical  [)icturc  is  very  inucli  alike  in  all  tiio  recorded  cases, 
paralysis  involves,  as  a  rnle,  the  arms  and   lej^s.     It  comes  on  wliei 
initients  are  in  i'nll  health,  and  witliont  any  a|i[)arent  cause,  often  dn 
sleep.     Sometimes  it  beijins  with  Aveakness  in  the  limbs,  a  sen.satio 
weariness  and  sleepiness,  not  often  with  sensory  symptoms.     The  para 
is  usually  complete  witliiu  the  lirst  twenty-bair  hours,  Ix'ginnin^r  in 
legs,  to  which  in  rare  instances  it  is  confined.     The  muscles  of  the 
sire  sometimes  involved,  and  occasionally  tliose  of  the  tongue  and  phai 
The  cerebral  nerves  and  the  special  senses  are,  as  u  ride,  uninvolved. 
attacks  are  afebrile,  sometimes  with  low  temperatures  and    slow  ]> 
The  deep  reflexes  are  reduced,  sometimes  abolished,  and  the  skin  retl 
may  be  feeble.     One  of  the  most  remarkable  features  is  the  extraordi 
reduction  or  complete  abolition  of  the  faradic  excitability,  both  of  niu 
and  of  nerves. 

lni})rovenient  begin.s  soinetimes  in  the  course  of  a  few  hours  or  af 
day  or  two,  and  the  itaralysis  disappears  completely,  and  the  patiei 
perfectly  well.  As  mentioned,  the  attacks  may  recur  every  few  week 
some  instances  even  daily;  nu)re  commonly,  an  interval  of  one  or 
weeks  elapses  between  the  attacks.  Cioldlhim  suggests  that  the  paraly.- 
due  to  an  auto-intoxication,  and  that  the  poisonous  material  acts  upon 
nerve-endings  in  the  muscles.  lie  has  made  experiments  with  the  u 
of  a  case  wliich  showed  that  during  the  attacks  the  toxic  properties  ot 
secretion  were  materially  increased.  From  the  recurring,  periodic  ( 
aeter  of  the  attacks  they  have  been  su.pposed  to  be  due  to  malaria,  hi 
this  there  is  no  evidence. 

IF.  Astasia  ;  Abasia. 


These  terms,  indicating  respectively  inal)ility  to  stand  ami  inabil 
walk,  have  been  applied  by  Charcot  and  Bloc(|  to  diseased  conditions 
jicterized  by  loss  of  the  power  of  standing  or  of  walking  with  retentii 
muscular  power,  coordination,  ami  sensation.     lUocffs  definition  is 
lows:  "A  morbid  state  in  which  the  impossibility  of  standing  erect 
walking  normally  is  in  contrast  with  the  integrity  of  sensation,  of  nii 
lar  strength,  and  of  the  coordination  of  the  other  movements  of  the 
extremities."     The  condition  forms  a  symptom  group,  not  a  morbid  ei 
and  is  probably  a  functional  neurosis.     Knapp  in  a  recent  paper  anti 
tile  50  cases  rei)ortiMl  in  the  literature.     Twenty-five  of  these  were  in 
2o  in  Avomen.     In  •-.*!  cases  hysteria  was  present;  in  ;J,  chorea;  in  •.' 
lepsy;  and  in  4,  intention  psychoses.     As  a  rule,  the  patients,  thougl 
to  move  the  feet  and  legs  perfectly  when  in  bed,  are  either  unable  tn 
properly  or  cannot  stand  at  all.     The  disturbances  have  been  very  > 


iYSTHM. 


RAYNAUD'S  DISEASE. 


1041 


U' 
SI'. 


notlicr  and  four  chiMivn 
nid  the  U-ndiMicy  t..    lie 

the  iTcordcd  ciiscs.     'I'lic 

It  coiiios  on  wlu'ii  the 

,'inTnt  cause,  often  dunni: 

tlio  Und)s,  a  sensation  i>f 
symptoms.  Tlie  paralvvis 
r'hours,  beginnin«!;  in  llir 

The  muscles  of  the  n«rk 
f  the  tongue  and  pharynv. 
IS  a  rale,  uninvolvcd.    '1 
peratures  and   slow  \n\\>' 
ished,  and  the  skin  rell 
nituves  is  the  extraordiiKin 
xeitability,  both  of  musclvs 

•se  of  a  fow  hours  or  aft<'i'  a 
pletelv,  and  the  patient  is 
y  reciu-  every  few  weeks,  m 

an  interval  of  one  oi-  two 
mggests  that  the  paralysis  is 
nous  material  acts  upon  th. 

experiments  with  the  uiiiR' 
^  the  toxic  properties  of  this 

10  recurring,  periodic  cIku'- 

to  be  due  to  malaria,  but  of 


[A. 

ity  to  stand  and  inability  to 
to  diseased  conditions  duu- 
^,1' walking  with  retention  of 
lUoctfs  definition  is  a>  tol- 
Llitv  of  standing  erect  mA 
Irrit/of  sensation,  of  niusm- 
^her  movements  of  the  h'Wrv 
[iurr,mp,notamorbidcnlit,v. 

Lin  a  recent  paper  aniily/A> 
Ity-tive  of  these  were  m  mn. 
lent;  in  :J,  chorea ;  in  •.'.  ^I"- 
lie,  the  initients,  though  i.We 
led,  are  either  unable  to  wiil 
lances  have  been  very  vaiu'l. 


and  difTcrent  forms  liavo  been  recognized.  Tlio  oommonost,  according  to 
Knapp's  analysis  of  the  recorded  cases,  is  the  jtaralytic,  in  which  the  legs 
iri\c  out  as  the  patient  attempts  (o  walk  ami  "bend  under  him  as  if  made 
of  cottoji."  " 'I'licre  is  n(»  rigidity,  no  spasm,  no  incoCirdination.  In  lied, 
>itting,  or  even  while  suspended,  the  muscular  strength  is  found  to  lie 
iroiid."  Other  cases  are  associated  with  s|)asm  or  ataxia  ;  thus  there  may 
lie  movements  which  stilfen  the  legs  and  give  to  the  gait  a  sdincwhat  spas 
tic  character.  In  other  instances  there  are  sudden  flexions  of  the  legs,  or 
rvcii  of  the  arms,  or  a  saltatory,  spring-like  spasm.  In  a  majority  of  the 
ruses  it  is  a  manifestation  of  a  neurosis  allied  to  hysteria. 

The  cases,  as  a  rule,  recover,  jiarticularly  in  young  persims.  !{ela])ses 
arc  not  nncommon.  The  rest  treatment  and  statii;  electrieitv  should  be 
I'liiployed. 


VI.    VASO-MOTOIi   AND  TliOPJIIC    I)IS(  )KI)EIIS. 

I.  RAYNAUD'S  DISEASE. 

Definition. — A  vascular  disorder,  jirobalily  depemlent"  uiion  vaso- 
motor influences,  characteriztd  by  three  gradi's  of  intensity  :  (//)  Local 
syncope,  (h)  local  asphyxia,  and  (c)  local  or  symmetrical  gangrene. 

/.oral  Si/nr<>/)c. — This  condition  is  seen  most  fre(niently  in  the  extreni- 
itifs,  producing  the  condition  known  as  dead  fingers  or  dead  toes.  It  is 
uniilogous  to  that  produced  by  great  cold.  The  entire  hand  may  be  af- 
fected with  the  fingers;  more  commonly  only  one  or  more  of  the  fingers. 
This  feature  of  the  di.scase  rarely  occurs  alone,  but  is  generally  a.ssociated 
with  local  asphyxia.  The  connnon  se(|uence  is  as  follows:  On  exposure  to 
sliirht  cold  or  in  c(!nse([Ui'nce  of  some  emotional  disturbance  the  lingers 
lici'oine  white  and  cold,  or  botli  fingers  and  ti»es  are  affected.  The  pallor 
may  continue  for  an  indefinite  time,  though  usually  not  more  than  an 
hour  or  so;  then  gnidnally  a  reaction  follows  and  the  lingers  get  bni'iiing 
liot  !md  red.  This  does  not  necessarily  occur  in  all  the  fingers  together; 
"iif  linger  may  be  as  white  as  marble,  while  the  adjacent  ones  are  of 
a  deep  red  or  plum  color. 

Land  Aspliji.rid. — Chilblains  form  the  mildest  grade  of  this  condition. 
It  usually  folic, ws  the  local  syncope,  but  it    may  conu'  on  indci)end(>ntly. 

fill' lingers  and  toes  are  ofleiu'st  atfected,  next  in  order  the  ears;  more 
r;;ivly  piu'tions  of  the  skin  on  the  arms  and  legs.  During  an  attack  the 
■  np'i's  alone,  sometimes  the  hands,  also  swell  and  become  intensely  (M)n- 
[?i  ted,  In  the  most  extreme  grade  tiio  fingers  are  jjcrfectly  livid,  anri 
I 'lip  cjipilliiry  circulation  is  almost  stagnant.  The  swelling  causes  stitf- 
"•■■^s  and  usually  pain,  tiot  acute,  but  due  to  the  tension  and  distention  of 

lie  skin.     Sometimes  there  is  nuirked  ana?sthesia.     Attacks  of  this  sort 
66 


1042 


DISEASES  OF  THE  XKRVOUS  SYSTEM. 


■':  I 


■  > 


V  ' 
lit .  L 


'.'  11 


may  rocur  for  yoiirs,  aiid  ho  I>r(Mi<flit  on  l)y  tlio  sli^diU'st  exposure  tocnldur 
in  coiisequeiK'o  of  tlisturbtinees,  either  mental  or,  in  son)e  instances,  gastric. 
Apart  from  this  un[)leasant  symptom  the  general  healtii  may  be  very  itikhI, 
The  attacks  may  recur  only  at  long  intervals  or  during  the  winter  time. 

Lonil  or  .Si/m/iu'/iinil  (ianijrcttc. — 'i'he  mildest  grade  of  this  eonilitiim 
follows  the  loi'al  asphyxia,  in  the  ehronic  cases  of  which  small  ncirotic 
areas  are  sometimes  seen  at  the  ti])s  of  the  lingers.  Sometimes  the  \)\iA> 
of  the  fingers  and  (jf  the  toes  are  (piite  cicatricial  from  repeated  Avj:\\[ 
lo.sses  of  this  kind.  So  also  when  the  ears  arc  alTected  there  may  he  .-iiikt- 
licial  loss  of  sul)stance  at  the  edge.  The  severer  cases,  which  teriiiiiiutu 
in  extensive  gangi'eiu',  are  fortunately  rare. 

in  an  attack  the  local  asphyxia  i)ersists  in  the  fingers.  The  teriniii;il 
phalanges,  or  j)eriiai)S  oidy  one  lingi'r,  become  black,  cold,  and  inseiiM- 
ble.  The  skin  begins  to  necrose  an<l  sui)erficial  gangrenous  blebs  a|i|H';ir, 
(iradually  a  lino  of  demarkation  shows  itself  and  a  portion  of  one  or  tiidiv 
of  the  fingers  sloughs  away.  The  resulting  loss  of  substance  is  nunli  lis; 
than  the  appearance  of  the  hand  or  foot  \vould  indicate,  and  a  coudiiinii 
which  looks  as  if  the  patient  would  lose  all  the  fingers  or  half  of  ;i  fim; 
may  result  perha[)s  in  oidy  a  slight  superlicial  loss  in  the  phalanges.  In 
severer  cases  the  greater  porti(m  of  a  linger  or  the  tip  of  the  nose  may  \w 
lost.  Occasionally  the  disease  is  noteonlined  to  the  extremities,  but  alTtrts 
symmetrical  ])atclies  on  the  limbs  or  trunk,  and  may  i)ass  on  to  rapid  i;uii- 
greiie.  These  severe  ty])es  of  cases  occur  i)arti(!ularly  in  young  chilihvii. 
and  deatii  nniy  result  witiiin  three  or  four  days.  The  atta(d<s  arc  usimlly 
very  painful,  and  the  motion  of  the  })art  is  nuich  impaired.  In  some 
cases  mnnbness  and  tingling  persist  for  a  long  time. 

The  (dimax  of  this  series  of  neuro-vascular  cdiangos  is  seen  in  the  ro- 
markable  instances  of  extensive  mu'lliplo  gangrene.  They  are  most  cuiii- 
mon  in  children,  and  nuiy  proceed  with  frightful  rapidity.  In  tin 
Medico-Chirurgicul  Society's  Transactions,  vid.  xxii,  there  is  an  extradiili- 
nary  case  rei)orted,  in  which  the  child,  aged  three,  lost  in  this  way  l»niii 
arms  above  the  elbow,  and  the  left  leg  below  the  knee.  There  also  liml 
been  a  spot  of  local  gangrene  on  the  nose.  S])ontaneous  amputation 
occurred,  and  the  child  made  a  complete  recovery.  The  cases  aic  iimp 
frequent  than  has  been  suppo.sed,  and  an  illustration  is  given  by  Wctk-. ; 
of  Marion,  Ohio,  in  whi(di  the  boy  had  rheumatic  pains  in  the  leus.  ami 
pur{)iiric  blotches  develo})od  before  the  gangrene  began  (Medico-Surgiral 
Bulletin,  July  1,  ]8!)4). 

There  are  rennirkable  concomitant  symptoms  in  Hayiuiud's  disease  to  I 
which  a  good  deal  of  attention  has  been  paid  of  late  years,     lla'iiieir'i'l'il 
nuria  may  develop  during  an  attack,  or  may  take  the  place  of  an  oiitbrrak. 
In  such   instances  the  alToction  is  usually  brought  on  by  cold  v.;;;;uri 
In  a  ease  reported  by  11.  M.  Thomas  from  my  clinic,  Kaynaud's  disia-n 
occurred  for  three  successive  winters  and  always  in  association  with  iKvinn- 
globinuria.     The  attacks  were  sometimes  preceded  by  a  chill.     Sevcial 


ANGIO-NEUROTIC  ffiPEM A. 


l()4;j 


t'l'rf.     'I'lii'  Irriiiiuiil 
colli,  luul  iiisi'U>i- 
cuous  blebs  ai'in'iiv. 
tiou  of  oiu'  or  iiinio 
istanc'f.  is  iiuuh  Iw^ 
to,  iind  !i  niiiiliunu 
rs  or  lialf  <il'  ;'  1'""^ 
i\w  plmhuip'^.    Ill 
of  tlie  nnsr  iiuiy  Ik' 
treuiities,  but  atlVcis 
mss  on  to  nqii'l  .i^^H'- 
y  in  young  i-liil'iivu. 
attacks  aro  usimllv 
impaired,     lu  soiiu' 


eases  of  tlie  kind  are  fouiul  in  Harlow's  appendix  to  his  translation  of 
Uavnaud's  paper  for  tlie  New  Sydetdiaiu  Society.  'J'iie  onset  witli  a  chill, 
as  in  the  case  just  mentioned,  has  doubtless  given  rise  to  the  idea  that  the 
liiseaso  is  in  some  way  associated  with  ague.  Cerebral  symptoms,  pat- 
ticularly  mental  torpor  and  transient  loss  of  consciousiu'ss,  have  a1 -■,  bei^n 
iioliced  in  some  eases.  The  case  just  meTitioned  with  ha'Uiogloltinuria 
luid  epilepsy  with  the  attacks.  Exposure  on  a  cold  day  would  biing  on  an 
I'pileptic  seizure  with  the  local  aspliyxia  and  bloody  urine.  Audtlicr  })a- 
tieiit,  the  subject  for  years  of  IJaynaiul's  disease,  has  had  many  attacks  of 
transient  henuplegia  on  one  side  or  the  other,  when  on  the  right  sidi'  with 
aphasia.  Oceasiofally  joint  altections  develop,  j)articularly  aiu'hylosis  am] 
thickening  of  the  phalangeal  articulations.  Soulliey  lias  I'cpdi'tcd  a  case 
ill  wluch  numia  developed,  and  Barlow  an  instance  in  whicii  the  woman 
liuil  delusions.     Periplieral  neuritis  lias  been  found  in  several  cases. 

Tiie  pdllioloiiji  of  tills  remarkable  disease  is  still  obscure.  Kaynaud 
suggested  that  the  local  syncope  was  produced  by  contraction  of  the  ves- 
sels, which  seems  likely.  The  asphyxia  is  (le[)eiulent  upon  dilatation  of 
the  capillaries  and  small  veins,  probably  with  tiie  })ersistence  of  some 
(logree  of  spasm  of  the  smaller  arteries.  There  are  two  totally  dilferent 
forms  of  congestion,  whicli  may  be  slujw  n  in  adjacent  fingers  ;  one  may 
be  swollen,  of  a  vivid  red  color,  extremely  hot,  tlie  eatiillaries  ami  all  the 
vessels  fully  distended,  and  the  aiuemia  produced  liy  prosiire  may  In-  in- 
Jtiuitaneously  obliterated  ;  the  adjacent  finger  may  be  eijually  swdllen, 
absolutely  cyanotic,  stone  cold,  and  the  ana'Uiia  [)ro(luce(l  by  ])ressuro 
takes  a  long  time  to  disappear.  In  the  latter  case  the  arterioles  are  j)rob- 
ubly  still  in  a  condition  of  spasm. 

Treatmeilt.— In  many  cases  the  attacks  recur  for  years  nninlhienced 
by  treatment.  Mild  attacks  require  no  ti'catment.  In  the  sevei'cr  forms 
iif  li)eal  asphyxia,  if  in  the  feet,  the  ])atient  should  be  ki'i>t  in  bed  with 
tilt'  legs  elevated.  The  toes  should  be  wrapped  in  cotton-wool.  The  pain 
is  often  very  intense  and  may  re((uire  morjihia.  Carefully  applieil,  sys- 
toinatic  massage  of  the  extremities  is  sometimes  of  ben.'lit.  (lalvanism 
may  be  tried.  J^arlow  advises  immersing  the  alTected  limb  in  salt  water 
;iii(l  jilacing  one  electrode  over  the  spine  and  the  other  in  the  water. 
Mtro-glycerine  has  been  warmly  recommended  by  Cates. 


|Uayimud'sdi<(';i^^'t"l 
years.  llaMuo,i.'i"lii- 
Iplace  of  an  outbreak- 
Ion  by  cold  v.;:i;b>i. 
lie,  KavnaudV  .lisui-^ 
Isociation  with  iKi'i""; 
by  a  chill.    Scviial 


II.    ANGIO-NEUROTIC    CEDEMA. 

Definition. — An  affection  characterized  by  the  occurrence  of  local 
'I'lkinatous  swellings,  more  or  le.ss  limited  in  extent,  and  of  transient 
iluration.  Sevens  colic  is  sometimes  associated  with  the  ontbreak.  'I'hcre 
i<:i  marked  hereditary  disposition  in  the  disease,  'i'lie  afTi!Ction  has  been 
iK'cially  studied  by  Quincke,  Jamieson,  .1.  K.  (Jrahain,  and  Matas. 

Symptoms. — 'L"he  (edema  appears  suddenly  and  is  usually  circum- 


104+ 


DISEASES  OF  THE   NERVOUS  SYSTEM. 


scribed.  It  may  a])pGiir  in  tlie  face;  the  eyelid  is  a  eonirnon  situation;  ur 
it  (nay  involve  the  lips  or  c^heck.  The  baeks  of  tlie  hands,  the  le^'s,  or 
the  throftt  may  be  attacked.  Usually  the  condition  is  transient,  associatni 
perhaps  with  sliifht  jfastro-intestinal  distress,  and  the  aU'ection  is  of  litilc 
nionient.  There  may  lie  a  I'emarkaljle  j)eriodieity  in  the  outbreak  ol'  the 
(edema.  In  .Matas's  case  this  periodicity  was  very  striking;  the  allmk 
came  on  evei'y  day  at  eleven  or  twelve  o'clo(;k.  The  disease  may  be  iicicd- 
itary  through  many  generations.  In  llie  family  whose  history  I  report, il, 
live  generations  had  been  alTected,  including  twenty-two  nienil)ers.  The 
swellings  appear  in  various  parts;  oidy  rarely  are  they  constant  in  nur 
locality.  The  hands,  face,  and  genitalia  are  the  parts  most  fi'cciiiiiiily 
aiteeted.  Itching,  heat,  redness,  or  in  some  instances,  urticaria  may  jm- 
cede  tlie  outbreak.  Sudden  u'denui  of  the  larynx  may  prove  fatal.  Tuu 
mend)ers  of  the  family  just  referred  to  died  of  this  complication.  In 
one  member  of  this  family,  whom  I  saw  repeatedly  i)i  attacks,  the  swell- 
ings came  on  in  diil'erent  parts;  for  example,  the  uiuler  lip  would  he 
swollen  to  such  a  degree  that  the  mouth  could  not  l)e  opened.  The  liamls 
eidarge  suddenly,  so  that  the  fingers  cannot  be  bent.  The  attacks  nciir 
every  three  or  four  weciks.  Ai-companying  them  are  usually  gastin- 
intestimil  attacks,  sev(>re  colic,  pain,  nausea,  and  sometimes  vomilinir. 
The  colic  is  of  great  intensity  and  usually  requires  morphia.  Arthritis 
apparently  does  m)t  occur. 

The  disease  has  aflinities  with  urticaria,  the  giant  form  of  which  is 
probably  the  same  disease.  There  is  a  form  of  severe  puri)ura,  often  with 
urticarial  manifestations,  which  is  also  associated  with  marked  gasti'o- 
intestinal  crises.  Quincke  regards  the  condition  as  a  vaso-motor  ticuioms, 
under  the  inlliuMice  of  whiidi  the  ])ermcid)ility  of  the  vessels  is  siidilciiiy 
increased.  Milroy,  of  Omaha,  has  tlescrilicd  cases  of  hereditary  (I'dcinn, 
twenty-two  individuals  in  six  generations,  in  wdiicli  there  existed  Inim 
birth  a  solid  (edema  of  one  or  of  Ixith  legs,  without  any  special  iiu.'oiivt'ii- 
ience  or  any  ])rogressive  increase  of  the  disease. 

The  fr('titmo)it  is  ver  ■  unsatisfactory.  In  the  cases  associated  with 
amemia  and  general  nerve  isness,  tonics,  particularly  large  doses  of  strych- 
nia, do  good  ;  but  too  citcn  the  disease  resists  all  treatment. 


III.    FACIAL    HEMI-ATROPHY. 


An  affection  charaiiterized  by  ])rogressive  wasting  of  the  bonces  ainl 
soft  tissues  of  one  side  of  the  face.  The  atro])hy  begins,  as  a  ruk',  in 
childhood,  but  in  a  few  cases  has  not  come  on  until  middle  age.  It  hidiisl 
diffusely,  but  in  some  instances  has  started  atone  spot  on  the  skin  ami  hib 
gradually  spread,  involving  at  first  the  subcutaiuions  tissues,  tln'ii  tlio 
muscles  and  the  bones,  more  particularly  the  u{)per  jaw.  The  wa-iiii,i.' 'M 
sharply  limited  at  the  middle  Hue,  and  the  ai)pearance  of  the  paliciu  h 


ACilOMEGALIA. 


J  045 


nou  situation ;  or 
lands,  the  Ic.US  m- 
msient,  associaltMi 
Tri'tion  is  of  little 
Hi  outbreak  of  the 
iking ;  tho  attack 
■a.se  may  bo  bcnnl- 
hititory  1  reportiil. 
'()  nionibers.  The 
•v  constant  in  nuo 
ts  most  frequently 
urtiearia  may  i>n- 
■  prove  fatal.  'I'wu 
(Mimplieation.  In 
aitaeks,  the  swdl- 
uider  lip  wouM  be 
)peiuHl.  The  luinils 
Tlio  attacks  r.nir 
are  usually  gastm- 
jmetimos  vomit iiit:. 
morphia.     Arthritis 

it  form  of  which  is 

purpura,  often  with 

ith  marked  jraslni- 

vaso-molor  neurdsb. 

i  vessels  is  suthlenly 

hereditary  o'deina. 

lliere  existed  fi'oin 
ny  special  inconvcti- 

lases  associated  with 
large  doses  of  slrvch- 
tment. 


of  the  bones  inul 
Ibetiius,  as  a  rulo.  i" 
lidille  age.  It  lu'^'ins 
It  on  the  skin  aiul  liii> 
lis  tissues,  thru  the 
Ijaw.  The  wa^iin,^''1 
Inceof  tlie  paticiu  i^j 


very  remarkablo,  tho  face  looking  as  if  made  up  of  two  halves  from  dilTer- 
ont  por.sons.  T'licrc  is  usually  change  in  the  color  of  the  sl\iii  and  the 
hiiir  falls.  Owing  to  the  wasting  of  the  alveolar  processes  the  teeth  be. 
conie  loose  and  ultimately  fall  out.  The  wasting  involves  the  tissues  of 
the  orbit,  and  the  eye  on  the  affected  side  is  suidxen.  In  a.  majority  of  the 
oases  tiie  atrophy  has  been  contined  to  one  side  of  the  face,  but  there  an* 
instances  on  record  in  which  the  disease  was  bilateral,  and  a  few  cases  in 
which  there  were  areas  of  atro[)hy  on  tlu;  back  aiul  on  the  arm  of  the 
same  side.  The  disease  is  rare.  Sachs  has  collected  uincty-seven  cases 
from  the  literature. 

Two  autopsies  have  been  made.  In  .MeiidcPs  case  there  was  the  ter- 
minal stage  of  an  interstitial  neuritis  in  all  the  branches  of  the  trigemi- 
nus, from  its  origin  to  the  ])erij)liery,  most  marked  in  the  superior  maxil- 
lary branch. 

In  Ilomen's  ca.se,  which  came  on  rapidly  ami  hardly  lielongs  to  the 
tvpical  form  of  the  disease,  a  tumor  was  found  pressing  upon  the  (ia.s- 
Mriiin  ganglion  and  the  trigeminus  nerve. 

The  disease  is  recognized  at  a  glance.  The  facial  asymmetry  asso- 
rjated  with  congenital  wryneck  must  not  be  confounded  m  ith  progressive 
facial  hcmi-atrophy.     The  precise  nature  of  the  disease  is  still  doubtful. 

IV.    ACROMEGALIA. 

Definition. — A   dystrophy   characterized    l>y  abnormal  processes  of 

k'rowth,  chiefly  in  tlie  bones  of  the  face  aiul  extremities. 

The  term  was  introduced  by  Marie,  and  signifies  large  extremities. 
Etiology. — It  occurs  rather  more  fre(|uently  in  women.     Of  the  38 

basi'.s  analyzed  in  the  monograph  of  Souza-Lcile,  lO  were  in  men  and  'i2  in 
«onien.     The  disease  usuallv  bey^ins  al)out  the  tweiitv-liftb  vear,  though 

[ill  sdiiie  instances  as  late  as  the  fortieth.     Ivheumatism,  .•syphilis,  and  the 
•iKcilii;  fevers  have  preceded  the  devclojnnent  of  the  disease,  but  probably 

liiavc  no  special  connection  with  it.     In  this  count i-y  many  ca.ses  have  now 

|iwii  re[)orted. 

Symptoms.  — In  a  well-marked  case  the  disease  i»resents  most  char- 
hi'icristic  features.  The  hands  ami  feet  are  greatly  enlargeil,  but  are  not 
reformed,  and  can  be  used  freely.  The  hyjiertrophy  is  geiuM-al,  involving 
all  the  tissues,  and  gives  a  curious  s])ade-like  character  to  the  hands.  The 
j'iisls  may  be  enlarged,  but  the  arms  are  rarely  affected.  The  feet  are 
linvohi'd  like  the  hands  and  are  uniformly  enlarged.  The  big  toe  nuiy  be 
ImiU'li  larger  in  proportion.  T'he  nails  are  usually  broad  and  large.  The 
hm\  increases  in  volume,  but  not  as  much  in  pro{)ortion  as  the  face, 
I'liicli  becomes  much  elongated  aiul  eidarged  in  consequence  of  the  in- 
rroaso  in  the  size  of  the  sujierior  atid  inferior  maxillary  hoiu's.  The  latter 
jiiimrticular  increases  greatly  in  size,  and  often  projects  below  the  upper 
ll'^v,    Tho  alveolar  processes  are  widened  and  the  teeth  separated.     The 


■l,". 


,il-'  I 


J? 


'  t 


ifi.  %  % 


1046 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


soft  purts  iilso  inoroiisc  in  size,  and  tlie  nostrils  arc  larpc  and  broad.  'I'lic 
cyeliduS  arc  soiiK'tinios  greatly  thickciu'd,  and  the  ears  enormously  hy|i(r. 
tropliied.  The  tongue  in  some  instances  becomes  greatly  enlarged.  Kate 
in  the  disease  the  s])ine  may  be  al?ected  and  the  back  bowed — ky])li(isis. 
The  bones  of  the  thorax  may  slowly  and  ])rogressively  enlarge.  With  this 
gradual  increase  in  size  tiie  skin  of  the  hands  and  face  may  api)ear  nor- 
mal. Sometimes  it  is  slightly  altered  in  color,  coarse,  or  flabby,  but  it  has 
not  the  dry,  harsh  appearani^e  of  the  skin  in  myxiedenia.  The  nnisdis 
are  sometimes  wasted.  Chiinges  in  the  thyroid  have  been  found,  but  are 
not  constant.  The  gland  has  been  noriiud  in  some,  atro])hied  in  others. 
•\m\  ill  a  third  grou[)  of  cases  eidarged.  Erb,  who  has  niiule  an  ehiliniati 
study  of  the  di.scase,  has  noticed  an  area  of  dulness  over  the  manidirimn 
sterni,  which  he  thought  possibly  due  to  the  persistence  or  enlargenieiii 
of  the  tiiymus.  Headache  is  not  uncomnu)n.  Somnolence  has  liieii 
noted  in  many  cases.  ^Menstrual  disturbance  may  occur  early,  and  there 
may  be  sii])])ression.  In  some  instances  vision  luis  been  involved,  owii)!: 
to  a  gradual  atrophy  of  the  optic  nerve.  The  disease  may  persist  for  lif- 
teen,  twenty,  or  more  years. 

'J'he  pafhoJofjical  auafowy  has  been  studied  in  a  few  cases.  In  addi- 
tion to  enlargement  of  the  bones,  which  is  a  true  hy})ertrophy,  enoriiioiis 
eidargement  of  the  hypophysis  (pituitary  body)  has  been  found. 

Owing  to  the  remarkable  changes  in  this  body  in  acromegaly,  it  li;i> 
been  suggested  that  the  disease  is  a  nutritional  disturbance  analoiinu- 
to  myxcedema,  aiul  caused  directly  by  disturbance  in  the  function  ef 
tliis  organ.  The  evidence  from  com])arative  aiuitomy  and  cmbryolncy 
shows  that  the  pituitary  body  is  a  very  "  complex  organ  consisting  of  an 
anterior  secreting  glandular  organ;  a  wiiter  vascular  duct;  a  posterinr. 
sensitive,  nervous  lobe,  of  which  the  last  two — namely,  the  duct  and  the 
nervous  lobe — were  morphologically  well  developed  ami  functioned  in 
ancestral  vertebrata,  but  have  become  obliterated  and  atrophied  in  strue- 
turo  ami  function  forever  above  larval  acraniates"  (Andriezen,  B.  M. .'.. 
1894,  i).  The  pituitary  body  continues  active,  but  the  duct  is  obliterateii 
"  and  the  gland  changed  into  a  ductless  glatid  ;  the  secretion  becomes  an 
'  internal  secretion,'"  which  is  absorbed  by  the  lymphatics. 

It  has  been  suggested  by  Massalongo  and  others  that  gigantism  ninl 
acromegaly  are  one  and  the  same  disease,  both  due  to  the  hyperfunetion 
of  the  ])ituitary  gland.  Certain  persons  exhibited  as  giants  have  been 
acromegalic,  and  the  sktdls  of  some  notable  giants  show  enormous  c'l- 
largenient  of  the  sella  turcica. 

Less  constant  have  been  the  changes  in  the  thymus  and  in  the  tliyroiii. 
In  some  instances  the  peripheral  nerves  have  been  involved. 

As  stated,  the  true  miture  of  the  disease  is  unknown.  !Marie  i('.<riinl> 
it  as  a  systemic  dystrophy,  analogous  to  myxocdema  and  due  to  the  iiier- 
bid  condition  of  the  pituitary  body,  just  as  myxoedema  is  associated  wiilij 
disease  of  the  thyroid. 


T- T^ 


[. 

iuul  broad.  'I'ho 
■norin()U!:^ly  liypcr- 
ly  cnliirf^t'tl.     Lute 

bowotl — ky))lnisis. 
iilarge.  \Vitli  I  his 
e  may  appear  iior- 
r  dabby,  but  it  luis 
ina.  The  muscles 
('(>n  found,  but  ;u'e 
tro])biod  in  otluTs. 

made  an  olalnii'atr 
ev  the  manubrimii 
icc  or  oTilargcnu'iu 
inolenec  has  birii 
ur  early,  and  tlu'vc 
■on  involved,  owiiij: 

may  persist  I'nr  lif- 

'ew  cases.     In  aiMi- 
lertropby,  en(iriiiiiii> 
;en  found. 
1  acromegaly,  it  lia> 
;turbance  analuguiu 
in   the  function  cf 
ny  and  embry(ilo;:y 
ran  consisting  of  iiii 
duct;  a  postcrinr. 
ly,  the  duct  and  tin' 
and   functioned  in 
atrophied  in  stnic- 
\ndriezen,  B.  M.  •'■• 
e  duct  is  obliteniti'il 
cretion  becomes  an 
atics. 

that  gigantism  mi'l 
0  the  hyperfuiution 
IS  giants  have  been 
show  enormous  m- 

Is  and  in  the  thyroi'l- 

k-olved. 

i,\vn.     Marie  reganis  I 
land  duo  to  the  inoi-| 

VA  is  associated  witli  j 


AC'ROMEC.ALIA. 


1041 


Diagnosis. — There  are  several  afTeetions  which  are  apt  to  be  con- 
fdunded  witli  acromegaly.  The  congenital,  progressive  liyjtertropliy  of  a 
single  member,  as  of  an  arm  or  leg,  or  of  one  side  of  the  body — the  so- 
oidled  giant  growth — is  readily  recognized. 

In  th(!  nsfri/is  (/('formans  of  Paget  the  shafts  of  the  long  bones  are 
cliipny  involved,  ami  in  the  head  the  bones  of  the  cranium,  but  not  those 
ef  the  face.  As  Marie  states,  in  I'aget's  disease  the  face  is  triangular  with 
the  ba.se  upward  ;  in  acromegaly  it  is  ovoid  or  egg-shaped  with  the  large 
end  downward  ;  while  in  myx(rdema  it  is  round  and  full-nioon-shapcKl. 

Afarie  has  given  the  iMUua  /t///)rr/rop//ic  /iiiliiKi/Hiri/  (i.sfrn-{trf/ir(i/itf//i/f 
to  a  remarkable  disorder,  characterized  by  eidai'gement  (d'  tlie  hamls  and 
fei't,  and  of  the  ends  of  the  long  i)ones,  chielly  of  the  lower  three  fourths 
of  the  forearm  and  leg.s.  Unlike  acromegaly,  the  bones  of  the  skull  and 
of  the  face  are  not  involved.  The  termimd  phalanges  are  much  spread 
with  both  transverse  and  longitudinal  curves  ;  the  nails,  too,  are  large  aiul 
much  curved  over  the  ends  of  the  phalanges.  Bf)th  scdliosis  and  kyphosis 
have  been  met  Mith.  The  disease  is  very  chronic,  and  in  nearly  all  cases 
has  been  associated  with  some  long-standing  affectioji  of  the  bronchi, 
lungs,  or  pleura  (hence  the  name  pi/Jiiiii)iar>/  os/co-ar/Jtrd/ifi/Jii/),  of  whicli 
sarcoma,  chrojiic  bronchitis,  chronic  tuberculosis,  and  em{)yema  have  been 
the  most  frequent.  There  are  .'several  instances  in  whicdi  disease  has  de- 
velo])e(l  in  the  subjects  of  syjdiilis.  The  disease  occurs  usually  in  adults 
and  in  the  male  sex.  Thorburn  (B.  ^f.  J.,  1893,  i)  has  collected  about 
thirty  cases. 

The  essential  jiathology  of  the  disease  is  very  obscure.  Marie  suggests 
that  the  toxines  of  the  pnlmonafy  disease  are  absorbed  into  the  circula- 
tion and  exercise  an  irritant  action  on  the  bony  and  articular  structures. 
Thorburn  thinks  that  it  is  a  chronic  tuberculous  affection  of  a  large 
iiuiuber  of  bones  and  joints  of  a  benign  type. 

Finally,  in  a  remarkable  condition  known  as  leonfiasis  ossck,  there  is 
hyperostosis  of  the  bones  of  the  cranium,  and  sometimes  those  of  the  face. 
The  description  is  largely  ba.sed  upon  the  skidls  in  museums,  but  Allen 
Starr  has  recently  reported  an  instance  in  a  M-omnn,  who  pri'sonted  a 
slowly  progressing  increase  in  the  size  of  the  head,  face,  and  neck,  the 
hard  and  soft  tissues  both  being  alfected.  He  has  ap])lied  to  the  condition 
the  term  megalo-ceplutUe. 

The  treatment  does  not  appear  to  have  any  influence  upon  the  prog- 
ress of  the  disease.  The  thyroid  extract  has  been  tried  in  many  cases, 
without,  so  far  as  my  personal  ex})erience  goes,  any  benefit.  Extract  of 
the  pituitary  gland  has  also  been  used.  The  lung  extract  has  been  em- 
ployed in  sotne  cases  of  pulmonary  osteo-arthropathy.  In  a  case  of 
Cat  oil's,  of  Liverpool,  an  unsuccessful  attempt  was  made  to  extirpate  the 
pituitary  body. 


'i-ri      * 


1(j48 


DISEASES  OF  THE   NERVOUS  SYSTEM. 


V.   SCLERODERMA. 


4.d 


Definition. — A  condilinn  of  localized  or  diiriiso  induration  of  llio 
skin. 

ri(>\viii  and  IlflkT  ( Din  Sclcrodcnnie,  neilin,  ]89."»)  have  recently  co]. 
liM'tcd  from  l\w.  literaturt!  5(18  cases. 

Two  forms  arc  recognized  :  the  circunisoribod,  which  corresponds  to 
the  kehnd  of  Addison,  and  to  nior2)lui)a ;  and  tho  dilfuse,  in  whicli  large 
areas  ari'  involved. 

The  disease  alTects  females  more  frequently  than  nniles.  The  Ki^m 
oecnr  ni(»st  (lommoniy  at  the  mitldle  jjcriod  of  life.  Tho  sclcrciiui  nc.inin- 
fonii/i  is  a  dilTerent  alFectioii,  not  to  bo  confounded  with  it.  A  large 
majt)rity  of  the  patients  have  been  French  or  (Jerinan;  among  the  col- 
lected cases  only  li'i  are  from  Xorth  America,  but  this  scarcely  represents 
the  incidence  of  the  disease;  four  cases  of  the  ditfuse  form  have  coiik! 
under  my  observation  within  the  j)ast  live  years. 

In  tlie  circi(msrri//nl  fiiriii  there  are  patches,  ranging  from  a  few  ccii- 
linietres  in  dianieti'r  to  tlu;  size  of  the  hand  or  larger,  in  which  the  skin 
has  a  waxy  or  dead-white  appearance,  and  to  the  touch  is  brawny,  hanl. 
aiul  inelastic.  Sometimes  there  is  a  prelimimiry  hypera-mia  of  the  skin, 
and  siibseqiiently  there  are  changes  in  color,  either  areas  of  })igmentalioti 
or  of  complete  atrophy  of  the  pigment — leucoderina.  The  sensory  changes 
are  rarely  marked.  The  secretion  of  sweat  is  diminished  or  entirely  ahnl- 
ished.  'J'he  disease  is  more  common  in  women  than  in  men,  and  is  situ- 
ated most  frecpiently  about  the  breasts  and  neck,  sometitnes  in  tho  coutm' 
of  the  nerves.  The  patches  may  develop  with  great  rapidity,  and  may  per- 
sist for  months  or  years;  sometimes  they  disappear  in  a  few  weeks. 

Tho  diffnxi'  form,  though  less  common,  is  more  serious.  It  develops 
first  in  tho  extremities  or  in  the  face,  and  the  i)atient  notices  that  the  skin 
is  unusually  hard  and  lirm,  or  that  there  is  a  sense  of  stilTness  or  tensidn 
in  making  accustomed  movements.  Gradually  a  dilfuse,  brawny  indiini- 
tion  develops  and  the  skin  becomes  firm  and  liard,  and  so  united  to  the 
subcutaneous  tissues  that  it  cannot  be  picked  up  or  pinched.  The  ski'' 
may  look  natural,  but  more  commonly  is  glossy,  drier  than  normal,  ami 
unusually  smooth.  With  reference  to  the  localization,  in  GG  observations 
the  disease  was  UTiiversal ;  in  203,  regions  of  the  trunk  were  aiTected ;  in 
1!»;3,  parts  of  the  head  or  face  ;  in  287,  portions  of  one  or  other  of  tliQ  uppii' 
extremities;  and  in  132,  portions  of  the  lower  extremities.  In  80  eases 
there  were  disturbances  of  seTisation.  The  disease  may  gradually  extend 
and  involve  the  skin  of  an  entire  limb.  When  universal,  the  face  is  ex- 
pressionless, the  lips  cannot  be  moved,  mastication  is  hindered,  and  it  iniiy 
become  extremely  difficult  to  feed  the  patient.  The  hands  become  fixed. 
the  fingers  immobile,  on  account  of  the  extreme  induration  of  the  skin 
over  the  joints.     The  disease  is  chronic,  lasting  for  many  months  or  niuny 


SCLEIIODKIIMA. 


1040 


uiuration  of  tlic 
liivc  recently  col- 
li con'o.-^iionds  to 
?,  in  wliieh  largo 

\iiles.  Tlie  (iiisA's 
>  sr.Jcnnna  ncoitn- 
nlh  it.  A  liir^^f 
I ;  among  the  cdI- 
carcely  represents 
form  have  eonii; 

<r  from  a  few  rcii- 
in  wliieli  the  skin 
h  is  brawny,  hanl. 
ii'mia  of  the  skin, 
lis  of  i)ignientali()u 
he  sensory  chanirt-'^ 
pd  or  entirely  ahol- 
n  men,  and  is  situ- 
Itimes  in  the  eoiii>f 
idity,  and  may  per- 
il few  weeks, 
rious.     It  develops 
;)tiees  that  the  skin 
stiffness  or  tension 
se,  brawny  induni- 
[l  so  united  to  the 
inched.     Tlie  ski" 
than  normal,  ami 
in  Gf)  observations 
|v  were  alTeoted  ;  in 
other  of  tlm  upper 
ities.     In  80  cases 
,y  gradually  extend 
"rsal,  the  face  is  ex- 
ndered,  and  it  niuy 
iinds  become  tUed. 
uration  of  the  skin 
ly  months  or  nniny 


years.  There  are  instances  on  record  of  its  persistence  for  nioi'i-  than 
twenty  years.  Iiccoverv  niav  iiccur.  or  tlie  disease  niav  be  arrested.  'Die 
patients  are  apt  to  succumb  to  jjulinonary  complaints  or  to  nephritis. 
Kheiimatic  troubles  have  been  noticeil  in  sonu;  instances;  in  others,  eiul"- 
carditis.  Raynaud's  disease  may  be  associated  witli  it,  as  in  two  cases 
described  by  Stephen  Mackenzie.  I  h.ive  seen  an  instance  of  the  dilTuse 
form  in  which  the  primary  symptoms  were  those  of  l^cul  asphyxia  of  the 
tlugers,  and  in  which,  with  extensive  scleroderma  (jf  tlie  arms  and  hands 
and  face,  tiierc^  were  cyanosis  and  swelling  of  the  skin  of  the  feet  without 
any  brawny  induration. 

'rh('  pathology  of  the  disease  is  unknown.  It  is  usually  regarded  as  a 
tropho-iHMirosis,  probaltly  dependent  upon  changes  in  the  arteries  of  the 
skin  leading  to  connective-tissue  overgrowth. 

The  ^tatients  require  to  be  warmly  clad  and  to  be  guarded  against  ex- 
posure, as  they  are  particularly  sensitive  to  changes  in  the  weather.  Fric- 
tions with  oil,  and  galvanism,  are  recommended. 

The  remarkable  dystrophy  known  as  sclcroiliirljiJie  belongs  to  this  dis- 
order. There  are  svmmi'trical  involvt-ments  of  the  finjjrers,  \vhi(;h  become 
(lel'ormed,  shortened,  and  atro]»hie(l  ;  tlie  skin  becomes  thickened,  of  a 
waxy  color,  and  is  sometimes  pigmented.  Bulla;  and  ulcerations  have 
been  met  witii  in  some  instances,  and  a  great  deformity  of  the  nails.  The 
dis(>aso  has  usually  followed  exjiosure,  and  the  patients  are  much  worse 
(luring  the  winter,  and  are  curiously  sensitive  to  cold.  Tlier(!  may  be 
changes  in  tlie  skin  of  the  feet,  but  the  deformity  similar  to  that  which 
occurs  in  the  hand  has  not  been  noted.  Some  of  the  eases  present  in  addi- 
tion diifuse  sclerodermatous  changes  of  the  skin  of  other  j)arts.  In  Lewin 
and  Ileller's  monograph  there  are  ;>.")  cases  of  isolated  sclerodactylism,  and 
lUti  cases  iu  which  it  was  combined  with  scleroderma. 

AINIIUM. 

Here  a  brief  reference  may  be  made  to  the  remarkable  trophic  lesion 
described  by  Da  Silva  Lima,  Avhich  is  met  with  in  negroes  in  Brazil, 
.\frica,  India,  aiui  occasionally  in  the  Southern  States.  It  is  contiued  to 
the  toes,  usually  the  little  toe,  and  begins  as  a  furrow  on  the  line  of  the 
digito-plantar  fold.  This  gradually  deepens,  the  end  of  the  too  eidarges, 
iuni,  usually  without  inflammation  or  pain,  the  toe  falls  olT.  The  process 
may  last  some  years.  Cases  have  been  reported  in  this  country  by  Ilorna- 
day,  Pittmau,  F.  J.  Shepherd,  and  Morrison. 


%  ^ 


SECTION   IX. 


DISEASES  OF  THE  MUSCLES. 


I.   MYOSITIS. 


ftpi 


Definition. — Tnfliinunution  of  the  voluntary  muscles. 

A  j)riMi;iry  myositis  ot-curs  as  an  acute  or  subacute  afTection,  and  is 
probably  (IcpciKlent  on  some  unktu)\vn  infections  agent.  Several  cliarai'- 
teristic  eases  have  lu'en  described  of  late  years.  The  case  of  K.  Wairtier 
!iiay  l)e  taken  as  a  typical  example.  A  tuberculous  but  well-built  woman 
oi\tered  the  liospital,  compIaiuin<i  of  stiffness  in  the  shoultlers  and  a 
slijfht  (edema  of  the  i»ack  of  the  hands  and  forearms,  '('here  was  ])aras- 
thesia,  the  arms  l)ecame  swollen,  tlie  skin  tense,  and  the  muscles  felt 
doughy,  (iradually  the  thighs  became  affected.  The  disease  lasted  about 
three  months.  The  post-mortem  showed  slight  pulmonary  tuberculosis: 
all  the  muscles  except  the  glutei,  the  calf,  and  abdominal  muscles  were 
stiff  and  firm,  l)ut  fragile,  and  there  were  serous  infiltration,  great  jtro- 
liferation  of  the  interstitial  tissue,  and*  fatty  degeneration.  Similar  cases 
have  been  reported  by  Unverricht,  llepp,  and  .lacoby  of  Xew  York.  In 
the  case  reported  by  .Jacoby  the  muscles  were  firm,  hard,  and  tender,  and 
tiiere  was  slight  icdema  of  the  skin  The  duration  of  the  cases  is  usuiillv 
from  one  to  three  months,  though  there  are  instances  in  which  it  has  liccii 
longer  The  swelling  and  tenderness  of  the  muscles,  the  u'dema,  arid  the 
pain  naturally  uuggest  trichinosis,  and  indeed  Hepp  speaks  of  it  as  a 
pseudo-trichinosis.  The  nature  of  the  disease  is  unknown.  Senator's  case 
presented  marked  disorders  of  sensation,  and  there  is  a  question  whetlicr 
the  peripheral  nerves  are  not  involved  with  the  muscles.  Wagner  suggests 
that  some  of  the.se  cases  were  examples  of  acute  progressive  muscular  atre- 
phy.  The  separation  from  trichinosis  can  be  made  only  by  removing  a 
portion  of  the  muscle.  There  are  septic  cases  in  which  a  diffuse,  purulent 
infiltration  of  the  muscles  of  different  regions  occurs.  Instances  iiave 
been  reported  in  which  this  has  been  described  as  the  jn-imary  affect  ii»ii. 
the  condition  of  the  muscles  even  passing  on  to  gangrene. 

A  remarkable  affection  is  myositis  ofisificans  progressiva,  in  wliieli 
portions  of  the  muscles  undergo  a  progressive  calcifieatioii. 


Tin:   MUSl'UliAU   DYSTIIOIMUHS. 


1051 


II.  THE    MUSCULAR    DYSTROPHIES 

(Dyxtro/i/tiii  nntsciildri.s  pmijremvii,  V.r\\). 


ES. 


aift'ction,  ami  is 
Si'voral  chann- 
iisc  of  H.  AN'airiifr 
well-built  Wdinaii 
shouliU'i's   mil  I  a 
'riuTo  was  panis- 
tlic   nuisck'ri  felt 
soase  lasted  abmit 
iiiiry  tuberculosis: 
inal  muscles  were 
ration,  fjreat  t"'"- 
)n.     Similar  (■iis<'> 
f  New  York.     1" 
luul  tender,  ami 
e  cases  is  usuallv 
wbicli  it  lias  been 
10  (cdema,  and  ilit 
leaks  of   it  as  a 
1.     Senator's  cusi' 
question  whether 
Wagner  sugsi'sts 
ivo  muscular  at  ro- 
ily by  removiiij:  « 
a  diffuse,  puruk'iit 
Instances  iiavc 
primary  affection. 

ressiva,  in  whii'li 
on. 


Definition.  —  Muscular  wiistini,',  with  or  without  an  initial  hyper- 
trophy, be;j;iniiiii;,'  in  various  groups  of  muscles,  usuiilly  progrcssivi'  in 
chanicter,  and  dependent  on  prinuiry  changes  in  the  muscles  them.si'lves, 
.V  marked  hereditary  disposition  is  met  with  in  tiie  disease. 

Before  cousi(k'ring  the  priiiiai'y  muscular  atrophies  it  may  be  well  to 
summarize  briefly  the  cliief  conditions  under  wbicii  muscuhir  atrophy 
occurs.     These  are : 

(1)  Acute  or  chronic  lesions  of  the  nu<'li'i  of  tlic  motor  patli,  wliiili 
maybe  (a)  cortical,  as  a  direct  result  of  a  cerebral  lesion;  {/>)  Imlbar,  as 
in  chronic  bulbar  jjaralysis;  (r)  spinal,  eitVier  acute,  as  in  poliomyelitis  of 
chiklren,  or  chronic,  as  in  the  jjrogre.ssive  muscular  atro[)hy  of  the  simple 
or  of  tlie  spastic  type. 

('i)  Neuritic  nuiscular  atrophy,  following  a  local  neuritis  due  to  trauma, 
a  multii»le  neuritis  due  to  alcohol,  lead,  and  th('  infectious  disi'ases.  in 
this  .same  catcgf)ry  j)rol)ably  may  be  ])laced  the  muscular  atrophies  a.sso- 
liated  with  joint-di.sease,  the  progressive  hemi-atro})hy  of  the  face,  and  the 
atrophy  sometimes  found  in  eases  of  hysteria.  The  peroneal  type  of  mu-s- 
cular  atropliy  belongs  in  this  division. 

(3)  Conditions  of  the  mu.scles  them.selves — muscular  dystrophy. 

Etiology. —  No  etiological  factors  of  any  moment  are  known  other 
ihan  heri'dity.  The  intluence  may  show  itself  by  true  heredity — that  is, 
the  di.seaso  occurring  in  two  or  more  generations — or  several  members  of 
the  same  generation  may  be  affected,  showijig  a  family  teiuleiu-y.  Many 
Miembers  of  the  same  family  may  be  attacked  through  several  generations. 
Males,  as  a  rule,  are  more  frequently  atfected  than  fenudes.  The  disease 
is  usually  transmitted  through  the  mother,  though  she  may  not  herself  be 
the  subject.  As  many  as  twenty  or  thirty  cases  liave  been  described  in 
live  generations.  In  Krb's  eases  4-t  per  cent  showed  no  heredity,  'i'he 
disea.se  usually  sets  in  before  puberty,  but  may  be  as  late  as  the  twentieth 
or  twent\'-iifth  year,  or  in  .some  instances  even  later. 

Symptoms. — The  first  symptom  noticed  is,  as  a  rule,  clumsiness  in 
the  movenu'iits  of  the  child,  aiul  on  examination  certain  muscles  or  groups 
of  mu.scles  seem  to  be  eidarged,  particularly  those  of  the  calves.  The 
extensors  of  the  leg,  the  glutei,  the  hunbar  muscles,  the  deltoid,  triceps, 
aiul  infraspinatus,  are  the  next  most  frequently  involved,  and  may  stand 
out  with  great  prominence.  The  muscles  of  the  neck,  face,  and  forearm 
rarely  sutfer.  Sometimes  oidy  a  portion  of  a  muscle  is  involved.  With 
this  hypertrophy  of  some  muscles  there  is  wasting  of  others,  jiarticularly 
the  lower  portion  of  the  pectorals  and  the  latissimus  dorsi.  The  attitude 
when  standing  is  very  characteristic.     Tlie  legs  are  far  apart,  the  shoulders 


ior>2 


DISKASKS  OK  TIIK   Ml'SCLKS. 


thrown  hiii'k,  I  In-  spine  i^i  irrciitly  ciirvcd,  iiiid  tin'  iiliildincn  in'otrmhs. 
'I'lic  ;,^iiit  is  uaiMlin;;  and  awkuai'd.  In  iri'ttini;  up  I'mni  llic  Moor  tin' 
position  assumed,  as  so  well  known  now  tliroiiirli  (iowers's  lijriires,  is 
jiathitijfnonionii'.  'I'lic  patient  first  turn,^  over  in  the  all-fours  position  and 
raises  the  trunk  with  his  arms;  the  hands  are  then  moved  aloi'-  liic 
ground  until  the  knees  are  reached  ;  then  with  one  hand  upon  ii  knee  In- 
lil'ts  himself  up,  ;,'rasps  the  other  knee,  and  ;rradually  pu>h(s  himst  If  inid 
the  erect  posture,  us  it  has  been  expressed,  i)\-  elimliiuLC  up  his  le^js.  The 
strikinij  contrast  hetweeii  the  feehli'iiess  of  the  child  and  the  powerful- 
luokin;,'  psen<lo-hypertrophie  muscles  is  very  charaelerislic.  'I'lii'  enlarged 
nmsules  may,  however,  he  relatively  vei'y  stroni;. 

The  course  of  the  disease  is  slow,  hut  pi'oijressive.  Wasting'  proceeds 
and  linally  all  traces  of  the  enlarijjed  condition  of  the  muscles  disappears. 
At  this  lat('  |)eriod  distortions  and  contrai'tious  are  common. 

Tlui  mns(!le.sof  the  shoiihler-girdle  are  ueaidy  always  alTected  early  in 
tlie  disease,  causing  a  s\ miitom  upon  which  h'.rh  lays  izi'eat  stress.  With 
tlie  liands  nnih'r  the  arms,  when  one  endeavors  to  lift  the  patient,  the 
shoulilei's  ar((  raised  to  the  level  of  the  eiirs,  and  nno  gets  the  impression 
as  though  the  child  were  slijiping  through.  These  "  loose  shoidders"  are 
very  characteristic.  The  ahm)rmal  m(tliility  of  the  shonldei'-l)lailes  gives 
them  a  winged  ajipearance,  and  makes  tlie  arms  seem  much  longer  than 
usual  when  they  are  stretched  out. 

The  j)atients  eomi)lain  of  no  sensory  .symjjtoms.  The  atroj)hic  mus- 
cles do  not  show  tin;  reaction  of  dogeneratiou  except  in  extremely  rare 
instances. 

Clinical  Forms.— A  number  of  ditTeront  types  Imve  been  described, 
depending  u|)on  the  age  of  the  ons(>t,  the  muscles  first  alTected,  the  occur- 
rence of  hy[)ertroph\',  the  pronniienee'of  heredity,  etc.  Hut  Erh  has 
shown  that  there  is  no  sharp  division  between  thc^e  difTerent  forms,  and 
classes  thetn  all  under  the  Tuirne  of  (///.sfrajj/iiii.  iinisrii/(tris  prof/rcssira. 
For  convenience  of  description  he  subdivides  the  disease  into  two  large 
groups : 

I.  Those  cases  which  occur  in  childhood. 

II.  The  cases  otjcnrring  in  yout:i  ,ind  adult  life. 

The  first  division  is  subdivided  into  (1)  the  hypertrophic  and  (2)  tlio 
atrophic  forms. 

Under  the  hypertrophic  form,  which  is  the  pseudo-hypertrophic  mus- 
cular paralysis  of  authors,  he  thinks  it  is  useful  to  distinguish  between 
the  cases  in  whitdi  (/t)  the  enlarged  muscles  have  undergone  lipomatosis  — 
i.  e.,  pseudo-hypertrophy — from  those  {b)  in  which  there  is  a  re.al  hyjier- 
trophy. 

The  atrophic  form  also  includes  two  subclasses :  (a)  Those  cases  in 
which  the  muscles  of  the  face  are  involved  early  ;  this  corres2)onds  to  the 
infantile  form  of  Duchenne — the  Landouzy-Dejerine  type,  (b)  Tho.'^e 
cases  in  which  the  face  is  not  involved. 


t'S  Wf-    "l| 


•rHK  MUSrt'I.AU  dvstiioimiiks. 


1U53 


hie  iviul  (2)  the 


I.    />!/■•</ riipfi id  iiniscii/iin's  priif/rr.ssii'fi  iiifdiitinu, 
I.    1I\  |icrlin|iliii'  form. 

{it)    Willi  |is('Uilii-liy|ii'i'tni|iliy. 
(A)    Willi  rral  liyiifrlin|iliy. 
'-J.   Al!(i|iliic  loriii. 

{ii)   With   priiiiarv   iiivtilvciiu'iit  of  the  face  (iiiraulilt'  fdriu  df 

Diichciiiic). 
(//)    W'illioiit  iiivdivciiiciil,  (if  till'  fare. 

II.  fii/sfrii/i/n'i(  ituisfithiris  jiriiijri ssirit  jiirruiim  ri'!  (n/iil/orKni  {Kv\)'^ 
jiivi'iiili'  fDriii). 

Morbid  Anatomy.  -Accoi'iliii;;  to  I'lrh,  the  discast'  consists  ill  ;i 
<'hiui,L,'c  ill  the  iiiiisi'ics  tliciiisclvfs.  At  tirst  the  iiiiisclc-liliifs  liypcr- 
tropliy,  then  hccoinc  roiiiid,  the  nuclei  increase,  ami  the  iiiiiselc-lihrcs 
may  becoiiu'  lissiired.  Al  the  same  titiie  lliere  is  a  sliirht  increase  in  tlu; 
coniiectivo  tissue.  Sooner  or  later  the  miiscle-llhres  hej^iii  to  atrophy, 
and  tiie  niudei  heeoiiie  ;;reatly  iii'ivased.  N'aciioles  ami  lissnres  appear, 
and  they  ilnally  hecoiiu*  completelv  atrophic,  the  cniiiiective  tissue  he- 
eomiiig  markedly  increased.  Fat  may  l)e  deposited  in  the  connective 
tissue  to  such  an  I'xteiit  as  to  cause  hypertro[)hic  lipoinalosis — pseiido- 
iiypertrophy. 

The  nervous  system  has  very  i^'eiicrally  heeii  found  to  he  without 
(lomonstrahle  lesions.  The  (lilVereiit  sta'^es  of  these  clianires  mav  be  round 
in  a  simple  muscle  at  the  same  time. 

Diagnosis. — The  primary  myopathies  can  usually  Ite  n^adily  distiii- 
i,Miislic(l  from  the  ci'ivliral,  myelopathic,  and  neurit ic  foi'iiis. 

{(i)  In  the  cerebral  atrophy  loss  of  power  usually  preci'des  the  atrophy, 
w'liich  hs  either  ol"  a  moiioplei^ic  or  lieiiiiple<,nc  type. 

{//)  In  the  myelopathic  or  spinal  muscular  atro[iliy  the  distinctions  are 
clearly  marke(l.  /'(i/iii-iiij/c/i/is  iiii/irior  chroiiicd  hcixins  in  the  small 
luii.scles  of  the  hand,  a  situation  rarely  if  ever  alTeeted  hy  the  )»riiiiary 
myopathies,  which  involve  tirst  those  of  th(>  calvi's,  the  trunk,  the  face,  or 
the  shoulder-girdle.  In  the  myelopaihie  atrophy  the  reaction  of  degeiu'ra- 
tion  is  present  and  lihrillary  twitchin^fs  occur  in  lioth  the  atrophied  and 
noii-atropliied  muscles.  In  many  cases,  in  addition  to  the  wastini;  in 
the  arms,  there  i.s  a  spastic  condition  in  the  lejjs  and  increase  in  the  re- 
tk'xes.  The  myelopathic  atrophies  come  on  late  in  life  :  the  myopathic 
fi)rms  develop,  as  a  rule,  earlv.  In  the  primary  muscular  atrojiliit's  he- 
ledity  plays  an  important  n'ih\  which  in  the  niyeIoi»athic  is  (piitc  sub- 
>idiary. 

(r)  In  the  neuriti(!  nniscular  atroj)hies,  whetlier  due  to  lead  or  to 
trauma,  the  general  characters  and  the  mode  of  onset  are  distinctive.  In 
the  cases  of  multi[)le  neuritis  seen  for  the  first  time  at  a  jieriod  when  the 
wasting  is  marked  there  is  often  dilliciilty,  but  the  absence  of  family  liis- 
iDi-y  and  the  distribution  are  important  features.  Moreover,  the  paralysis 
is  out  of  proportioii  to  the  atrophy.     Sensory  syni2)toms  may  be  present, 


■4^  ' 


105-i 


DISEASES  OF  THE   MUSCLES. 


^   '1  J 

1    -'! 
I 

ill 

•  'ft   1 

h'i 


;ui(l  in  llio  eases  in  which  tlie  logs  are  cliictly  involved  tliero  is  usuallv  the 
.si('j)/)(ii/r  '^lui  so  ehanu'ti'i'istic  of  periphd'al  neuritis. 

{</)  I'l'oirressive  neural  museuiar  atro])hy.  Here  heredity  is  also  u 
factor,  and  the  disease;  usually  beirins  in  early  life,  hut  the  distribution  (.f 
atrophy  ;ind  paralysis,  wliieh  in  this  aiTeetion  is  at  first  eonlined  to  the 
periphery  of  the  extremities,  lu'l})s  to  distinguish  it  from  the  dystrophie>; 
while  the  oeeurrcncc  of  sensory  syinjitoms,  fil)rillary  eontraetiotis,  and  the 
juai'ked  decrease  in  the  electrical  excitability  usually  makes  the  distiiir- 
tion  clear. 

The  outlook  in  the  primary  myopathics  is  had.  'J'he  wasting  pro- 
gresses uniformly,  uninlluenci'd  by  treatment.  Erb  holds  that  l)y  elec- 
tricity and  massage  the  jirogress  is  oecasicially  arrested.  The  general 
health  ishould  ho  carefully  looked  after,  moderate  exercise  allowed,  fric- 
tions with  oil  ajiplied  to  the  muscles,  and  when  the  patient  becomes  bed- 
fast, as  is  inevitable  sooncsr  or  later,  care  should  be  taken  to  prevent  con- 
tractures in  awkward  positions. 

Progressive  Neural  Muscular  Atrophy.— This  form,  known  also  as  the 
peroneal  lyj)t',  or  by  the  names  of  the  men  who  have  described  it  nio.-t 
accurately  of  late — tnimely,  Chai'cot,  .Marie,  and  Tooth — occurs  either  ii> 
a  hereditary  or  as  a  family  alTectiou.  It  usually  begins  in  early  chihl- 
hood,  tilfecting  first  the  inuseles  of  the  feet  and  the  peroneal  grouj),  and  .is 
a  result  of  the  weakening  of  these  muscles,  club-foot,  either  pes  eepiiuiis 
or  pes  ecjnino- varus  occurs.  In  rai'e  instances  the  disease  may  begin  in 
the  hands,  but  the  upper  limljs,  as  a  ridi',  are  not  alTected  for  some  years 
after  the  legs  arc  attacked,  and  the  trouble  then  begins  in  the  small  mus- 
cles of  the  hands.  Sensory  disturbanees  are  frerpieiitly  present  and  form 
important  diagnostic  features.  I'ibrillary  contractions  and  twitchings 
also  occur.  The  electrical  reactions  are  altei'ed  ;  there  is  eitlu'r  a  loss  or 
a  very  great  decrease  of  the  excitability,  which  can  be  dt'inonstrated  not 
oidy  ill  the  atrophic  muscles,  but  also  in  muscles  and  nerves  which  arr 
ap])arently  nornud. 

There  have  been  only  two  recent  autojisies — that  of  l)id)reuilh,  wlm 
found  changes  in  the  })eripheral  nervt's,  and  of  l)cjcrine  and  Sottas,  win 
found  hypertrophy  of  the  nerve-trunks  and  of  the  nerve-roots,  with  ^ 
ondary  altt'rations  of  the  {)osterior  columns  of  the  cord.  They  call  tin 
neuritis  interstitial  and  hypertrophic;  and  in  another  case  there  was 
marked  hypertro^jhy  and  hardness  of  the  nerve-trunks  of  the  lindjs. 


Hi.    THOMSEN'S    DISEASE;    MYOTONIA    CONGENITA. 


Definition. — An  hcrt'ditary  disease  characterized  l)y  tonic  cram;' "!' 
the  muscles  on  attempting  voluntary  movements.  The  disease  received 
its  name  from  the  physician  who  lirst  described  it,  in  who.se  family  it  h;is 
existed  for  live  ireneratious. 


PARAMYOCLONUS   xMULTIPLEX. 


1055 


is  usuallv  '.ho 


Etiology. — ^All  tho  typical  eases  )iavo  occurred  in  family  jrroiips; 
a  few  isolated  instances  have  heen  deserihcd  in  which  siiuilai'  syniptonis 
iiavo  been  present.  The  disease  is  rare  in  this  country  and  in  lMi,<:land  ; 
it  seems  more  common  in  (ieriminy  an<I  in  Scandinavia. 

Symptoms. — The  disease  coines  on  in  childhood.  It  is  noticed  tiiat 
on  account  of  the  stiifness  the  children  are  not  ahle  to  take  part  in  oi'di- 
nary  ganu's.  The  peculiarity  is  noticed  only  durin<^  voluntary  movements. 
The  contraction  uhiidi  the  patient  wills  is  slowly  aecomjilishcd  ;  the  re- 
laxation which  the  ])atient  wills  is  also  slow.  The  contraction  often  per- 
sists for  a  little  time  after  he  has  dropped  an  object  which  he  has  pickeil 
up.  In  walking,  the  start  is  dillicult ;  one  leg  is  jiut  forward  sh.wly,  it 
halts  from  stilTiu-ss  for  a  seeoml  or  two,  and  then  after  a  few  ste])s  the 
legs  beconu'  lindjcr  and  he  walks  without  any  ditliculty.  The  muscles  of 
the  arms  and  legs  ai'c  those  usually  implicateil  ;  rarely  facial,  ocular,  or 
laryngeal  muscles.  Kniotion  and  cM)ld  aggravate  the  condition.  In  sonu> 
instances  there  is  mental  weakness.  The  sensation  and  the  rellexcs  are 
normal.  The  condition  of  the  muscles  is  interesting.  The  jiatients  a|)- 
pear  and  are  museular,  and  there  is  sometimes  a  dclinite  hypertrophy  of 
the  muscles.  I'he  force  is  scarcely  proi)ortionatc  to  the  size.  Erb  has 
described  a  charictcristic  reaction  of  the  lu'rve  and  muscle  to  the  elec- 
trical currents — tha  so-called  myotonic  reaction,  the  chief  feature  of  whitdi 
is  that  iu>nnally  the  contractions  caused  by  either  current  attain  their 
maxinium  slowly  and  relax  slowly,  and  vermicular,  wave-like  contractions 
pass  from  the  cathode  to  the  anode. 

The  disease  is  incur;d)le,  l)ut  it  may  be  arrested  temporarily.  The 
iiaturi!  of  the  alTecti(Ui  is  unknown.  There  is  an  extraoi'dimtry  incrtnise  in 
the  size  of  the  voluntary  fibres.  In  the  oidy  autopsy  imide  Dejcrine  and 
Sottas  have  founil  hypertrophy  of  the  primitive  libres  with  multii)lication 
of  tlie  nuclei  of  all  the  muscles,  including  the  diaphragm,  but  not  the 
heart.  The  s{)inal  cord  and  the  nerves  were  intact.  No  treatment  for 
the  condition  is  known. 


IV.    PARAMYOCLONUS    MULTIPLEX 

(M  iliicl()iii<i). 


ONGENITA. 


An  alTection,  described  by  i-'riedcrich,  characterized  Ijy  clonic  contrac- 
tions, chiefly  of  the  muscles  of  the  extremities,  occurring  cither  constantly 
iir  in  paroxysms. 

The  cases  have  been  chiefly  in  nudes,  aiul  the  disease  has  followed 
cmotioiud  disturbance,  fright,  or  straining,  '['he  i'i)ntractions  are  usually 
I'ilateral  and  may  vary  from  fifty  to  one  hundred  ami  fifty  in  the  minute. 
Occasionally  tonic  spasms  occur.  It  is  not  accompanied  by  tmy  sensory 
iir  motor  disturbances.  In  the  intervals  between  the  attacks  there  may  be 
tiruu)rs  of  the  muscles.     In  the  severe  spasms  the  movements  may  lie  very 


1050 


DISK  ASKS  OF  TIIK    MUSCLES. 


violent ;  tlio  Ixxly  is  toss('(l  about,  and  it  i^  sdiiiotiiiu's  dinieult  to  kocii  tlio 
patient  in  bed.  (Jueei  hsis  described  a  family  in  which  the  alTection  Ims 
oceiirred  in  three  pfeiiei'atioiis. 

Weiss  has  also  i\ote(l  heredity  in  four  generations.  Aceordini,'  to  this 
author  the  essential  symptoms  are  continuous  or  paroxysmal  niusi'uLir 
<'ontractioiis,  usually  svmnictrical  a!id  rhythmical,  of  muscles  otiicrwisc 
iu)rinal,  which  crease  durin<;  sleep.  There  are  neither  psychical  nor  sen- 
sory disturbances.  The  condition  is  most  common  in  you)iir  males,  and  i.-: 
niKilTccfcd  by  treatment.  Raymond  jrruups  tins  disease  with  tibrilhu'v 
ti'cmors,  (dectric  (diorea  (Henoch),  tic  non  douhuii'eux  of  the  face,  and  the 
convulsive  tic  under  tlu^  name  of  myodunirs,  hidieving  that  it;  is  only  one 
link  in  a  tdiain  of  pathological  manifestations  in  the  degenerate. 


mmimmmwwf^ 


SECT  I  ox   X. 

THE   INTOXIGATIOXS,   SU:\-STROIvE, 

OBESITY. 


s  '•[■  i; 


I.   ALCOHOLISM. 

(1)  Acute  Alcoholism. — Wlicn  a  lar.LCc  (iiiantity  of  ulcdliol  is  takon,  its 
inlliUMico  oil  the  nervous  systt'Mi  is  luaiiii'cstcd  in  Tnusciiiai'  incooniina- 
timi,  mental  distilrbance,  an;l.  tinally,  narcosis.  Tiie  individual  |)resents  a 
lliislied,sonielinies  slij^htly  eyanosed  l'ace,u  full  ])ulse,  with  (k'e|)  but,  rarely 
sicrtoro'.is  res[)irations.  The  i)ii|)ils  arc  dilated.  The  teni])eratHre  is  fre- 
ijiii'iitly  ])elo\v  normal,  particularly  if  the  patient  has  heeii  exposed  to 
injil.  Perhaps  tlie  lowest  rej)orted  temperatures  have  been  in  cases  of  this 
suit.  An  instance  is  on  record  in  which  the  patient  on  admission  to  hos- 
|iital  had  a  temi)erature  of  •*4°  ('.  (ca.  1.')°  !•'.),  and  ten  hours  later  the 
iiiiiperaturc  had  not  risen  to  Ui°.  The  unconsciousness  is  rarely  so  (ie(>p 
t!i;it  tlio  patient  cannot  be  rousi'd  to  some  extent,  and  in  reply  io  (juestions 
lie  mutters  incoherently.  Muscular  twitcliinifs  may  occur,  but  I'arciv  con- 
wilsions.     The  breath  has  a  heavy  alccdiolic  odor. 

T!io  dia^ijnosis  is  not  dillicult,  yet  mistakes  are  frofpuMitly  made.  Per- 
-II1-;  are  sometimes  bn)U<(ht  to  hospital  by  the  police  supposed  to  be  drunk 
>.l  ;  ii  reality  they  arc  dyini;  from  upopK'xy.  Too  f^reat  care  cannot  be 
il,  and  the  patient  should  receive  tlie  benefit  of  the  doubt,  in 
iv3t;!  .ces  the  mistake  has  arisen  from  the  fact  that  a  p(>rson  who  has 
iii'iTi  ilil'  Ai'ig  luiiivily  has  been  stricken  with  apoplexy.  In  this  condition 
the  nima  IS  usually  deeper,  stortor  is  present,  and  there  may  be  evidence  of 
iu'iiM[)le<i;ia  in  the  jj^reater  flaccidity  of  the  limbs  on  om>  side.  Tlu'  sul)ject 
li;i<  ah'eady  bei"  considered  in  the  section  upon  ura>mic  coma. 

ri)  Chronic  Alcoholism. — In  moderation,  wine,  beer,  and  spirits  may 
iif  tuki'ii  throughout  a  lonj;  life  without  impairins;  the  jfeneral  health. 

.\ccor(ling  to  I'ayne,  the  poi.sonous  effects  of  alciihol  are  manifested  (1) 

■11  functional  poison, as  in  acute  narcosis;  {'i)  as  a  tissue  ])ois(ui,  in  which 

!■  'I'l'ts  are  seen  on  the  ))arenchymat()us  elements,  j)articular!y  ej)ilhe- 

ai  1   iicrve,  produciiifj  a  slow  degeneration,  and  on  the  hl()()d-ve.s.sols, 

iiisiug  thickcni' ig  and  ultimately  fibroid  changes;  and  (:})  as  a  chockei' 

«7 


1058 


TlIM    INTOXICATION'S,   SUN-STllOKK,   OBKSPrY. 


of  tissue  ().\i(liiti(>n,Hiii('t'  tli(>  alcohol  is  coiisiniicd  in  iilai'cof  tiic  fat.  This 
loiids  to  fatty  cliaii.ms  and  siiiiictiiiics  to  a  condition  of  ircnci'al  steatosis, 

'riic  ciiicf  clVccts  of  clironic  alcojiol  jioisonini;'  may  be  llui.s  sunmm- 
rized  : 

\i'ri'(i/f.^  Si/.s/fi)i. —  I"'niicli(inal  disturlKincc  is  cotninon.  —  rnstcadimss 
of  the  muscles  in  pei'toi'minir  any  action  is  a  constanl  fealiire.  Tic 
tremor  is  best  seen  in  the  hands  and  in  tlii'  ton,u;ui'.  The  mental  |iroe  ■■scs 
may  l)e  (hdl,  partieularly  in  tlie  early  morning,'  hours,  and  the  iiaticiit 
is  unahle  to  ti'ansact  any  husiiiess  until  he  has  had  his  acciistome(l  stiiim- 
liint.  ii'ritahility  of  temper,  foi'ucl fulness,  and  a  ehaiiL:-!'  in  the  iimral 
character  of  the  individual  j;radually  come  mi.  'J'he  judgment  is  s(  ri- 
ously  impaired,  the  will  i-nfeeliled,  aiul  in  the  linal  staires  di'UK'ntia  iii;i\ 
Bupervetu'.  The  relation  of  chronic  alcoholism  to  insanity  has  been  nnirli 
discussed.  Accoi'din:^'  to  Sava^'e,  of -ijOOO  patients  admitted  to  the  I'elli- 
k'hem  Hospital,  l^liliiave  driid<  as  the  cause  id'  their  insanity.  Cliiniiic 
jileoholism  i  '•■'  ''.'*  -d  i)y  many  to  be  oiu'  of  the  special  causi'S  of  demciiii:i 
])aralytica,  but  _)inions  of  expeHs  on  this  (|uestion  are  still  disconlant. 

Savai^e  .'tales  tli.  iu»t  more  than  seviMi  per  cent  are  caused  bv  alcuhnl 
alone.  In  many  ca.^es  it  is  ci'riaiidy  oiu'  (d'  the  important  tdements  in  tin' 
strain  whi'.'h  leads  to  this  breakdown. 

No  ch;;racte!'!-;tic  chaiiixes  ari^  found  in  the  nervous  system.  Ua'innr. 
rhaiiic  pachymeninn'itis  is  not  very  uncommon.  Opacity  and  thickenin.; 
of  the  pia-aracdinoid  nuunbranes,  with  more  or  less  wastini;-  of  the  <'uii\ii- 
luii(Mis.  u-encrally  occur.  These  are  in  no  way  pecidi.ir  to  chronic  alculiol- 
ism,  but  ai'c  found  in  old  persons  and  in  chronic  wastinj^  di.seases.  in  ll.r 
very  pnttracteil  cases  there  may  be  chronic  enccphalo-im'uiny'itis  willi  ;i.i- 
hesions  of  the  membranes.  \>\  far  tju'  most  striking'  ell'ect  id'  alcolml  dii 
tlu'  nervous  sysiem  is  the  pi'oduction  (d'  the  ulcdholic  lU'Ui'itis,  which  lia- 
alreaily  been  considered. 

/)i,/i's/irr  Sjisli'iti. — Catarrh  of  the  st(unaeli  is  tlio  nH)st  eommon  svnip- 
t(Mn.  The  toper  has  a  furred  tiuiixue,  heavy  breath,  atul  in  the  iuorniiiLr;i 
sensation  (d'  sinkinir  at  the  stomach  until  he  has  his  dram.  Tlu^  appditf 
is  usually  impaired  and  the  liowels  are  constipated.  These  features  air 
associated  wit'.i  a  chronic  catarrh  of  the  stonuudi. 


Alcohol 


prroiluces  lU'linito  (dian^es  o 


n  the  livr,  leadinii:  to  the  varinii 


forms  (tf  cirrhosis  already  described.     The  elfect  is  jirobably  ii  | 
(le<ri'nerative  chauLTe  in  the  liver-eoUs,  althouijfh  nianv 


irniiiirv 


I'ood   oiiserNcrs  .•HI 


hold  that  the  poison  acts  lirst  upon  the  coiniective-tissue  (demeids.  l!  i> 
probable  that  a  special  vuhu'rability  of  the  livor-cidls  is  nece.ssary  in  tlir 
eti(doiry  (d'  alcoholic  cirrhosis.  'I'here  are  eases  in  whitdi  eomi)aralivi'ly 
luodei'ate  drinkin,i>;  for  a  few  years  has  been  followed  by  cirr]K)sis;  oa  llio 
otiier  haiul,  the  livers  of  persons  who  have  been  steady  di'inkei's  for  lliiri) 
forty  years  mav  show  onlv  a  moderate  sfrade  of  s(der 


or 


osis.      With  the  ;:ii> 

trie  and  hepatic  disorders  the  I'acies  often  becomes  very  (diaraidcristic.    Tlh 
venules  (d'  the  cheeks  and  uo.su  arendated;  the  hitter  becomes  oularircJ 


■^^—H 


ATiCOIIOUs^r. 


lor.o 


'  tlu'  fill.     'I'lns 
Till  sU"iit(>si>. 
t.   thus  suuuiiii- 

Viisli'iulim'ss 

I'ciitiWf.      'Ht' 
iiUMiliil  imir  rSis 

cuatoineil  sliiuu- 
_rt.  in  llu^  iiionil 
u, lenient  is  Mvi- 
,.s  (Inm'iitia  in;ty 
IV  l\as  ln'fU  uiiirh 

lU'd    l«>  tlH'   I'nlll- 

iHiinity.  Clironu' 
■ausrs  nf  (Innmiui 
,.,.  still  tlisconlunt. 
,,,n,s,.a  l>y  illrnh..! 
„t,  ..U'lm'Uls  in  ili»' 

,  system.      U;iiiinr- 

,-,t,v  iinil   Ihicki'iiin': 

slinii-  of  tlH'  n'ii\"- 

lo  chvoiii"'  al<'nli"l- 


lisciisr 


inu'iiinu' 


11  \\y 


\\\<  Willi  U'l- 


,u.uritis.  whu'li  lia- 


■lll): 


|H 


;(  (Miininiiu  syiiiii- 
1  in  tin-  m<>niiiiu;i 


riini. 


Tlu-  ill 


lH'lll<' 


'I'lu'si'  IVutuws  ;in' 


ladiiitj; 
ni'dl) 


to  thr  vai 


loU 


(i|H»l 


al.ly  11  I 

I    ohsiTVt' 


iviniiU'v 
rs  :-ull 


ksue  uk'iuou 


Is.     li 


emissary  ni  tuc 


IS  w 
:U\v\\  coiuiKira 

il)V  cirrhosis^;  ' 


y  * 

Irosi- 


li-iukcrs  loi- 


111  IIh' 

thiny 


With  til."  p'^ 


•  lianu'tvristu' 
■  r  becomes  e 


iilai;;^*'' 


red,  luid  rnuv  present,  tlie  eoiiditioM  kn  iwri  as  (n')if'  rnanrm.     'I'lie  {'\v:i  arc 
waterv,  tlie  eon  junctiva'  liyiierM'mie  ami  Miiietinies  liile-tiiiLTeii. 

Kidiii'iis. — 'I'lie  inlhieiire  of  ctiroiiir  ali-olmlj.-m  upon  these  origans  is 
i)V  no  nu'ans  so  marked.  .Xeeonliii^-  to  hickinson  tlie  total  of  renal  dis- 
ease is  not  ,i,n-eater  in  the  drinkiiij,'  e!ass,  and  he  liolds  that  the  etl'eel  (if 
alcohol  on  the  kiilni-ys  has  been  much  ovei'fatcd.  l-'ormad  ha^  dii'cctcd  at- 
tention t(»  the  I'art  that  in  a  lar^'c  propdrlimi  nf  ehrnnic  alcDluilics  the  kid- 
nevs  ai'e  increased  in  si/,i'.  'I'lio  (iuy's  Hospital  statistics  siipjiort  this 
statement,  and  Pitt  notes  that  in  forty-three  [ler  cent  of  the  bodies  of  hai'(l 
ili'inkers  the  k>dnevs  were  hypertrophied  without  showini:  morhiil  ehanire. 
The  tvjiical  iri'aniilai*  kidney  seems  to  result  indirectly  fnnu  alcohol 
thfouirh  the  arteriiil  (dianijes. 

It  was  forniei'ly  thouy'lit  that  alcohol  was  in  some  way  antairoiiistic  to 
tiihenailous  disease,  liiil  tlu'  oliservatious  of  late  yeai's  indicate  clearly  that 
the  I'e verse  is  the  case  and  that  (dironic  drinkers  arc  much  more  liaiilc  to  lioth 
acute  and  pulmonary  tuhercniosis.  It  is  prolialily  altoL;'et  her  a  i|iiestioe.  of 
altered  tissue-soil,  the  alcohol  jowerini;'  the  \  italily  and  cnaliliun'  the  liacilli 
more  readilv  to  develop  and  irrow. 

(:>)  Delirium  Tremens  {m/niin  a  jxiIh)  i-  really  only  an  iiicideiii   ill   the 

history  of  chi'oiiie  ah'oholism,  and  result^  from   the   lonii-cont  inneil   action 

of  the  poison  on  the  brain.     The  coiidit  ion   was   lirst   ai'ciiralcly  described 

early  in  this  century  by  Sutton,  of  (Ireeiiwicli,  who  had   niimei'ous  oppor- 

liinit-ies  for  studying;"  the  dilfi'rent  forms  amom;-  the  sailors.      One  of  tiio 

most  thoroiiijfli  and  careful   studies  of  the  <li<case  was   nuide  by    Wai'e,  of 

be-tou.     A  spree  in  ,;  lenijicratc  ]iei'soii,  no  matter  Imw  proloii^'ed,  is  rare- 

K  if  ever  followe:l   iiy  delirium   tremens;  but    in   the  case  of  an   habitual 

ihiiiker  a  temporary  excess  is  .apt  to  briiiir  mi  an  attatdx.     it  sometimes 

ileveloiis  in  eonse(|uence  of  the  sudden  withdrawal  of  the  alcohol.     There 

;ire  cireiimstaiii'es  which   in   a    heavy   drinker  deterniinc,  sometimes  witii 

aliiiiptiiess,  the  onset  of  delirium.     Such  are  au  accident,  a  sudden   fri^dit 

iir  shock,  ami  an  acute   inllanimatioii.   pai'ticiilarly   pneumonia.     .\t   the 

uiilsi't  of  the  attack  the  patient  is  rc<lle-s  and  depressed  and   sleeps  l)a<lly, 

symptoms  whi(di  cause  hitn  to  lake  alcohol   nioi'c   freelv.      .\fter  a  ilay  o'" 

two  the  characteristic  delirium  sets  in,      Tl>'    patient    lalk-  ;  onstaiitl v  and 

iiieohercutly  ;  he  is  incessantly  in  motion,  and  desires  to  iro  out  ami  attend 

til  soinc^  imauinacy  business.     IlalliK'inatioiis  of  siufht  ainl  heariuLr  develop. 

lie  sees  objects  in  the  room,  such  as  rats,  mice,  or  snakes,  ami  fancies  that 

tliey  are  craAvling  over  his  body.     The  terror  inspired   by   these   imairiuai'y 

'ilijects  is  ,i^reat,  and  has  sriveii  the  popular  name  "  horrors"  to  the  diseaso. 

Tile  ])atients  need  to  ho  \vat(died  constantly,  for  in  their  delusions  they 

may  jump  out  of  the  window  or  escape,     .\iiditory  hallmdnations  are  not 

><icoinnion,  ])iit  the  patient  may  complain  of  hearintr  the  roar  of  animals 

"I'tlie  threats  <d'  imairinary  enemies.     There   is  much   muscular  tremor: 

till'  tonuriie  is  covered  with  a  thick  wliite  fur,  and  when  jirotrudeil  is  treinu- 

Iws.     The  pulse  is  soft,  ra])i(l,  and  readily  compressed.     'Inhere  is  usually 


'1!  W 


lor.o 


TIIK    INTOXICATIONS,  SUN-STROKE,   OI'.KSITY. 


fcncr,  l)iit  the  tciniK'ratun^  riircly  ro<,Mst(M's  iihovc  U)'i°  or  lo;}°.  In  I'tital 
cases  it  iiui}  la-  hiifliiT.  Jiisoiuiiiii  is  a  (ioiistant  ft'iitiire.  On  the  tliinl  m- 
fourth  (lay  in  i'avoral)i('  cases  tlic  rcstlossiKss  altatcs,  tlic  |)aticiit  sliMps 
and  iiii[)ruvcnR'nt  gradually  sets  in.  The  tivnior  })ersists  for  soini;  (hns, 
the  halhicinations  <ria{liiaily  disappear,  and  the  ap])etite  returns.  In  nioic 
serious  cases  the  insomnia  persists,  the  delirium  is  incessant,  the  \)\i\-v 
liccomes  more  frequi'nt  and  t'cel)le,  the  tonjrue  dry,  thi'  prostration  ex- 
treme, and  deatii  takes  place  from  Lfradual  iieai't-i'ailure. 

Diagnosis. — 'I'he  clinical  i)icture  of  the  disi'ase  can  scarcely  l)e  cdn- 
founded  with  any  other.  Cases  with  fever,  however,  may  he  mistaken  fur 
meningitis,  iiy  far  the  most  common  error  is  to  overlook  some  local  dis- 
ease, such  as  pneumonia  or  erysii)elas,  or  an  accident,  as  a  fractured  rih, 
which  in  a  chronic  drinker  may  jnx'cipitate  an  attack  ol'  delirium  treiiu'iis. 
In  every  instance  a  careful  examination  should  he  made,  particularly  of 
the  luiiirs.  It  is  to  he  remembered  that  in  the  severci-  I'oi'ms,  partieuliu'lv 
the  febrile  cases,  congestion  of  the  bases  of  the  lungs  is  by  no  means  im- 
comnion.  .Vnother  point  to  l)e  borne  in  miiul  is  the  fact  that  pneunidiiia 
of  the  a[)ex  is  apt  to  be  accompanied  by  delirium  similar  to  nuiuin  a 
liiiin. 

Prognosis.  —  Recovery  takes  place  in  a  large  jiroportion  of  the  cases 
in  private  practice.  In  hospital  practice,  particularly  in  the  large  citv 
liospitals  to  which  ihe  debilitated  ])atients  are  taken,  the  death  rate  is 
higher,     (ierhard  states  that  of  l,'-i41  cases  admitted  to  the  I'hiladelpliia 


II 


ospital 


ni'ovcd 


fatal 


Kccurri'nce  is  ireciueii 


t,  al 


if  the  diMuking  is  ke[it  up. 


Treatment. — .\cute  alcoholism  r 


iirely 


nu)st  indeed 


Ue  I'lilr, 


r(>(iuires  any  special  measiir 


as  till'  patient  sleeps  ojf  the  ell'ects  of  .the   debauch.      In  the  case  of  jiro- 


foiind  alcoholic 


('(-, 


.la  it  niav  be  advisable  to  wash  out  the  stomach,  aiui  if 


collapse  symptoms  o(!cur  the  Iiinl)s  should  be  rubbeil  and  hot  ajijilicatinns 
made  to  the   body.     Should   convulsions  supervene,  chloroform   may  lit' 


carefiillv  administered.     In  the  acute,  violent  alcoholic  mania  tl 


le  hy]iii- 


'1,  i< 
icar- 


derinic  injection  of  apoinorphia,  one  eighth  or  one  sixth  of  a  grai 
usually  very  elfectual,  causing  nausea  and  vomiting,  and  ra})id  disapi 
aiice  of  the  maniacal  symptoms. 

Chronic  alcoholism  is  a  condition  very  diHicult  to  treat,  and  once  fully 
established  the  habit  is  rarely  abandoned.  'I'he  most  obstinate  cases  jirc 
are  those  with  marked  hereditary  tendency.  Withdrawal  of  the  alcolml  is 
the  iirst  essential.  This  is  most  {^Ifectualiy  accomplished  by  placing  tlie 
jiatient  in  an  institution,  in  which  he  can  be  carefully  watched  during  tliC 
trying  ])eriod  of  the  Iirst  week  or  ten  days  of  abstention.  The  absi  H' 
of  temptation  in  institution  life  is  of  special  advantage.  For  the 
les.sness  the  bromides  or  hyoseine  may  be  employed.     Quinine  and  si 


sU'cii- 


rvi'li- 


nine  in  tonic  doses  may  be  given.  Cocaine  or  the  lluid  extract  of  coni 
has  been  recomnuMided  as  a  substitute  for  alcohol,  but  it  is  not  of  iiiiuli 
service.     I*rolonge<^l  seclusion  iu  a  suitable  institution  is  in  reality  the  oiil} 


MOHIMIIA    TIAHIT. 


umi 


c'Tcetnal  inciuis  of  cure.  When  the  hcroditiiry  tondcMU'V  is  stron<rly  (Icvcl- 
oped  a  lapse  into  tlie  (lriiikiii<;  lial)its  is  almost  iiu'vitalilc. 

Ill  (k'lirium  trciuciis  the  patient  should  he  eoufiued  to  hed  and  eare- 
I'lilly  wati'lieii  uiiilit  and  day.  The  danger  of  esea[H'  in  these  eases  is  very 
^roat,  as  the  patient  inia<;ines  himself  pursued  hy  enemies  or  d'tnons. 
riint  mentions  the  ease  of  a  man  who  escaped  in  his  niirht-eiothes  and  ran 
liarefooted  for  lifteen  miles  on  the  frozen  ^^n'ound  hefore  he  was  over- 
taken. The  patient  should  not  he  strap])ed  in  hed,  as  this  a<:i:ravates  the 
ilelirium :  sometimes,  however,  it  may  he  necessary,  in  which  case  a  sheet 
tied  across  the  hed  may  he  sutTieient,  and  this  is  certainly  hetter  than  vio- 
lent restraint  hy  three  or  four  men.  Aleohol  should  he  withdrawn  at 
once  unless  the  pulse  is  feehle. 

Delirium  tremens  is  a  disease  which,  in  a  lar<i:e  inajorily  of  cases,  runs 
a  course  very  sli<,ditly  inilueiiced  hy  medicine.  'I'he  indications  for  treat- 
ment are  to  procure  slee])  and  to  support  the  stren^'th.  In  mild  eases  half 
;i  druc-hni  of  hromide  of  potassium  cond)ined  with  tincture  of  eajisicum 
may  he  given  evctry  three  hours.  Chloral  is  often  of  i^nvat  service,  and  may 
lie  given  without  hesitation  unless  the  heart's  action  is  feehle.  (iood  re- 
sults sometinn^s  follow  the  hypodermic  use  of  hyoscine,  one  one-hundredth 
of  a  grain.  Opium  must  he  used  cautiously.  .\  special  merit  of  Ware's 
work  was  the  demonstration  that  on  a  rational  or  expectant  plan  of  treat- 
ment the  i)ercentage  <»f  recovery  was  greati-r  than  with  the  indiscriminate 
use  of  .sedatives,  which  had  heen  in  vogue  for  many  years.  \\  hen  opium  is 
indicated  it  should  he  given  as  morphia,  hy])oderniieally.  The  elfeet 
should  lie  carefully  watched,  and  if  after  three  or  four  (puirter-grain  doses 
li;ive  heen  given  the  patient  is  still  restless  and  excited,  it  is  best  not  to 
push  it  farther.  When  fever  is  present  the  trantpiillizing  elTects  of  a  cold 
ilouche  or  cold  hath  may  he  ti'ied,  or  the  cold  pack.  The  large  doses  of 
iligitalis  formerly  employed  are  not  advis':l)le. 

Careful  feeding  is  the  most  important  element  in  the  treatment  of 
these  cases.  Milk  and  concentrated  hrotiih  tfhoiild  he  given  at  stated 
intervals.  If  the  pulse  V)eoonies  rapid  and  shows  signs  of  flagging  aleohol 
may  he  given  in  ('ond)ination  with  the  aromatic  spirits  of  ammonia. 


II.  MORPHIA    HABIT  {:if(n-phi()m(ini(i :  Jlorphini.wt). 

This  lKil)it  arises  from  the  constant  use  of  morphia — taken  at  first,  as  a 
rule,  for  the  purpose  of  allaying  ])ain.  The  craving  is  gradually  engen- 
ili  red,  and  the  hal)it  in  this  way  acfpiired.  The  injurious  effects  vary 
very  much,  and  in  the  East,  where  oi)ium-smoking  is  as  common  as  tohaeco- 
sJiioking  with  us,  tlie  ill  elTects  are,  according  to  good  ohser\ers,  not  so 
^t  liking. 

The  hahit  is  particularly  ])revalent  among  women  and  ])hysieians  who 
use  the  liypodermic  syringe  for  the  alleviation  of  pain,  as  in  neuralgia  or 


I 


10(52 


TUH   INTOXICATIONS,   SUN-STKOKI-:,   OIIKSITY. 


*^!. 


^4 


scMiitica.     'I'lu!  acfjui.sitioii  of  tlu^  liiibit  us  ti  piiro  luxury  is  raro  in  tin"-; 
con  II  try. 

'I'liL'  syiii|)t(inis  ill  lirst  aro  sliylit,  and  iiiinlcriitc  dosi'S  may  lio  taken  lor 
iiioiitlis  witlidiil  serious  injury  and  willioul  distiii'hiiiicc  of  liealtli.  'rinre 
are  exee|)ii<(nal  instances  in  wliieli  for  a  period  of  years  excessive  i\u>v.<, 
liave  iieeii  taken  witiiout  deteniiiiiatiou  of  tlie  menial  or  hodily  I'liMctions. 
As  a  ruU',  llie  dose  necessary  to  oldain  the  desired  sensations  lias  gradu- 
ally to  be  iiiereased.  As  the  elTecfts  wear  olT  the  victim  ex|>erieii('es  sensa- 
tions of  lassitude  and  ineiilal  ih'pressioii,  aceoinpanicd  often  with  sli<;iit 
nausea  and  epigastric  distress,  symptoms  which  are  relieved  iiy  another 
dose  of  the  drug.  The  eonlirmed  opium-eater  often  presents  a  very  ehni'- 
at'teristic  appearance.  There  is  a  sallowiiess  uf  thu  eomjtlexioii  which  is 
almost  jiatiiognomonie,  and  he  becomes  omuciated,  gray,  and  prematurely 
aged,  lie  is  restless,  irntable,  and  unable  to  ri'inaiu  (|uiet  lor  any  tiiin'. 
Itidiing  is  a  c<iminon  synn»tom.  The  sleep  is  disturlied,  the  appetite  and 
digestion  are  deranged,  and  except  when  direi-tly  uiuler  the  iiillueiice  of 
the  drug  the  nu'Utal  I'ondition  is  one  of  depression.  ()c(  .isionally  there 
are  profuse  sweats,  which  may  lie  preceded  by  chills.  The  [lupils,  except 
when  under  the  direct  intluence  of  the  drug,  are  dilated,  sometimes  un- 
equal. lVrs(jns  addicted  to  morphia  are  inveterali'  liars,  and  no  reliiiiuf 
wh.itever  can  be  placed  upon  their  statements.  In  nuiny  instances  this  i> 
not  confined  to  nnitters  relating  to  the  vice.  In  women  the  symptoms  niny 
be  associiiti'il  with  ihose  of  pronouncid  hysteria  or  neurasthenia.  Tho 
practice  may  be  continued  for  an  indelinite  time,  usually  re(|uiring  in(;re:i<f 
in  the  dose  nntil  nltimately  iMiornmns  (pumtities  may  be  net'ded  to  obtiiiii 
the  desiri'd  elTect.  JMiially  a  condition  of  asthenia  is  induced,  in  which 
the  victim  takes  little  or  no  food  and  dies  from  the  extreme  bodily 
debility. 

The  frcdiiiii'iil  of  the  morphia  habit  is  extremely  dillicult,  and  i-iii 
rarelv  In-  successfully  carried  out  by  the  gi'iieral  practitioner.  Isolalimi, 
systematic  feeding,  and  'fradual  withdrawal  of  thedi'ugare  the  essential 
elements.  As  a  rule,  the  patients  must  be  under  control  in  an  institution 
aiul  shonid  be  in  bed  for  the  first  ten  days.  It  is  best  in  a  majority  nf 
cases  to  reduce  the  morjihia  gradually.  The  diet  should  consist  of  iu'cf- 
juices,  milk,  and  egg-white,  which  should  be  given  at  short  intervals.  The 
sufferings  of  the  pjitients  are  usnally  vcit  great,  more  jiarticularly  the  ab- 
dominal pains,  sometimes  nausea  and  vomiting,  and  the  distressing  rest- 
lessness, rsually  within  a  wi-ek  or  ten  days  the  opium  may  be  entirely 
withdrawn.  In  all  cases  the  pnkse  should  be  carefully  watched  and.  if 
feeble,  stimulants  .should  be  given,  wi:h  the  aromatic  spirits  of  ammniuu 
and  digitalis.  For  the  extreme  restlessness  a  hot  bath  is  .serviceable.  Tlu 
sU'ejilessness  is  the  most  distressing  symjitom,  and  various  drugs  may  ha\o 
to  be  resorted  to,  iiarticularly  hyoscine  and  sulphonal  and  sometinu  -.  if 
the  insomnia  persists,  morphia  itself. 

It  is  essential  in  the  treatnu'iit  of  a  case  to  be  certain  that  the  [lali'  ut 


I'Y. 


LKAD-rOISONIXG 


J  0(1:] 


/  is  rare  in  llii-^ 

nay  l>o  talscii  I'm- 
f  lu'alLh.     'Hino 
s  cxft'risivo  (Id.-is 
hdilily  runciiuiis. 
lions  has  j,n'a«lii- 
x|HTii'iu'('s  sciisa- 
ol'lcii  w'itli  slight 
ievi'd  Wy  aniitlirr 
ionls  a  vi'i-y  cliai'- 
iipk'xiuu  whicli  is 
,  and  prc'iiiaturfly 
|iii('t  I'or  any  timr. 
,  tl\('  appt'tiU'  and 
!•  till'  iutlniMiiT  of 
Occasionally  thnv 
Till'  pnpils,  v\rv[)\ 
li-d,  sonii'tinirs  uii- 
rs,  and  no  ivliaiur 
iiv  instanct-'S  ihir-  i> 
liu'  synii)ton\s  inay 
u'urastlu'nia.      TIh' 

n'(|uirinfi;  increase 
,e  mvdrd  to  nlitnia 

indured,   in  wliirli 
hv  extreme   Imdil} 

difficult,  and  can 
llitioner.     Isolation, 
\-y  are  Hh'  essential 
•ol  in  an  institution 
l^.st  in  a  nnijority  of 
,ii,l  coiisist  ot;  Inrf- 
hort  intervals.    Tl'^' 
particularly  the  ;>1'- 
lu-  distressin.o;  n>t- 
iiu  may  bo  entirely 
illy  watrhed  and.  if 
spirits  of  ammor.ui 
is  .scrvicoable.    'H"' 
,,us  drugs  may  have 
.1  and  sometime-,  if 


lias  710  moans  of  obtaitung  morpliia.  Kvon  uiidcM-  llic  favorable^  eircmii- 
staneos  of  seclusion  in  an  institution,  and  constant  watidiiiiLT  by  a  niirlit  and 
a  day  nurse,  I  have  known  a  patient  to  practice  deception  for  n  pcrio(|  of 
tliroo  months,  .\rter  an  apparent  cure  the  patients  are  oidy  too  apt  to 
lapse  into  the  ha!)it. 

'I'he  condition  is  one  which  has  beeomo  so  oommcm,  and  is  so  iiincli  on 
the  increase,  that  physicians  shoulij  exercise  the  utmost  cantiiii  in  pre- 
.serihinjf  morphia,  particularly  to  female  patieids.  I'lider  no  circnnistani'cs 
whatever  should  a  patient  with  neuralizia  oi'  sciatica  he  allowed  to  use  the 
hy[)()(Uu'ini(;  syringe,  and  it  is  oven  .safer  not  to  intrust  this  dangerous 
instrument  to  the  hands  (»f  the  nurse. 


III.    LEAD-POISONING  (/'/umlnSm  .-  S>ifuniis,„). 

Etiology. — The  disease  is  wide-spread,  particularly  in  lead-workers 
and  among  pluinbers,  painters,  and  gla/iei-s.  'i'he  metal  is  introduced 
into  the  .system  in  many  forms.  Miners  usually  escape,  but  those  engagetl 
in  till!  smelting  of  lead-ores  are  often  attacked.  Animals  in  the  neighbor- 
hood of  smelting  furnaces  have  siilTered  with  the  disease,  and  even  the 
iiii'ds  that  feed  on  the  berries  in  the  nei!.:;h'.)orlio(»d  may  bo  atfected.  Men 
engaged  in  the  white-lead  factories  ai'c  particularly  prone  to  pliiml)isin. 
Accideiilal  contamination  may  come  in  many  ways;  most  coninionly  l)y 
drinking  water  which  has  ()asse(l  thnaigh  lead  ])ipes  or  heen  stoi'eil  in 
lead-lined  eisterns.  Wines  and  cider  which  contain  acids  (piickly  b(!coiiie 
contaniinatod  in  contact  with  lea<l.  It  was  the  freipieney  of  colic  in  eer- 
lain  of  the  cider  districts  of  Dovonsliii'o  which  gave  the  name  Devonshire 
colic,  as  the  freijuenoy  of  it  in  Poitou  gave  the  name  (■d/ic/!  I'ldinniin. 
.Vmong  the  iiinumerable  sources  of  accidental  contamination  may  be  men- 
tioned milk,  various  sorts  of  beverages,  hair  dyes,  false  teeth,  and  thread. 
.\  .serious  outliroak  of  load-poisoning,  whiidi  was  investigated  by  David  I). 
Stewart,  occurred  recently  in  Pliiladol[)liia,  owing  to  the  disgraceful  adul- 
teration of  a  iiaking-powdor  with  chromate  of  load,  vhicli  was  used  to  give 
a  yellow  tint  ^o  the  cakes.  Lead  givt'u  medicinally  rarely  ])roducos  poison- 
ing. 

All  ages  an-  attacked,  but  J.  J.  Putnam  states  that  children  are  ri'la- 
tively  les.s  liable.  The  largest  number  of  cases  occur  between  thirty  and 
foi'ty.  According  to  Oliver,  from  whoso  recent  (ioulslonian  lectures  I  here 
i|iiote,  females  arc  more  susco[)tihle  than  males.     lie  states  that  they  are 

•h  more  quickly  brought  under  its  inthience,  and  in  a  rec(Mit  epidemic 


nuu 


ill  which  a  thousand  cases  wore  involved   the   proportion  of  females  to 
liialos  was  four  to  oiio. 

The  load  gains  entrance  to  the  system  through  the  lungs,  the  digestive 
oigans,  or  the  skin.     Poisoning  may  follow  the  u.so  of  cosmetics  contain- 
lain  that  the  patiiut  ■     j^jr  1^^^^    Through  the  lungs  it  is  freely  absorbed.     The  chief  chunuol, 


I(»<i4 


TIIK    INTOXICATIONS,  SUN-STUOKK,   OliKSITV. 


if 


acconliiiLr  to  Oliver,  is  tlic  diifcstivc  system.  It  is  rapidly  climitiatod  iiv 
the  kidneys  and  skin,  and  is  present;  in  tiie  urine  of  lead-workers.  Tlic 
iuiS(;oi)til»iIity  is  reiiiarkahly  varied.  Tho  syniptoinn  may  !»('  nianit'est  \viil| 
u  iMontli  of  exposiire.  On  the  otiier  hand,  TaiKpierel  (des  I'l;:nclies)  iin  i 
with  a  ease  in  a  man  who  had  been  a  leail-worker  for  lifty-two  years. 

Morbid  Anatomy.— Small  4nantilies  of  lead  occur  in  the  h<»\\  ui 
health.  .1.  J.  i'utiiam's  reports  show  that  of  l.')t»  persons  iU)t  presentiiiLT 
Hymptonis  of  load-poisoning  tractes  of  lead  occurred  in  the  urine  of  '4'>  p.r 
cent. 

In  chronic  poisonin^^  lead  is  found  in  t lie  various  ori,'ans.  'I'lie  atl'ecti  i| 
muscles  are  yellow,  fatly,  and  tihroid.  Tlu!  nerves  j)resent  the  features  n|' 
a  peri]>heral  dei^enerativo  neuritis.  'Phc  cord  and  tlu?  nerve-roots  are,  a-  u 
nik',  nniiivolveil.  in  the  primary  atrophic  form  the  <j:an,i,dion  cells  of  the 
anterior  hurus  are  proliahly  involved.  In  the  acute  fatal  cases  there  iiuiv 
be  the  most  intense  entcro-colitis. 

Clinical  Forms. — Acute  J'oisdin'ti;/. — We  do  not  refer  here  to  thi- 
accidental  or  suicidal  cases,  which  j)resent  vomitinji,  pain  in  the  ahdoiiicii, 
and  c{)llai»se  .symptoms.  In  workers  in  lead  there  arc  several  nuinifesiu- 
tions  whicdi  follow  a  shoi-t  time  afti-r  exposure  and  set  in  acutely,  'riuic 
may  he,  in  the  tirst  place,  a  rapidly  developing  ana'mia.  A(uite  neuritis  lias 
been  (Icscrrijcd,  and  coiivalsic.us,  oiiTlep.sy,  and  a  delirium,  which  may  lir. 
as  Stcphci'  Mackenzie  lias  iio*^eil,  not  unlike  that  jinnliiced  by  alcolnil. 
There  are  also  cases  in  which  the  gastro-intestinal  symptoms  are  iimst 
intense  and  rapi'lly  i)rove  fatal.  There  was  admitted  nnderniy  care  in  the 
IMiihulelphia  lIos])ital  a  jiaiiucr,  aged  fifty,  suffering  with  aniemia  .iiul 
£  vere  abdominal  pain,  which  liad  lasted  about  a  week.  He  had  vomitiiiLr. 
constipation  at  tirst,  afterward  severe  diarrluca  and  mehena,  with  distention 
and  tenderness  of  the  al)domen.  There  were  albumin  and  tube-casts  in  thu 
urine.  The  temperature  was  usually  subnormal.  Death  oc(!urred  at  tlif 
end  of  the  second  week.  There  was  found  the  most  intense  cnttn'O-colitis 
with  lia'morrhages  and  exudation.  'IMie.se  acute  form.s  develop  more  fiv- 
qiiently  in  |)ersons  recently  exposed,  and,  according  to  Mackenzie,  are  nioix' 
frequent  in  winter  than  in  summer. 

(?/i ran ic po jso niiiy  ])resents  the  following  .symptoms: 

{a)  Anwinia,  the  so-called  saturnine  cachexia,  which  may  be  profouiul. 
As  a  rule,  however,  the  corpus(des  do  not  sink  below  50  jier  cent. 

{/j)  nine  line  on  gums,  which  is  a  valuable  indication,  but  not  invari- 
ably jirosent.  Two  lines  must  be  distinguished:  ojie,  at  the  margin  in- 
tween  the  gums  and  teeth,  is  on,  not  \\\  the  gums,  and  is  readily  removeil  liv 
rinsing  the  mouth  and  cileansing  the  toeth-  The  other  is  the  vvell-kncwu 
characteristic  blue-hlack  line  at  the  margin  of  the  gum.  The  color  is  imt 
uniform,  but  being  in  the  papilla;  of  the  gums  the  line  is,  as  seen  wiiii  n 
magnifying-glass,  interrupted.  The  lead  is  absorbed  and  converted  in  tin' 
tissues  into  a  black  sul[>liide  by  the  action  of  sulphuretted  hydrogen  finiii 
the  tartar  of  the  teeth.     The  line  may  form  rapidly  after  exposure  aud 


'V. 


LKAIM'UISOXINI}. 


100 


K) 


r  eliminated  l^y 
-workers.  'I'lic 
(>  nianift'rit  wiih 

S    IMl.llclu'S)   lIKl 

■two  yciirs. 
r  ill  the  1iim1\  111 
■<  not  iiri'SiMitiiiLT 
•  urine  of  ^.")  per 

IS.  The  atTe.tiil 
t  the  feutiuvri  uf 
ve-roots  are,  as  a 

i^rlioll    Ci'Us  of  till' 

ca.seri  there  may 

refer  liere  to  thr 
in  tlie  ulxhinicii, 
I'Veral  nianifesta- 
aoutely.     'Huto 
Vciite  neuriti.H  lias 
1,  which  may  l^i', 
lucetl  by  aU'olini. 
iii[>toins  are  im'st 
fler  my  care  in  tlif 
ith  anu'mia  ami 
had  vomiting', 
I,  with  distciitinii 
tube-casts  in  \\\v 
(HHturred  at  tlii.' 
use  entero-eolitis 
>velop  more  fi''- 
•keuzie,  are  nmie 


may  be  profouiul 
)er  eeut. 

iU,  Init  not  invari- 
at  the  margin  l)i- 
,>adily  rem  (net  1  'iv 
is  the  well-kudwu 
The  color  is  imt 
is,  as  seen  "with  a 
;l  eonverted  in  tlu' 
:mI  liydrogen  fi'Hi' 
ftor  exposure  aud 


^ 


Kmk; 


TlIK   INTOXK'ATIOXS,   SUN-STUOKi:,   OI'.MSITV. 


(ini^irnHxt'il  I'lilsiis. — 'I'licrc  iiiiiy  lie  ii  slow,  cliroiiit^  juiralysifj,  {rr,i  In. 
jilly  iiivdlviii^'  tlif  cxtrt'tiiitics,  hcLjitiiiiii:;  with  the  clas-iii-il  iiictiiir  (,f 
\vi'i>t-(lr()|>.  Mure  ri'r(|iiciitly  I  here  is  a  rapid  L'l'iicrali/atiiin,  |inMliii 'iii; 
(•(tinpli'tc  paralysis  ill  all  llic  imisrlcs  ot' the  parts  in  a  IVw  days.  It  jiku 
jtiirsiic  u  ('(tiii'sc  liUc  an  ascciidiiii;  [lai'alysis,  associated  with  rapid  wa.-liiii,r 
(•fall  t'liiir  limits.  Siirji  cases,  Iniwovcr,  arc  very  rare.  DiMfh  lias  occiirinl 
l>y  iii\(ilvcinciit  (if  the  diaplira;,Mii.  Oliver  reports  ii  case  (if  I'liiiipson"-  in 
which  complete  paralysis  siiperveiici].  I  )e jeriiie-Kluiiipke  also  rcco^nizis 
a  I'eiirile  foi'iii  of  ;:eiieral  paralysis  in  lead-poisoning,  which  may  clo-clv 
r('send)l(^  the  sid)acnte  spinal  paralysis  of  Duchenne. 

There  \A  also  a  primary  satnrnii'.'  miiscniar  atrophy  in  which  ilic 
ess  and  w.ast  im,' come  on  toi^^ether  and   develop   pi'opoi'l  ionatelv.     It 


weals  11 


iw  this  form,  according  to  (lowers,  which  inctst    fri'ipieiitly  assumes   tlic 
Aran-J)iichenne  type. 

'I'lie  electrical   reactions  are  those  of  lesions  of  the  l(»wer  motor  sci;- 


iiient.and  have  hceii  descrihed  under  lesions  of 


lie  nerve 


he  deireiHi'- 


ivc  reaction  in  its  dill'erent  grades  may  he  present,  depending  \\\ 


at 


Severitv  of  the  disease, 


loll  llir 


I'sually  with  tli<'  onset,  of  the  paralysis  there  are  pains  in  the  leg.- 
joint.s,  the  .so-calh'd  sacnrniiie  arthralgias.  Si'usation  may,  howeve 
ulianVeted. 

('')    The  rrrrhraJ  sijiiiphniix  are   numerous.     Optic   neuritis  oi'  n 
retniitjs  Diay  develop.      Ilysti'rical  .-symptoms  occasionally  occur  ' 
Convulsions  are  not  uncommon,  and   in  tits  devel 


ami 
r,  111' 


eliro- 


opiny  111   tile  a 


po.ssihility  of  h'ad-poisoiiing  should  always  bu  considered,  'i'riie  epiic|i.-v 
may  follow  the  convulsions.  An  acute  (jelirium  may  occur  wit  h  halliiri- 
nations.  The  patients  may  have  traiieerlike  attacks,  which  follou  or 
alternate  with  convnlsioiis.  A  few  cases  of  li'ad  encephalopathy  lliiallv 
drift  into  lunatic  asvlums.  Tremor  is  ono  of  tlio  commonest  manil'istii- 
lions  of  lead-poisoning. 

(/')  A)icri()-srlcrusi>t. — Lead-workers  are  notoriously  subject  to  aitr- 
rio-sclerosis  with  contracted  kidneys  and  hypertrophy  of  the  heart.  Tln' 
cases  usually  show  distinct  gouty  deposits,  [larticularly  in  the  big-lur 
joint;  but  in  this  country  acute  gout  in  lead-workers  is  rare.  Accordiiii,' 
to  Sir  William  Hol)ert.s,  the  lead  favors  the  precipitation  of  the  crystalliiit 
urates  of  the  ti.ssues»  b'alfo  has  shown  that  lead  diminishes  the  alkalinity 
of  the  blood,  and  so  lessens  the  solubility  of  the' uric  acid. 

Prognosis. — In  the  minor  manifestations  of  lead-])oisoning  tlii-^  i- 
goi_)£[.  A(-cordiiig  to  (iowers,  the  outlook  is  bad  in  the  ])rimary  atropliii' 
form  of  paralysis.  Convulsions  arc,  as  a  rule,  serious,  and  the  mental 
symptoms  which  succeed  maybe  peiMnaucnt..  Occasionally  the  wrist-diup 
persists. 

Treatment. — Prophylactic    measures    should    be  taken  at  all    Icii'I- 


■woi 


ks,  b 


lilt   unless  employes  are  careiiil    poisoning  is  apt  to  occiii 


CVi'll 


under  the  most  favorable  conditions.     (  leanliiicss  of  the  hands  and  of  tl 


I'Y. 

[iiiralysiii,  pralii- 

«ic;ll     pil'tlU'r     nf 
ition,    priiilurlli;; 

w  (hivs.     ll  jiiiiy 

til     I'illlill    Wll.-til)^' 
•iltll    IkIS  Ol'CUIlVll 

dl"  riiilipsoii".-  ill 
u'  iilso  rccojfui/r'i 
vliicli  miiy  cln-ily 

liv  ill  wliii'li  ilic 
i)|)()rtiiiiKilt'ly-  It 
iilly  iissiinit's  lln' 

lower  motor  m-^- 
cs.  'I'lir  ilcL'i'iuT- 
p'Muliii.u;  141011  ilii' 

lis  ill  the  leg.'*  iind 
iiiiiy,  howoviT,  1h' 

neuritis  or  nnn'n- 

jlUy   oiriir  '        "'-■ 

IT  in   liic  ;i  ''••' 

,     'rnii'.  f|Mirii.-y 

riir  witti  liiilluri- 

wliicli    follow    "V 

liiilopiithy  litiiilly 

noiicst  luiuuftstii- 

y  subject  to  inn- 
,f  the  heart.  'I'll'' 
Iv  in  the  l)i,i:-t"^' 
is  rare.  Aecordiir: 
,,f  the  erystalliin- 
ishe.s  the  alkalinity 

eid. 

il-poisoniiig  thi>  i- 
11.  primary  atroi'lii'' 
s,  ami  the  meiitul 
uiUy  the  wririt-eli"!' 

taken  at  all  I'^i'l" 
jijtt  to  octnir  evni 
,e  liaiuls  ami  el'  tlie 


AHSKNK  AL   l>(»IS()NMN(i. 


10( 


M 


finger-nails,  fre(|iient  halhing,  ami  the  iisi'  nf  respirators  when  iKvessary, 
siioiild  lie  insisleij  upon.  When  the  had  is  in  tlie  system,  tin!  iodide  of 
iiotassiiim   should   he  >riven  in  iVuni    li\e-  to  ten-uraiu  doses  three  times  a 


dav.      l''or  the  <Mili( 


loeai  appiicalions  iind.  il  .-evere,  tnnrplmi  may  lie  used 


An  occasional  morning  purge  id'  sulphate  i>(  magnesia  may  l)e  given.  l'"or 
I  he  anaMiiia  iron  siiould  I'c  used,  in  the  very  ai'Ute  eases  it  is  well  not. 
lo  give  the  iodide,  as,  according  to  some  writers,  the  lilieralion  of  the  lead 
whiidi  has  hcen  deposited  in  the  tissues  may  increase  the -evcriiy  of  the 
syniplonis.  l''or  llii'  local  palsies  nuLSsage  and  the  eon.>la!it  eiirniit  ^hoiiM 
he  useil. 


IV.    ARSENICAL    POISONING. 

Ariifr  piiisiDilinj  l)y  ai'senie  is  common,  |iartieularly  hy  Paris  greon  ami 
HM(di  mixtures  as  ••  K'ougli  on  Hats,"'  whi(di  are  \\:<v\.\  to  destroy  vermin 
,111(1  insects.  'The  (diief  symptoms  are  inli'iisc  pain  in  the  stomaidi,  vomit- 
ing, ami,  later,  colic,  with  diai  rluen  and  tenesmus;  occasionally  the  symp- 
toms are  those  of  collapse,  if  recovery  takes  jdace,  paralysis  may  follow. 
The  treatment  should  lie  similar  to  t hat  <d'  other  irritant  poison.* — rapid 
removal  with  the  stomach  pum[i,  the  pi(UiiolioM  of  vomiting,  and  the  use 
of  milk  and  i''^]:^!^.      if   the  poison  has  hi'en  takci   in  solution,  tiialyzed 


iron  niav  oe  used  111  iarti'e  doses  o 


f  from  six  to  eiL:lit  draclm 


IS. 


('//runic  .1  rscitifiil  I'nisiiniini. —  Arsenic  is  used  extensively  in  the 
arts,  particularly  in  the  manufacture  of  colored  papers,  artiiicial  llowers, 
and  in  many  of  the  fabrics  emjdoyed  as  clothing.  The  glazed  green  and 
lid  papers  used  in  kindergartens  also  contain  arsi'iiie.  It  is  present,  too, 
ill  many  wall-papers  and  carpets.  Miudi  attention  luio  been  paid  to  this 
i|iiestioii  of  late  years,  us  instances  of  poisoning  have  been  thought  to  de- 
peiid  upon  wall-papers  and  other  houseludd  fabrics.  The  ar.^eiiie  eon\- 
|iiiunds  may  be  either  in  the  form  of  solid  jiarticles  detached  fi'oin  the 
paper  or  as  a  gaseous  volatile  body.  The  iiiveslii^atioiis  (d'  (losio,  eoii- 
liriiied  by  Sanger,  have  shown  that  a  volatile  eompoiiiid  is  formed  iiy  the 
action  on  arsenical  organic'  matter  in  wall-papers  of  sevei'al  moulds,  notably 
pciiieillitni  brevicaule,  miicor  miieedo,  I'tc.  in  moisture,  and  at  a  tein- 
pcraturo  of  from  (.!()°  to  9.")°  F.,  a  volatile  coinpoiiiiil  is  .set  free,  pi'obal)ly 
"an  organic  derivative  of  arseiiii;  peiitoxide'"  (Sanger).  The  idironic 
jioisoning  from  fabrics  and  wall-papers  may  be  due,  according  to  this 
author,  lo  the  ingestion  of  miniiti'  continued  doses  of  this  derivative, 
'•  which  from  its  state  of  oxidation  is  liktly  to  be  aeenmulated  in  the  sys- 
ti  111,  from  wliiidi  it  is  slowlv  eliiiiinateil.'"     Arsenic  is  eliminated  in  all  the 


M-cr 


etions,  and  has  been  found  in  tlu'  milk.     .1.  d.  I'utnam,  it 


hoiild  oe 


1  b 


I'liiembered,  has  shown  that  it  is  not  uiicommon  to  Iind  traces  of  arsenic; 
ill  the  urine  of  many  persons  in  apparent  health  (.'ii)  per  cent).  Tho 
(■H'ects  of  moderate  quantities  of  arsenic  are  not  infrerpiently  seen  in 
iiiedieal  practice.     In  chorea  and  in  pernicious  aiuemia,  steadily  increas- 


10G8 


TIIK   INTOXICATIONS.   SFN-STROKE,   OBHSITY. 


Ikmu. 


Bl 


''."k 


inir  •li>^(  s  iireofk'H  <i'\\v\i   until  tlif  patient  takes  from  fifteen  to  twenty 
(lro|i,s  of   l''o\vler's  solution   three  times  a  day.      ."lusliini;  anil  liyjieraMiiia 


)f  ti 


le  sKin. 


pull 


IIU'SS  o 


f  tl 


10  eveluls  or  i 


ibovo  the  t'vebrows,  nausea,  voi 


nii- 


injr,  and  diarrluea  are  the  most  common  sym})toiiis.     IJedness  and  son 
times  bleediiiiif  of  the  pums  and  salivation  oeeur.     In  the  protracted  ;; 


ministration  of  arsenic  patients  may  complain 


if  111 


imoness  ;ind  tiiiiiiiii'' 


in  the  fingers.  I'igmentation  of  tlio  skin  I  have  seen  on  si'veral  occasions. 
In  chorea  neuritis  has  occurred,  and  a  patient  of  mine  with  lfod<ifkiirs 
di.sease  developed  iiuiltiple  neuritis  after  taking  3  iv  3j  of  Fowler's  solu- 
tion in  seventy-iive  days,  during  which  time  there  were  fourteen  days  on 
wliicli  the  drug  was  omitted. 

In  the  slow  poisoning  by  the  absorption  of  arsenic  in  minute  doses,  as 
from  wall-})aper  and  falu'ics,  tliesyin])tomsare  varit'd.  d.J.  I'litiiam  groups 
them  into  the  cases  in  which  the  symptoms  mainly  concern  the  general 


nutrition  without  signs  of  local  irritation 

)f  tl 


tl 


lose  111  wliicn 


tl 


le  sv 
til 


nijit 


OIIIS 


VOIIS 


are  due  to  irritation  ot  the  (•onjiinctiva',  nioutii,  or  jiharynx  ;  those  with 
symptoms   pointing  to   the  digestive  tract;    cases  with  marked  ner 
j)heiionie!ui ;  and  those  in  whicii  the  nutrilion  of  some  special  })art  of 
bodv  is  involved.     The  most 


common  svn 


i[)toms  are  those  of  aiuvmia 
debility,   ])erliaps   with   slight    irritation  of  the   mucous  membrane,  a 


nm 


III! 


nil 


mbness  and  tingling,  and  gastralgia.,  How  far  these  symptoms  are  to 
be  attributed  to  the  small  quantities  of  arsenic  absorbed  from  wall-paptis 
aiicl  fabrics  is  by  some  considered  doul)tful.  'I'iiat  childi'eii  and  adults 
may  take    with    impunity    large    doses    for    months    without    unpleasant 


■tfect> 


and  the  i'ai't  of  the  Lrradiial  estalili-hment  of  a  toh'i'ation  wlii 


eiialiles  Styrian  j)easants  to  take  as  much 


eiilht  irrains  of  arsei 


ell 


nulls 


acKl 


in  a  day,  speak  strongly  against   it.     Ou  tlie  other  hand,  as  Saii;:cr 


states,  we  do  not  know  accurately  the  elTects  of  many'  of  the  conip 


oiiiias 


in  mimite  and  lonsr-coiit iniicd  d( 


iiotablv  the  arsenate, 


Ar.^niiral  jiiiriiljisin  has  the  sanii'  characteristics  as  lead-palsy,  but  rbc 
legs  are  more  all'et'ted  than  the  arms,  particularly  the  extensor^  and  pi  re- 
iieal  group,  so  that  the  patient  has  the  characteristic  sfvppiKje  gait  el 
jieripheral  neuritis. 

The  electrica'  reaction  in  the  muscles  may  be  disturbed  before  anv 
loss  of  power,  and  when  the  patient  is  asked  to  I'Xteiid  the  wrist  fully  auil 
to  spread  the  lingers  slight  weakness  may  be  delected  early. 


PTOMAIXE   POISONING. 


1000 


V.    PTOMAINE    POISONING. 


Ill  the  bacterial  (Icconiiinsition  ot'  animal  iiiaticrs  ciu'iiiical  ('oiiipo'"M]3 
arc  fonupd,  the  jnitret'ai'live  alkaldiih  known  as  ptomaines  and  to  ■!  s, 
some  of  which  are  hiirhly  jioisonoiis.  They  dillri'  cxlraonliiiarily  in  their 
chemical  i-haracters  and  jihysi()ioL;ical  elTccts.  Some  only  are  li;. 'ions, 
and  these  Hricifer  has  desi^niated  as  toxines.  The  sjK'cilie  actii  •  of  liie 
inicri)-or<j;anisms  in  disease  ■  now  attril)ntcd  in  lar^e  part  to  the  forma- 
tion of  tliesc!  bodies,  anil  the  whole  (juestion  of  immunity  and  pi'otection 
is  now  lieinir  worked  out  in  this  direction,  a  special  stimulus  having  been 
liiven  of  lat(!  in  the  discovery  by  ilaiikin  of  the  so-ealleil  defensive  alka- 
loids (see  under  I'lu'umonia). 

Our  interest  iiero  is  in  the  eireets  of  these  poisons  when  taken  with 

foods.* 

It  is  (jiiite  possil)le  that  tlio  leueomaiiies,  the  l)asi(!  substances  formiMl 
in  the  livin<f  body,  may  under  certain  circumstances  be  capable  of  causinif 
disease.  Proilucts  also  of  the  i)acterial  decomposition  in  the  inti-stines 
inav  be  absorbed  and  act  as  poisons.  Our  knowledge  on  these  points  is  as 
yet  scanty  and  uncertain.  A  sn«r,srostive  chapter  (XI 11)  upon  the  sul)ject 
is  to  be  found  in  the  work  of  Vaiighan  and  Xovy. 

Ainon<r  \ho  more  common  forms  arc  the  following  : 

(1)  Meat  Poisoning. — Cases  have  usually  followcil  tin*  eating  of  sau- 
.-ii'ics  or  pork-})ic  or  hcad-checsc,  and  also  occasionally  beef,  veal,  and  mut- 
ton. S.iusag(!  jtoi.soning,  which  is  known  by  the  name  of  (mhiUsiii  or 
nUdutii  <is,  has  long  been  rec.'ognized,  and  there  have  been  numerous  out- 
breaks, particularly  in  jtarts  of  (icrmany.  Similar  attacks  have  Iteen  ])]■(;- 
ilnced  by  ham  and  by  head-cheese,  'i'hc  pi'ecise  nature  of  the  poison  in 
llic.se  cases  has  not  yet  been  determined.  Other  oiitbicaks  have  followi'd 
the  eating  of  beef  and  veal.  In  the  majority  of  these  cases  the  meat  has 
undergone  decomposition,  though  the  change  juay  iu)t  haw-  been  evident 
to  the  taste.  The  symptoms  of  meat  poisoning  are  those  oi'  acute  gastro- 
intestinal irritation.  I^allard's  dcseripiion  of  the  Wcllbeck  cases,  (pioted 
liy  Vaughan,  ludds  go.xl  for  a  nuijoi'it\  of  them  : 

"A  ])criod  of  incul)ation  preceiled  the  illness.  In  .M  cases  where  this 
'luild  be  accurately  detei'mine(l,  it  was  twelve  hours  or  less  in  .")  cases;  be- 
luecn  twelve  ai\d  thirty-six  hours  in  'M  cases;  b;Mveen  thirty-six  and 
''H'ty-eight  hours  in  S  cases ;  and  later  than  this  in  "idy  I  cases.  In  many 
i;i-i's  the  tirst  delinite  .symptoms  occurred  sinldo.iy,  and  evidently  uncx- 
letodly,  but  in  some  cases  there  weri'  oitserved  during  the  incubation 
iiinro  or  less  feelitig  of  languor  ami  ill-health,  loss  of  appetite,  nausea,  or 
fugitive,  griping  pains  in  the  belly.     In  about  a  third  of  the  cases  the  lirst 


*  For  a  full  (li.-^cussion  of  tho  wholo  salijopt  tho  student  is  rpfcrred  to  the  Mnmml 
U'  la  Ptoinaini's  iind  lii'ueoniiiinos,  In  Vauglian  uad  N'ovy,  scfoiul  oditioii,  I'liiladi'l- 

illMll,  isui. 


1070 


Till';   IXTOXICATIOXS,  SUN-STROKK.  (H'.KSITV. 


deliiiiU'  syiii|itoin  was  a  seiiso  of  fliilliiio?,«,  usually  with  riirors.  or  trom- 
bliuj^f,  in  one  cases  ucronipanicil  hy  dvspnn'a;  in  a  U-w  cases  it  was  i^iddj- 
no.ss  with  faiiitiu'ss,  soiiictiuu-^  accii;n|innii'd  hya  culd  sweat  an  1  totteriu'j  ; 
in  othei's  the  lirst  symptom  was  headache  or  jiain  soniewhei'e  in  the  trunk 
of  llu!  body — e.  Lf.,  in  the  chest,  l)ack,  between  the  shoulders,  or  in  the  ab- 
donu'ii,  to  which  part  the  i-ain,  wherever  it  miirht  have  comineiu'ed,  subs"- 
(|uently  extended.  In  one  ca-e  the  first  sym|)ttim  noticed  was  a  dilliculi  . 
in  swallowiuL,'.  in  two  cases  it  \va-  intense  thirst.  Ihit  howcvci'thc  attack 
may  have  comnu'iu-ed,  it  was  usually  not  hmir  Ijcfore  pain  in  the  abdomen. 
diiirrlura,  ami  vomitim,' came  on,  diarrho'ii  be  in;;  of  m<ii'e  certain  occur- 
rence than  vomitini:.  The  pain  in  several  cases  commenced  in  the  clu-r 
or  between  the  shouldci's,  and  e\teiide(l  first  tn  the  up[)er  and  then  to  tlir 
lower  part  of  the  abdomen,  it,  was  usually  very  severe  iiidceii,  (piicklv 
]H'oducin;;  prosti'ation  or  faintness,  with  cold  sw<>ats.  It  was  vai'iouslv  di- 
.seribed  us  erumpy,  burnini,^  teai'imr,  etc.  The  diai'rlueal  discdiarires  wdv 
in  some  cases  ((uite  nnrestrainable,  and  (wlu're  a  description  of  them  could 
be  oblaiue(l)  wei'c  said  to  have  been  exceediniiiy  otl'cnsive  and  usually  of  a 
dark  colm', 


M 


uscular  weaKiiess  w;is  an  cai'lv  and  verv  remarkaole  svmp 


tom  in  nearlv  a 


II  tl 


10  eases,  and  in  maiw  it  was  so  iri'cat  that  tlus  initieiit 


could    onlv  stand   bv  lioldinsjf   on    to    soinethinir-     ileaihudie,  .souietii 


IK'S 


sevei'e,  was  a  common  and  earlv  svmptom 


am 


I   in  most  ca>es  ther 


0  w;h 


thirst,  nfteii   intense  and  most  distressinii'.     The   tnim-ne,  when   observed 


rciwu,  velvi't  V  fur,  but  re 


was  deseribeil  usually  as  thickly  eoatt'd  with  a  b 
at  the  tip  and  edires.  In  t'.io  early  staLic  the  skin  was  often  cold  to  the 
touch,  but  aftt'rwaj'd  fevei-  set  in,  the  temperature  risinjjj  in  some  cases  to 
ItU/',  lit;}",  ami  104'  I',  in  a  few  severe  cases,  where  the  skin  was  aetmdiy 
cnld,  the  jiatient  complained  of  heat,  insisted  on  throwinii'  olT  tlu'  bed- 
elolhes,  and  was  very  restless.  The  pulse  ii\  the  heiiiht  of  the  illness  be- 
came (piick,  (.'ountinjj:  in  some  cases   KM)   to   I'.'S.     The  above   wer(>  the 

however, 

now    lll'n- 


ici'  svmiitoms  occurred 


symproms  most  frerpiently  noted.     OtI 

some   in  a   few  cases,  and   Sdine  (Hilv  in   solitarv  case 


Tl 


ie.<e 


(U'cd    to  iMiumerate 


'Ixcessivc  sweating,  cramps  in  the  leirs,  or  in  belli 
h'H's  aiul  arms,  convulsive  llexioii  of  the  hands  or  Ihii^-ers,  muscular  twitcli- 
'n,^,^<  of  the  face,  shoulders,  or  haiuls,  aehiiiLT  ]>iiin  in  the  shoulders,  joints 
or  extremities,  a  sense  of  stilTness  of  the  joints,  pricd^liiiir  or  tinii'linir  nv 
nunii)ness  id'  the  bands  lastini;'  far  into  coii\aleseence  in  Sdine  ca>es.  a 
sense  (d"  ;j:encr:il  compression  of  the  skin,  drowsiness,  lialliicinati(;ri.s,  ini- 
])erl'ection  of  vision,  and  intoleraiu'c  of  lijrht.  Jn  three  eases  (one  .liat  ef 
a  niedieal  man)  there  was  observed  yellowness  of  the  skin,  either  fxeneral 


)r  coiilined   to  the  face  and   eves.      I 


n  on 


e  case,  at  a  late  stage  (d'  the  ill 


ness,  there  was  «onie  |iulmonary  eoni;estioii  and  an  attack  of  what  was  i>- 
trardeil  as  gout.  In  the  fatal  cases  death  was  pi'ccedi'd  by  collapse  likr 
that  (d'  cholera,  coldness  ol"  the  surface,  pinched  features,  and  blueiiess  nl 
till'  lingers  and  toes  and  around  tlie  snid<en  eves.     'I"he  debilitv  of  coina- 


Jesct'iice  was 


in  nearlv  all  cases  protracted  to  several  weeks. 


PTOMAINK    POISONIXC 


loTl 


"Tlie  mildest  cases  were  cluiractcrlzed  usually  by  little  roiiiarkuble 
beyoii'l  tlio  l'ull(»\viii<r  syiiiptoiiis,  vi/.,  abdiniiiiial  jjaiiis,  V()initiii<r,  dhir- 
I'lid'a,  tliirst,  bcadaelie,  and  imiseidar  weakness,  any  one  or  two  oi  wliich 
iiii,i:lit  be  absent." 

Many  instances  arc  on  record  of  |if>isoninii  liy  canned  l;<ioi1s,  particu- 
larly meat.  Some  of  tliese,  according  to  Julm  (i.  .Iclinsoii,  lia\c  been  cases 
of  eori'osive  poisonin;;  fi'om  muriate  of  zinc  and  mi.riatc  of  tin  nsed  as  an 
amal^ram,  but  jtoisoiions  elTects  identical  with  those  ju>l  described  have 
I'olbtwed  tlic  use  of  caniicti  nn'ats. 

Certain  ,<fame  i)irds,  particularly  the  irrousc,  are  stated  to  be  poisonc 
in  special  disti'icts  and  at  certain  seasons  of  tiic  year. 

(•-')  Poisoning  by  Milk  Products. 


)US. 


(tlSOl 


linir  l>y  cheese  lias  loiii,^  been 
known,  in  Michii^-an,  in  IS.s;}  and  is.sf,  thci'c  weie  neai'ly  ^Inii  eases  of 
cliccse  pois(jnin^',  and  fi'om  pieces  of  the  dieese  \  auu'han  si'pai'atcd  a  suli- 
>tance  which  he  called  tyrotoxii^on.  Sin<'c  that  date  other  outiireaks  have 
lieen  reported.  Apparently  to  this  poison  also  an- due  tlu' outiireaks  foi- 
lowinif  the  nse  of  milk,  several  (tf  which  are  I'cportcd  in  the  mainud  by 
\  aui,dian  •did  Now.  Still  more  numei'ous  of  \n\v  years  have  been  the 
cases  due  to  ])oisoiious  ice-cream,  in  which  also  the  tyrotoxicou  has  been 
found. 

The  s.niptoms  are  those  <pf  acute  irastro-intestinal  irritation,  anil  are 
>iiiiilar  to  those  already  detailed  by  IJallard. 

(:!)  Poisoning  by  Shell-flsh  and  Fish.— l'erha|is  the  most  serious  form 
of  ichf/ii/siiniK,  as  the  disease  is  called,  is  that  produced  by  the  mussel, 
many  epidemics  of  which  have  l)een  .studied  of  late,  more  i)articularly  an 
(iiitbreak  at  Wilhelmshavcn.  I>rie<,fer  has  .si'parated  a  p(»ison  which  Ik'  has 
called  ,iif//i/(ifo.ri/i.  It  has  been  shown  that  thise\i>t-  chicllv  in  the  livei' 
iif  the  mussci.     It  does  not  yet  appear  to  be  selili'd  wbelliei'  there  is  a  spe- 


cial   })olSOIU)US 


varietv  or  whether  the  m 


USSe 


v  uecoiiK's   toxie   unde, 


certain  conditions.  The  latter  seems  to  be  tlu  rmot  prob;iide  view,  as 
Sehmidtmaiin  found  that  the  non-poisoiious  mussels  m^-  >  liecanic  toxie 
wlien 


SOOIi 


])IaiH'd   in   the  \\  ilhelmshavcii   liay,  while   those  from   the  hay 
ist  their  toxii;  ])ropcrties  when  jilaeed  in  the  open  sea. 

Tlui  symiitoms  of  mussel  jioisoning  follow  the  eatinir  (d"  either  raw  ur 
H)ked  mnssels.  The  symptoms  are  those  of  an  acuti'  poisotiiiiLr  with  pro- 
•1111(1  action  on  the  nervous  svstem,  and  without   i:-astro-iiite>liiial  >.imi»- 


toins 


iiei'e  are  inimhnc; 


an 


d   coldness,  no  lever,  oilateil    pupii<,  rap 


idse,  and  death  (n'curs  soniclim 


es  within   two  hours  with  collapse  sym| 


CilUS. 


I'oisoning  ooeasionally  follows  the  eatinu"  of  oysters  which  are  stal«     m- 
ileeoniposed.     The  symptoms  are  nsmdly  gastro-intcstinal.     Certain  tish 


illS( 


)  cause  ])oisonin<;',  more  particularly  the  salteil  sturixeon  used  in  part,- 


Ri 


issia,  wliicli  lias  son 


letimes  [troved  fatal  to  lar;jfe  numbers  of  person 


III  the  middle  parts  of  Kuropi'  the  barb  is  state<l  to  be  sometimes  poison- 
eiis,  producing  the  so-ealleil  "' barbcit  cliuhra.'"     In  China  and  Jaiian  vari- 


w 

I 
II 


1072 


THE  INTOXICATIONS.   SLTN-STUOKK.   OBKSITY. 


ous  specios  of  the  trlroihm  arc  also  toxic,  soniotiiiu's  proviiij,'  fatal  witliin 
UTi  hour,  witii  syiiiptonis  of  intciisf!  ilisturliauct'  of  tiu^  irtvous  systcin. 
Several  otluT  |»oisoiious  forms  are  known,  whieh  produce  symptoms  de- 
scribed as  ic/i//ii/.s!in<s  parah/firns. 


VI.    GRAIN    POISONING. 

(1)  Ergotism. — 'I'lie  prolon^^ed  use  of  meal  made  from  {Trains  contam- 
inated wilii  liie  ertrot  funtriis  {rjnrirrps  pKrjiiiri'ii)  causes  a  series  of  symp- 
toms known  as  erirotism,  epidemics  of  wliicii  have  prevaileil  in  diiTerent 
parts  of  i'liirope.  'Two  furms  of  this  chronic  erudlism  are  described — the 
{^faiijjrenous  aiul  the  convulsive  or  spasmodic.  In  the  former,  mortilicatimi 
atTects  the.  e:;tremities— usually  the  toes  iind  llnircrs,  less  commonly  the  ears 
and  nose.  J'recediiiir  the  onset  of  the  p'antri'cnc  there  are  usually  aiues- 
thesia,  tiiiirlinir,  ])ains.  spasmodic  movements  of  the  muscles,  and  gradual 
blood  stasis  in  i-ertain  vascular  territorit'S. 

The  nervous  manifestations  are  very  reiiuirkable.  After  a  prodromal 
staire  of  ten  to  fourteen  days,  in  which  the  patient  complains  of  weakness, 
headache,  and  tiniiliui:  sensations  in  diiTerent  ])arts  of  tlu'  body,  pci'liap- 
accompanieil  with  sli^dit  fever,  spiismodic  symptoms  devchtp.  produciuir 
"•ramps  in  llic  muscles  ami  contractures.  The  arms  ai'c  ili'xed  and  the 
legs  and  toes  extemled.  These  spasms  may  last  from  a  few  hours  to  many 
days  and  relapses  arc  fretpu'nt.  In  severer  cases  cpile[)sy  develo|is  and  tlic 
patient  may  die  in  convulsions.  Mental  symptoms  are  connnon,  nuiiii- 
fested  sonu'times  in  a  pii  liminary  delii'ium,  but  more  connnonly,  in  the 
chronic  poisoning,  as  melancholia  or  denu'iitia.  Posterior  spinal  sclerosis 
occurs  in  chronic  ergotisju.  in  the  int'erestiug  group  of  ".'it  cases  studied  liv 
'I'uczek  and  Sienu'us,  nine  died  at  vai'ious  periods  after  the  infection,  ami 
four  i)ost-mortems  showed  degeneration  of  thi'  posterior  columns.  A  con- 
dition similar  to  tabes  dorsalis  is  gradually  iiroduced  by  this  slow  degen- 
eration in  the  spinal  cord. 

{'i)  Lathyrism  (  /.u/iiimsis). — An  atlVction  [U'oducfd  by  the  use  of  inciil 
from  varieties  of  vetches,  ehietly  the  Lallninis  xalirus  and  //.  circni. 
The  grain  is  |iopulai'ly  kno\\u  as  tlic  chick-pea.  The  grains  art'  usuallv 
powdered  and  mixed  with  the  meal  from  other  cereals  in  tlu^  jireparatioii 
of  bi'ead.  As  early  as  the  seventeenth  century  it  was  notii'cd  that  the  u-c 
of  Hour  with  which  the  see(ls  of  the  Jy(ff/ii/nis  were  mixed  caused  stitfne.-s 
of  the  legs.  The  subject  did  not,  however,  attract  much  attention  until 
the  studii's  of  .fanu's  Irving,  in  India,  who  between  ls,M»  and  ISCS  pub- 
lished several  im])ortant  communicati<ms,  describing  a  form  of  sj)as;ic 
jtaraplcgia  alVecting  large  luuubi'rs  of  the  inhabitants  in  certain  regions  of 
India  and  diw  to  the  use  of  nu'al  made  from  tlx'  Lc/lii/nis  seeds.  It  also 
prodm'cs  a  spastic  paraplegia  in  aninuils.  The  Italian  observers  describe 
u  similar  form  of  para])legia,  and  it  has  been  observeil  in  Algiers  by  the 


Y. 

lit:  fiitiil  witli'ui 

K'vvous  systi'tii. 

svmptonis  ih- 


SUX-STROKR. 


1073 


{Xruins  ccmtani- 
ii  Horit'sof  syiup- 
ilotl  in  (liiTcri'iit 
e  (U'scrilH'ii — the 
WW  iui>rtilicati(tn 

)llUlHHlly  till'  ('ills 

ii-c  usuiiUy  iUiiis- 
■les,  and  gradiutl 

t'ti'i'  a  prodromal 
iiiiis  of  wcakiu'ss, 
he  lioily,  lu'rhaps 
■vi'lop.  prodiifinir 
•(.   llc'M'd  and  tlu> 
•,.\v  liour?;  to  many 
develops  and  the 
;  coniinon,  tnani- 
•oiiimonly,  in  the 
,1-  spinal  sck'rosis 
J',1  cases  studii'd  liy 
he  infection,  ami 


(■olunins. 


A 


Coll- 


this  slow  degeii- 

,v  the  use  of  nu'iil 

,v  and    /-  ciri'iv. 

;rains  are  nsuallv 

the  preparation 

It  iced  that  the  use 


d  can 


;ed  stifTnes> 


stir 


[•h  atti'iitioii  until 
|,<,»  and  ISOH  puh- 

fonii  of   sjm 

I  certain  refjions  of 

\iis  seeds.     It  also 

ihservers  deserilu' 

in  Algiers  hy  the 


I'l-pnch  physloians.  The  condition  is  that  of  a  spastic  paralysis,  involving 
chiefly  the  leirs,  wiiich  may  jiroceed  to  complete  paraplejria.  Tiie  arms 
lire  rarely,  if  ever,  alTeeted.  It  is  evidently  a  slow  sclerosis  induced  under 
the  intluence  of  this  toxi(^  ajreiit.  'I'he  precise  anatomical  condition,  so 
far  as  I  can  ascertain,  has  not  yet  heeu  determined. 

(3)  Pellagra. — This  is  a  nutritional  disturhaiice  due  to  the  use  of  altered 
maize.  'I'he  disease  occurs  extensively  in  ]>arts  of  Italy,  in  the  south  of 
France,  and  in  Spain.  It  has  not  been  observed  in  this  country.  It  ])re- 
vails  extensively  among  the  poorer  classes,  particularly  in  the  country  dis- 
tricts, and  apjiears  to  be  associated  in  some  way  with  the  use  of  maize 
which  (accordinir  to  most  authorities)  is  fermented  or  diseased.  In  the 
early  stage  the  symptoTus  are  indefinite,  characterized  by  debility,  jiains  in 
the  .spine,  insomnia,  digestive  disturliance.s,  more  rarely  diarrho'a.  The 
tiist  clear  manifestation  of  the  disease  is  the  pellagral  erythema,  which  al- 
most invariably  ajtpears  in  the  spring.  This  is  followed  by  desiccation 
iiiid  exfoliation  of  the  I'liidermis,  which  becomes  very  rough  and  dry,  and 
(iicasionally  crusts  form,  beneath  which  there  is  siippurati(Hi.  With  these 
rutaneous  manifestations  there  aredigestive  troubles — salivation,  dyspepsia, 
ami  diarrluea — which  may  be  of  a  dy.senteric  nature.  After  lasting  for  a 
fi'W  months  improvement  occurs  in  the  milder  cases  and  convalescence  is 
.nailually  estal'lished.  In  the  more  .severe  and  chronic  forms  there  are 
)iroii()unced  nervous  symjitoms — headache,  backache,  spasms,  and  finally 
paralysis  and  mental  disturbance.  The  paralytic  condition  affects  the 
Kgs  and  leads  gradually  to  ]iara])legia.  The  mental  manifestations,  which 
are  rarely  met  Avith  until  the  third  or  fourth  attack,  are  melancholia  or 
suicidal  mania.  Finally,  there  may  be  a  condition  of  tlie  most  pronounced 
laihexia. 

The  anat(miical  changes  are  indefinite,  riironic  degenerative  changes 
tiive  been  found,  particularly  fatty  degeneration  and  a  peculiar  ])igmenta- 
timi  in  the  visi'cra.  The  measures  to  be  em])l()yed  are  change  in  diet,  re- 
moval from  the  infected  district,  ami,  as  a  prophylaxis,  proper  preserva- 
tion of  the  maize.* 


VII.    SUN-STROKE. 

'Ih'it   Erhn  list  inn  ;    Insolafion  ;    T/icniiic   Fcrer  ;    Ileaf-stroke  ;    Coup   tie    Soleit). 

Definition. — A  condition  iirodiiced  by  expo.sure  to  excessive  heat. 

It  is  one  of  the  oldest  of  recognized  diseases;  two  instanci's  are  men- 
ti  (tied  in  tlie  Hible.  It  was  long  confounded  with  apoplexy.  The  Anglo- 
lii'iian  surgeons  gave  admirable  descriptions  of  it.  In  this  country  the 
111  i>t  important  contributions  have  come  from  the  New  York  Hospital  and 
iIh'  Pennsylvania  liosjiital ;  from  the  former,  the  studies  of  Swift  and 


*  Tlic  most  I'liihorato  (liscussioii  of  tlii>  subject  is  liy  .laics  Ariioulil  in  tlio  Dictiori- 
haiiv  iMieycloputlinuc  des  Scieiuoa  Midicalcs,  tome  xxii,  l!S8U, 

m 


1074 


TIIK   INTOXICATIONS,  SUN-STROKE,  OIJKSITY, 


Diirnieh,  from  the  latter,  tlie  papers  of  (^erlianl,  (Joorgo  H.  Wood,  ilio 
elder  I'epper,  and  Levick.  In  New  Orleans,  Hennett  Dowler  studied  the 
disease  and  reco,i;nized  the  dilferenee  between  heat  exhaustion  and  sun- 
stroke. Very  little  has  been  added  to  our  kiu)\vledge  of  the  disease  siiu n 
the  pul)liciiti()n  of  a  niono<fraph  by  H.  ('.  Wood.  Two  forms  are  reeoi^- 
nized,  heat  exhaustion  and  heat-stroke. 

Heat  Exhaustion. — I'rolonj^i'd  exposure  to  hi^h  temperatures,  particu- 
larly when  combined  with  physical  exertion,  is  liable  to  be  followed  liy 
extrenut  prostration,  collapse,  restlessness,  and  in  severe  cases  by  delirium. 
The  surface  is  usually  cool,  the  pulse  small  and  rapid,  and  the;  tem])eratiir(! 
may  be  subnormal — as  h)w  as  'J5°  or  Wi\  The  individual  need  not  iuhics- 
sarily  be  exposed  to  the  direct  rays  of  the  sun,  but  the  condition  may 
come  on  wluai  working  in  close,  contined  rooms  durinp'  midsummer.  It 
may  also  follow  exposure  to  great  artificial  heat;  thus  the  stokers  in  tlui 
Atlantiir  steamshi[)s  sometimes  succumb  to  the  ell'ect  of  the  gi'eat  heat  in 
the  engine  rootns. 

Sunstroke  or  Thermic  Fever. — The  cases  are  chiefly  found  in  persons 
who,  while  working  very  hard,  are  exposed  to  the  sun.  Soldiers  on  tlui 
march  with  tlieir  heavy  accoutrements  are  })articu!arly  lialdt^  to  atbuk. 
In  the  larger  cities  of  this  country  the  cases  are  almost  exclusively  con- 
fined to  workmen  who  are  much  exposed  and,  at  the  same  time,  iiuvi- 
been  drinking  beer  and  whisky. 

Morbid  Anatomy  and  Pathology.— 7t*/V/or  mortis  occurs  t  uly. 
Putrefactive  changes  develop  with  great  rapidity.  The  venous  engorm'- 
ment  is  extreme,  particularly  in  the  cerebrum.  The  left  ventricle  is  con- 
tracted (Wood),  and  the  right  chamber  dilated.  The  blood  is  usiialh 
fluid  ;  the  lungs  are  intensely  congested.  Parenchymatous  changes  occur 
in  the  liver  and  kidtu'ys. 

Acc(n'ding  to  Wood,  "heat  exhaustion  with  lowered  temperatinv 
represents  a  sudden  vaso-motor  palsy,  i.  e.,  a  condition  in  which  the  exist- 
ing etfect  of  the  heat  paralyzes  the  centre  in  the  medulla.""  On  the  ollur 
hand,  thermic  fever  is  held  to  be  due  to  paralysis  under  the  influence  o! 
the  extreme  external  heat  of  the  centre  in  the  medulla  which  regulate:;  | 
the  disposition  of  the  bodily  heat.  Owing  to  this  disturbance,  more  iuiit  I 
is  produceil  and  less  given  oti  than  normally. 

Symptoms. — The  patient  may  be  struck  down  and  die  within  an  I 
hour   with   symptoms  of  heart  failure,  dysiJiuca,  and  conui.     This  form, | 
sonu'times  known  as  the  asphyxial,  occurs  chiefly  in  soldiers  and  is  grapli 
cally  described  by  Parkes.     Death  indeed  may  be  almost  instantaneous,  tli 
victims  falling  tis  if  struck  upon  the  liead.     The  usual  form  in  this  hit 
tude  comes  on  during  exposure,  with  pain   in  the  head,  dizziness,  a  tViii 
ing  of  oppression,  aiul  sonu'times  nausea  and  vomiting.     Visual  distuil'i 
ances  are  common,  and  a  patient  may  have  colored  vision.     J)iarrliiiJ| 
or  frequent  micturition  may  supervene.     Insensibility  follows,  which  iiiiivj 
be  transient  or  which  deepens  into  a  profound  coma.     The  patients  are! 


Y. 


SUN-STKOKE. 


1075 


a  B.  Wood,  tlio 
vler  stmUcil  tlu- 
^istion  and  wiu- 
he  disease  siiuc 
:ovms  arc  rocoj?- 

-vatnrt's,  particu- 
„  1h-  followed  Ny 
,.j,es  h\  deliriiun. 
I  the  temperatmc 
ill  need  not  noc.s- 
l,e  condition  nuiy 
t  luidsummer.     It 
"the  stokers  in  tl"' 
[  the  g.-eat  heat  m 

V  found  in  persons 
;,.  Soldiers  on  the 
[V  litdtle  to  attaek. 
ost  exelusivoly  e<m- 
ic  same  time,  l>avo 

morUs  occurs  t  wly. 

Phe  venous  engov-e- 
oft  ventricle  is  cen- 
ho  Idood  is  usiiiiUy 
atous  changes  occur 

„wercd   temperatuiv 
in  which  the  exi^t- 

alia."-    Ontheotlurl 
mlcr  the  inlUiencc  of 

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Ina.     The  patients  an' 


107G 


THE   INTOXICATIONS,  SUN-STROKE,  OHESITy. 


usually  admitted  to  hospital  in  an  iinconsinous  state,  with  tlu;  face  fluslu>l, 
tile  skin  pun^'cnt,  tlie  pulse  rapid  and  full,  ami  tlie  temperature  ranfjiu'i 
from  H»r°  to  lHt%oreven  iii.ylier.  F.  A.  Paci<ard  states  that  of  the  ;U  eiis.s 
admitted  to  the  iV'nnsylvania  Hospital  in  the  siimnu'r  of  1887,  in  a  ni;i- 
jority  of  them  tlu'  temperatun;  was  hetween  110°  and  lU"".  In  one  ea-c 
the  temperature  was  1  l"«i°.  The  hreathinjf  is  lahored  aiul  dee}),  sonietiims 
stertoi'ous.  I'siially  there  is  complete  n  laxation  of  the  museles,  hut 
twitchinfifH,  jactitation,  or  very  rarely  convulsions  may  ocfuir.  The  ])upils 
may  at  first  he  dilated,  hut  hy  the  time  the  cases  are  admitted  to  hospital 
they  are  (in  a  nuijority)  extremely  contracted.  Petechia'  may  he  present 
upon  the  skin.  In  the  fatal  cases  the  coma  deepens,  the  cardiac  j)uls,i- 
tions  l)ecome  more  ra[)i(l  and  ft'chle,  the  hreathin<;  Iiecomes  hurried  and 
shallow  and  of  the  Cheyne-Stokes  type.  The  fatal  termiiuition  may 
occur  within  twenty-four  or  thirty-six  hours.  Favorahle  indications  aiv 
the  recovery  of  consciousness  and  a  fall  in  the  fever.  The  recovery  in 
tlu'se  cases  nuiy  he  com})lete.  In  other  instances  there  are  remarkahlc 
after-elfects,  the  most  constant  of  which  is  a  permanent  inal)ility  to  hear 
hi<fh  temperatures.  Snch  patients  hecome  very  uneasy  when  the  tht  r- 
monu'ter  reaches  80°  F.  in  the  shade.  An  extraordimiry  instance  eanie 
under  my  notice  in  which  the  ])atient  was  suhsequently  so  sensitive 
to  temperatures  in  the  nei<,dd)orhood  of  To"  F.  that  at  such  times  he  livi'il 
comfortahly  only  in  the  cellar,  and  timilly  souffht  refuge  in  Alaska.  lioss 
[  of  the  power  of  nuMital  concentration  and  failure  of  memory  are  more 
,  constant  and  very  trouhlesome  se(iuehe.  Such  ])atients  are  always  worse 
in  the  hot  weather.  Oceasioiudly  convulsions  and  marked  mental  disturb- 
ance may  develop.  II.  C  \\  ood  states  that  in  a  case  of  this  kind  ehrouic 
meninfjitis  was  found. 

(iuiteras  has  called  attention  to  a  form  of  fever  occurring  in  the  South. 
known  in  Florida  as  '•  Florida  fever,''  in  the  t'arolinas  as  "country  fevei'.'' 
ami  in  tropical  countries  usjievre  iiijlaininaloire.  The  cases  last  for  a  vjiri- 
ahle  time,  and  are  mistaken  for  malaria  or  typhoid ;  hut  he  helieves  tliciii 
to  he  entirely  distinct  and  due  to  a  prolonged  action  of  the  high  tempera- 
tnres.     He  has  called  the  condition  a  "continued  thermic  fever," 

The  diagiuisis  of  heat  exiuuistion  from  thermic  fever  is  readily  made, 
as  the  dilference  between  the  two  comlitious  is  striking.  "  In  solar  ex- 
haustion the  skin  is  moist,  pale,  and  cool ;  the  breathing  is  easy  though 
hurried ;  the  pulse  is  small  and  soft;  the  vital  forces  fall  into  a  tem])oran 
collai)se ;  the  senses  renuiin  entire"  (Dowler);  whereas  in  sunstroke  ur 
heat  apoj)lexy  there  is  usually  uncon.sci(Usness  aiul  ]»yrexia. 

The  mode  of  onset,  together  with  Mie  circumstances  under  which  it 
occurs  and  the  high  temi>erature,  permits  thermic  fever  to  be  readily  liil- 
fereiitiated  from  apo[)lexy,  ami  coma  from  other  comlitious. 

Treatment. — In  heat  exhaustion  stimulants  should  he  given  freely. 
and  if  the  temperature  is  below  normal  the  hot  hath  should  he  useil 
Ammonia  nuiy  be  given  if  necessary.     In  thermic  fever  the  indications 


V. 

bo  face  flusl\("i, 
oruture  raiif^iiri 
,t()fthoaifi>sis 

:  1887,  in  ii  ma- 
1°.     li\  one  {'ii-i- 
deep,  sometiiius 
he  muscles,  Iml 
•nr.     The  \n\Y\\< 
itted  to  h().-i)iial 
V  iviay  be  pres^ent 
R.  ciinliac  pulsa- 
)merf  hurried  and 
tonniuation   luiiy 
le  indications  uro 
The  recovery  in 
■0  are  reinavkalil^' 
:  inal)iUty  U)  hvM 
,y  when  tlie  tluv- 
ary  instance  canio 
lently   so  sensitivu 
sucii  times  he  livod 
re  in  Alaska.     T.^ss 
'menu )ry  are  n\<'ve 
J  are  always  worse 
icd  mental  disturli- 
i  this  kind  chronic 

iirring  in  the  South. 
as  "country  fever,' 
,ascs  last  for  a  vari- 
ut  he  believes  tbcni 
i  the  high  tempera- 
mic  fever." 
vcr  is  readily  nuuU, 
ing.     "  In  solar  rx- 
liug  is  easy  thougli 
•all  into  a  temporal} 
■oas  in  sunstroke  ur 
irexia. 

lu'os  under  whicb  u 
loi-  to  be  readily  -lit- 
itious. 

,uld  be  given  frcrlv. 

lath  shouUl  be  u^i'l, 

ever  the  iudicaii""' 


OBESITY. 


1077 


are  to  reduce  the  temperature  as  ra))idly  us  possible.  This  may  he  done 
i>y  packing  the  patient  in  a  bath  with  ice.  I{ii])l)ing  the  body  with  ice  was 
practised  at  tlie  New  York  IIos[)ital  l)y  Darracli  in  1S,')T,  and  is  an  excel- 
lent procedure  to  lower  the  ternpcirature  rajtidly.  Ice-water  encnuita  may 
also  be  employed.  At  the  Pennsylvania  Hospital  in  tlie  summer  of  1S87 
the  ice-pack  was  used  with  great  advantage.  Of  31  cases  oidy  12  di(!d, 
a  result  probably  as  satisfactory  as  can  be  obtained,  considering  that  many 
(if  the  patients  are  almost  moribund  when  brought  to  h()Sj)itaI.  It  should 
l)e  compared  with  .Swift's  statistics,  in  which  of  150  cases  78  died.  In  the 
cases  in  whicji  the  symptoms  are  those  of  intense  asphyxia,  iind  in  which 
death  may  take  place  in  a  few  minutes,  free  bleeding  should  he  pi'iictised, 
a  proceduH!  whi<di  saved  Weir  Mit(du'll  when  a  young  man.  For  the  con- 
vidsions  (diloroform  should  be  given  at  once.  Of  other  renu'dies,  the  ajiti- 
pyretics  have  been  employed,  and  may  be  given  when  there  is  any  special 
(il)jection  to  hydrotliera])y,  for  which,  however,  they  cannot  be  substituted. 

VIII.   OBESITY. 

Corpulence,  an  excessive  development  of  the  bodily  fat — an  "oily 
dropsy,"  in  the  words  of  Lord  liyron — is  a  condition  for  which  the 
physician  is  frequently  consulted,  and  for  which  much  may  be  done  by  a 
judicious  arrangement  of  the  diet.  The  tendency  to  jtolysarcia  or  obesity 
is  often  hereditary,  and  is  particularly  apt  to  be  manifest  after  \hv.  middle 
jicriod  of  life.  It  may,  however,  be  seen  early,  and  in  this  country  it  is 
not  very  nncommon  in  young  girls  and  young  boys. 

A  very  important  factor  is  overeating,  a  vice  which  is  more  i)reva- 
loiit  and  only  a  little  behind  overdrinking  in  its  disastrons  ell'ects.  A 
majority  of  persons  over  forty  years  of  age  habitually  eat  too  much.  In 
.simie  of  the  most  aggravated  cases  of  obesity,  however,  this  plays  lU)  pai-t, 
and  the  unfortumito  victim  may  he  a  notoriously  small  eater.  A  second 
(lenient  is  lack  of  proper  exercise;  a  third  less  important  factor  is  the  tak- 
ing largely  of  alcoholic  beverages,  particularly  beer. 

In  obesity  it  is  now  generally  conceded  that  the  carbohydrates,  which 
were  so  long  blamed,  are  not  at  fault,  since  they  are  themselves  converted 
into  water  and  carbon  dioxide.  On  account,  however,  of  the  facility  with 
which  they  are  utilized  for  the  purjioses  of  oxidation  the  albuminous  ele- 
nicnts  of  the  food  are  less  readily  oxidized,  not  so  fully  decomposed,  and 
the  fat  is  in  reality  separated  from  iliem.  So,  too,  the  fats  themselves  are 
iiiit  so  prone  to  cause  (d)esity  as  the  carboliydrates,  being  less  readilyox- 
itlizcd  and  interfering  less  with  the  complete  metabolism  of  the  albumi- 
nous elements. 

Many  plans  are  now  advised  for  the  reduction  of  fat,  the  most  impor- 
l.int  of  which  are  those  of  Banting,  Ebstein,  and  Oertel.  In  the  Banting 
iiu'tliod  the  amount  of  food  is  reduced,  the  li<piids  are  restricted,  and  the 
tilts  and  carbohydrates  excluded. 


m 


1078 


TllK    INTOXICATIONS,   SUN-STIiOKH,   0I5K.SITY. 


K!)st('iii  rcooniniciiils  tlic  tis(>  of  fat  ainl  tlio  rapid  cxctliision  of  tho 
ciirljo-liydratcs.     Tliu  I'oUowiiij,'  i.s  an  (iXiiiuple  of  liis  dietary: 

lirvakfasl  ((1  A.  M.  iti  Hiiniiia'r,  |.;5()  A.  M.  in  winter). — Wliitc  hn-ad, 
well  toasted  (rather  less  than  two  oun(;es)  and  well  covered  with  Iniih  r. 
Teu,  without  milk  or  snj^'ar,  ei;,dit  or  nine  ounces. 

Dinner^  'I  i'.  M. — Soup  nuidc  witii  boef-nuirrow.  Fat  moat,  with  f^-t 
sauee,  four  to  live  ouuitcs.  A  moderate  ([uantity  of  .isijara'fiis,  spina'  h, 
eai)biigo,  i)ea.s,  and  beans.  Two  or  three  glasses  of  light  white  wine. 
After  tho  meal,  a  large  cup  of  tea  without  milk  or  sugar. 

Si(pj>n\  ut  "i.'-W  I'.  Ai. — An  egg,  a  little  roust  meat,  with  fat.  Alioiit 
a!i  ounce  vif  bread,  well  covered  with  butter.  A  large  cup  of  tea,  without 
milk  or  sugar. 

Oertel's  nuithoil  has  already  been  considered  in  connection  with  tlio 
treatment  of  fatty  heart,  and  is  combined  with  systematic  bodily  exercise. 
It  is  particulai'ly  adapted  for  stout  ju-rsons  with  weak  heart. 

Tho  so-called  Schweninger  cure  is  in  reality  Oerttd's,  with  the  sole 
nujdiflciation  of  the  forbiddijig  of  any  fluid  ut  meals.  Liquids  nuist  be 
tukon  more  than  two  hours  after  the  food. 

Yeo,  after  a  full  consideration  of  tho  various  methods,  gives  the  follow- 
ing useful  summary  ; 

"The  albuminates  in  the  form  of  animal  food  should  bo  strictly  lim- 
ited. Farinaceous  and  ull  starchy  foods  should  be  reduced  to  u  mininuiin. 
Sugar  should  be  entirely  prohibited.  A  moderute  amount  of  fats,  for  the 
reasons  given  by  Ebstein,  should  bo  ullowed. 

"Only  a  small  quantity  of  fluid  should  be  i)ormitted  at  meals,  Itiit 
enough  should  be  allowed  to  aid  in  tho  solution  and  digestion  of  the  food. 
Hot  water  ov  warm  aromatit;  bovoragos  may  be  taken  freely  between  iiieals 
or  at  the  end  of  the  digestive  process,  especially  in  gouty  cases,  on  aceoiiiit 
of  their  diminutive  ac^tion. 

"  No  beer,  })orter,  or  sweet  wine.^  of  any  kiiul  to  be  taken ;  no  spirit, 
except  in  very  snudl  (piantity.  It  should  be  generally  recognized  that  tlie 
use  of  alcohol  is  one  of  tho  most  common  provocatives  of  obesity.  A 
little  Hock,  still  Moselle,  or  light  claret,  v/ith  some  alkaline  table  water  in 
all  that  should  be  allowed.  Tho  beneficial  effects  of  such  diet  will  be  aided 
by  abundant  exercise  on  foot  and  by  the  free  use  of  saline  j)urgatives,  so 
that  we  may  insure  a  complete  daily  unloading  of  the  intestinal  canal. 

"  It  is  only  necessary  to  mention  a  few  other  details.  Of  aiumal  foods, 
all  kinds  of  lean  meat  may  bo  taken,  poultry,  game,  lish  (eels,  salnioii, 
atul  nuickerel  are  best  avoided),  eggs. 

"  Meat  shouh'.  not  be  taken  more  than  once  a  day,  and  not  more  tliim 
six  ounces  of  cooked  meat  at  a  time.  Two  lightly  boiled  or  poached  eggs 
may  be  taken  at  one  other  nu^al,  or  a  little  grilled  fish. 

"  Bread  should  bo  toasted  in  thin  slices  and  completely,  not  brownel  on 
the  surface  merely. 

"  Hard  captain's  biscuits  may  also  be  taken. 


T^ 


xciltision  of  I  lie 

—White  l.nad, 
i-cd  with  hutti  r. 

t  meat,  willi  U't 
iiim;,nis,  spiuii'li, 
ght  white  \viiu>. 

vith  flit.  Ahout 
[)  of  tea,  wiUiout 

noc'tion  with  tlie 
(;  Ixulily  exercise. 
irt. 

\\  with  the  sdlo 
Liquids  must,  be 

,  gives  the  foUnw- 

id  he  strictly  lim- 
ed to  a  iniuiinuiii. 
lut  of  fats,  for  llu; 

ted  at  meals,  hut 

estion  of  tlie  fni'd. 

ely  hetweeu  iiu'uls 

cases,  on  account 


OBESITY. 


1(»T9 


"Sonps  should  ho  avoided,  except  a  few  tahlospoonfula  of  clear  soup. 

"  .Milk  shdulil  he  iivoidcd,  uidcss  skinimcil  and  taken  as  the  chief  arti- 
cle of  diet.  All  milk  and  farinaceous  puddin;,'s  and  pastry  of  all  kinds 
are  forhidden.      Fresh  veii;etahles  aiul  fruit  are  permitted. 

"  It  is  importanl  to  hear  in  mind  that  the  actual  ipiantity  of  food  per- 
mitted must  have  a  due  relation  to  the  ))hysical  development  of  the  indi- 
vidual, aiul  that  what  would  he  ade(|uate  in  oiu'  ca.sc  lui^dit  he  altogether 
inadcfpiati!  in  the  case  of  another  jierson  of  larger  physi(itie.'"  * 

The  tliyroid  extract  has  hi'cn  used  in  ohesity,  in  a  few  cases  with  suc- 
cess.    It  may  he  tried  t)eginning  with  simill  dose.s,  as  in  myx(e<liina. 

*  A  System  of  Tlierupeuties,  val;i,  t'dilwl  by  II.  A.  Ilure,  Phiiiidelpliiti,  18i)l. 


taken ;  no  spirit, 
o((ognized  thai  iho 
'es  of  obesity.  A 
iliue  table  water  is 
li  diet  will  he  aided 
jline  purgatives,  so 
.testinal  canal. 

Of  animal  foods, 
llish  (eels,  sahiion, 

lind  not  more  tlnm 
Id  or  poached  eggs 


ly,notbrownol  on 


SECTION  XL 


DISEASES  DUE   TO   ANIMAL   PARASITES. 


I.    PSOROSPERMIASIS. 


Uxniou  this  term  are  oinbnio(!(l  sovonil  afTcctioiis  produced  by  the  spo- 
rozoii.  These  [)ariisite.s,  beloiigiiii^  to  the  protozoa,  are  also  known  ii>; 
psorospcrms  and  f^rej^arinithe.  They  are  extraordinarily  abundant  in  the 
invertebrates,  and  are  not  unconinion  in  the  hif^her  mammals.  The  entire 
group  of  blood  parasites,  ha-nuitozoa,  wliieh  live  within  the  corpuscles,  are 
closely  related  to  them.  I'sorosperms  are,  as  a  rule,  parasites  of  the  cells 
—  Cytozmt.  The  commonest  and  most  suitable  variety  for  study  is  the 
Cnccidium  oviforme  of  the  rabbit,  which  produces  a  disease  of  the  liver  in 
which  the  organ  is  studded  througliout  with  whitish  nodules,  rangin.i:  in 
size  froin  a  pin's  head  to  a  split  pea.  On  section  each  nodule  is  seen  to  lie 
a  dilated  portion  of  a  bile-duct;  the  walls  are  lined  with  ei)ithelium  in  tiie 
interior  of  which  are  multitudes  of  ovoid  bodies — the  coccidia.  Another 
very  common  form  occurs  in  the  muscl'es  of  the  pig,  the  so-called  Kainey's 
tube,  which  is  an  ovoid  body  within  the  sarcolemma  containing  a  nuiuher 
of  small,  si{;kle-shapiHl,  unicellular  organisms,  the  SfO'cnri/sfis  Jlicschcri. 
Another  species,  the  *S'.  hoininifi,  has  been  described  in  man. 

These  bodies  probably  i)lay  a  more  important  role  in  human  pathology 
than  has  liitherto  been  tliought.  The  cases  reported  may  be  groupetl  un- 
der the  following  divisions:  internal  and  external. 

(1)  Internal  Psorospermiasis. — In  a  majority  of  the  cases  of  this  gronji 
the  psoros[»erms  have  been  found  in  the  liver,  producing  a  disease  siniiliir 
to  that  which  occurs  in  rabbits.  In  (Juebler's  case  there  were  tumors 
which  could  be  felt  in  the  liver  during  life,  and  they  were  determined  liy 
Ijeuckart  to  be  due  to  coccidia.  In  W.  B.  lladdou's  case  the  patient  uas 
admitted  to  St.  Thomas's  Hospital  with  slight  fever,  drowsiness,  and  giad- 
ual  unconsciousness ;  death  occurred  on  the  fourteenth  day  of  observa- 
tion. Whitish  neoplasms  were  found  upon  the  peritona^im,  omentum,  ami 
on  the  layers  of  the  pericardium  ;  and  a  few  were  found  in  the  liver,  S])leen, 
and  kidneys.  A  somewhat  similar  case,  though  more  remarkable,  as  if  ran 
a  very  acute  course,  is  reported  by  Silcott.     A  woman,  aged  fifty-tiuee, 


T' 


rSOIlOSl'MUMlASlS. 


lOsl 


lASITES. 


iced  by  tlie  spo- 
also  known  us 
bund'.mt  in  the 
ills.     The  cntiri! 
0  corpusek'S,  iire 
isiterf  of  the  cells 
for  study  i--*  tilt' 
se  of  the  liver  in 
hiles,  riU\;^iiij.'  in 
lide  is  seen  to  lie 
))itheUuin  in  tiie 
•cidiii.     Another 
)-called  Kiiiney's 
linin*,'  a  nuiuher 
•i/stis  Mii'.sc/icri. 

in. 

unian  patholu;!y 
be  grouped  uii- 


udniitted  to  St.  Mary's  Hospital,  was  tliou<,'ht  to  bo  snlTiTiii;,'  from  typhoid 
fever.  She  had  liad  a  chill  six  w«'eks  bcforo  admission,  'riicie  were  h  vcr 
of  iin  intermittent  type,  sli^dit  diarrluea,  nausea,  lendcriu'ss  over  tlie  liver 
and  spleen,  and  a  dry  tonf,'ue ;  death  occurred  from  heart-failure.  Tlic 
liver  was  enlarged,  weighed  eighty-three  ounces,  aiul  in  its  substance  there 
were  caseous  foci,  around  each  of  which  was  a  ring  of  congestion.  The 
spleen  weighed  sixteen  ounces  and  contained  similar  bodies.  The  ileum 
I  resented  six  papule-like  eh^vations.  'I'he  masses  reseml)led  tubercles,  but 
ou  examii.,    ion  coccidia  were  found. 

The  parasiti'S  are  also  found  in  the  kidneys  aiul  ureters.  Cases  of  this 
kind  have  been  recorded  by  Uland  Sutton  ami  Paul  I-'.vi'.  In  the  case 
reported  l)y  Eve  the  symjjtoms  were  Inenuituria  and  frerpieut  micturition, 
and  death  took  place  on  the  seventeenth  day.  The  nodules  throughout  the 
pelvis  and  un^ters  have  l)een  regardeil  as  luiicous  cysts.  In  a  case  re[)orted 
by  Joseph  (li'iililhs  the  tutnoi's  in  the  ureter  caused  hydronephrosis. 

{''I)  Cutaneous  Psorospermiasis.— The  jjarasitii;  nature  of  the  /rm/av/.s 
folUcidaris  of  White,  and  of  I'aget's  disease  of  the  nipi)le,  which  seenu'd 
to  have  been  established,  has  been  called  in  question,  and  the  bodies  de- 
scribed as  psorosperms  are  believed  to  be  the  result  of  epithelial  degener- 
ation. So,  too,  in  jnolluscum  contagiosum  and  in  epitheliouui,  the  nature 
of  the  structures  which  lie  in  and  between  the  epithelial  cells,  and  which 
have  some  resemblance  to  psorosperms,  is  still  unsettled;  some  claiming 
that  they  are  tridy  parasitic,  others  anirming  that  they  arc  nothing  but 
altered  protoplasm  of  the  epithelial  cells. 

Tiiere  are  several  undoubted  instances,  liowever,  of  parasitic  sporozoa 

(loducing  extensive  disease  of  the  skin.     In  Wernicke's  case  (of  Uuenos 

Ayres)  the  lesions  were  scattered  over  the  face,  trunk,  ami  left  thigh. 

The  sporozoa  were  found  in  numbers  in  the  pus  of  the  skin  lesions,  and 

also  in  the  inguinal  glands,  whicli  were  exciseil. 

Ivixford  and  (Jilchrist  describe  two  cases  (Johns  Hopkins  Hospital  K'e- 
jiorts,  vol.  i).  In  the  first  case,  which  was  regarded  as  tuberculosis  of  the 
skin,  the  lesion  remained  local  for  nearly  eight  years.  The  lymphatic 
glaiuls  then  became  involved.  The  alTection  graelually  attacked  the  iu)se, 
cheeks,  and  other  parts  of  the  head,  the  left  hand,  the  leg,  ami  the  left 
testicle.  For  seven  or  eight  years  the  patient  had  no  constitutional  symp- 
toms, but  after  the  glands  l)ecame  involved  an  intermittent  fever  devel- 
iipod.  In  the  later  stages  he  had  a  cough  with  purulent  expccitoration. 
Tlie  autojjsy  revealed  what  appeared  to  be  tubercidosis  of  the  lungs, 
adrenals,  and  testis.  There  were  numerous  tuberculous-looking  nodules 
in  the  spleen,  on  the  surface  of  the  liver,  and  the  pleune.  In  all  of  the 
lesions  enormous  numbers  of  sporozoa  were  found,  especially  in  the  case- 
ous masses.  Successful  inoculations  were  nuido  into  rabbits  and  dogs. 
The  second  case  was  similar,  but  much  more  acute.  There  were  thirty 
skin  lesions  distributed  over  the  body.  The  patient  died  within  three 
months  of  the  initial  lesion.     In  an  excised  ]ymj)h  gland  enormous  num- 


i!  ,,  W 


10S2 


DISKASKS   DTK  TO    AN'IM  \I.   TAKASITHS. 


IxTS  of  s|>oroz(»ii  \V(>iv  fmiiHl.  'I'lu*  cycle  of  (l('vcl()|iinciit  \v;is  nviilily  fol- 
lowed. Tliesc  tiddics  liillVr  in  :ill  points  from  the  or^^anisms  deserihed  ;i.- 
pi°olozo:i  i:i  ciiiu'cr  and  in  iiioUiisciiiii  contagiosiiiii. 


i\    '  -i 


HI     . 
" . ;    I 


m 


■■H  ■ 


1 

llih  ■ 

1 

i: 

II-Mii-;v' 

II.    PARASITIC    INFUSORIA. 

Several    Haixellatcs   have   heeii    fmind    |)arasitic   in    man.      Amonfj  tli 


most   common   aic   the  7'rii//iiiii 


iis,  which   measures   I.")  to  •?," 


miei'om 


(Ul(l'<      ••lll/l/KI 

illiiiieti'es  in  leiii-th.and  has   four  llairella,  which  are  as  lonir  as 


loiiLU'r  than   the  Itodv.      It  is   hv  no  i 


neans  an  Mneommoii   [larasite   m   tl 


acKl  vaiiiiial  niiUMi^ 


'I'ho  TriilKiniiiiKis  ov  CircoDUiiiiis  /iniiiiin's  lives  in  the  in((\slines,  and 
is  met.  with  in  the  stools  under  all  surts  of  c(Uiditions.  !t  is  prol)ah|\-  nut 
parasitic.  1  have  mc'  -.villi  it  al.-o  in  the  vonnt  in  acas"  of  clii'o  lic  gas- 
tric catarrh.  'riiclKuuonads  lia\e  hccii  met  with  also  in  the  nrine  in  sev- 
eral cases,  and  may  l)c  truly  pathoifeiuc.  in  Dock's  case  the  parasites  were 
us.sociated  with  a  li,enHirrha,;,dc  cyst.tis  without  haderia. 

The  /.mii/i/iii  iii/i':./iiifi/i.s  is  another  intestinal  nnniad,  lari,fcr  than  the 
common  '/'nCf/iiiiniiiiis.  i''la;4ellates  have  also  liccn  f(Uiiul  in  the  expec- 
toration incases  of  yamii'enc  of  the  Iuiil,'  and  of  hronchiectasis,  and  in 
jdeurisy. 

.\moiiij  the  parasitic  Ciliithi  may  he  menti(Uied  the  HnJiiiit iiliiim  cnli, 
whi(di  has  heen  found  o-'casionally  in  the  lar^'c  intestine  in  forms  of  dys- 
entery.    The   |)arasite   is  oval    in    fiu-m,  lo  to   IdO   nucronnllimclres  loiiir 


ill 


i<l  .">((  to  lO  micronullinu'lres  hroad.      It  is  dcihtful  wlictlu".  it  is  pati 


i<i- 


};eiiie. 


III.   DISTOMIASIS. 


Several  forms  of  trematoclcs  or  flukes  are  parasitic  in  man,  and  when 
in  nundiers  mav  cause  serious  disease. 

(I)  Lirrr  /■'//^/v'.x.-  'The  follow  iiiL;' species  of  llukes  have  been  fonnd  : 
The  /■'iisn'ii/ii  /ir/Kifirti,  a  ve-y  common  parasite  in  rur  nnanis,  which  hi-^  a 
leni^th  of  fi'oni  twcniy-eiiihl  to  thii'ty-two  millimetres.  The  hishiiii'nti 
/aiii-i'o/n/niiiy  a  nnudi  smaller  form,  fi'oin  eiirhl  to  ten  nnllimeti'cs  ui 
lenulh,  whi(di  is  also  very  common  in  sheep  and  cattle.  The  fh's/n'in 
Jiu.sii,  the  larijest  form,  measuring  from  four  to  eiuhl  centimeti'cs  n 
length.  One  or  two  other  ,ess  important  forms  have  oecasionallv  hei  ii 
met  with.  The  stuilies  of  the  .lapaiu'sc  phvsicians  have  hrouirht  to  liulit 
the  intercstinir  f;ict  that  there  is  a  disloma  widelv  endemic  in  certain 
provir.ces  in  that  connlrv.  The  two  forms  dcscrilxd  as  ni.sluiihi  i'ikIihii- 
mill  anil  Disloiiui  jirniiciusii in  ;ire  identical,  'ind  are  known  now  as  /'/>- 
ti»))<i  siiienst'.  According  to  !?aelz,  fidly  twenty  per  cent  of  the  inhaliit- 
.iiils  of  eprtaiii  proviiu'cs  an'  alTected.  The  histtmia  fi'liiirii^ii,  which  lias 
biHMi  found  recentlv  hv  W'aid  in  Nehruska,  in  cats,  also  occurs  in  man. 


•^■^-U ..  KJiifTiKMBUm 


as  iv;\ilily  fi' 
IS  ili'srrihiMl  : 


snrc>  1"'  to  ■'.■> 
•f  as  liMijj;  as  ur 
parasiU'  in   the 

iiitcslim's,  and 

is  ]iriil)!ibly  not 

(>f  (.'hronii'  <j;as- 

lic  uriiu'  in  scv- 

II'  jtarusitos  wen' 

lar^^'t'i-  than  llic 
1  in  tlu'  I'xpir- 
iiit'ctiisi.s,  iind  in 

UthDiliilinm  c(>li> 

in  forms  of  ilvs- 

lillinu'livs  lonii 

•{\\v\  it  is  piitlio- 


itian,  iind  ^vlicii 

ivf   been  found  : 
nts,  w  liii'li  h  1-  ii 

'I'lic    Pis/<llll"lll 

niillinu'trt's  in 
Tlir   Ih'sfo'iii 

(•(■nlinw  trt's  n 
iccasionallv  1"'  'i 
hrouirlit  to  liuii' 
t'inic  in  t'tTtain 
fhs/iiinti  t'lit/i mi- 
,,\vii  now  as  I'l^- 
;  uf  till'  inlia''!'- 
iirii.iu  wlii'di  li;i^ 

•iirs  in  man. 


DISKASKS   (WrsKI)    HV    NHMATODKS. 


10S3 


Tilt'  IliiUcs  (ic('n|iy  the  liili'-passaL'''^  ami  the  upiicr  |iortioii  of  tlu! 
small  inlfsliiu'.  When  in  lai'm'  nniiihcrs  they  may  cansc  sciions  ami 
fatal  (iiscas,'  of  the  liver,  iisnally  villi  ascites  anti  Janmliee.  'The  liver 
may  lie  enormously  enlariruil  ;  in  Kieiiiier's  ease  it  weijilieil  eleven  poumls. 
'I"lu'  thikes  may  eanse  a  eliroiiic  eholani;ilis,  leading  to  great  thickening 
oi  even  ealciliealioii  of  the  walls  of  the  tule-duet. 

The  emiemie  IliiUe  disease  of  JapaM  is  eharai'terized  by  enlargement  of 
the  liver,  emaeiation,  diarrho'a,  and  fr('(|uenlly  ascites. 

(vM  7'//r  liiiiiiil  Fliikr;  Siltislnsiniiii  hininilnliiinit  { /lii/i(tr:ifi  li(r)}ialo- 
lii(i).  This  tcematode  is  found  in  Muypl,  S(Uithcin  .Vfi'ica,  and  Aiahia, 
and  is  the  canse  in  these  connti'ies  of  the  endemic  ha'tnaturia.  Tin; 
female  is  a!>ont  two  centimetres  in  length,  cylindrical,  liliform,  and  alotit 
•(t|  millimctri'  in  diameter.  'I'he  |tarasite  lives  in  the  vciions  system,  par- 
ticularly in  the  portal  vein,  and  in  the  veins  of  the  s|ilren,  bladder,  kid- 
neys, and  mesentery,  .\ccording  to  iiilharz,  at  least  lifly  per  cent  of  the 
I.;}v«'r  classes  in  I'lgypt  are  infected  with  it.  it  is  not  yet  Known  how  tiu' 
parasite  gains  entrance  to  the  body.  In  all  |)robabilily  it  is  by  drinking 
impure  water  I'ontaining  the  cinliryos. 

The  symptoms  are  due  to  changes  in  the  mucous  mcTiibi'aiu'  of  the 
urinary  organs  caused  by  the  pi'csencc  of  the  ova  in  the  blood-vessels  of 
these  parts.  Ihematuria  is  the  tirst  and  most  constant  symptmn,  leading 
gradually  to  anainia.  There  is  geiiei'ally  pain  during  mictuiil  ion.  The 
lilooil  is  iH)t  constant  in  the  urine.  The  o\a  of  the  Uilharzia  ai'e  readily 
seen  under  ;i  Tuicroscopi'  with  a  low  power.  They  are  ovoicl  in  shape, 
Iransluccnt,  with  a  small   spike  at  otu'      ul. 


lu'  emhi-\o  can   i)e   readilv 


seen. 


The  disease  is  rarelv  fatal;  a  great  majority  of  the  eases  recover, 
("hildrcu  are  imire  c(unmoidv  attacked  than  grown  persons,  ami  the  dis- 
ease often  disappears  by  the  lime  of  pulici'ty. 

(;>)  /Irtiiii'/iiii/  lliilx-r  ;  /h'sfiiiinnii  W  >  .^/I'mimini  ;  f'tintsi/ir  //irniap- 
///.v/.v.      In   parts  of  ( 'hiiia,  Japan,  and    l''ornuisa   there  is  an  epidemic  dis- 

nd    .Mans(Ui,  (diaractcrized  iiv  attacks  of  i'oui,di 


ease,  (ti'scriheil  liv  liincci'  a 


an( 


1  ha'UHiptysis  associated  with  the  presence  of  a  small  llukc  in  the  lirtui- 


'hial  tubes. 


IV.     DISEASES    CAUSED    BY    NEMATODES. 

I.     .\>('Al;l  ASIS. 

(it)    .\sciiris  liiiiihrii oitlfs,  the  most  c(Uumon  Iniuum  pai'asite 


found 


■hietl 


V  in  cliildicn. 


The  fciu  lie  is  fi-oiu   seven  to  'welvc  inches  in  leni;tli. 


the  male  from  four  to  eight  inches.     The  worm   i-  <'\  liiidrical,  pointed   at 
both  ends,  and    has  a  vcllowish-brown,  soinctiiui's  a  .sli^btlv  reddish   color. 


l'"oiir  loiii^iludinal  bands  can  b 


'U.  and  it  is  striateil    transversely.     Th 


ova,  wliicli  arc  suiuctiincs  found  in  large  luiinbers  in  tlu'  fa'ces,  urc  .siiiull, 


1084 


DISEASES   DUE  TO   AXIMAI.   PARASITES. 


brownish-rod  in  color,  t'llii)tical,  and  Imve  a  very  thick  covering.  Tlicy 
measure  -OTo  niiilinH'trc  in  Icngtli  and  -OoS  inilliinetro  in  widtli.  The  lilV 
liistory  has  been  (h'inonstriitcd  to  be  "  direct" — i.  e.,  without  interniediutf 
liost.  The  para.site  occupies  tlie  upper  portion  of  tlie  small  inlestiiu'. 
Usually  not  more  than  one  or  two  are  present,  hut  occasionally  they  occur 
in  enormous  luimbers.  Tlie  migrations  are  peculiar,  Tliey  nuiy  pass  into 
the  stonnich,  from  which  they  may  be  ejected  by  vomiting,  or  they  may 
«;rawl  up  the  ovsophagus  and  enter  the  ])harynx,  from  which  tliey  may  be 
withdrawn.  A  child  under  my  care  in  the  sniall-pox  department  of  the 
General  Hospital,  during  convalescence,  withdrew  in  this  way  more  tluiu 
thirty  round  worms  within  a  few  weeks.  In  other  instances  tlie  woriii 
passes  into  the  laryn.x,  and  has  been  known  to  cause  fatal  asphyxia,  or, 
passing  into  the  trachea,  to  cause  gangrene  of  the  lung.  They  may  pass 
into  the  Eustachian  tube  and  api)ear  at  the  external  meatus,  'i'he  most 
serious  migration  is  into  the  bile-duct.  Tlu're  is  a  specimen  in  the  Wistar- 
Ilornor  Museum  of  the  University  of  Pennsylvania  in  whit-h  not  only  the 
connuon  duct,  ])ut  also  the  main  branches  throughout  the  liver,  are  enor- 
mously distended  and  packed  with  numerous  round  worms.  The  bowel 
may  be  jH-rforated  by  them  and  peritonitis  result. 

The  symptoms  are  not  definite.  When  a  few  are  present  they  may  l)o 
passed  without  causing  disturbance.  In  children  there  are  irritative 
symptoms  usually  attributed  to  worms,  such  as  restlessness,  irritability, 
picking  at  the  nose,  gi'inding  of  the  teeth,  twitchings,  or  convulsions. 
These  symptoms  nuiy  l)e  marked  in  very  nervous  children. 

Treatment. — Santonin  can  be  given,  mixed  with  sugar,  in  doses  of 
from  oiu'  to  three  grains  for  a  child  and  three  to  five  grains  for  an  adult, 
folbiwed  by  a  calomel  or  a  saline  purge.  The  dose  may  be  given  for  tliree 
or  four  days.  An  unpleasant  consequence  which  sometimes  follows  the 
administration  of  this  drug  is  xanthopsia  or  yellow  vision. 

(/v)  (h-j/iiris  imin'ruhiris  [Tliridil-u'oDn ;  Pin-tronH). — This  com- 
mon parasite  occupies  the  rectum  and  colon.  The  male  measures  about 
four  millimetres  in  length,  the  fennde  about  ten  millimetres.  They  pro- 
^diice  great  irritation  and  itching,  particularly  at  night,  symj)toms  which 
become  intensely  aggravated  by  the  nocturnal  migration  of  the  jiarasites. 

The  patients  become  extremely  restless  and  irritable,  the  sleep  is  often 
disturi)od,  and  there  may  be  loss  of  appetite  ami  anjemia.  Though  nie.-l 
common  in  children,  the  jiarasite  occurs  ut  all  ages. 

The  worm  is  readily  detected  in  the  fa'ces.  Infection  ])robably  tnk'  - 
place  through  the  water  or  possibly  through  salads,  such  as  lettuces  ami 
cresses.  A  j'l  , on  the  subject  of  the  worms  passes  ova  in  large  numlnr- 
in  the  fa'ces,  and  the  possibility  of  reinfection  must  be  scrupulou>ly 
guarded  against. 

The  treatment  is  simple,  though  occasioiudly  there  are  instamn^s  in 
which  all  forms  of  medication  are  resisted.  A  cjise  is  mentioned  of  a  gi  n- 
tleiuan,  aged  forty,  who  had  sull'ered  from  chiklhood  and  had  failed  h> 


DISEASES  CAUSED    BY   NEMATODES. 


1085 


rinp.     They 
li.    The  lilc 
iuterniediatf 
ill   intestine. 
y  lliey  oecuir 
lay  pass  into 
or  they  may 
they  may  be 
tnient  of  the 
ly  more  than 
I'S  the  worm 
asphyxia,  oi\ 
hey  may  pass 
;<.     The  most 
.11  the  Wistar- 
I  not  only  the 
ver,  are  enor- 
i.     The  bowel 

t  they  may  be 

iire   irritative 

is,  irritability, 

r  (;onviilsion>. 

ar,  in  doses  of 
s  for  an  adult, 
;iven  for  three 
cs  follows  the 

.—This   eoiu- 

lieasnres  about 

■s.     Tliey  pi'o- 

Lptonis  wliieh 

the  parasites. 

•  sleep  is  often 

'I'hough  most 

Ijtrobably  tak'-^ 
Is  lettuces  aii'l 
llarc-e  numln's 
si'rupulously 

ic   instances  in 

loncil  of  a  ^'(11- 

had  failed  to 


obtain  any  benetit  from  prolon<ied  treatment  by  many  helmiutbobiirists. 
Santonin  may  be  used  in  small  doses,  and  mild  jiiir<(alivcs.  particularly 
rhubarb.  Large  injections  containing  carbolic  acid,  vinegar,  quassia, 
aloes,  or  turpentine  may  be  em[)loyed.  In  children  the  use  of  cdld  injec- 
tions of  strong  salt  and  water  is  usually  elVicacious.  They  should  be  re- 
peatecl  for  at  least  ten  days.  In  giving  the  injection  care  should  be  taken 
to  have  the  hips  well  clcvati'd,  so  that  the  fluid  can  !)e  retained  as  long  as 
jiossible.  For  the  intense  it(diing  and  irritation  at  night  vaseline  may  be 
freely  used,  or  belladoniiii  ointment. 

II.   Ti{i(  iiiNiAsrs. 

The  Trirltiun  spiralis  in  its  adult  condition  lives  in  the  small  intes- 
tine. 'J'he  disease  is  jiroduced  by  the  eml)ryos.  which  pajs  from  the 
inte.'itines  and  reach  tln'  voluntary  muscles,  where  they  finally  become 
encapsulated  larva- — muscle  trichina'.  It  is  in  the  miLrration  of  the  em- 
iiryos  that  the  grou))  of  symptoms  known  as  ti'icliinia<is  is  prodiu'ed. 


f)r.'<friji/i(i)i   (if  till'   /'(inisifi's. — {a)    .Adult   or   iutesliiial    form.      T 


le 


female  measures  from  three  to  fctur  millimetres;  the  male.  To  millimetre, 
and  has  two  little  ])rojections  from  the  hinder  end. 

(li)  The  larva  or  mus(dc  tiichina  is  from  (m;  to  one  millimetre  in 
length  and  lies  coiled  in  an  ovoid  caj)suh',  whicdi  is  at  first  translucent, 
l)Ut  subsc(|ueiitly  opaipie  and  intiltriitecl  with  lime  salts.  The  worm  pre- 
sents a  pointetl  heai 


1  and 


a  somewhat  roundec 


1  tail. 


W 


len  ilesh  containin<f  tiie  trichina'  is  e.atcn  liv  man  or  I)V  anv  am 


m 


id  in  \vhi(di  the  development  can  take  place,  the  capsules  are  digested 
and  the  trichina'  set  free.  Tbi-y  jtass  into  the  small  intestine,  and  about 
the  third  day  attain  their  fidl  growth  au<l  become  sexually  mature.  Vir- 
chow's  experiments  have  shown  that  on  the  sixth  or  seventh  day  the  em- 
l)ryos  are  fully  developed.  The  young  jiroduced  by  eatdi  female  trichina 
have  been  estimated  at  several  hundreil.  Leiickart  thinks  that  various 
l)roods  are  devclojied  in  succession,  and  that  as  many  as  a  thousaTid  (-m- 
liryos  may  be  produced  by  a  single  worm.  The  time  from  the  ingestion 
of  the  flesh  containing  the  muscle  trichina'  to  the  development  of  the 
l)rood  of  embryos  in  the  intestines  is  from  seven  to  nine  days.  As  soon 
as  born  the  embryo  trichina' leave  the  intestines ;  wandering  through  the 
peritona'um  and  tht^  connective  tissues,  probably  through  the  mesentery 
and  retroperitoneal  tissues — some  hold  by  means  of  the  blood  current — 
they  finally  reach  the  muscles,  which  constitute  "the  seat  of  election." 
After  a  preliminary  migration  in  the  intermuscular  connective  ti.ssue  they 
penetrate  the  |)rimitive  muscle-fibres,  and  in  about  two  weeks  develop  into 
the  full-grown  muscle  form.  In  this  process  an  interstitial  myositis  is  ex- 
cited and  gradually  an  ovoid  caj)sule  develops  about  the  parasite.  Two, 
Hccasionatly  three  or  fo.ir,  worms  may  be  st-en  within  a  single  capsule. 
This  process  of  enca[isulation  has  been  estimated  to  take  about  six  weeks. 


108C 


DISHASE.S   DVE  TO    ANIMAL   PARASITKS. 


"Witliin  (lie  niuscl(!s  tlio  parasites  do  lujt  undergo  further  developnioiit. 
(iradiially  tlic;  f'a|)siile  l)cc(»iiit's  tliicker,  and  iiltiiiiately  liriio  wdts  are  de- 
posited witliin  it.  This  chauire  may  tal\e  phice  in  man  witliin  fonr  (n- 
five  months.  In  the  lioii;  it  may  lie  deferred  for  many  years.  The  e;il- 
citieation  renders  the  cyst  visible,  and  since  lii'st  seen  iiy  Tiedi'iiiiinn,  in 
1822,  and  Hilton,  in  1832,  tlies(.>  small,  opaque,  oat-shaped  bodies  liin.' 
been  familiar  objects  to  demonstrators  of  normal  and  morbid  anatoniv. 
Tile  trichina;  may  live  within  the  muscles  for  au  indeliiiite  jieriod.  Thcv 
have  been  found  alive  and  capable  of  developinj;  as  late  as  twenty  or  even 
twenty-live  years  after  their  eiitraiice  into  tlie  system.  In  many  instances. 
liowevcr,  the  woruis  are  couiplctely  calcilied.  The  ti'ichiiia  has  been 
found  or  "raised"  in  twenty-six  dillerent  species  of  animals  (Stiles). 
Mi'dical  liteniture  abounds  in  referem^o  to  its  presence  in  tish,  earth- 
worms, etc.,  but  these  iKii'asites  heloiiii;  to  other  yeiiera.  In  fa'cal  exani- 
illations  for  the  parasite  it  is  wvW  to  remember  that  the '"  cell  body  "  uf 
the  anterior  portion  of  tin;  intestine  is  a  diai^niostic  criterion  of  the  7'. 
{spiralis.  It  was  first  found  in  the  iiog  by  the  late  Joseph  Ijcidy.  K\- 
perimentally,  guiiiea-pi<,'s  and  rabbits  are  readily  infected  by  feeding  theiii 
with  muscle  containing  the  larval  form.  Dogs  are  infected  with  ditlieiilty ; 
cats  more  readily.  Kxperinientally,  animals  sometimes  die  of  the  disease 
if  large  numbers  of  the  parasites  have  been  eaten.  In  the  hog  the  trichinie, 
like  the  i^ysticerei,  cause  lew  if  any  .symptoms.  An  animal  the  muscles  of 
which  are  swarming  with  living  trichina'  may  be  well  nourished  ami 
healthy-looking.  An  important  point  also  is  the  fact  that  in  the  hog  the 
capsule  does  not  readily  bt'cenne  calcilied,  so  that  the  parasites  are  net 
visible  as  in  the  human  muscles.  For  a  long  time  the  trichina  was  looked 
ii[ion  as  a  pathological  curiosity,  hut  in  18(!()  Zenker  discovered  in  a  girl 
in  the  Dri'sdeii  IIos[)ilal  who  had  symptoms  of  typhoid  fever  both  the 
intestinal  and  the  muscle  forms  of  the  tricdiiiue,  since  whicdi  time  the  di-- 
oase  has  been  thoroughly  studied. 

Mail  is  infected  by  eating  the  llesli  of  trichinons  hogs.  The  ineidonee 
of  the  disease  in  swine  varies  much  in  dilferent  countries.  In  (Jermanv, 
whei'c  a  thorough  and  systematic  microscopic  examination  of  all  swine 
ilesh  is  made,  I  In;  pro]iortion  of  triidiinous  liogs  is  about  I  in  1.8.V'.  At 
the  Herlin  abattoir,  where  the  niicrosi'opic  examination  is  eoiidueted  by  a 
stalT  of  ov((r  eighty  men  and  women,  two  portions  are  taken  from  the  iili- 
doininal  muscles,  from  the  dia|)hragiii,  and  from  the  intercostal  muscles. 
and  one  piece  fi'om  the  miusclesof  the  larynx  and  tongue.  A  special  coiii- 
pres.sor  is  used  to  (latteii  the  fragments  of  the  muscle,  and  tlie  exaininaticii 
is  maile  with  a  magnifying  power  of  from  seventy  to  one  hundretl  diiini- 
etors.  During  the  three  years  ending  in  1885  there  were  (i(>3  trifdiiimus 
hogs  detecteil,  a  ratio  of  1  to  1,292.  Statistics  are  not  available  in  I'.wj- 
land.  In  the  United  States  systematic  inspection  is  unknown,  ami  tlie 
statistics  are  by  no  means  extensive  enough.  "Taking  all  the  examiMn- 
tious  of  Amoricuu  pork  tlms  far  made,  both  at  home  and  abroad,  and  ue 


DISEASES  CAUSED  BY   NEMATODES. 


1()S7 


have  a  total  of  )29iS,7S'J,  in  wliich  trichina;  wero  found  (),'2S0  times,  hi'injf 
2-1  per  cent,  or  1  to  48"  (Salmon,  ISS-t). 

In  1SS:5,  in  (lonjunction  with  A.  \V.  (Moment,  1  exaniine(l  1,000  hofjs 
at  tlio  Montreal  abattoir,  and  found  only  4  infeeted.  There  is  no  reason 
to  believe  tliat  tiie  ho<^  of  this  (!ountry  is  less  liable  to  trichina  than  the 
(lorinan  animal. 

Millies  (if  liij)(iii))i. — Tiie  danger  of  infection  depends  eiitirclv  upon 
the  nu)dc  of  pre|»aration  of  the  flesh.  Tiioi-ouLrh  cookini,',  so  tiiat  all  parts 
of  the  nu'at  reach  the  boiliiiL,'  i)oint,  (U'sti'oys  the  i)arasites;  but  in  lai'irc; 
joints  the  central  portion.s  art;  often  not  raised  to  this  temperature.  The 
frcHpiency  of  the  disease  in  dilfereiit  countries  depends  Iar.i,'ely  upon  tiio 
habits  of  the  pcopUi  in  tiie  pre[iaratioii  of  pork.  In  Noilh  (iermany, 
where  raw  ham  and  wiirxt  are  freely  eaten,  the  ^M'catest  nund)er  of  cases 
have  occurred.  In  South  (iermany,  France,  and  Knijlaiul  cases  are  rare. 
In  tliis  country  tlie  greatest  nund)er  of  persons  attacked  have  lieeii  (ier- 
mans.  Salting  and  smoking  the  flesh  iirc  not  always  suilicient,  aiul  the 
JIavre  experiments  .sh  iwed  tiiat  animals  are  I'l'adily  infected  when  fed 
with  j)ortions  of  the  pickled  or  the  smoked  meat  as  prepared  in  this  coun- 
try. Carl  Fraenkel,  however,  states  that  the  experiments  on  this  ))oint 
have  been  negative,  aiul  that  it  is  very  doubtful  if  any  eases  of  triciiiniasis 
in  (Jermaiiy  have  been  caused  by  Amei-ican  jinrk.  (Iermany  has  yet  to 
show  a  single  case  of  tiichiniasis  dwv  to  jiork  of  uiupiesiioneil  .American 
origin. 

Frriptc/irij  (if  Inffctimt. — The  (lissectiii'i-roum  and  post-mortem  statis- 
tics show  that  from  one  half  tn  two  per  cent  of  all  bodies  cdiitain  tiiehina;. 
Of  1,000  consecutive  autopsies  of  which  I  have  notes  tlie  trichina'  were 
present  in  six  instanci's.  I  have,  in  adililion,  seen  tiiein  in  two  dissecting- 
room  eases  and  in  two  bodies  at  the  I'hilaih'Iiihia  Hospital. 

The  disease  often  occurs  in  epidemics,  a  large  nundiend"  persons  being 
infected  from  a  single  sourc(\  Among  the  best  known  of  these  outbreaks 
are  the  Iledersleben,  in  which  there  were  '.V.u  persons  alTi'cted,  and  the 
Kmcrsleben,  in  wliich  tliciH!  were  '^.")0  persons  attacked.  Tiie  extensive! 
outbreaks  of  this  sort  have  been,  with  few  exceptions,  in  N<uMh  (iermany. 
Alfred  Mann,  after  a  carefid  search,  at  my  rei|ucst,  of  the  literature  in  the 
Surgeon-(ienerars  lii)rary.  liiids  records  of  4ri((  cases  in  this  country.  The 
two  largest  groups  of  cases  were  at  Astoria.  Ore.,  repoi'ted  liy  Kinney,  15 
cases  and  one  death;  and  at  Colerain,  .Mass.  (IS'.f,!),  in  which  ."id  persons 
were  attacked,  four  of  whom  died. 

Symptoms. — The  ingestion  of  trichinous  llesli  is  not  neces-^arily  fol- 
lowed by  the  disease.  When  a  limited  number  are  eaten  only  a  few  em- 
ttryos  pass  to  the  muscles  and  may  cause  no  symptoms.  Well-characterized 
cases  })re,sent  a  gastro-inte.-tinal  pi-riod  and  a  period  of  g<'neral  infection. 

In  the  course  of  u  few  days  after  isiting  the  infected  meat  there  are 
.-igns  of  gastro-intostinal  disturbance — pain  in  the  alxlomen,  loss  of  appe- 
tite, vomiting,  and  sometimes  diarrhcea.    The  preliminary  symptoms,  how- 


l^- 


loss 


DISEASES   DUE  TO   ANIMAL    PARASITES, 


I! 


ever,  are  by  no  moans  constant,  and  in  some  of  tlie  larjrc  cpidomics  cases 
liave  l)eeii  ohscrved  in  wliicli  tliey  liave  been  absent.  In  otlier  cases  tln' 
gustro-intestiiial  I'eatnres  have  been  marked  from  the  outset,  and  tlie  attack 
has  resemlilctl  eliolera  nostras.  J'ains  in  dilTeront  parts  of  tlie  l)0(]y,  •gen- 
eral debility,  and  weakness  have  been  noteil  in  some  of  the  epidemics. 

The  invasion  symptoms  develop  between  the  seventh  and  the  tenth  dav, 
sometimes  not  until  the  end  of  the  second  week.  'J'here  is  fever,  exce})t  in 
very  nnld  eases.  (Udlls  are  not  common.  The  thermometer  may  re«^istir 
lO'-i"  or  1 04",  and  the  fever  is  usually  remittent  or  ii\termiltent.  The  mi- 
gration of  tile  parasites  in  the  nuuscles  excites  a  more  or  less  intense  myo- 
sitis, which  is  characterized  by  pain  on  pressure  and  movement,  and  liy 
swelliiii^  and  tension  of  the  nniscles.  The  limbs  arc  placed  iJi  the  posi- 
tions in  whicli  the  muscles  are  in  least  tension.  The  involvement  of  the 
muscles  of  mastication  and  of  the  larynx  may  cause  difllcnlty  in  chewiiii: 
and  swallowinij.  In  severe  cases  tlie  involvement  of  the  dia[)liragm  aini 
intercosfid  muscles  may  lead  to  intense  dyspiuea,  which  sometimes  proves 
fatal.  (Kidema,  a  feature  of  great  im})ortanco,  may  be  early  in  tlie  face. 
Later  it  develops  in  the  extremities  when  the  swelling  and  stilTness  of  the 
muscles  are  at  their  height.  l'rofu.se  sweats,  tingling  and  itching  of  the 
skin,  and  in  some  instances  urticaria,  have  been  described  The  general 
nutrition  is  much  disturbed  and  the  patient  becomes  emaciated  and  often 
ana'inic,  particularly  in  the  protracted  cases.  The  patellar  teiulon  retlcx 
may  be  al)scnr.  The  patients  are  usually  conscious,  except  in  cases  of  wvy 
intense  infection,  in  which  the  delirinu),  dry  tongue,  and  tremors  give  a 
picture  similar  to  tyiilioid  fever.  In  addition  to  the  dyspna>a,  present  in 
the  severer  cases,  there  may  be  bronchitis,  and  in  the  fatal  cases  pneumo- 
nia or  ]tleurisy.  In  some  epidemics  polyuria  has  been  a  common  symptom. 
AlbumiiHiria  is  frequent. 

The  intensity  and  duration  of  the  symptoms  depend  entirely  upon  the 
gra<le  of  infection.  In  the  mild  cases  recovery  is  complete  in  from  ten  to 
fourteen  days.  In  the  severe  forms  convalescence  is  not  estaitlished  for 
six  or  eight  weeks,  and  it  may  be  months  before  the  patient  recovers  the 
muscular  strength.  One  case  in  the  Iledersleben  epidenuc  was  weak  eight 
years  after  the  attack. 

Of  7'i  fatal  cases  in  tlie  Iledersleben  ej)idemic  the  greatest  mortaliiy 
occurred  in  tlie  fourth  and  fifth  and  sixth  weeks;  namely,  52  cases.  Two 
died  in  the  second  week  with  severe  choleraic  symptoms. 

The  mortality  has  ranged  in  diiferent  outbreaks  from  one  or  two  per 
cent  to  thirty  per  cent.  In  the  Iledersleben  epidemic  101  persons  die  I. 
Among  the  45')  cases  reported  in  this  country  there  were  Vi'l  deaths. 

'IMie  nnntomiral  c/i<iuf/es  are  chiefly  in  the  voluntary  miuscles.  In  tlic 
early  stages  they  look  normal,  but  in  the  fourth  or  fifth  week  grayish- 
white  areas  apjiear  in  which  the  muscle-fibres  are  extensively  degenerali  1 
and  in  the  neighborhood  of  the  tricliime  there  is  an  acute  interstiti  il 
myositis.     C'ohiiheim  has  dcscrihed  a  fatty  degeneration  of  the  liver  and 


niSEASKS  CArsKD    I5V   NKM  Al'oDKS. 


lOSl) 


r 


oTiliirfyomont  of  the  mesenteric  ifliiiids.  At  tl)(>  time  of  dc^ntli  ii)  tlio 
fourth  or  lifth  wei'k  or  later  tlie  adiill  trieliime  are  still  fouixl  in  the  iii- 
testiiios. 

'The  f)r(ii/n(isi.<<  depeiuls  iiiiieh  iijioii  the  quantity  of  iiifeeted  meat  which 
has  lieeii  eaten  and  the  numl)er  of  ti'iehiiiM' which  mat  ure  in  the  intestines. 
In  children  the  ontlook  is  more  favoi'al)le.  Karly  diai^rlnea  and  jnodcr- 
ately  intense  i^aslro-intostiiuil  symptoms  are,  us  a  rule,  more  favoral)Io  than 
I'onstipation. 

Diagnosis. — The  disease  should  always  bo  suspected  when  a  largo 
liirtliday  party  or  /-'rsf  anions^  (iermans  is  foll(iwe(l  l)y  ca<es  of  apparent 
typhoid  fever.  'I'he  parasitt-s  may  he  found  in  the  remnants  of  the  ham 
nr  saiisanfes  used  on  the  occasion.  'IMie  worms  may  he  discovered  in  tin; 
stools.  The  stools  should  lie  spread  on  a  ixlass  plate  or  hlack  liackirroiind 
and  examine(l  with  ii  low-power  lens,  when  the  trichina'  ure  s(>en  as  small, 
;.distenin<;,  silvery  threads.  In  douhtfiil  ca.^es  the  diau;nosis  may  he  made 
l>y  the  removal  of  a  small  fraijment  of  niuscle.  A  s])ecial  harpoon  has 
lieen  devised  for  this  pur|)ose  by  means  of  which  a  small  poriinii  of  the 
hiceps  or  of  the  pectoral  muscle  may  he  readily  removed.  I'lidcr  cocaine 
aiia'sthesiu  an  incision  may  he  ma<le  uiul  a  siiudl  fraLMucnt  remove(l.  The 
(lisea.se  may  he  mistaken  fiir  ai'iit(^  rheumatism,  particularly  as  the  pains 
are  .so  severe  on  movt'tiuMit,  hut  there  is  no  special  swellinir  of  the  joints. 
The  tcntlerness  is  in  the  muscles  both  on  pressure  and  on  movement.  TIk! 
intensity  of  the  <rastro-iiitestinal  sym[itoms  in  some  cases  has  leil  to  the 
iliairnosis  of  cliolera.      Many  of  the  former  eiiidemics  were  douhtless  de- 


,<iiihed  as  typhoid  fever,  which  the  .severer  cases,  owinjr  to  the  prolonged 
IVver,  the  sweats,  the  delirium,  dry  tontriu",  aiul  ,t;';istro-ii\testiMal  symp- 
toms, .somewhat  resemble.  The  pains  in  the  muscles,  swellinjr,  (r'dema, 
.nid  .shortness  of  breath  tire  the  most  important  iliairuostic  jminis.  I'nder 
ai'iite  myositis  reference  has  already  been  made  to  the  cases  which  closely 
lesomble  trichiniasis.  The  e[)idemic  in  ISTO  on  board  the  trainiiiff  ship 
Cornwull  presented  symptoms  similar  to  thn.se  of  trichiniasis.  Oiu'  patient 
ilied.  Two  months  after  hurial  the  body  was  e\-amiiicd,  and  living  and 
ili'ud  nematode  worms  were  found  which,  as  Hastian  showed,  were  m)t  the 
tijchiiui,  but  a  rhaliditis.  They  weiH^  probably  not  parasitic,  but  entered 
tile  l)ody  of  the  cadet  after  hurial. 

Prophylaxis. —  It  is  not  dellnitely  known  how  swim'  beconu'  ilis- 
o;wed.  It  has  been  thought  that  they  are  infected  from  ratsaliout  slaugh- 
ter-houses, but  it  is  just  us  reasonable  to  lielieve  that  the  rats  are  infected 
liy  eating  portions  of  the  trichinous  flesh  of  swine.  The  swine  should,  as 
far  as  possible,  be  grain-fed,  and  not,  as  is  .so  eonimon,  allowed  to  eat  olTul. 
T!ii'  most  satisfactory  prophylaxis  is  the  complete  cooking  of  pork  and 
>ausages,  and  to  this  custom  in  Kngland,  France,  South  (Jermany,  and 
particularly  in  this  country,  immunity  is  largely  due. 

Treatment.  — If  it  has  been  discovered  within  twenty-four  or  thirty- 
six  liours  that  ii  large  number  of  jjorsons  have  eaten  infected  mout,  the 
00 


1090 


DISK  ASKS   Dl'K   TO    ANIMAL    I'AKASITKS. 


iridiciitioiis  nvc  to  tliorniiirhly  cviiciiatc  tlic  ;iiislnt-iiit('stiiiiil  ciitKil.  I'liri'a- 
tivcs  ol"  rliiil);iil)  iUid  sciiiiii  may  lie  uivcii,  or  an  occa.-ioiial  flnsc  dl"  caldiiit  1, 
(ilyccriii  has  Itccii  :'('c(imiii('H(ic<l  in  lai'j^'c  (loses  in  onlci'  that  hy  |>a>siii^r 
into  tlio  inti'stiiK's  il  may  l)y  its  hy.Lii'oscoiiic  proportii's  dt'stioy  the  worm. 
Mak'-fcrn,  kaniahi,  santonin,  and  thymol  have  all  licen  rccommcndcil  in 
this  slajxc.  'l'iir(K'nliii('  may  lie  tiicil  in  I'ldl  ihiscs.  'I'hcic  is  no  douht, 
that  diarriui'a  in  the  lirst  wct-k  or  ten  (hiys  of  the  intVction  is  distinctly 
favoi'alilc.  'I'iic  indications  in  llic  staLTc  of  invasion  arc  to  relieve  the 
[jains.  to  sccnrc  s!ih'|),  and  to  sii|»|iort  the  patit-nl's  stren,i,dh.  There  arc 
no  medicines  which  have  any  inlliient'e  npon  the  eadjryod  in  their  lui^'ra- 
tion  tiiroiii'li  tlio  imiscles. 


f^'' 


M- 


'  I 


uS 


III.   .\N'rirYi,(»sT()Mi Asrs. 

The  I'litinarid  (Ixirluiiiiis^  >'^/noi(/i/liis)  diiodeiKilis,  also  known  a^ 
the  Srlcriishiiiiiiiii  or  Aiirlijihisluinum  dnoih'nale,  i.s  the  only  stronsxyli^ 
harmfnl  to  man.  it  l)elon,ys  to  the  same  fannlyas  the  Sf/rros/oininii  rijiii- 
viiiii,  which  canses  the  vernunons  anenrism  in  the  horse.  The  parasites 
live  in  the  npper  portion  of  the  small  intestine,  chielly  in  the  Jeiiiiiiiin. 
They  are  easily  .seen,  the  male  haviiii,^  a  leni^th  of  from  six  to  ten  inilii- 
metres,  and  tlu!  female  from  ten  to  eiifjiteen  millimetres.  The  niouth  i-; 
I)rovided  with  a  series  of  tooth-like  hooks,  hy  means  of  which  the  ])arn-iic 
attaidies  itself  to  th»(  mncoiis  mend)ran('.  'I'he  male  lia.s  a  prominent  ex- 
pansion or  Ixirsa  at  the  t.'iil  end.  The  existence  of  the  parasite  has  Ioiilt 
heeti  known,  hut  it  was  not  thonirht  to  be  ])atho;,rerne  until  (iriesinuir 
demonstrated  its  association  with  the  Kiryptian  chlorosis.  It  has  also  iicni 
shown  to  be  the  cause  of  the  ana'inia  to  which  miners  and  brick-makers 
are  subject.  '1'hrou.s.dioiit  Kiirope  the 'disea.se  has  been  widely  spread  liv 
the  employ?iicnt  of  Italian  and  I'olish  laborers.  In  certain  Italian  piii\- 
iru'es  it  is  extremely  [)revalent  and  serious.  It  occurs  in  the  Indies,  in 
Tirazil,  and  the  West  Indies,  and  has  been  describ(Ml  in  . Jamaica  (Straclian). 
Dolley  states  that  tlu'  parasite  was  (lescril)ed  many  years  airo  i)y  j)hysici;iii- 
in  the  Southern  States,  but  no  recent  observations  upon  tlu'  disease  1 


ia\(' 


been 


made  in  tins  coiintrv. 


Symptoms. — The  parasites  withdraw  blood  l)y  suction,  and  tlic 
8ym[)toms  ri'sidt  from  this  slow  depletion.  In  the  early  sta>,'e  there  iii;iy 
only  be  jjastric  or  gastro-intostinal  disturbance,  but  if  the  parasites  ate 
present  in  larfro  numbers  ana-mia  is  jjradually  prodiu-ed  ami  eonstiiutcs 
the  charaeteristic  feature  of  the  disease.  The  Kiryptian  chlorosis,  brick- 
maker's  ana'inia,  tuniud  ana'inia,  miner's  cachexia,  and  mountain  aiueiniii 


are  due 


to  tl 


us  cause, 


Tl 


le  clinical  eour.ie  is  variaole. 


n  some  iiistain'i's 


H', 


the  ana'inia  develops  acutely  and  rea(dies  a  hiifh  ;:rade  within  a  sliort  tin 
causing  great  shortness  of  breath  and  o'deimi.  There  is  .serious  distiirli- 
ance  of  nutrition,  sometimes  diarrluea  and  I'olicky  pains;  but  tlu'  im'-t 
pronounced   symptom  is  the    pallor   and    the   a.ssociated    plieuomena  ot 


J^ii  ■    ■''>W>»(wr<<«<WWyWjgjj 


PISRASKS  CAUSED    liV    NKMAToDKS. 


1001 


oliroiiic  an.Tniiii,  witli  dcliility  luid  wiistiiiir.  'IIh'  lesions  of  tlio  intcstinos 
iiff  tliosc  of  cliroiiic  catjiirli,  aiul  siiiall  lia'morrliairi's  occiir  in  the  iiiiicnsa. 
Tlic  wiiriii-;  arc  I'miinl  within  two  nicti'cs  ol"  the  jiyloi'iis.  often  with  thcii* 
heads  l)nriei|  iti  the  inueosa.  I)ihitation  and  liypei'lropliy  of  thc!  heart 
hav(!  l)een  found  in  many  cases.  Saiidwiih  states  tiiat  iti  l';i:\  pt  the  (lis- 
casc  is  most  comiiKtn  in  peasants  wlio  worl\  in  tiic  (hiinp  earlli,  tnanv  of 
wliom  are  eafth-calcfs. 

'I'iie  liiaLrnosis  is  not  ditHenlt.  'I'iie  ova,  whiih  are  ahniKhmt  in  tlio 
stools,  are  oval,  aliout  ")•.'  inienxnillinietres  lotiix  by  ."i"*  niicroniilliinetrps 
broad,  and  possess  a  tliin,  transpaccnt  shell.  There  is  no  operenlnin,  as 
in  thc  ovnm  of  the  oxyiiris,  and  e<r,irs  fonnd  in  the  fa'ces  are  in  vai'ioiia 
.stiigcs  of  s('i;tn('iitatioii.  'I'lie  larva'  devehtp  in  moist  earth  and  readily 
get  into  the  (]riiikiii<:f  water,  thronLrh  whi.'h  infection  occurs. 

The  systematic  employment,  of  latrines  and  the  boilinir  of  all  Wiitcr 
ii.sed  for  (lriid<inif  pnr[)oses  arc  the  important  pro|)iiylactic  measures. 
'I'liymol,  re(H»mmcnde(l  by  Hozzolo,  is  a  spceilic,  and  shoidil  l»o  <riven  in 
larL^c  doses,  two  Lframmes  (in  wafers)  at  S  a.  m.  and  twi/  grammes  at 
10  v  M.  (Sandvvitli).  'I'he  diet  should  lie  milk  and  soup.  Two  lioiira 
after  the  second  do.se  of  thymol  a  purine  of  castor  oil  or  magnesia  is  ;,Mven. 
If  n('ces.sary,  the  trciilmciit  may  be  ie[)eated  in  a  week. 


1\'.     l''ll,Al;lAS!S. 

Zooloirieally  the  Fihiria  sdminiiiis  limiiiuis  is  as  yet  siift  Jin/irr.  iVfan- 
son's  views  are  as  follows  : 

I'lidcr  the  <rcneral  ternt  llho-ia  s(iii(/in'/n's  /loininis  three  .species  of 
nematodes  are  iiKdnded  : 

1.  I'lhirid  /»Vn/6'/v;/7/,  ('ol)old,  IH'T?.  'I'his  is  tho  ordimiry  })lood  filaria. 
The  embryos  are  fonnd  in  the  peripheral  circulation  oidy  dnriiijj;  sleep  or 
.■it  niii'ht.  The  inosfpiito  is  the  intermediate  host.  The  embryos  measiiro 
"v'TO  to  ;J4()  mieromillimetres  lon,<?  by  7  to  11  micromillimeti-es  broad;  tail 
point(>d.  'i'he  adidt  male  n;easiircs  s;?  millimetres  lonir  liy  "407  milli- 
metres broad  ;  tii(>  tiiil  forms  two  tnrns  of  a  spiral.  The  adult  fcmalo 
measures  lA.")  millimetres  lonij;  by  'Tl.")  millim<>tres  broad  ;  vulva  •*ri<i  mil- 
limetres from  anterior  e.x'tremity  ;  e<rirs  '5<S  mieromillimetres  by  II  micro- 
millimetres.  This  is  the  specties  to  which  the  ha'malo-chyliiiia  and  ele- 
phantiasis are  attributed. 

"i.  Film-ill  iliiiriKt,  .Manson,  ISitl.  The  larva^a^ree  witli  tlie  preceding, 
o\ce))t  that  Manson  indicates  the  abseticc  of  e-ranidcs  in  the  axis  of  the 
body.  The  worms  oeeur  in  the  peri()h('ral  circidation  oidy  durini,^  the 
ilay,  or  when  tin;  patient  stays  awake.  Man.sou  suspects  that  the  Filaria 
hid  represents  the  adult  staire. 

;5.  Filaria  pern/diis,  M.iiison,  l.Sltl.  Oidy  the  end)ryos  are  known. 
These  are  much  smaller  than  the  preceditifj— '^'(10  mieromillimetres  lonij, 
juKterior  oxtroniity  obtuse,  anterior  extremity  with  a  sort  of  retractile 
ruslellutn. 


1092 


1)ISI;ASKS    DFK   to   ANIMAF.    I'AUASITKS. 


Tliis  is  tlio  species  to  wliidi  Maiisoii  is  ijicliiied  to  attriliiite  tlic  sleep- 
iiiji-sicUiiess  (if  tlic  lu'ifnies.  Il<!  is  also  iiicliiicil  (o  rc;:,ii'(i  tins  Fihuiii 
/)i'rsfiiiis  ;[.>>  the  euiise  ol"  rrair-rrti/r,  a  p!i|>iii()-|)iistulur  si\iii  eruption  i,|" 
tiie  west  I'oast  (if  Al'iica,  wliidi  is  pi-Dlmhly  tlie  siunc  as  Niellv's  ilrnuiitiisv 
piinisi/itiir,  tlie  paiusile  of  wliicii  was  ealleti  iiy  Bliiiieiianl  UluilidHis 
Mrlli,. 

'I'lie  iiiosi  iiiipnrtaiit  (»f  tiifse  is  tlie  Fibiria  /lioirrofti,  wliicli  produces 
the  ha'duitiichvhiria  and  the  lytnph-scrotuiM. 

'I'iu'  female  produces  ati  extraonliiuirv  iiuinher  of  einhryos,  whicji 
i'lit(!r  the  idood  current  throiif,di  the  1\  iM[diatics.  Kach  mdiryo  is  witlini 
its  shell,  which  is  elonifate(l,  sciiroely  percept ihle,  and  in  no  way  impedes 
the  movements.  Thex  are  ahout  the  ninetieth  part  (d' an  in(di  in  lcn;:tli 
and  the  diameter  of  a  red  hlood-eorpuscdi^  in  thickness,  so  that  tliev 
readily  pass  tlirou;.di  the  capillaries.  'I'lii'y  move  with  the  <:reatesl  ai'- 
tivity,  and  form  very  strikiui^  and  readily  reco<,Miized  objects  in  a  hloed- 
dro[i  under  the  Tuicroscope.  A  remarkaltK;  feature  is  the  periodicity  iii 
the  occurrence  of  the  einhryos  in  the  hlooii.  In  the  daytime  they  are 
almost  or  entirely  absent,  whereas  at  ni<_dit,  in  typical  cases,  they  are 
present  in  larjre  numliers.  If,  however,  as  Stephen  Mackenzie  has  shown, 
the  patient,  rcver.-in;j  iiis  liahits,  sleeps  durinj,'  tlie  day,  the  jieriodicity  is 
reversed,     'riie  further  development  of  tie   embryos  appears  to  be  assuci- 


ated  with  tiie  inos(|iiito,  vvhi(di  at  ni<,nit 


vs  the  idood  and  in  this  w.iy 


frees  them  from  the  body.  Some  sli^dit  development  takes  place  within 
tlic  body  of  the  mos(|uito,  and  it  is  probal»le  that  the  embryos  are  set  fice 
in  the  water  after  the  death  of  the  host.  The  further  development  is  iiut 
known,  but  it  is  probably  in  drinkinj;  water.  'I'he  lilaria'  may  Ite  present 
in  the  body  without  causinu^  any  symptoms.  In  animals  blood  lilaria:  are 
very  common  and  rarely  cause  inconve'nieiu'e.  It  is  only  when  the  adult 
worms  or  the  ova  block  the  lymph  (diannels  that  certain  definite  symp- 
toms occur.  Mauson  sii{f<jests  that  it  is  the  ovu  (prematurely  discharired), 
which  are  considerably  shorter  and  tliicker  than  the  fuli-^rown  embr\es, 
whiidi  block  thel\nipli  (duiniuds  and  pnxiiice  the  conditions  of  lueuiatu- 
chyliii-ia,  elephantiasis,  and  iymph-scirotum. 

The  parasite  is  widely  distribute',  partioularl}  in  tropical  and  sul)- 
tropical  count rii^s.  (riiiteras  lias  shown  that  the  disease  prevails  exten- 
sively in  the  Soutlierii  States,  and  siiu^c;  his  ])aper  aj)peared  contributimi-^ 
have  been  made  by  Matas,  of  New  Orleans,  Mastin,  of  Mobile,  and  I'o 
Saussure,  of  (Miarlestoii. 

'J'he  etTects  produced  may  be  deserilxMl  under  the  above-mentioned 
conditions. 

{(i)   llo'imifdrlniiiirid. — Without  any  ext(>rnal  manifestations,  and   in 


many  cases  without  special  disturbance  of  health,  the  .«n])ject  from  ti 
to  time  jiasses  urine  of  an  opa(pie  white,  milky  appearance,  or  bloc 


n:e 


)(|V.  iT 


a  idiylous  fluid  which  on  settling  shows  a  slij;htly  reddish  clot.    'J'lit^  iiiiih' 
may  be  normal  in  (piantity  or  increased.     The  condition  is  usually  inier- 


niSKASKS  CAUSKD    HV    N'KMATODKS. 


tc  tlio  8U'0l>- 

tlu!    Fi  1(1  lit 

v's  (lfniiiiti'>- 
nl    h'hii/'dilis 

lich  produ.iH 

ihrvos,  wliirh 
l)ryti  is  within 
)  wiiy  imiiiilis 
iiicli  in  li'iiL'lh 

so     tllllt     tlu'V 

ic  j:n'iit<'sl  :ir- 
•  ts  ill  ii  1)1<»;(1- 

poriodicity  in 
ytiiiie  tlu'V  sii-o 
fuses,  tlicy  me 
jzic  lias  slidwii, 
IC  jH'riodicity  is 
irs  to  \k'  assiK'i- 
atul  in  tliis  way 
cs  place  witliin 

vos  are  si't  f''^'"' 
L'lopmenl  is  nut 

may  1h'  l^'esciit 
ilddd   lihiria;  an' 

when  the  athiU 
.Irtinite  synip- 

cly  dischartri'il). 
niwn  eiiil)r\"S 

(Ills  of  liu'iiiato- 


i|)ical  anil  ;^ 


uh- 


1"' 


avails  cxtfii- 


d  contributions 


Mobile,  an< 


1   I)v 


Lbove-incntionr 


Stations,  and  m 
))ci'l  from  tiir.i- 


)!•  bloody. 


or 


Iclot.    The  unm' 
lis  usually  i"'^'""' 


ittent,  and  the  patient   may  pass  tiorinal  urine  for  W(>el\s  or 


ni 


time 


M 


leroseopicidly,  tlie  cliyloiis  urine  eontaiiis  minute 


griiJiules,  usually  r{'i\   lilood-eorpusclrs  in  various  amounts. 
were  first  discovered  by  l)eman|iiuy,  at  Paris  (ISO.'J),  and   in 
Wuclierer,  at  Itahia,  in  iStiC).     It  is  remarkalde  for  liow  loii;^ 
may  persist  wit  bout  serious  impairment  of  the  beaitli.     A  pa 
ine  by  Dawson,  of  (  liarlestoii,  lias  lia<l  Inematocdiyliiria  inter 
<'ijfliteeii  years.     Tlio  only  incoiivpiiienee   has  beni   in   the   passa;x 
blood-clofs  will'  h   collect    in   the   bhidder.      At   times  he   ha 


l(i<»3 

r  months  at  a 

molecular  fat 

■ 

The  endiryoH 

the  urine  by 

the  condition 

iticiit,  »cnt  to 

•iiiitti'ntly  for 

assa;xc  of  the 

s  aNo  uiieasv 

sensations  in  the  lumbar  rcjijion.     The  embrv< 


)s  are  jiresciit  in 


his  blood 


at  nii,dil  in  larire  numbers.  Chyluria  is  not  always  due  to  the  lilaria.  The 
non-[)arasitie  form  of  the  disease  has  already  iueii  considered. 

Opportunities  for  studyinji  the  anatomical  coiulition  of  these  casosi 
rarely  occur.  In  th((  case  described  by  Stephen  Mackenzie  the  renal  and 
peritoneal  lymph  plexuses  were  eiiorinoiisly  eiilarired,  exteiidiiii,'  from  the 
diapliraj.'m  t(»  the  pelvis.  The  thoracic  duct  ab(»ve  the  (liapliraj,Mii  was 
imjiervioiis. 

(ft)  /,i/iii/i/i-srr(tt9ni}  and  certain  forma  of  flcplidtitidsix  are  also  ciuised 
by  the  iilaria.  In  the  former  tiie  tissues  of  the  .scrotum  are  enormously 
tlii(d\ened  and  tlie  (listeiided  iymph-ves.sels  may  be  plainly  seen.  A  clear, 
sometimes  a  turbid,  lliiid  follows  puncture  of  the  skin.  The  parasites  are 
not  always  to  be  found.  I  have  examined  two  typical  cases  wiihout  find- 
iiii,'  lilaria  in  the  exuded  lliiids  or  in  the  blood  at  nijriit.  So  also  the 
majority  of  ea.ses  of  elephantiasis  which  occur  in  this  country  are  non- 
parasitie.     In  China  it  is  stated  that  the  para-sites  occur  in  all  Ihe.so  cases.* 


\'.    I)liA<'()NTl.\sis  (d iiiiicii-iriinii    l)is('iisf). 

The  Fi/iiri(t  or  Drdcn iinihtx  mi ili noisis  is  a  widely  spread  parasite  in 
parts  of  Africa  and  the  Kast  Indies.  In  the  I'liited  States  cases  oci  a.-ion- 
ally  occur.  .larvis  reports  a  case  in  a  post  cha|)!aiii  who  hail  lived  iU  l'"or- 
iress  Monroe,  \'a.,  for  thirty  years.  Van  llarlin<reirs  patient,  a  man  a<red 
forty-seven,  had  never  livi'd  out  of  Piiiladelpliia,  s(j  that  tiie  worm  must 
lie  iiududed  ainon<x  the  parasites  of  this  country.  A  majority  of  the  cases 
reported  in  American  journals  have  been  iinportt'd. 

Only  the  female  is  known.  It  develops  in  the  subcutaneous  and  inter- 
Tnusciilar  connective  tissues  and  produces  vesicles  and  ab.scesses.  In  the 
larije  majority  of  the  ea.ses  the  partisitc  is  found  in  the  le^.  Of  ISI  eases, 
in  ViA  the  worm  was  found  in  the  feet,;)."!  times  in  the  lej^',  and  11  times  in 
the  tliiirh.  The  worm  is  usually  .solitary,  though  there  are  eases  on  re(!ord 
ill  which  six  or  more  have  been  iire.^ent.  It  is  eylindrieal  in  form,  about 
t^vo  millimetres  in  diameter,  and  from  fifty  to  eij,dity  centimetres  in  icii<;tli. 

*  l''ipr  full  ('(insi.li'riition  of  the  siitijcct   of  (•<iiij;cnitiii  (nclusiiui  miuI  (liltitiilioii  of 
Ivinpli  iliaiuu'ls.  sec  work  on  this  sultji'ct  by  Suniiicl  ('.  Uu:<('y,  Xi'W  York,  ISTM. 


y,. 


1(>1>4 


ItlSKASHS    IKK   TO    AN'IMAL    I'AUASITKS. 


'I'lii!  worm  ^'iiiiiM  ciilrimci'  to  llio  system  lliroii;^'li  tlio  stoiUfU'li,  \  n\, 
t)in)ii;;li  till!  skit),  as  was  formerly  siipposcd.  It  is  {irolialilc  tlmt  li<>;ii 
nialo  and  female  are  iiiirested  ;  liiit  tlie  former  dies  and  is  diseliari:' i|, 
while  tlie  latter  after  imiire^f|iatioii  penetrates  tlie  intestine  and  atlain.>  n.s 
full  deve|(ii»nient  in  the  sul)eutane()\is  tissnes,  wli^re  it.  may  remain  <|iii. - 
cunt  for  a  lon^'  time  and  ean  he  felt  iu'nealh  the  d<in  like  a  hundli  ..f 
strini,'.  Su|iiiiiration  is  after  a  time  excited,  and  w'u  ;i  ilie  aliseesses  ;,ir 
ripened  or  hiir.-t  the  worm  appears  and  is  sonielimes  uisehar^^'il  entire, 
''"he  worm  contains  an  enormous  numher  of  living;  embryos,  v.  hich  es(;i|ic 
into  till'  water  and  deselop  in  ihc  cy(;|ops— a  small  ernsiac-e!in--aiid  it 
tseems  likely  that  man  is  infectt'd  by  drinkin*;  the  water  eonlainiu;,''  these 
(levelope(l  larva-. 

'I'hi'  trnihiiriit  consists  in  promotiiic;  the  snppnration,  and  when  the 
worm  is  seen  the  common  pi'oceilui'e  is  to  roll  it  rnimd  a  portion  of  smuoili 
wo(»d  and  in  this  .vay  prevent  the  retra(;tion,  and  each  day  wind  a  liiilc 
more  niitil  the  entire  worm  is  withdravvti.  It  is  stated  that  special  fiuv, 
must  l)e  taken  to  prevent  tearin;,'  of  the  worm,  as  di.-astroiis  consefpienns 
somotimes  follow,  probably  from  the  irritation  caused  l)y  the  nn.ujration  nf 
the  end)ryos.  It  is  stated  that  the  leaves  of  the  plant  called  iniiKriinlhi- 
are  almost  a  speeilic  in  the  disease.  Asafii'tida  in  full  dodcs  is  said  to  kill 
the  worm, 

VI.  OriiKit  .\i:m.\T(iih:.s. 


{(t)  Amonji  less  important  lilarian  worms  parasitic  iri  man  the  follow- 
inf(  may  be  mentioned  :  Fihiriii  l.iut,  which  is  a  cylindrical  worm  of 
abont  thi'ce  centimetres  in  length  and  whose  habitat  is  beneath  the  cnn- 
jiincli\a.  It  has  been  found  on  the  West  African  coast,  in  Brazil,  and  in 
the   West   Indies.      I'ihiriit  If/i/is,   wliifh    has  Iieen    found    in   a   cataract. 

lia> 


A',  wima 


Three  specimens  have  beiMi  found  toffciher.  I- ihtrin  /(t/n'ti/is,  which 
been  found  in  a  pustidi'  in  the  upjier  lip.  /■'i/arid  /tdtiiinis  on' 
was  desei-ibed  l)y  Leidy,  from  the  month  of  a  iddld.  Fihiriii  hnnn'liiaiis^ 
which'  has  been  found  occasionally  in  the  trachea  and  brondii.  'riii> 
parasite  has  been  seen  in  a  few  cases  in  the  bronchioles  an. I  in  the  luii.'v 
Tiu're  is  no  evidence  that  it  ever  produces  an  extensive  verminous  hmn- 
cliitis  similar  to  that  which  I  have  described  in  doys.  /■'i/iin'ii  inii/i'<  - 
the  common  Filtiria  ,snii;/iii>iis  of  tlie  dop: — of  which  Bowlliy  Inis  ilt- 
seribed  two  cases  in  man.  In  one  case  with  luemaLuria  fciuale  woiiii« 
were  foniul  in  the  jiortal  vein,  and  the  ova  wt-re  present  in  the  ihiekeiinl 
bladder  wall  and  in  the  ureters. 

(/>)  7'n'i/i(ii-r/i/iii/ns  ilisjiitr  (  W hi))  iroriii). — This  parasite  is  not  iiil'iv- 
(piently  found  in  the  cM'cum  and  larj^e  intestine  of  man.  It  measiiic- 
from  four  to  live  centimetres  in  length,  the  mali'  being  somewhat  shoriir 
than  the  female.  Thi'  wortn  is  readily  recogiuzeil  by  the  remarkalilc 
difference  between  the  anterior  and  posterior  portions.  The  foruhr. 
which  is  at  least  three  lifths  of  the  body,  is  extremely  thin  and  hair-like 


IW»WWiFrW<>»1»"  »ii"MI 


niSFASKS  CAl'SKD   BY   NKMATOlUX 


1()!»: 


Ktomiu'li,  tint 
ill'  tint  l)..;li 
s  (lis(-luuv  '1. 
iiiil  utlaiii.>  Its 
rfmii'm  <|Uh  <- 

'  iibsi't'ssus  I  in; 
iiiir^M'tl  oiitiri'. 
,  viliicli  cs'  :M"' 
iiL'ciili  — iilnl  it 
iilaiiiiiif,'  tiust! 

and  wlion  tlic 

tiull  ul"  Sllini'lll 

ly  wiinl  11  linli' 
at  spiTiiil  '•iirti 

8  COIlSl'«|ll(lli  rf< 

u'  ini,i.M'iitinii  of 
[loil  (iiiKir/iiilhf 
!8  is  said  U)  liill 


iiiin  the  foll'iw- 
'i'i(;id   \V(H'in   "f 

Cillll      till'     Cdll- 

r.iii/.il,  and  in 
ill  ii  cataract. 
//,s',  wliii'li  li;i.s 
is  oris,  wliirli 

)i'()iichi.  'riii-^ 
I  in  till!  h\u'A>^. 
nninDiis  ln'i'ii- 
'il(iri((  iiiiilis— 
iuwlliy  lias  tli'- 
t'l'iiialc  worms 
1  tlR'  Ihickoiu'd 

~\\v  is  not  infiv- 
n.  It  nu'asun'S 
jinewliat  slioiUT 
tlie  roinarl<alilt' 
The  foniirr, 
in  and  hair-lil^^' 


in  contra-t  In  the  tliick  liindcr  pm'tinn  of  tlic  liody,  which  in  (lie  fciii;dc  is 
conii  ,'il  find  |ioiiiicd,  and  in  the  male  more  nlitn^c  mid  iisiiiiily  rolled  likt) 
a  s|irinLr.  'I'he  n\ii  ;ire  oval,  lenioii-sliaped,  -(iri  niillinietre  in  icn^MJi,  iind 
each  is  pi'ovided  with  a  Imttoii-like  |iroji'ction. 

'l'ln»  niinilier  of  the  worms  ntiind  is  variable,  as  many  as  a  thonsand 
hasinj^f  been  counted.  It  is  a  widely  spreinl  parasite,  in  jiarts  of  Miiropc 
it  occurs  ill  from  ten  to  tliiriy  per  cent  of  all  Imdies  exainineij.  Imt  in  this 
country  it  is  not  soconiinon.  'The  triehocephalns  rarel\  caimes  .symptoms. 
It  has  hecn  tlioii;.'ht  hy  certain  physiciinis  in  the  Kast  to  he  the  cause  of 
heri-hcri.  Sever.d  cases  liavr  heen  re|)orted  rei'cnt ly  in  which  profound 
aii.i'iiii.'i  has  occiirreil  in  cdiiiiecl ion  with  this  parasite,  usually  with  diar- 
rlid'a.  I'liiorinoiis  niiinliers  may  occur,  as  in  Rudolj)hi"s  ca.se,  without  pro- 
diiciii'^f  any  symptoms. 

The  dia;;nosis  is  readily  madi'  l)y  thu  examination  of  the  fa'ces,  which 
(•nntaiii,  sometimes  in  j,'reat  ahuiuiance,  tho  clmracl«.'ri,stic  lemon-.shapi'd, 
hard,  dai'k-liroun  ci^sjs. 

{(■)  UiiirlDjiliiinir  (jiiiKs  (Fiistroiiijiihis  f/ii/ns). — 'F'his  onormoiis  notiia- 
tode,  the  tmiie  of  whicli  measures  ahoiit  a  foot  in  leiiirth  and  the  female 
ahoiit  three  feet,  occurs  iii  very  m.iny  animals  and  ha^ 
met  with  in  man.  it  is  usually  foiiiiil  in  tiie  rciial 
tir(dy  destroy  the  kidney. 

{(/)  StniinijiJitiilrs  iii/rsfiiKifis. — ruder  this  name  arc  tiow  iiiclude(i 
the  small  iieinatodi!  worms  found  in  the  fa'ces  and    formerlv  descrilied  jis 


occasion.'illy  lieeii 
re'Moii  and  inav  eii- 


.lit;/iii/hi/(t  sfrmirolis,  AiKiuilhiln  iiiti'stiiuili 


s.  ami 


ItluiliiliDiniiii  i II lest i- 


iiiilr.  This  parasite  occurs  ahiindMntl\  in  the  stools  id"  the  endemic  diar- 
rliiea  of  hot  countries,  and  has  heen  .specially  descrihed  l»y  the  Freiudi  in 
the  diarrlura  of  ('o(diin-('hina.  It  occurs  also  in  Brazil,  and  has  oeeii 
found  ill  Italv  in  connection  with  the  aiudiylostoma  in  cases  of  miner's 
aii.emia.      It  is  stateij   that   the  worms  occupy  all   parts  of   the   intestines. 


and  have  even  lieen  foiii 


(I  III 


the  liiliarv  and  iiancreatic  ducts.      It  is  onlv 


when   they  are  in  very  lari^e  niimhers  that  they  proiluce  st-vere  diarrhtea 
and  anaMiiia. 


Ac.WTlKXKl'lIAI.A    (  TllonillCddi'd    Wnnils). 

The  (lifKiiifiirlniiifJiiis  or  /■,'r/iiiiiir/i>/nrhiis  i/ii/iis  is  a  common  parasite 
in  the  intestine  of  the  hoi;  and  att;iiiis  a  larijro  size.  The  larva-  dcveloj) 
ill  cock(diafer  jrriihs.  The  .\iiierii;iii  intermediate  host  is  the  .Fmie  liuj; 
(.Stiles).  I>amhl  fouiul  a  small  /■.''■/liinir/ii/iir/iiis  in  the  intestine  of  a  lioy. 
Welch's  speciiiK'ii,  which  was  found  encysted  in  the  intestine  of  a  soldier 
at  Netloy.  is  stated  hy  Cohliold  prohalily  not  to  have  he(>n  an  /Cr/tinorhi/ii- 
rlnis.  Ut'cently  a  case  of  /■'i/iiii'ir/if/uchua  viuniiij'unnift  has  been  dcscribod 
in  Italy  by  Grussi  and  Calandruccio. 


1<»90 


DISKASKS    DTK   To    ANIMAL    I'AIiASlTKS. 


V.    DISEASES    CAUSED    BY    CESTODES 

{Tdjii'-irDiDix :  //i/'/(i/iil  Disi'fisi'), 

M;m  liart»(iiN  the  adult  ]iiira>itc.s  ii>  the  .small  intestine,  lliu  liirvul  furin.s 
ill  the  iiiu.seles  ami  sulid  {)ri_raii.s. 


VM: 


1.    IVTKSTINAT,    Cl-TODKS;    T.\  I'l' -WOi;  MS. 

{(I)  '/'(I'ln'a  s(i/i/i/ii,  i>\'  pcii'k  taiK'-wi  ;  111.  This  is  i,(it  a  coniinoii  form  in 
this  coiiiitrv.  it  is  iiiiicii  iiuire  rreqiicnt  in  parts  of  Kiirop(!  ami  Asia. 
When  mature  it  is  from  six  to  twelve  feet  in  leiiirtli.  'The  lieiul  i.s  small, 
round,  not  so  larire  as  the  head  of  a  pin,  and  provided  with  fonr  sm^kiiiL; 
disks  and  a  doiihle  row  of  hooklets  ;  heiiee  it  is  ealled,  in  eontradistinetion 
to  the  other  lorm  in  man,  tne  ai'incd  ta[ie-worni.  'To  the  head  siieijeeds  a 
narrow,  thread-like  neck,  then  tlir  seirnieiits.  or  proi^lottiiles,  a.!  they  arc 
called.  'I'he  seirmi'nts  possess  lioth  male  and  female  LCeiu'rati'.e  ori,fan-. 
and  uiioiit  the  foni'  hundred  and  liftieth  heeome  mature  and  contain  ripe 
ova.  The  worm  ii.,aiiis  its  full  growth  in  from  three  to  three  and  a  ha!!' 
nionihs,  after  which  time  the  sesrmen's  ai-e  continuously  shed  and  appear 
in  the  stools,  '{"lie  seirments  are  aliout  one  centimetre  in  leii<rtli  and  from 
seven  to  eiijlu  millimetres  in  hreadth.  I'ressed  hetween  jj^lass  jilates  the 
uterus   is   seen   as   a    median    stem   wiili   ahoiit   eiirht   to  fourteen    later:' 


I 


iranciies.  There  ai'c  many  thousands  (if  ova  in  each  ripi;  sejxinent,  and 
each  ovuth  consists  of  a  linn  shell,  inside  of  which  is  a  litthi  emhryo,  pr- 
vided  with  six  hooklets.  The  seirments  are  continiioiisly  passed,  a'ld  if 
the  ova  are  to  attain  further  development  they  must  he  taken  into  the 
btoimieh,  either  of  a  piir.  or  of  man  himself.  'I'he  eLr.ir-shells  are  tliycstcij, 
the  six-hooked  emliryos  hecoiiie  free,  and  passiiiir  from  the  stonuK'h  reach 
various  parts  of  the  hody  (the  liver,  niusc.es,  hrain,  or  eye),  where  the\ 
develoj)  into  the  larva'  or  eysticerci.  A  ho,<;  under  these  eirenmstances  is 
.said  lo  he  ixedslid,  and  the  cystieerei  are  spoken  of  as  measles  or  hladder 
worms. 

The  l(r,ii(i  siiUkdi  received  its  name  heeause  it  was  tho'i<rlit  to  exist  as 
a  solitary  parasite  in  the  howel,  hut  two  or  time  or  even  niori'  worms  may 
oceiir. 

{!))  Tiniiit  siiijiiidlii  oi'  nicilidraiicUiila — the  unarmed  or  hcef  ta|te-woriii. 
Thi>  is  a  longer  and  lar;:er  parasite  than  the  'I'lriiid  soli  inn.  it  is  eertainl\ 
till'  common  tape-woiin  of  this  eoiinlry.  Of  scores  of  spei'imens  which  1 
have  examined  almost  all  were  of  this  variety.  .Veeordin.t:^  to  Kereiiirer 
Feiaml  it  has  spread  rapidly  in  western  Kiirope,  owinjj  prohahly  to  tin 
iniporlalioii  of  heef  and  live-stock  from  the  .Mcdilei'iMtiean  basin.  It  ma- 
uttain  a  leii_th  of  lifieen  oi'  t went v  feet,  or  more.  The  heail  is  larire  in 
(!omparis(Mi  to  the  Ttcniii  sn/iiim,  and  measures  over  two  millimetres  in 
breadth.     It  is  sfpiare-shajied  and  providi'd  with  four  laryo  sucking  disk.-, 


DISKASRS  CArsKD    P.Y   CES'IODKS. 


I<t0( 


(.!  Uii'vul  f')riiis 


innioii  form  in 
ope   iiiul    Asia, 
lie;   1  is  sniiill, 
h  fniir  suclxiivj, 
Kiriulistinctitiu 
iciiU  siu'CI'imIs  :i 
Ifs,  iUi  thov  an- 
iTati\o  or.traii-, 
11(1  contain  rip«' 
lu'ci'  and  a  lisilf 
lied  and  appear 
onjitli  and  from 
•ilass  i)laU'.s  tlir 
fourteen   latiTal 
)u  sej^niont,  and 
lo  embryo,  ]>i' 
passed,  a'ul  it' 
alsen   into  the 
s  are  digested, 
s(oma<di  reaeh 
(.),  where   tlies 
ircumstanees  is 
isles  or  hladiler 

Mirlit  to  exist  as 
luit'  worius  may 

)cef  tape-worm. 
It  is  eerlaiiil^ 
Mimens  wliieh  1 
liT  to    Herenjrer- 

prohahly  to  till 

1  basin.     It  ma\ 

licuil   is  lar^'c  ill 

(I  niillimetri's  in 

;o  siu'king  disk,-, 


but  tlioro  are  no  booklets.  The  ri|u^  segments  are  froiu  seventeen  to 
o'lfhteea  milliuietres  in  Icuuib,  and  froiu  iM^dit  to  tin  millinitlics  in 
breadtii.  The  uterus  consists  of  a  lucdiau  steiu  with  fidiii  lificcii  to 
thirty-live  lateral  branches,  which  an^  iii\cn  (dV  more  di<diolnmously  than 
in  the  'I'u'nia  suliinii.  'i"he  ova  arc  somewhat  larger,  ami  the  -hell  is 
thiekt'r,  but  the  two  forms  can  scarcely  be  disliiigiiished  by  their  ova. 
'J"he  ripe  segments  ai'e  jiussed  as  in  the  ln'iiin  suliniii,  and  are  ingisud  hy 
cattle,  ill  the  llesh  or  organs  of  whicdi  the  eggs  dcvdnp  into  the  bhuMer 
■  'Mns  or  eysticerci.  Mo  instanci!  of  the  cysiiccrcus  of  tiic  /ir/n'n  .^ftyiiuifn 
nas,  so  far  as  1  know,  been  re[iorted  in  man. 

Of  other  foi'ius  of  tape-wiii'm  may  lie  menlinne<l  : 

(r)  />i/i>//ii/iii/ti  ciiiiiiiinn  (  '/'irhin  illijil ini,  7'<riiiti  cKninirri im).  A 
small  parasite  very  comniuii  in  the  dog  and  occasionally  fniind  in  man; 
the  larva'  develop  in  the  lice  and  tleas  of  th.'  dog. 

{il)  Ifi/Dintii/i'/isis  (/iiiiiiiNfd  ('Driiiii  jIiii'-iHDitiiilii).  .\  siiiali  cestode 
was  found  in  the  inte.-line  of  a  diild  in  i>o.-.|nn,  and  has  since  been  met 
with  in  one  or  two  eases.  It  is  common  in  rats.  'I'hc  lar\;e  (b'velop  in 
Lrj)ii/ii/)/rr<t  ami  in  l)eetles 

(' )  /li/iiiniii/i/isis  iHiHii  ['/'(find  iKiiiii)  ;[]\>\  the  Ihirai nm  M(i>l<i<i(i.yiti- 
rii'tisis  \T(i'ni(i  Miiihni(is((nii'iisls)  ha\c  iieeii  found  oid\  once  nr  twice. 

(  /')  Until riiircjilidhis  Idlits.  A  cestnde  worm  found  only  in  certain 
disti'icts  bordering  on  the  Baltic  Sea  and  in  parts  of  Switzerland.  So  'ar 
as  I  know,  il  has  not  bet  ii  found  in  this  country  except  in  a  few  imporle(| 
eases.  'I'lie  parasite  is  large  and  long,  measuring  from  twenty-live  to 
thirty  feet  (U-  more.  Its  head  is  dilTcrcnt  from  that  of  the  tania,  as  it 
po.ssL'.s.ses  two  lateral  grooves  or  pits  and  has  no  booklets.  'riie  larva* 
develop  in  the  peritomciim  and  muscles  of  the  pike  and  other  lisb,  and  it 
lias  been  shown  L.xperimentally  that  lhe\  grow  into  the  adult  worm  when 
•■aien  by  man. 

Symptoms.— These  parasites  ai'c  foiiml  at  all  at'cs.  They  are  not 
uncommon  in  childi'cn  and  ai'e  occasionally  fniiml  in  smd^liiigs.  \V.  T. 
I'lant  refers  to  a  number  id'  cases  in  children  under  two  years,  and  there  is 
a  case  in  the  literatiiic  in  which  it  is  stated  that  the  tape-worm  was  found 
111  an  infant  live  days  (dd. 

'I'lu!  parasites  may  caii.se  no  disturbance  and  are  rarelv  dau'j'erous.  .\ 
knowledge  of  the  existence  of  the  worm  is  geiierallv  a  snuree  id"  worry  and 
;uixiety;  [\\v  \,.A'.:\\i  may  havi-  considcraltlc  distress  and  coniplain  of  ab- 
d'Piiiinal  pains,  nausea,  and  sometime-;  diarrhoM.  ( ►ce:i>iitiially  the  ajjpe- 
titc  ks  ravenous.  In  women  and  in  iiervcius  patient-;  the  cmi-tiluiional  dis- 
turbance may  be  considerable,  and  we  imt  infrccpiently  see  great  menial 
depression  and  even  bypoidioiidria.  N'arious  nervous  phenomena,  smdi  a.s 
chorea,  conviiisions,  or  epilepsy,  are  believed  in  l»e  caused  by  the  parasites. 


icji   elTcct.s,  li(ev'.-ver,  arc  \erv  rari 


li<'lin 


rion'plnihifi   may  cause  a 


re  and  even  fatal  form  (d'  amemia,  whiidi  has  been  de.scribeil  fully  in  a 
lit  monograph  by  S(diaumaii,  of  Ibdsiiigfors. 


10!»S 


DISKASKS  DUE   TO   ANIMAL    PAIIASITES. 


Tiio  t/idf/iiosis:  is  never  (litulttfiil.     The  jiroseiieo  of  the  seirnietils  is  (] 


I-- 


tiiietive.  The  ova,  too,  may  he  recognized  in  the  stools.  It  makes  hui 
litlh"  (lilTei'ence  as  to  tiie  I'oiiii  of  Ia|u'-\vorm,  hui  ihe  ripe  seLTinents  of  tin' 
'l\t'iii(i  siKjiiinht  are  lari:cr  ami  hroa'ler.  and  show  dilTermees  in  the  <;('iiii-- 
ati\c  s>.-Iem  as  already  men'.ioiieil. 

Till' ///'(////^y/r^r/.v  is  most  im|ioi'tant.  Carrful  attention  should  heijiviii 
to  two  |ioinIs.  I''iisl,  all  tape-woi'm  seirmeiits  slnadd  he  hui'iieil.  T 
should  ne\er  lie  thi'oun  into  the  water-closet  or  ontside.  And  ■second,  lie 
meat  slioidil  he  cooked  t  hi'ouiihout,  in  w  Inch  way  alone  larva'  arc  destrovcd. 
I'ossihiy  it  is  owiMLT  •"  'he  fact  that  in  this  country  pork  is,  as  a  rule,  hettir 
cooked  than  hcef  that  the  'Driiin  stKiiiHilu  is  the  most  common  form.     ( 


H  V 


IT- 


tainly  in  tiic  market  and  at  the  ahattoirs  one  inoi-e  commonly  sees  mea-lv 
poi'k  than  measly  veal.  In  the  examination  of  a  thousand  hoir^  in  Mont- 
real there  wci'c  seventy-six  insiamcs  of  cysiicerci.  The  im'asle  is  iiiurc 
readily  overlooke(l  in  heef  than  in  pork,  as  in  the  former  it  has  not  surh 
an  opaque  while  color. 

Treatment.  -  I'or  two  days  prior  to  tin'  admiiustration  of  the  I'ciiii'- 
dics  the  patient  ~h.oidd  take  a  very  liuht  diet  and  have  the  odwcls  moved 
oeeasionallv  ity  a  saline  eatliartic.  'I'he  jj.raciilioiier  has  the  (dioice  of  a 
jarirc  niiinl«'r  of  druirs.  As  a  rnh'.  tlii'  male  fern  acts  j)romptIy  and  will. 
'I'he  etlierea!  extract,  in  t wo-draiditn  do-.s,  may  he  iiiven  fastiriLT,  and  fol- 
lowed i[i  the  course  iif  a  eouplt'  (if  hoiii's  hy  a  hiisk  piirsxative.  'I'his  iisu- 
;<lly  succeeds  in  hringin;^'  a     ly  a  lai'i^c  portion.  Init  not  idwa\»  the  entire 


wurm. 


.\   condiination   id"  t!ie  remedies  is  sometimes  verv  etTeeiive.      .\ti 


in- 
fusion is  made  of  pnUH'i^ramite  root,  half  an  ounce:  pumpkin  s<-»'il!*,  oiu* 
ounce;  powih  red  crtioi.  a  drai  hm  ;  and  hoilinjx  watei-.  ten  oiinee.«.  'I'u 
an  emulsion  id'  the  male  feiai  (a  drachm  id'  ethereal  extract),  nuide  vviih 
acacia  powder,  two  minims  of  croton  oil  arc  added.  'I'he  patient  should 
have  had  a  low  diet  the  previous  day  and  have  laktii  a  dose  of  salts  in  the 
eveiiin;:.  'idle  emulsion  and  infusion  arc  mixed  and  taken  fa.-tiiiij  at  nil  r 
in  the  morniii;.,'. 

The  pomcirranate  root  is  a  very  efficient  remedy,  and  may  Iw  frivon  as 

an  infusion  of  the  hark,  thr ninces  of  whiidi   may  Ite  macerated   in   ten 

ounce-:  of  water  and  then  rcdii:  ed  to  one  half  hv  evanoratioti.     The  entiit 


ipiantity  is  then   taken   in   divide 


It 


occasionaliv  oi'mluees  eolii 


hut  is  a  very  ell'ecMive  retni'dy.  The  active  principle  id'  the  root,  pelle- 
lieriiu".  is  now  nnich  employed.  It  is  niveii  in  doses  of  one  fourth  to  one 
half  of  a  irrain,  and  is  followed  in  aii  hour  hv  a  piirirc 

I'limpkin  .seeds  are  soinetiiiies  very  cllicicnt.  Three  or  fourounn-: 
should  he  cand'ully  hriiised  and  then  macerated  for  twelve  lU'  foiirii'i 
hours  and  tlu'  entire  quantity  taken  and  followed  in  an  hour  hy  a  puru  •■ 
Of  other  remedies,  kodsso.  turpentine  in  laiiu'c  (loses  in  lioiu'v,  and  kainiili 
may  he  nicniioned. 

I'nless  the  head   is  hroiiyht  away,  the  pi'.rasite  eontiiiues  t(;  grow,  an«i 


DISEASKS  CAUSED   I5V   CESTODES. 


l(t!>9 


•  LMiicnls  is  ili- 

It  iniiki's  liiit 
ruiiicnts  of  till- 
■!j  in  tlie  gencr- 

-liduld  bo  flivrn 
hiiriK'il.  Tiny 
\ii(l  siTond,  tlif 
ji>  iii'c  (U'>tr<iV(Ml, 
,  asii  ruli',  lu'tii  r 
non  form,  t'fi"- 
,iilv  sees  iiiciisly 
1  h(><rs  ill  Moii'- 
iiiciisli'  is  ini'i'' 
1-  it  li.is  not  siu'li 

i,,ii  of  Ihc  iviii'- 

lu'    ilOWl'l-    lilONCil 
til,'    rhni.T    of   :l 

i-i,iiiplly  and  well. 

1  l";istii\:J.  iinil  fol- 

rativr.     Tliis  USll- 

al\v;i>>  tlu'  onliiv 

•  fTntivo.     A"  ii>- 
uuiikiii  (^••••1.,  oil'- 

ten  (iniH'cs.     'Ill 

ract ),  niinlf  wiiii 
■  |)iitifiil  should 
,sc  of  salts  in  till' 
■n  fasting  at  ninr 

may  !•••  {livon  ii'^ 

iiaivrati'd  in  tr'i 

ation.    'rin'onti' 

lUv  pro'lucfs  coll'  . 

,,1'  the  ro..t.  1"11' 

one  fourth  tool  . 

,,,,  ,„•  f<Mir  (Minr>  - 
,„-,.lvi'  or  fourtc'i 
,  nnur  hy  a  \n\i-y'- 
l„„u-y,and  kain;il:i 

niu's  to  grow,  ai-1 


witliiii  a  few  months  the  scgnionts  a^aiii  ajipcar.  Some  instances  aiv 
extraordinarily  ol)stinat(>.  Doubtless  it  deiunds  a  <:in>A  deal  ii])on  the 
exposure  of  the  worm.  'I'he  head  and  iie(d<  may  l)e  thoroughly  iiroteetcd 
beneath  the  valvuhe  eoiiniveiilcs,  in  whirh  ease  the  remrdirs  may  not  act, 
( )uinix  to  its  armature  ''u'  hriiin  sii/iinii  is  more  dilliiMilt  to  e\|iel.  1(  is 
])rol)al)le  that  no  deifree  of  ju'ristalsis  eoiild  dislodu'e  tiie  head,  and  unless 
the  worm  is  killed  it  iloes  nut  let  go  its  extraordinarily  linn  hold  on  the 
inueuus  niumbrunu. 


TI.   \'is(i;ii.\i,  ('i;sT<ti)i:.s. 

Whereas  adult  ta'uia'  cause  little  or  no  disturbance,  and  rarely,  if  ever, 
prove  directly  fatal,  the  an'ections  caused  hy  the  larva'  or  immatnn,'  forms 
ill  the  solid  organs  are  serious  ami  important.  'I'licic  arc  tuo  chief  ce-tdde 
larva!  known  to  freipieiit  man— (^;)  the  ( 'i/s/iirrfu.s  iflliihis(i\  the  larva  of 
the  '/'(ruin  soliinn,  and  (//)  the  /■,'>■// 1 /mrdi-riis,  the  larva  of  the  7'<i'/ii(i  c/ii. 

HOCdfCIIS. 

1.  Cysticercus  celllllosa). — When  man  accidentally  takes  into  hi-  stnm- 
a(di  the  ripe  ova  of  I'd'nitt  sollinii  he  is  liable  to  beconu'  the  intermediale 
host,  a  part  usually  played  for  this  tape-worm  by  the  pig.  This  acci<lent 
may  occur  in  an  individual  the  subject  of  'I'lvnid  scliiiin,  in  which  case 
the  matnro  proglottides  either  themselves  wandi f  into  the  stoma(di  or, 
what  is  more  likely,  an'  furced  into  the  organ  in  attacks  of  prolonged 
vomiting.  Of  eoiir.se  the  accidental  ingesiidn  from  the  outside  (d'  a  few 
ova  is  (piite  possible,  and  the  liability  of  infi'ction  shonlij  always  be  limne 
in  mind  in  liiindling  the  segments  of  the  worm. 

'I'he  .symptoms  depend  I'litircly  upon  the  number  of  n\a  ingested  and 
the  loealilies  readied.  In  the  hog  the  cystieerei  produce  vei'y  little  dis- 
lurhance.  The  muscles,  the  connective  tis.^uc,  and  the  brain  may  he 
-warming  with  the  measles,  as  they  arc  called,  and  yet  the  nutrition  is 
nuiintained  and  the  animal  does  not  appear  to  he  sei'iou>lv  ine<>inmo(|cil. 
In  the  invasion  ]ieri.)d,  if  large  ntinihers  id"  the  parasites  are  taken,  there 
IS,  in  all  probability,  constitutional  disturhaiice  ;  certainly  there  is  in  the 
'■alf,  when  fed  with  the  ripe  seirim  nis  of  'rn'uui  siiijiiiiitf!. 

In  man  a  few  cystieerei  Iodised  beneath  the  skin  or  in  the  mu.>icie< 
•M;iy  cause  no  daiiiaLre,  and  in  I'lne  the  larva'  die  and  hei'omc  ealcilied. 
I  iiey  are  occasionally  found  in  dissection  subjects  or  in  post-mortems 
I-  ovoid  white  bodies  in  the  muscles  or  suhciitancoiis  tissue.  In  this 
iiintry  they  arc  very  rare,  I  have  seen  but  one  instance  in  my  post- 
mortem experience.  Depei  ding  on  the  numher  and  tiie  locality  spe- 
ially  alTected,  the  symptom^  may  be  i,n(inped  into  general,  cerehro-.-pinal, 
md  (X'uiar. 

(!)  (li'iicntl. — As  a  rule  tlu^  invr.sion  of  tlie  larva'  in  man,  uiilc-s  in 
very  large  nuinhers.  iloes  not  cause  very  deliin'e  symptoms.  It  occiusioii- 
ally  iiajipens,  however,  that  a  .--iriking  [Mciurc  is  pi'oduced.      I"or  instance, 


1100 


niSKASKS    Dl'M   TO   ANIMAL   PARASITES. 


^ 


w 

o 


'-'!m< 


I' 


h 


a  piiticiit  was  iidniitU'il  tt  iiiv  w.inls  very  stilT  iitul  Iicl|»li>.<s,  so  niiifh  so 
that,  lui  lia<l  to  b((  assisted  up-stairs  ami  into  ix'il.  lie  coiiijilaiiKMi  df 
miiiiliiH'SS  and  tiiiirliiiif  in  the  cNtri'iiiitics  and  iri'iiiTul  weakness,  so  tliat  ;ii 
first,  lie  was  tlioiijrjil,  to  have  a  |ie!'ii»iieral  neuritis.  Al  tlie  exaiiiinatimi. 
liowe.ver,  a  iiunilier  of  painful  siiheiitaneoiis  nodules  were  discovered, 
wliiidi  prt(V-.'d  on  excision  to  l)e  the  cyslicerci.  Altop'tiiei'  seveiitv-IIvi 
colli. 1  he  felt  .siiheiitaiieoiisly,  and  from  the  soreness  and  stillness  tliev 
proi»al)ly  existed  in  lai'ffe  nimihers  in  the  muscles.  There  were  none  in 
his  eyes,  ami  he  liad  no  symptoms  ])ointin,Lr  to  hiain  lesions. 

('v')  CiTrliro-spiiinl. — Hemarkahle  symjitoms  may  irsiilt  from  the  pres- 
ence of  the  cyst ieerci  in  the  hraiii  and  cord.  In  the  silent  re,i:ion  they 
may  he  aliiindant  without  produciii;;  any  symptoms.  I  liave  in  my  pos- 
.sessidii  the  liraiii  (d"  a  piir  containinir  scores  of  "■measles,"  yet  the  animal 
in  the  few  moments  in  which  I  saw  it  just  prior  to  death  did  not  jiresciit 
any  symptoms  to  atti'act  attention.  In  the  ventricles  (d'  the  hrain  the 
(^ysticerei  may  attain  a  consideralile  si/e,  owiiiu;  to  the  fact  that  in  nirioiis 
ill  which  they  are  unrestrained  in  their  irrowth.  as  in  the  jieritomeiim. 
the  hiadderdike  body  j^rows  freely.  When  in  the  fourth  ventricle  re- 
minkahje  iriitative  symptoms  may  he  produced,  in  iss!  I  saw  wilh 
l'":'ie(lliiii(lcr  ill  I'crlin  a  case  from  h'iess's  wanis  in  which  diiiinir  life  tiiere 
had  hi-eii  symptoms  (d'  diabetes  and  anomalous  nervous  symplnins.  I'ost 
mortem,  the  cystieerciis  was  found  iiciieath  the  valve  of  N'ieus.seiis,  pre.-<s- 
in<j  upon  the  Hoor  of  the  fourth  ventri<de. 

(.'})  Oinhir. — Since  von  (Iraefe  dctn  .iistratcd  the  presence  of  the  cysti- 
eerciis in  the  vitreous  humor  many  ca.ses  have  been  [ijaci'd  on  record,  and 
it  is  a  condition  easily  reco<jiiize(l  l)y  oculists. 

Kxce[)t  in  the  eye,  the  diairr.osis  can  rarely  be  made;  when  the  cysli- 
cerci are  sui)cutaiieous.  one  may  be  exci.-eii.  It  is  j)ossible  that  when 
numerous  throuLrhoiit  the  mii.«cles  they  may  be  seen  under  the  lonjjue,  in 
which  situation  tlicy  nuiy  exist  in  the  pitr  in  numbers. 

11.  EcllinocOCCUS  Disease. — The  hydatid  worms  or  eehinococci  are  the 
larva' (d'  the  Td'nid  fciti iiticu -riifi  n^  the  do<j.  This  is  a  tiny  eestodo  not 
more  than  four  or  live  millimetres  in  len;.;tli,  coiisistiuir  of  only  three  or 
four  seifinents,  of  whi(di  'he  terminal  one  alone  is  mature,  and  has  a 
len;.'th  of  alxiut  two  millimetres  and  a  i)reailtli  of  (••(>  millimetre.  The 
head  is  small  and  provided  with  four  snckiiii!;  disks  and  a  rostelliim  with  a 
doiiljle  row  of  booklets.  This  is  an  exeeediiiirly  rare  parasite  in  the  doL' 
('oi)bold  states  that  he  has  never  met  with  anatiiril  specimen  in  Mnirland. 
r,eidy  had  not  one  in  his  larire  collection.  I  have  not  met  with  an  in 
Hiaiice  in  this  country,  nor  do  I  know  of  its  (vor  havinji:  been  deseribeil. 
The  only  specimens  in  my  eal)iiiet  I  procured  exivriiuentally  by  fooditiL'  m 
doir  with  eehinococci  I. .<  cvsts   from  an  ox.     The  worms  are  so  small   thai 


tliev  may  b(>  readilv  overlooked,  since  they  form  small  white,  threaddik 


Ti 


le  Y\\ 


bodies  closely  a<lherenf  aniontr  the  villi  (d'  the  small  iu*e-:tinci 

seymciit  (ioiitains  about  O,0lt<)  eggs,  which  attain  their  development  in  tli 


DISKASKS  CArsKI)    I5V    CKSTODES. 


IIOI 


,  so    IIllH'h    Si. 

i)ini»liiiiH'il  nf 
CSS,  so  tluU  at 
fxaiiiinalioii. 
•e  (liscovci'til. 
■!•  scvi'uty-tivt' 

.  were  noiu'  in 

from  the  pivs- 
iit  rcLnoii  tli«'y 
ivi'  in  my  pos- 
yct  Uu'  iiiiimal 
liid  not  jHTsml 
till'  Itraiii  the 
tliat  in  riLMons 
11,'  ju'iitniiiVMim, 
til  ventricle  re- 
;S4    1    saw    wiih 

hirin;r  Ul"*'  'l"''''' 
.luui'inis.  I'l'-l 
Vii-Kssens.  press- 

•iiceof  the  eysti- 
.(1  (111  recunl,  and 

when  the  eysti- 
ihle  that  when 
the  tongue,  in 

inococci  nro  the 

inv  costode  not 

t  only  three  or 

lure,  imd   has  ;. 

iUinietre.     Tli' 

rostelluni  with  a 

site  in  the  do;.' 

lien  in  Kn,irhin<l 

met  witli  an  in 

iX  h(«en  desefihed. 

tally  liy  feodin.ir  n 

;,,v  so  small  that 

,vhite.  t!ireiid-lik 

■stines.     Tlie  ri)" 

■  velopmont  in  tli' 


tin 


111 


solid  oriTiins  of  various  animals,  particularly  tiie  Imir  and  o\  ;  more  rarely 
the  horsf  and  the  sliee|t.  In  some  enuntrii's  man  is  a  (•oiiimoii  inl.ermedi- 
iite  Iiost,  owini,'  to  the  accidental  imreslioii  of  ihe  o\a. 

Di'rrliijniinif. — Tiie  litllo  six-liooked  einhryo,  freed  from  the  eir.U- 
slieli  hy  iligestion,  hurrowrf  llironj,rh  the  intestinal  wall  and  reaches  tlie 
peritoneal  cavity  m"  the  muscles;  it  may  enter  tlii^  portal  vessels  and 
is  carrieti  to  the  liver.  It  may  enter  the  systemic  vessels,  and.  p.issiiiii; 
the  pulmonary  capillaries,  us  it  is  protoplasmic  and  elastic,  may  reach  the 
lirain  or  other  parts.  Once  havi!i!j;  reached  its  destination,  it  underi^oes 
the  followmi^f  clian;res  :  Tlic  liooklcts  disappear  and  the  little  emi)iTo  is 
•'raduallv  converted  into  a  small  cvsl  which  iirescnts  two  di>lin<'t  lavi'rs — 
an  external,  laminated,  cuticiilar  neinhi'anc  or  capsule,  and  an  in'.ei'tial, 
.i,franular,  parenchvmatoiis  layer,  tlu'  endocyst.  'The  littli;  cyst  or  'esicle 
contains  a  clear  llnid.  There  is  more  or  less  reaction  in  the  neiirhl>orin<( 
tissiH's,  and  the  cyst  in  time  has  a  lihrous  investment.  When  th.is 
primary  cyst  or  vesicle  has  attained  a  certain  si/c  Imds  dc\elop  fi'uiii  llio 
parenchymatous  layer,  wiiicli  are  <,'radually  converted  itito  cysts,  jtre.sent- 
ing  a  structure  idcnti-'al  with  that  of  the  orii;inal  cyst,  namely,  an  elastic* 
chitiuons  menihramf  lined  with  a  .irranidar  p.irencliymatous  layer.  These 
secondary  or  dan<,diter  cysts  are  first  coimcclcd  with  the  iiniiiL,''  nicmlnane 
of  the  primary.  Imt  are  soon  set  free  In  tlii>  way  the  primary  ey.^t  as  it 
f^rows  may  contain  ado/en  or  more  (laiiu:litcr  cysls.  Insitle  these  daui^htcr 
cysts  a  similar  process  nniy  occui',  and  fidin  hnds  in  the  walls  graml- 
dauirhter  cysts  are  developed.  Krotn  the  irraiiular  layer  of  tlu!  parent  ami 
daugliti'r  cysts  hnds  arise  which  develop  into  lu'ood  capsules.  l'"rom  the 
lininif  membrane  the  little  outtfrowths  arise  and  i;radually  (h^velop  into 
i)odies  known  as  scolices,  which  represent  in  reality  the  head  of  the  Ttvuia 
I'fhiiKwiicciis  and  pi'e.^eiit  four  siickin'.,'  disks  and  a  circle  of  liooklcts. 
Mach  scole.K  is  capaldi^  when  transferred  to  ilie  intestines  of  a  dni,f  of  de- 
velopin<f  into  an  adult  tape-worm.  The  dilTeveiice  helweeii  the  ovum  of 
an  ordinary  tape-worm,  such  as  the  Tiriiia  shHidii,  and  the  'ianiiit  crlnno- 
iiicriis  is  ill  this  way  very  strikinir.  In  the  former  case  the  ovum  devel- 
ops into  a  simple  larva — the  ( //.sfifrrms  crl/ti/asd' — whereas  the  etr;;  of  the 
Tit'iiitt  rc/ii»(ifiirniy  develops  into  a  cyst,  which  is  I'apalile  of  multiplyiiif; 
iiior.mously  and  from  tlu*  lining'  memtn-ane  of  which  millions  of  larval 
lajie-worms  develop.      Ordinarily  in  man   the  development  of  the  echino- 

' '.'u.s  takes  place  as  al)ove    mentioned  and   hy  an  endoi,'enous  form  in 

viiie.'.  tiie  see<t!ulary  and  tertiary  cysts  are  contained  within   the  primary; 

iit  ill  animals  the  formation  may  he  dill'erent.  as  the  imds  from  the  pri- 
■"■•.•y  ■     t  penetrate  between  the  layers  and  develop  externally,  formiii<; 

.u  >\r,,i/niiiifn  v.ariety.  A  third  form  is  the  mnllilociilar  echinococcus,  in 
which  from  tlio  prinuiry  cysts  i)U(ls  develop  which  are  cut  off  completely 
i!id  are  surrounded  Ijy  thick  capsules  of  a  coiiiu'ctivo  tissue,  whiclr  join 
1  lu'c     cr  and   ultimately  form  a  hard   nuiss  represent^'d  hy  stramls  of  eon- 

ectivo  tissuo  cnclo.sing  alveolar  spaces  about  the  size  of  peas  or  a  little 


IKi'J 


DISKASHS    DTK  TO   ANIMAL    I'AUASITKS. 


V'  I 


\tA 


i  <!' 


I.irirt'i'.  Ill  llicso  spiU'os  jirc  foiiiul  tlir  rciiiiiniits  .if  I  lie  rcliiiiiicoccns  ov-;t, 
occiiyioiiiiilv  llic  scolicc's  or  liookK'ts,  hut  tlicv  arc  ot'ti'ii  sterile 

'riic  lliiiil  of  till-  (■(•liiiiocdcciis  cysts  is  clear  ami  limpid,  ami  lias  a  spc- 
cilic  yrav  i' \  iVdiii  l-i)i);i  to  l-i)iiii.  It,  docs  not  contain  all)iiniin,  lint  nun 
coMlaiii  t  I'aci's  of  sii^ar.  A- a  rule,  the  cysts,  when  not  deu-encratcd,  con- 
tain the  hydatid  heads  or  scolicc-;  iw  the  characterisl  ie  hooklets. 

C/i/ini/rs  lit  f/ir  Cf/s/.  —  li  is  not  known  dclinitcly  how  lonir  the  cchin". 
cncciis  remains  alive.  i)ut  it  [iroliuhly  lives  many  years — accordinir  to  some 
authors  as  Ioiilt  as  twenty  years,  '{'he  most  connnon  chaiiLri'  is  death  and 
the  ;,'ra(lual   insjii>-at  ion  id'  the  contents  and  conversion  (d"  the  cyst  into  ,i 


III 


iiss  (!ontainin;j;  piittydikc  or  i^rrannlar  material  wlii(di   may  Ix-  pari 


tallv 


oiilcilicd.  I{('!iinants  of  the  chitinous  cyst  wall  or  ho(d<lels  may  he  fonml. 
Tlicso  ohsolctc  hydatid  cysts  arc  not  infrcfpu'ntly  found  in  the  liver.  A 
more  serious  Icrmination  is  rupture,  which  may  take  ]ilaee  into  a  serous 
sac.  or  perforation  i;iay  take  place  c\tcriially,  when  the  cysts  are  dis(diar'ied. 
us  into  the  iiroiudii  or  alimei.tai'y  canal  or  urinary  pa.-saires.  More  uid:i- 
vorahle  are  the  instances  in  which  rupture  oceurs  inlo  the  hilc-passaircs  or 
into  the  inferior  cava.  Heeovery  may  follow  the  rupture  ami  discdiarLrc  of 
the  hydatids  extcriuilly.  Sudden  death  lias  heen  known  to  follow  thi- rup- 
ture. A  third  and  very  serious  mode  of  termination  is  suppuration,  w  hieli 
may  occur  spontaneously  or  follow  rupture  and  is  found  most  frc'pientlv 
in  the  liver.      Lar<'e  ahsees.ses  mav  he  formed  which  contain  the  hvdatid 


mem 


iirai 


ics. 


(irniinijiliiftil    /)i^/rifiii/iiin  iif  llir   F.rli 


niiirdmis. 


'I'he  disease  preva 


most  extensively  111  those  countries  .in  whudi  man  is  hroimht  into  (dosi 
contact  with  the  doir,  particularly  when,  as  in  .\ustralia,  the  do,<rs  are  usei 
extensively  for  hcrdinix  sheep,  the  animal  in  whi(di  the  larval  form  of  tin 
riis  is  mo>t  fi'eipieiitly  found.  In  Iceland  the  cases  aii 
la   Kiirope  tlu'  iliseasc  is  not  uncommon.      In  this  eouu 


7 


'if  III  (I  rrli  I  iiiiiiit 


verv  numerous. 


try  it  is  extremely  rare  and  a  <;rcat   majoritv  (d"  all  cases  are  in  fortMLjiicr- 
Up  to  .Iiiiv,  IS'.tl,  I  have  heen  ahh?   to  liiid    in   the  literature  (and  in  tli 


museums)   onlv  S,"t  case 


ill  the  I'liitcil   States  ami   Cai 


lail 


In   tile  ie 


laiidic  settlements  of  Maidtoiia  many  cases  occur.  A.  II.  I-'criruson,  wIm^ 
has  ojn'raled  on  a  numlii'r  (d'  ca.ses  at  the  Winx  |ic,ir  (ieiicral  llospitul, 
states  that  h(dwcen  forty-live  and  fifty  persons  with  e(diinococciis  disca-e 
liavo  heen  treated  in  Wiiiniiicg  since  18T4,  the  date  of  the  Icelandic  immi- 
gration. 

[UsIrihiiliiDi  ill  the  lloili/. — Of  the  l,8()'-i  cases  comprised  in  tlio  .statis- 
tics of  Davaine,  Cohhold,  Mnsi'ii,  and  N'eisser,  the  parasites  existed  in  th' 
liver  in  !l.").'5,  in  the  intestinal  canal  in  Kili,  in  the  Iuult  <»r  ph'iira  in  1").'),  in 
the  kidneys,  hiaddcr.  and  li'enitals  in  JMCi,  in  the  hrain  and  spinal  canal  in 
l".iT,  hone  (i|,  heart   and   Mood-vc^scls   (il,  other  oriraiis   I.^S.f     Of  the  '"■' 


*  .\miTiriui  .1  MU-niil  nf  tin'  M.'ilii  m1  Seiviiccs.  (hUilicr.  1'^*^',*.     Since  tliiit  diitc  Alfod 


.M; 


mil  li:i>  coiicrlcd  for  UK'  il  I'jisc 


tldilieii  1(1  llic  lit  iluTf  reported. 


f  Dicliiiiuiuirt^  Kiieyelti['tdii|iU'  ilos  .Suicnt'os  .MiHIiealis,  tome  x.\.<ii,  1885. 


n'l  ■■',■  ,wia 


IHSKASKS  CArSKD    I5Y    ('F.ST(tI»i:s. 


lio; 


)Coccus  cyst, 

id  1ms  a  siH- 
lin,  l>iit  tn;i\ 
ticriiti'd,  (''lil- 
ir tlu'  Crlli)!'- 
•,lill<r  to  Snr.M 

.  is  (Ifiitli  iiii'l 
h,.  cyst  intn  ii 
y  lie  piirliallv 
iiiiy  Ik-  i'(i\inil. 
the  liver.  A 
>  ititu  a  scrniis 
ire  (liscliiirL;<il. 
i.  Mdvc  uiit';i- 
liK'-jtassiiLii'S  or 
1,1  (li.<ch!ir,ir<'  "f 
follow  tlu'  YU\<- 
uiraliiiii,  whii'li 
nost  l'r('(i\iftitly 
lin  tlii>  hytliitMl 

klisrasc  prevail 
iPilit   into  clo-c 
(loiTs  avo  usi'il 
,1   foi'in  of  tl"' 
tlu>  casi'S  arc 
111  tliis  couii- 
.  in  foiH'iniii'i-. 
re   (aiitl  in  the 
*     In  the  li'c- 
l-'crLT'ison,  wli" 
.ncval  Hospital, 
icoccus  disoa-i' 
l,'claiHli<'  imiui- 

s(m1  in  tlio  statis- 
ts oxisti'd  in  tl"' 
ileiira  in  1 -'>:>•  "' 
1  s\)inal  canal  m 
:,S,t     or  tin"  ^"' 

uc  tlmt  .lute  Alfi"! 

I'tnl. 

xii.  IHHr). 


rasos  in  this  comitry,  the  liver  W!is  the  seat  of  the  di-ease  in  .'tl.  (»!'  ."»(! 
eoiiseenlive  cases  treated  Iiy  .Mosler  at  tlie  ( I reil'sualtl  clinic,  :>ii  involved 
the  liv<'r,  10  the  IniiLrs,  '>i  the  riirlit  kidm  y,  and  1  the  s|ileeii. 

Symptoms.  —  (n)  //i/i/n/ii/.i  o/'///r  I.inr. — Small  cy.M-  may  cause  no 
disliirliance  ;  lari^e  and  iri'owin;,'  cysts  [irodiico  si;:ns  (d'  Imnor  of  the  liver 
willi  ^real  inei'ease  in  the  size  of  the  ()r;,Mii.  .Naturally  tlie  jdiysical  .-iirns 
depeiiil  much  u|ion  the  situation  of  the  <:ro\vth.  Near  the  anterior  siir- 
fact'  in  the  eiii'^aslrii;  region  tlu'  tumor  may  fiUMii  a  disiinei  lu'ouiinenee 
and  have  a  tense,  lirm  tVeliiiLT,  sonielime,-.  wiili  Ihictual  ion.  A  noi  infi'c- 
(juent  situation  is  to  the  left  of  the  siis|iensory  lii:anient,  fiirmiiiL'' a  tunmr 
which  (lUshes  up  the  heart  and  causes  an  extensivt-  area  of  dulne-s  in  the 


)\vcr  sternal  ami   hft   liy|>ochondriac  rejrions.     In   the  li^ilit 


if  th 


tumor  is  oil  the  posteiior  surface,  the  eniaru'ement  of  tlie  ortran  is  ehitdly 
upward  into  the  pleura  ami  the  vertical  area  of  diiliie.-<  in  the  po.-tcrior 
axillary  line  is  iiicicased.  Superiiidal  i-ysts  may  _<,dve  what  i-  known  as  ihe 
liydatid  fi'cmittis.  If  the  tumor  is  palpateil  liirhtly  with  the  linLicr^  of  tla^ 
hd't  hand  and  percussed  at  the  same  time  with  those  »d'  the  rii:lit,  there  is 
f(dt  a  vihration  or  tremlilim,'  moveinenl  which  persists  for  a  certain  time. 
It  is  not  alw.'iys  jireseiit,  ami  it  isdouiitful  whether  it  is  peculiar  to  the 
hydatiil  tuniois  or  is  due,  as  Urianc/on  lield,  to  the  colli-ion  of  the  <lan,t:h- 
ter  cysts.  N'ery  larije  cysts  are  accompanied  hy  ftclinus  (d'  pressure  or 
draiTirini.'  in  the  hepatic;  region,  sometimes  actual  pain.  The  ireiieral  con- 
dition of  the  patient  is  at  lirst  j,foo(l  and  the  nutrition  little,  if  at  all.  in- 
terfered with.  I'nless  some  of  the  accidents  already  refi'rred  to  oi'ciir. 
the  symptoms  indeed  may  lie  trilliiiu''  ami  due  only  to  the  pres.-uic  or 
weiii'ht  of  the  tumor. 

Siippurat  io.i  (d'  the  cyst  (diauLTcs  the  clinical  [licl lire  into  one  of  pva'inia. 
There  are  rii;ors,  sweats,  more  or  less  jaundice,  and  rapitl  loss  uf  uei'jht. 
Perforation  may  occur  into  ili<'  stoinaidi,  colon,  pleura,  hromdii,  or  exter- 
nally, and  in  some  instances  recovery  has  taken  place.  I'erforation  into 
Ihe  pericardium  ami  inferior  vena  cava  is  fatal.  In  tlie  latter  ease  the 
daughter  cysts  have  heeii  f'lund  in  the  heart,  pliiLi'Ll'in.ir  I  lie  tricii-pid  ori- 
iice  and   the   pulmonary  artery,      i'eiforalion   of  liic  l)ile-pa.ssa<,a'S   causes 


intense  jaundice,  aiul  may  lead  to  suppurati\e  (diolaiiLriti 


An  inferi'stinii  sviniitom  connected  with  tl 


le  riiiiliire  or  hvdatid   cvst 


IS  the  dev(dopment  of  iirliearia,  wliiidi  may  also  follow  as|)iratioii  nf  the 
cysts  and  is  probably  due  to  the  ahsor|itioii  of  toxii'  materials  contained  in 
llie  lliiid. 

Didi/iiosi.'i. — Cysts  of  moilerate  size  may  exist  without  pro(lii(dn,ir  symp- 
loais.  Larije  multijilo  echiiioeocei  may  cause  sjjreat  eiilarLreineiit  v,  itii 
irreiriiliirity  of  the  out  line,  and  smdi  a  condition  persi-tini:  for  any  time 
uith  retention  of  the  health  and  stren,iftb  snt^iiests  hydatid  di-ease.  \n 
{''rcLTiilar,  painless  enlarm'inent,  particularly  in  the  lefr  lolie,  or  the  pres- 
'  iic(>  of  a  larir(<,  snooth,  lluetiiatiinj;  tumor  of  the  epiirastrie  reirion  is  also 
try  siiggesLivo,  and  in   this   situation,  when   aceossiblo  to  palpation,  it 


lltll 


DISKASKS   ])[']•:   TO    AN'IMAF.    PAUASITKS. 


i^f 


fiivcs  ii  aotiaatiiiM  of  ii  smuotli  cliistic  <fri»\vtli  iiiid  txissihiv  alsn  tlic  livdiifid 


trciimr. 


W 


ii-i 


1  suiipiiraliiiii  (icciirs  tlic  cliiiii'iil  pictiin'  is  really  tliiit  of 
iil)S('(fSS,  mill  only  till'  cxisti'iicc  of  previous  ciiliirirciiicnt  of  IIk;  liver  witli 
fjood  lieiillli  would  |ioiiit  to  the  fact  that  the  siiji|iiiratioii  was  associated 
wit!)  hydatids.     Syphilis  may  produce  irrejiidar  enhii'<;enient  without  ruiich 


distiirhaiice    in    tli 


alth,  soiuctitnes  also  a  verv  dtdiiiite  tumor  in  tli 


epigastric  rcLiion,  hut  it  is  usually  linn  and  not  lluctuatini:.     The.  (diiiieal 
features  may  simulate  cancer  very  closely.     In  a  case  whicdi    I    reported 


the   liver 


as   <freally  enlariri 


d 


and 


th 


ere  were   manv  nodular  tumors  in 


the  ahdoineii.  'riie  post-mortem  showed  enormous  siippMi'atinLT  hydatid 
cysts  in  the  left  lohe  of  the  liver  which  had  pei'i'orated  the  stomaidi  in 
two  places  ami  also  the  duodenum,     'i'he  oiueiiMim,  nioenlery,  and  pelvis 


also  contained  nimieroiis  cvsts. 


.\s  a  rule,  the  (dinical  course  of  the  dis- 


ease would  siiilice  to  separate  it  clearly  from  cancer.  Dilatation  of  thr 
j;all-l)ladder  and  liyilroiiephrosis  have  hotli  lieeii  mistaken  for  hydatid 
di.sease.  in  the  former  the  movahI(>  character  of  the  tumor,  its  shape, 
and  the  mucoid  character  of  the  contents  siiHice  for  the  diaLMiosj.s.  In 
.some  instances  of  hydronephrosis  only   the  exploratory  laiiictiire   could 


(llstiiiLTUish    helween    the  condition." 


.More   freiiiient   i.s   the   mistake   of 


coiifoiiudini:  a  hxdatid   cyst  of  the  ri,i;ht   lolie   pushini:  up  the  pleura  with 
pleural    etTn>ioii   of   the   ri;,dit    side.      'I 


The  heart  may  l)e  dislocatcil,  the 
liver  d.epressed,  and  diilness,  feehle  lireathin.ir,  and  diminished  fremitus 
are  present  in  hoth  conditions,  l-'rcrichs  lays  stress  upon  the  dilTerent 
character  of  the  line  of  dulne-^s;  in  the  ('(diinocoeeus  cyst  the  upper 
limit  presents  a  ciirveil  line,  the  maximum  of  which  is  usually  in  the 
scapular  reLrioii.  Suppurative  pleiiri.^y  may  he  caused  hy  tlu*  perforation 
of  the  cyst.  If  adlie^ious  result,  the  perforation  takes  place  into  the  luiii,'. 
and  frairments  of  tlie  cysts  or  small  'dauirhtcr  cysts  may  he  c(m<_'-lied  up. 
For  diairiiostie  purpose-;  the  exploratory  puncture  slnuild  he  used.  As 
stateil,  the  llnid  is  usually  perfectly  clear  or  sli;,flitly  opalescent,  the  reac- 
tion is  neutral,  ami  the  specific  <:ravity  varies  from  I'dO.")  to  rodlt.  It  is 
non-alhiimiiioiis,  hut  contains  chlorides  and  sometimes  traces  of  siii^ar. 
Ilooklets  may  he  found  either  in   the  (dear  fluid  or  in  the  .suppuratini: 


cvsts. 


T 


lev  are  someliiiK's 


ih-;ent,  however,  as  the  cvst  niav  he  .sterile. 


(//)  /■Jc/iiNociircns  nf  llii'  /kt's>i:riff<iri/  Si/sffDi. — The  larva-  may  develop 
jirimarily  in  the  pleura  and  attain  a  larire  size.  The  .symptoms  are  at  first 
those  of  compression  of  the  Iuiilt  tmd  di.-«lo('ation  of  the  heart.  The  phys- 
ical sii:ns  are  those  of  lliiid  in  tlu'  pleura  and  the  condition  could  .scarcely 
lie  distinguished  from  ordinary  elTusioii.  Tlu'  line  of  diihies.s  may  ht 
ipiite  irreirular.  .As  in  the  ecdiinococcus  of  the  liver,  the  general  condition 
of  the  ]»atient  may  be  excellent  in  s})ite  of  the  existence  of  extensive  dis 
ea.se.  Pleuri.sy  is  rarely  excited.  The  cy.sts  may  become  intlamed  and 
perforate  the  chest  wall.  In  a  ca.se  of  D.  !•'.  Smith's,  of  Walkertown. 
Ontario,  a  girl,  ageil  twenty,  had  a  running  .sore  in  the  eighth  left  inter 
costal  space.     This  was  freely  opened,  and  in  the  pus  which  flowed  oiii 


DFSKASES  ("AUSKD   BY  CKSTODKS. 


1105 


,  the  hydatiil 

i'Cillly   tlllU   nf 

\w  liviT  Willi 
,;is  assocMiilfl 
,vitlu)Ut  niiK'U 
tmunr  in  tlif 
'riic  cliiru'iil 
.),   1    ivix'Vtoil 
liir  tumors  in 
atin.u'  liy'1:i''''l 
he  sldiniu'li  in 
ivy,  and  pi'lvis 
s,.  "'f   till'  ilis- 
iliitiition  of  tilt* 
.11   l",.r  liydatid 
jiior,  its  sliaiK.", 
(li.itriiosis.     In 
iiinrtuiT    roulil 
tlio   mistake   of 
the  ploura  with 
(lislocatoil,  tlu- 
iiisluMl    fi-cmitiis 
,„i,  tin-  (litTcrt'iit 
cyst   tin'   nit|H'r 
usually   in  the 
tlic  iicrforatiou 
,.  into  till'  Umji. 
U'  (■(.ui.'lifd  >i!'- 
1   hi'   used.      As 
,,sri>nt,  till"  vi'iu'- 
,  to  l-*»ti'.».     It  i^ 
t races  of  sutjar. 
,1„.  supiiuratini: 
av  \h'  strvilo. 
va-   m:>y  tU'Vclol' 


itotus 
[■art. 
)I1  cou 


afo  at  tirst 
The  1)1 


ivs- 


Id  Kcafci'ly 


duhu'ss  may 


rone 


ral  com 


Ution 


of  oxtpnsive 


di> 


no  in 


tlamo« 


1  and 


of  Walkortown, 
leiuhtli  U'ft  inter 
,liieh  flowed  out 


wore  a  niim))or  of  wcJl-eliaraeterized  cchinoeoccus  eysts  of  various  size. 
Tlu'  patient  I'oeovered. 

P<('hiMococci  occur  riuire  froqtipntly  in  the  lun;;  than  in  the  ])leufa.  If 
small,  they  may  exist  for  Home  time  without  causiiiij  serious  symptoms. 
In  their  ijrowth  tiiey  compress  the  Iiinij  and  sooner  or  later  lead  to  ititlam- 
matory  processes,  ol'teii  to  ^an^jjrene,  and  the  formation  lA'  cavities  which 
connect  with  the  lirunchi.  Krairments  of  memhrane  or  small  cysts  may  bo 
expectorated.  Ilaiiiorrhage  is  not  infrequent.  Perforation  into  the  pleura 
with  empyema  is  common.  A  majority  of  the  cases  are  rciranled  duritig 
Hf(^  as  either  phthisis  or  ;.'aii<:rene,  and  it  is  only  the  detection  of  the  char- 
acteristic memhranes  or  the  liooklels  which  leads  to  the  diairnosis.  The 
condition  is  usually  fatal  ;  only  a  few  cases  have  recovered.  Of  the  8r» 
American  cases,  in  six  the  cysts  occurred  in  the  lun;L(  or  pleura. 

(r)  /u-/ii>inr()riit.<<  of  f//e  h'idnrt/n. — In  the  collected  statistics  referred 
to  above  the  i^eiiito-iirinary  system  comes  second  as  the  seal  of  hydatid 
disease,  thotiirh  it  is  rare  in  cojni)arison  with  the  alTe(-'tion  of  the  liver.  <>f 
the  8')  American  (iase.s  there  were  oidy  three  in  which  the  kidneys  or  blad- 
•  ler  were  involved.  The  kidney  may  he  converted  into  an  enormous  cyst 
resembling  hydronephrosis. 

The  diagnosis  is  only  possible  by  puncture  and  examination  of  the 
fluid.  The  cyst  may  perforate  into  the  [lelvis  of  the  ki<lney,  ami  portions 
of  the  membrane  or  cysts  may  be  discharged  with  the  urine,  sometimes 
producing  renal  colic.  I  have  reported  a  case  in  which  for  many  months 
the  patient  jias.sed  at  intervals  numbers  of  small  cysts  with  the  urine. 
The  general  health  was  little  if  at  all  disturbed,  except  by  the  attacks  of 
colic  during  the  j)assage  of  the  parasites. 

((/)  EcliiininxTHx  of  the  Xcrrons  Si/sfcn. — In  this  country  very  few 
instances  have  occurred  in  the  brain.  One  or  two  reports  indicate  clearly 
that  the  common  cystic  disease  of  the  choroidal  plexuses  has  been  mis- 
taken for  hydatids.  Davies  Thomas,  of  .\ustralia,  has  tabulated  Wi'  ca.ses, 
including  some  of  the  Ci/sticerrus  reUiilosiv.  According  to  his  statistics, 
tilt!  cyst  is  more  common  on  the  right  than  on  the  left  side,  and  is  most 
frequent  in  the  cerebrum. 

The  symptoms  are  very  indeiinite,  as  a  rule,  being  those  of  tumor. 
IVrsistent  headache,  convulsions,  either  limited  or  general,  and  gradtially 
developing  blindness  have  lieen  prominent  features  in  many  cases. 

Multllocular  EchinOCOCCUS. — This  form  merits  a  brief  separate  descrip- 
tion, as  it  dilTers  so  remarkably  from  the  usual  type  of  the  disease.  About 
oru^  hundred  instances  are  on  record,  the  great  majority  of  wlii(di  have 
occurred  in  Havaria  and  in  Switzerland.  Only  one  case  has  been  reported 
in  the  United  States.*  The  patii'iit  was  a  (Jerman,  who  had  been  in  the 
country  five  years.  For  a  year  i)revious  to  his  death  he  was  out  of  health, 
jiuuuliced,  and  somewhat  emaciated.     A  fluctuating  tumor  was  found  in 

•  Dolaflnld  and  Prudilen,  Pathological  Anatomy,  third  edition,  page  317. 
70 


1KH5 


rUSKASES   nrK  to   .WIMAIi   F'ARASITKS. 


the  liL'^lit  Iiimli;ir  ami  luiihilical  n';:i(»tis,  appunMitly  connected  with  tlie 
liver.  'I'liis  was  (i|icii(m|,  iiiid  ilcatii  fullnwed  fnmi  li;eiinirrliai:e.  AlioiM 
a  fimrtli  of  tlif  rJL'lit  loln'  i>\'  ijic  li\(f  was  (K'eii|ii<'(i  by  an  iireu'iilar  eavits 
with  r()ii;:li,  ruL'iXeil  walls,  wliirji  in  [ilaees  were  tVnm  uiie  to  two  ii\ehes  in 
thickness  and  enclosed  irrejrular  small  cavities.  'I'lic  lamellatcd  cnticida 
cliarai'terisi  ic  of  the  echiuocnccus  cysi  was  found  liidn!.'  these  cavities.  In 
sotrie  instances  the  ttiuior  heans  a  .ntrikinj,'  likeness  to  colloid  cancer,  as  on 
section  it  presents  a  lihrons  stnuna  with  cavities  containing'  ^.'clatinoii- 
material,  'i'licy  are  often  sterile — that  is,  wilhont  the  hvdaliil  heads  or 
larvic.  'i'liis  foini  is  almo^i  exclnsividy  conlineil  to  thr  liver,  and  tln^ 
syniptfitns  reseniiile  more  those  of  tumor  or  cirrho>is.  'I'he  liver  is,  as  a 
rule,  cnlartrcd  and  sumoth,  not  irrei,qdar  as  in  the  ordinary  eidiinoc-oc- 
ctis.  .laiimlici'  is  a  cfinimon  symptom.  The  spleen  i>  usually  enlar^fed, 
tiiere  is  progressive  ernaeiation,  and  toward   the  closi'  hicmorrhages  are 


......        ....         ...         ■ ...         .....  ..   ..^.        ..  ..  ..„^.     ...,..,      ...         n....^.        .^.         ......  -.V    ....   V  ....  .....  I    . 

radical  procedinv  (tf  incision  ami  evacuation  of  the  cysts.  Su]tpuriition 
has  occasionally  followed  the  punctnre.  Injections  into  the  sac  should 
not  he  practised.  With  modern  m<'tho(|s  surgeons  now  open  and  evacmilr 
the  e(diinoeo(!cus  cysts  with  great  boldness,  and  the  .\ustralian  records, 
which  are  the  most  numerous  and  important  on  this  suliject,  show  that 
recovery  is  the  ride  in  a  large  proportion  of  the  eases.  Siijipui'iitive  cysts 
in  the  liver  should  be  treateil  as  ahsee.ss.  Naturally  the  outlook  is  less 
favoi'alilc.  'The  pntctical  treatment  of  hydatiil  disease  has  Ih'cu  greatly 
aHvanced  by  Austi'alian  surgeons.  The  recent  work  of  .hnues  (iraham,  of 
Sydney,  may  be  consulted  for  interesting  tletails  in  diagnosis  and  treat- 
ment. 

VI.    PARASITIC    ARACHNIDA. 

(1)  Pentastomes. — (a)  Liuiindlnht  rliiuaria  (/'ii//((.^lt)iiia  tivnioidis] 
has  a  somewhat  lancet-shaped  body,  the  female  from  three  to  four  inelics 
in  length,  the  male  about  an  inch  in  length.  The  body  is  tapering  ami 
marked  by  luimerous  rings.  The  adult  worm  infests  the  frontal  sii\usis 
ami  nostrils  of  the  dog,  more  rarely  of  the  horse.  The  larval  form,  whic'i 
is  known  as  the  LiniiudtiiUt  scrrittu  (Pe)ii(is(oniiiiii  (Irii/iniltifiim),  is  f(HiiMl 
in  the  internal  organs,  particularly  the  liver,  but  has  also  been  found  in 
the  kidney.  The  adult  worm  has  been  found  in  the  nostril  of  man,  l)iit 
is  very  rare  and  seldom  occasions  any  inconvenience.  The  larva'  are  h\ 
no  means  uncommon,  particularly  in  parts  of  Gernumy. 


PARASITIC    AI{A<'IINII)A. 


Iln7 


ted    with   tlif 

iT^iilivr  t!tvvit> 
two  it\i'lu's  ill 
hihtl  culiculii 
;,.  ciivitics.     In 
1  .•iiiiccr,  as  (111 
iiijr  •:fliitiiioii> 
liititl  hcadh  or 
lisHT.  and   till' 
ic  li\i'r  i^i  ii^^  •' 
,;,iv  iM'hiiioc'oc- 
<niillv  cnlariro*!. 
viiiorrliajies  art' 

incs    are    of    '>" 
iiiiiidii'i'  of  cases 
nitivc    im'asnrt;* 
lu'.     'llu'  siinplf 
uundn'r  of  case.-, 
In't'orc  lilt'  niort- 
ts.     Suppuralioii 
,,  till'  sac  should 
|R.n  and  I'vucuatc 
istralian  iTCoi'ds. 
lUjri'U  show   that 
ui.iuirativo  cysts 
111,'  (Hit look  is  less 
li;is  Ih'cu  tircatl.v 
jiincs  (iraham,  of 
<ruusis  iind  troal- 


Iiec  to  four  iuclu'- 

Iv  is  tapcvins  an^ 

j'u.  frontal  sinus.s 

iU'val  form,  whi''i 

]so  been  found  m 
liostril  of  man,  hm 
I'rhe  larva'  are  ''V 


{//)  The  ronxijihiihis  iditsl  rill  lis  (/'ni/ii.^/oiiiinn  cunsirirliini),  whieli 
is  !il)(»ut  the  Icti^th  of  half  an  Iticli,  with  twt'iity-three  rin<;s  on  the  ahdo- 
iiicn,  was  foniid  hy  Aitkeii  in  thi'  liver  and  liiii^s  of  a  soldier  of  a  West 
indi.'iii  re.iriineiit. 

The  |iiirasile  is  very  rare  in  this  country.  Flint  refers  to  a  Missouri 
ease  ill  which  from  7.')  to  I(i(t  of  the  parasites  were  expcctoi'ated.  The 
liver  was  enlar<red  and  the  parasites  prohahly  occupied  this  region.  In 
l:>ti'.»  I  saw  a  specimen  which  had  heeii  passe(l  with  the  urine  hy  a  patient 
of  .lames  II.  Kicliardson,  of  Toronto, 

(•.')  Deinodex  (Acarus)  folliculonim  (var.  hominis).  A  miiiut(>  para- 
site, from  (»■;{  niilliiiietre  to  (e  I  iiiiilimetre  in  leiiiilli,  wlii(di  lives  in  tlu^ 
sehaceous  f(»llicles,  particularly  of  the  face.  It  is  doiiliifnl  whether  it  pro- 
duces any  symptoms.  Possibly  when  in  lar^'e  nuiiii»ers  they  may  e\cit(! 
inllammation  of  tiie  follicles,  IcadiiiL,^  to  acne. 

(:{)  Sarcoptes  (Acarus)  scabiei  (//'•//  ///.srr/).— 'I'his  i.^  the  most  im- 
portant of  tlie  arachnid  parasites,  as  it  produces  troublesome  and  (li<- 
tressiii;,'^  skin  eruptions.  The  male  is  -iW  millimetre  in  leiiLrth  and  lU 
inilliinetre  in  breadth  ;  the  female  is  Oh")  millimetre  in  lenj;th  and  (i';i."» 
millimetre  in  width.  'I'lie  female  can  be  seen  readily  with  the  nakitl 
eye  and  has  a  pearly-white  color.  It  is  not  so  uoninion  a  parasite  in  the 
United  Slates  and  Canada  as  in  Kurope. 

The  insect  lives  in  a  small  burrow,  about  one  centimetre  in  lenu'th, 
which  it  makes  for  itself  in  the  epidermis.  .\t  tlH>  end  of  this  burrow  the 
female  lives.  The  male  is  .seldom  found,  'i'he  chief  seat  of  the  para>ite 
is  in  the  folds  where  the  skin  is  most  (h'licate,  !is  in  the  wel>  between  the 
lingers  and  toes,  the  backs  of  the  hands,  tlie  axilla,  and  the  front  of  the 
ahdomen.  The  head  and  face  an*  rarely  involved.  The  lesion.s  whi(di  re- 
sult from  the  presence  of  tlu(  itch  insect  are  very  numerous  and  result 
largely  from  the  irritation  of  the  .scratching,  'i'he  ('(unmonest  is  a  papular 
and  vesi(!ular  rash,  or,  in  children,  an  ('(tthyinatotis  eruption.  The  irrita- 
tion and  i)ustulation  which  follow  the  scratfdiing  may  completely  destroy 
the  burro'.v.s,  but  in  typical  ','ase.s  there  is  nirely  doubt  as  to  the  diagnosis. 

The  treatment  is  simple.  It  should  consist  of  warm  baths  with  a  thor- 
ough use  of  a  soft  soap,  after  whi(di  the  skin  slxuild  be  anointe(i  with 
sulphur  ointment,  which  in  the  case  of  children  should  be  diluted.  .\ii 
ointment  of  naphthol  (drachm  to  the  ounce)  is  very  ellicacious. 

(♦)  LeptUS  autumnalis  (Ilnrvcst  Huij). — This  reddish-colored  jtara- 
sito,  about  one  half  millimetre  in  size,  is  often  fcuind  in  largi;  numbers  in 
lields  and  in  gardens.  They  attach  themselves  to  animals  and  man  with 
their  sharp  proboscides,  and  the  booklets  of  their  legs  produce  a  great  deal 
<if  irritation.  They  ur,  most  fre(pieiitly  found  on  the  legs.  'IMiey  an; 
i"<  adily  destroyed  .ly  snljilnir  ointment  or  corrosive-sublimiite  lotions. 

Several  varieties  of  ticks  arc  occasionally  foutul  on  man — the  Lmdes 
I'i'iini.'i  and  the  Deri.'idoeu/ur  iimerii'diuis,  which  are  met  with  in  horses 
and  oxen. 


IMAGE  EVALUATION 
TEST  TARGET  (MT-S) 


/> 


^  A. 


1.0 


I.I 


1.25 


•so  '""^~ 


2.5 


2.2 


2.0 


1.8 


U    III  1.6 


Photographic 

Sdences 
Corporation 


23  WEST  ^tAIN  STREET 

V«:.V?8R,N.Y.  14580 

(716)  872-4503 


O^ 


1108 


DISEASES   DUE  TO   ANIMAL   PARASITES. 


VII.    PARASITIC    INSECTS. 


(1)  Pediculi  {Phthiriasis ;  Pediculosis). — Tliero  are  tlirco  varieties  of 
the  body  louse,  wliich  are  found  only  in  persons  of  uncleanly  habits. 

Pediculus  capitis. — The  male  is  from  1  to  1-5  millimetre  in  lonirfh 
and  the  female  nearly  two  millimetres  in  length.  The  color  varies  soiiu- 
what  with  the  different  races  of  men.  It  is  light  gray  with  a  black  mar- 
gin in  the  European,  and  very  much  darker  in  the  negro  and  Chinese. 
They  are  oviparous,  and  the  female  lays  about  sixty  eggs,  which  mature  iu 
a  week.  The  ova  are  attached  to  the  hairs,  and  can  be  readily  seen  us 
white  specks,  known  poj)ularly  as  nits.  The  symptoms  are  irritation  and 
itching  of  the  scalp.  When  numerous  they  may  excite  an  eczema  or  a 
pustular  dermatitis,  which  causes  crusts  and  scabs,  particularly  at  the  back 
of  the  head.  In  the  most  extreme  cases  the  hair  becomes  tangled  in  tlusc 
crusts  and  matted  together,  forming  at  the  occiput  a  firm  mass  wiiicii  is 
known  as  plica  polonica,  as  it  was  not  infrequent  among  the  Jewish  in- 
habitants of  Poland. 

Pediculus  corporis  {vestimentoruvi). — This  is  considerably  larger  than 
the  head  louse.  It  lives  on  the  clothing,  and  in  sucking  the  blood  causes 
minute  haimorrhagic  specks,  which  are  very  common  about  the  iitM'k, 
back,  and  abdomen.  The  irritation  of  the  bites  may  cause  urticaria,  and 
the  scratching  is  usually  in  linear  lines.  In  long-standing  cases,  particu- 
larly in  the  old  dissipated  characters,  the  skin  becomes  rough  and  greatly 
pigmented,  a  condition  which  has  been  termed  the  vagabond's  disease— 
Diorhus  errorum — and  which  may  be  mistaken  for  the  bronzing  of  Addi- 
son's disease. 

Phthirius  pubis  differs  somewhat  from  the  other  forms,  and  is  found 
in  the  parts  of  the  body  covered  with  short  hairs,  as  the  puijes;  more 
rarely  the  axilla  and  eyebrows. 

The  taches  Ueudtres  are  stated  by  French  writers  to  be  excited  by  tlie 
irritation  of  pediculi.  They  are  certainly  associated  with  them  in  a  con- 
siderable number  of  cases,  but,  if  really  caused  by  these  parasites,  it  is  dilVi- 
cult  to  understand  why  they  should  only  be  present  with  fever. 

Treatment. — For  the  Pediculus  capitis,  when  the  condition  is  very 
bad,  the  hair  should  be  cut  short,  as  it  is  very  difficult  to  destroy  thor- 
oughly all  the  nits.  Repeated  saturations  of  the  hair  in  coal-oil  or  in  tur- 
pentine are  usually  efficacious,  or  with  lotions  of  carbolic  acid,  one  to  iifty. 
Scrupulous  cleanliness  and  care  are  sufficient  to  prevent  recurrence.  In 
the  case  of  the  Pediculus  corporis  the  clothing  should  be  placed  for  sev- 
eral hours  in  a  disinfecting  oven.  To  allay  the  itching  a  warm  bath  con- 
taining four  or  five  ounces  of  bicarbonate  of  soda  is  useful.  The  skin 
may  be  rubbed  with  a  lotion  of  carbolic  acid,  two  drachms  to  the  pint, 
with  two  ounces  of  glycerin.  For  the  Phthirius  pubis  white  precipit.ito 
or  ordinary  mercurial  ointment  should  be  used,  and  the  parts  should 


■f  ' 


MYIASIS. 


1109 


^e   thoroughly  washed   two   or   three   times  a  day  witli  soft  soap   and 
water. 

(2)  Gimex  lectularius  {Common  Bed-buy). — This  parasite  is  from  tliree 
to  four  millimetres  in  length  and  has  a  reddish-brown  color.  It  lives  in 
the  crevices  of  the  bedstead  and  in  the  cracks  in  the  floor  and  in  the  walls. 
It  is  nocturnal  in  its  habits.  The  })eculiar  odor  of  the  insect  is  caused  by 
the  secretion  of  a  special  gland.  The  parasite  possesses  a  long  proboscis, 
with  which  it  sucks  the  blood.  Individuals  diff*  r  remarkably  in  the  reac- 
tion to  the  bite  of  this  insect ;  some  are  not  d'sturbed  in  the  slightest  by 
them,  in  others  the  irritation  causes  hypeia^mia  and  often  intense  urti- 
caria. Fumigation  with  sulphur  or  scouring  with  corrosive-sublimate 
solution  or  kerosene  destroys  them.     Iron  bedsteads  should  be  used. 

(3)  Pulex  irritans  {The  Common  Flea). — The  male  is  from  2  to  'i') 
millimetres  in  length,  the  female  from  3  to  4  millimetres.  The  flea 
is  a  transient  parasite  on  man.  The  bite  causes  a  circular  red  spot  of 
hyperajmia  in  the  centre  of  which  is  a  little  speck  where  the  boring  ajipa- 
ratus  has  entered.  The  amount  of  irritation  caused  by  the  bite  is  variable. 
Many  persons  suffer  intensely  and  a  diffuse  erythema  or  an  irritable  urti- 
caria develops ;  others  suffer  no  inconvenience  whatever. 

The  Puh'.v  penetrans  {sand-flea ;  jifjyer)  is  found  in  tropical  coun- 
tries, particularly  in  the  West  Indies  and  South  America.  It  is  much 
smaller  than  the  common  flea,  and  not  only  penetrates  the  skin,  but  bur- 
rows and  produces  an  inflammation  with  pustular  or  vesicular  swelling. 
It  most  frequently  attacks  the  feet.  It  is  readily  removed  with  a  needle. 
Where  they  exist  in  large  numbers  the  essential  oils  are  used  on  the  feet 
as  a  preventive. 


il 


VIII.    MYIASIS. 


Of  these,  the  most  important  are  the  larva?  of  certain  diptcra,  particu- 
larly the  flesh  flies — Creophila.     The  condition  is  called  myiasis. 

The  most  common  form  is  that  in  which  an  external  wound  becomes 
living.,  as  it  is  called.  This  myiasis  vulncrum  is  caused  by  the  larvfe  of 
either  the  blue-bottle  or  the  common  flesh  fly.  The  larvfe  of  the  Lucilia 
macellaria,  the  so-called  screw-worm,  has  been  found  in  the  nose,  in 
wounds,  and  in  the  vagina  after  delivery.  The  larvae  can  be  removed 
readily  with  the  forceps ;  if  there  is  any  difficulty,  thorough  cleansing  and 
the  application  of  an  antiseptic  bandage  is  suflicient  to  kill  them.  The 
ova  of  these  flies  may  be  deposited  in  the  nostrils,  the  ears,  or  the  con- 
junctiva— the  myiasis  narium,  aurium,  conjunctivae.  This  invasion  rarely 
takes  place  unless  these  regions  are  the  seat  of  disease.  In  the  nose  and 
in  the  ear  the  larvae  may  cause  serious  inflammation. 

The  cutaneous  myiasis  may  be  caused  by  the  larva;  of  the  Mu.sea  vomi- 
(oria,  but  more  commonly  by  the  bot-flies  of  fh^  ox  and  sheep,  which 
occasionally  attack  man.     This  condition  is  rare  in  temperate  climates. 


1110 


DISRASr<:.S   DUK  TO   ANIMAL   PARA.SITKS. 


Miitas  has  described  a  case  in  wliieh  o'strus  larva?  were  found  in  the  i^ln. 
teal  region.  In  })arts  of  Central  America  the  eggs  of  another  bot-flv,  il,,. 
Dermnfo/jio,  are  not  infro(iiiently  deposited  in  the  skin  and  j)rn(lu(  ■•  a 
swelling  verv  like  the  ordinary  boil. 

Myiasis  interna  may  resnlt  from  the  swallowing  of  the  larva;  of  iho 
common  house  tly  or  of  species  of  the  genus  Aiiflmtinfia.  There  are  niniiv 
eases  on  record  in  which  the  larva?  of  the  Mtisra  ihtinoslira  have  been  dis- 
charged by  vomiting.  Instances  in  which  dipterous  larva;  have  \w\\ 
passed  in  the  fitces  are  less  common.  Finlayson,  of  (ilasgow,  has  recemly 
reported  an  interesting  case  in  a  physician,  who,  after  protracted  const i- 
pation  and  pain  in  the  back  and  sides,  passed  large  numbers  of  tlic  Imivh- 
of  the  llower  Hy — Ant/ioini/id  canicnhiris.  Among  other  forms  of  laiva. 
or  f/e/itles,  as  they  are  sometimes  called,  which  have  been  f(-und  in  the 
fa'ces,  are  those  of  the  common  house  fly,  the  blue-bottle  ily,  and  tlir 
Techomyza  fusca.  The  larva'  of  other  insects  are  extremely  rare.  It  is 
stated  that  the  caterpillar  of  the  tabby  moth  has  been  found  in  the  fa-cs. 

Here  may  be  mentioned  among  the  effects  of  insects  the  remarkaltlt' 
itrtiraria  epidemicn,  which  is  caused  in  some  districts  by  the  procession 
caterpillars,  jjarticularly  the  sjiecies  din'tliurdnipn.  There  are  districts  in 
the  Kahlberger  Schweiz  which  have  been  rendered  almost  uninhabitalilc 
by  the  irritative  skin  eruptions  caused  by  the  presence  of  these  insects. 
the  action  of  which  is  not  necessarily  in  consequence  of  actual  contait 
with  them. 

In  Africa  the  larva?  of  the  Cayor  fly  are  not  uncommonly  found  be- 
neath the  skin,  in  little  boils. 


^^r-.-^.-^-CM-IT  .■..^VO^.tf 


INDEX. 


Abnsia,  1040. 

AluloiiR'ii  iti  typlioiil  fever,  24. 

AlMloiiiiiml  tyiilius,  1. 

Aluluoens  nerve  (.see  Si.xtii  Nkuve),  S51. 

AlHTrimt,  tliyroiil  i;liiii<ls,  7"il  :  iu'ri'iiiiLs  811. 

Aliortlon,  in  cluireii,  '.'"-T  :  in  nlap.sini,'  t'ever, 
49;  in  sniall-pox.  Hii ;  in  .sy|iliilis.  I'.t'.i. 

Aiiscess,  utlieroniatdii.s,  7nl  ;  ot'  brain,  '.t74  ;  in 
appendicitis,  4-":i,  4:;7 ;  in  i.'lanilers,  iisl  ;  of 
iiiilney  ipyoneiilirosis),  71'!i ;  of  liver,  4sn  ; 
of  luns,  586 ;  of  meiUastinmn,  ill:);  of  pa- 
rotid fjland,  ^'>7  ;  of  tonsils,  HOS  ;  perine]ilirie, 
814;  pulinonai-ccrel)ral,  !i7'> ;  pVieniie,  1;!i>; 
retroperitoneal,  4:;  t  :  retropliiiryn>fCul  in  eer- 
vioal  earies,  .3til.  111"). 

.•\eantiiocenlnila,  lO'.i."). 

.\eardia.  It'.)'>. 

Aearus  seuliiei,  .V.  follienloruni.  11(>7. 

.Veeentuated  second  sound,  in  chronic  Hriirht's 
disease,  704  ;  in  arterio-solcro.sis,  704, 

Aeecssnry  ppasm,  868. 

Accpiuiloeysts  (see  Hydatid  Cysts >.  1100. 

Acetonremia,  S'2i\. 

Acetone,  3'J4  ;  test  for  (I.e  Nohers),  324. 

Aeetonuria,  777. 

Aohondroplnsy,  332. 

Aclironiatoi>sia  in  liysteria.  1026. 

Aene,  from  iodide  of  [lotassiuni,  lOlO;  rosacea, 
.  (I')!!. 

Acronieiralia,  104."),  and  iriu'antisni.  Io40. 

Actinomyces,  or  ray  funiriis,  2^2. 

Actinomycosis,  2S2  ;  i)idinonary,  283;  cuta- 
neous, 284 ;  cereliral,  2S4, 

Acupuncture,  in  dropsy,  786  ;  in  luniliairo,  304  ; 
in  sciatica,  87'.'. 

Acute  buitjar  pa-;ilysis,  922. 

Acute  tuberculosis,  217. 

Ac'ite  yellow  atrophy.  450. 

Addison's,  disease,  746  ;  pill,  202  ;  keloid.  lOiS. 

Adenie,  742, 

Adenitis  in  scarlet  fever,  77. 

.\denitis,  tuberculous,  226,  745. 

.\denoid  prrowtlis  in  pharyn.\,  364. 

.\dherent  pericardium,  624. 

Adliesivo  pylcplile\)itis,  462. 

Adirondack  Mountains  for  tuberculosis,  273. 


Adrenals  in  Addi.son's  disease,  747. 

.■Ki.'opli(iny,  ."i54,  5','6. 

.•\;,'e,  inlluence  vi'.  in  tuberculosis.  212. 

.V^reusia,  ^^63. 

Af.'rai)liia,  1130, 

.\(.'Ue,  155. 

Ajruc  cake  (see  Kxi,.\i!ok1)  Si-lkkn',  171. 

Aiidiuni,  Umi. 

"'  Air-hunirer  "  in  dialietes.  326. 

.'Mr.  iniy>ure,  intluencc  in  tuberculosis,  213, 

.Mbiiii,  nod\des  of,  ()'.i6. 
;  Albinism,  in  leprosy  (lepra  albai,  27!t;  of  the 
I      lun^'.  580. 
!  .Vlbuniin,  tests  for,  760. 

Albuminuria.  767.  and  life  assurance,  77ii :  cy- 
clic, 76)8 ;  felirile,  76s;  funeti'iual,  767;  in 
aeutc  Briirht's  disease,  7^:!  ;  in  chronic 
BriL'ht's  disease,  793 ;  in  diabetes,  324 ;  in 
diphtheria,  113;  in  epilepsy,  liiOi! ;  in  ery- 
sipelas, 125;  in  gout,  317;  in  iineumonia, 
555 ;  in  scarlet  fever,  74,  75 ;  in  tyi)hoid 
fever,  28;  in  variola.  59;  neurotic,  769; 
physiolottical,  7''>7  ;  projrnosis  in,  77i'. 

Albununous  expectoration  in  pleurisy,  tiii-t. 

Albuminuric  retinitis,  S42. 

Albuminuric  ulcerntion  of  the  bowels,  423. 

Albumosi;  in  cultures  of  tubercle  bacilli,  205. 

.Mbumosuria,  770. 

.\lcaptonuria,  777. 

Alcohol,  ellects  of,  on  the  diirestive  system, 
1058  ;  on  the  kidneys,  1059  ;  on  the  nervous 
system,  1058  ;  poisonous  ellects  of,  1057. 

.Mcoholie  neuritis,  836. 

Alcoholism,   1057;   acute,    lo57  ;  and  tubercu- 
)      losis,  1059  ;  chronic,  lo57  ;  treatment  of,  lOOO. 

Alexia,  930. 

Aluid  form  of  malaria,  170. 

Alimentary  canal,  tuberculosis  of,  260. 

.Mkaloids.  putrefactive,  lOOii. 

Allantiasis,  1069, 

Alloelieiria.  907. 

AUorrhythmia,  685. 

Alopecia,  insy|)hilis,  187. 

AlternatiiiLt  paralysis  (see  Citos.sED  I'aiialy- 
sis). 

Altitude,  cftoets  of  higli,  289. 


1112 


INDEX. 


Altitude  in  tiilicroulosit<,  204,  2T2. 

Aiiiiinrosis,  lijuterioiil,  M:!,  10'J<i ;  toxic,  843 ; 
iirii'iiilc,  7!i-'> ;  ill  iiii'iiiuti'iiu>Ki»,  413. 

Aiiililji)|iiu,  M'i ;  (.'I'dssud,  Ml". 

Aiiilmlutory  tviilioiil  fever,  1.'!,  31. 

Aiiiirlia  e"li  (uiiin'l)ii  (i\  Kcnteriie ),  147  ;  in  liver 
ulj.sceHs,  147,  4S0;  in  r<i>iitu,  ir)3. 

Ania'liic  tlysentery,  147. 

.Aiiiinoniiieiil  (leennipusition  uf  urine,  77o. 

AnnnDiiiieriiiu,  77H,  Si'2. 

Amnesia,  atulitory,  ',i2'J  ;  visual,  028. 

.\nipiiorie  breutliintr,  247,  GIO. 

.Vinplioric  eelio,  247. 

Aniusia,  !I2!). 

.Vniylciiil  disease,  in  plitliisiH,  238;  in  sypliili-s, 
IHH  ;  of  kidney.  7HM  ;  of  liver,  4110. 

.\niyotro|iliie  lateral  silerosis,  ItHt,  1)21. 

Anu'iiiia,  720;  botlirioeeplialus,  10117;  in  an- 
eiiylosloiniasis,  Iimhi;  from  Hilliarzia,  1on.'3; 
from  jfastrie  atroiiiiy,  3NI ;  from  lueniorrliai;e,  j 
720;  miner'.s,  loDU ;  briek-maker'.s,  lOito; 
tunnel,  lOHO  ;  from  inanition,  722;  from  lead, 
1064;  idiopntliie,  721') ;  in  frastrie  cancer,  407  ; 
in  frastrie  uleer,  3!i8 :  mountain,  2811,  lO'JO; 
in  nialurial  fever,  170 ;  in  rlieuiiuitism,  2li4; 
in  sypliiiis,  1S7;  in  tyiilioid  fever,  18;  ])ri- 
mary  or  essential,  723;  cldorosis,  723;  pro- 
ftressivo  pernicious,  72(3 ;  secondary  or  .synip- 
tomatie,  720;  siiiiuil  cord  lesions  in,  880; 
to.vic,  722. 

AnuMiiie  murmurs  isee  II.kmu^  Miumius). 

Aniestliesia.  dolorosa,  !tl4;  in  chorea,  ItlU  ;  in 
hemiple^'ia,  114(1;  in  hysteria,  1025;  in  lepro- 
Ky,  280;  in  locomotor  atu.xia,  900;  in  Mor- 
van's  disease,  913;  in  railway  spine,  1037;  in 
unilateral  lesions  of  the  cord,  8StO. 

Analgesia  in  hysteria,  1025;  in  Morvan's  dis- 
ease, 913;  in  syring()-niyclitt,.913. 

Anartliria,  927. 

Ana.snreft  (see  Duopsy). 

Anastomotic  ]>ulse,  704. 

Anehylostonm,  421. 

Anehylostominsis,  1000;  symptoms  pt,  1090. 

Anchylostonuim  duodenalc,  1090. 

Aneurism,  7(Mi;  arterio-veiious,  700,  718;  cir- 
soid, 700;  congenital,  718;  cylindrical,  700; 
dissecting,  700  ;  embolic,  7o7  ;  etiology  of, 
708  ;  false,  700 ;  fusiform,  700  ;  mycotic,  707  ; 
of  the  abdominal  aorta,  710;  of  the  branches 
of  the  abdominal  aorta,  717  ;  of  tiie  cerebral 
arteries,  955  ;  of  the  ca'liac  axis,  717 ;  of  heart, 
681;  of  tlio  hepatic  artery,  718;  of  the  renal 
artery,  718 ;  of  tiie  sj)lcnic  artery,  717  ;  of  tlie 
superior  mesenteric  artery,  718;  of  pulmo- 
nary ,<rtery,  237  ;  true,  700. 

Aneurism,  of  thorai'ic  aorta,  707  ;  cougii  in,  711 ; 
diagnosis  of,  709;  dyspno'a  in,  711  ;  liaMiior- 
rhage  in,  711;  pain  in,  711;  physical  signs 
of,  709;  symptoms  of,  708  ;  treatment  of,  714; 


Tufnell's  treatment  of,  714  ;  unilateral  ^^v.  ■, 
ing  in,  712. 

Aneurism,  verminous.  In  the  liorse,  707,  ln'm 

Angina,  l.udoviei,  301  ;  simplex,  350;  siilb.  ,, 
tiva,  1113. 

Angina  pectoris,  000;  pseudo-  or  hystcriial, 
003 ;  vaso-motoria,  001. 

Angio-cholitis,  4t)0. 

Angio-neurotie  <edema,  I043;  lieredity  in,  l(Mt; 
recurring  colie  in,  lo44. 

Angio-sclerosis,  703. 

Aiigor  animi,  092. 

Anguiliula  stereoralis,  A.  iutestinalis,  1095. 

.\iiinud  lympli,  08. 

Anisocoria,  850. 

Ankle  clonus,  in  iiysterieal  paraplegia,  imi, 
10:i4;  in  s]iastie  parupleyia,  899;  8puriiPii>, 
1023. 

Anorexia  nervosa,  1027. 

Anosmia,  m41. 

Ano-vesical  centre,  917. 

Anterior  cerebral  artery,  embolism  of,  953. 

Anterior  crural  nerve,  paralysis  of,  876. 

Anthomyia  eanieiilaris,  1110. 

Anthracosis,  of  lungs,  587  ;  of  liver,  474. 

Anthrax,  174;  bacillus,  174;  in  animals,  174; 
external,  175;  internal,  170. 

Antiperistalsis,  388. 

Antipncumotoxin,  f48. 

.\ntiseptic  medication  in  typhoid  fever,  40. 

.\ntitoxine  of  diphtheria,  lOf!,  121;  of  piii  u 
monia,  548  ;  of  tetanus,  183. 

Anuria,  703;  complete,  758;  from  stone.  71):;; 
hysterical,  704. 

Anus,  imperforate,  445. 

Aorta,  aneurism  <if,  707  ;  dynamic  pulsation  i>(. 
713;  throbbing,  717,  lo34  ;  hypoplasia  of,  iu 
chlorosis,  723  ;  tuberculosis  of,  207. 

Aortic  incompetency,  037  ;  sudden  dcatl'  in, 
042;  symptoms  of,  030. 

Aortic  orifice,  congenital  lesions  of,  697;  size 
of,  038. 

Aortic  stenosis,  643. 

.\ortic  valves,  bicuspid,  condition  of,  690;  rchi- 
tive  insutliciency  of,  i')3S. 

Ajiex  of  lung,  catarrh  of,  251  ;  puckering  of, 
271 ;  in  tuberculosis,  234. 

Apex  pneumonia,  550,  559. 

Aphasia,  927;  anatomical  locolization  of,  0?.i); 
ataxic,  029;  hemiplegia  with,  930;  in  in- 
fantile hemiplegia,  900;  mixed  forms  nf, 
930;  motor,  929;  of  conduction,  930;  in 
phthisis,  249 ;  prognosis  of,  931 ;  sensory, 
928 ;  in  typhoid  fever,  27 ;  tests  for,  0"! ; 
transient,  in  migraine,  1012;  Wernicke's,  ',0'. 

Apheniia(8ee  Aphasia). 

Aphonia,  hysterical,  1026;  in  acute  laryngitis, 
518,  in  obductor  paralysis,  865;  in  pericar- 
dial ctlusion,  620. 


INDEX. 


1113 


Aplithip  (nvo  St(imatitis,  AriiTiiorsi,  S'>\. 

Ai)litliipuH  t'evcr,  'J!M). 

Apopk'ctio  hithitnn,  H40  ;  tttroko,  !»4:i. 

Apoplexy,  ccreljriil,  'J40 ;  iii)^ruvu»ct'nt,  943; 
pulriKmury,  >>\'i. 

Apparitions  in  migruiiie,  loll. 

A]>p(Miirn'itis,  ■!•_'!•;  olilitiTiiiis,  4".l  ;  intVctivc, 
4;i-J ;  piirfunilivc,  4^1  ;  rulupsiii;^,  4y'>i ;  ulcuru- 
tivo,  4;U. 

Appoiulii'uh.r  colio,  4:!1,  4.").'). 

Appoiuiix  VLTtnitorniis,  Hituution  of,  430;  per- 
Ibrution  of,  in  typlioiil  fevor,  'J;  fitciil  con- 
cretions in,  4;!0;  forcijin  liodics  in,  430;  uu- 
orosis  anil  sloujjliinjf  of,  432. 

Apraxiii,  ;ti!s. 

Aprose.xiu,  304,  30". 

Arachnida,  pura.sitio,  1100. 

Araol  liitis  isuu  Mknixhitisi,  033. 

Aran- 1) mill  line {\\w  of  niusciiliir  atropliy,  (119  ; 
in  k'ail-i>oi!<oniiif;,  1()00. 

Arch  of  aorta,  aneurism  of,  70S. 

Arcu.s  Honilin,  0"U, 

Argyll- lioherUon  pupil,  800;  in  ataxia,  905. 

Aritlimoniania,  9'.>7. 

Ann,  peripiienil  '  uralysia  of  (see  Paralysis  of 
BUACIIIAL  I'le.\  ■  s). 

Arryihinia,  08"). 

Arsenical  neuritis,  b;,7. 

Arsenical  pi),'inentation,  10(38  ;  in  chorea,  992. 

Arsenical  poisoninj;,  1007  ;  paralysis  in,  1008. 

Arteries,  diseases  of,  O'.Ht ;  calcitication  of,  099; 
degeneration  of,  099 ;  fatty,  099 ;  liyaline, 
700  ;  tubcrculo.iis  of,  207. 

Arterio-capillary  libnisis,  700. 

Arterio-sclerosis,  700;  diffuse,  702;  in  Icad- 
poisoiiing,  lOOO;  in  niigraine,  1012 ;  nodular 
form,  701 ;  in  phtiiisis.  253  ;  senile  form,  702  • 
symptoms  of,  704 ;  treatment  of,  705. 

Arteritis  in  typlioid  fever,  10,  20. 

Arteritis,  syphilitic,  197. 

Artliraljfia  from  lead,  1000. 

Arthritides,  post-febrile,  131 ;  in  (rout,  315. 

Arthritis,  297;  acute,  in  infants,  298;  gonor- 
rha-al,  301 ;  in  acute  myelitis,  890 ;  in  cerebro- 
spimd  meningitis,  loO;  in  eliorea,  985;  in 
dengue,  95 ;  in  dysentery,  152 ;  in  liivmo- 
philla,  349;  in  snuiU-pox,  59;  in  tabes  dor- 
salis,  907  ;  nmltiple  secondary,  297  ;  in  pur- 
pura, 344;  rlieumatoid,  305;  in  scarlet  fever, 
76 ;  septic,  297. 

Arthritis  deformans,  305 ;  chronic  form,  307 ; 
general  progressive  form,  306;  Jkberden'a 
nodosities  in,  300 ;  partial  or  mono-articular 
form,  308. 

Arthropathies  in  tabes,  907. 

Ascariasis,  1083. 

Asearis  lumVmcoides,  1083. 

Ascites,  507, 511 ;  chylous,  509;  from  cancerous 
peritonitis,  507 ;  from  cirrhosis  of  the  liver, 


477  ;  from  sypliiUs  of  tlie  liver,  lOil ;  in  cancer 
of  tlie  liver.  4SH  ;  in  tuberculous  peritonitis, 
259;  physical  signs  of,  50m;  treatment  of, 
511. 

Ascitic  fluid,  chylous,  5o9  ;  seriuis,  5o9; 
hiemorrliagif,  .'lo;!. 

.\seoinyceU'  in  typhus  fever,  44. 

Aspect,  facial,  in  typhoid  fever,  13  ;  in  pneu- 
monia, 551;  III  hereditary  lues,  190;  in  pa- 
ralysis agitans,  9^3. 

Aspergillus  in  lung,  242. 

Asphyxia,  local,  1041 ;  death  by,  in  phthisis, 
255. 

.\spiration,  Ilou'ilitrh's  eonclusions  mi,  ilo4 ; 
in  empyema,  0o5 ;  in  pericardial  ( ll'usinn, 
024  ;  in  [>leuritic  ell'usioli,  ilu.; ;  tuberculosis 
after,  213. 

.Vspiration  pneumonia,  571. 

.\slasia-abasia,  I040. 

.Vstlmia,  bruuehial,  531 ;  etiology  of,  5.'!1  ;  nasal 
altections  in,  532  ;  sputum  in, 533;  symptt>m» 
of,  533;  treatment  of,  534  ;  cardiac,  531;  hay, 
515;  /,(//(/< h'«  crystals  in,  534;  renal,  780; 
tiiyndc,  520,  014. 

Atavism,  in  Im'mophilia,  o4s  ;  in  gout,  309. 

Ataxia,  cerebellar,  920;  cerebellar-heredo,  912; 
hereditary,  91 1  ;  in  peripheral  neuritis,  837: 
in  [irogressivc  paresis,  909;  locomotor,  902; 
after  small-pox,  59. 

Ataxic  gait,  900. 

Ataxic  paraplegia,  900. 

Ataxic- varioliciue,  59. 

Atelectasis,  puimomiry,  571. 

Atheroma  (see  AnTKuio-scLERosis  and  PiiLEno- 

SCI.EIIOSIS). 

Athetosis,  900;  bilateral  or  double,  962. 

Athlete's  lieart,  037. 

Athyrea,  751,  754. 

Atmospheric  pressure,  effects  of,  888. 

Atroidiic  cirrhosis,  475. 

Ati'ophy,  acute  yellow,  of  liver,  459;  of  brain, 
diffuse,  in  general  paresis,  907 ;  of  brain, 
unilateral,  959;  of  muscles,  various  forms  of, 
1052;  progressive  muscular,  of  spiiud  origin, 
919  ;  unilateral,  of  face,  1044. 

Attituile,  in  pseudo-hypertropbic  muscular  pa- 
ralysis, 1051 ;  in  paralysis  agitans,  9s,'j. 

Auditory  centre,  affections  of,  859  ;  nerve,  dis- 
eases of,  859;  vertigo,  861. 

Aura,  forms  of,  in  epilepsy,  1004. 

Auto-infection  in  tuberculosis,  218. 

Automatism,  m  j)etit  tnal,  1006;  in  cerebral 
syphilis,  192. 

Autumnal  fever,  3. 

Avian  tuberculosis,  203. 

Baccelli's  sign,  596,  598. 

Bacillus,  anthracis,  174;  of  cholera,  133. 

Bacillus  coli  communis— distinction  from  ty- 


ft' 


1114 


INDEX. 


jilinid  liacillus,  !?;  in  bilc-pnssiiffos,  4»'i0;  in 
fu'ct's  of  siicl<liiij.'.-(,  417.41s;  in  fat  ni'i'iusix 
witli  ciililis,  I'.il;  in  ]ii'i-ili)iiiti>.  4'.i'.» ;  i  i  sii))- 
|iiinilivc  ciiciiilyiiiitis,  ',i:;.'i. 

Haciiliis  <li]i|itlicriiu,  105,  ytiy ;  valine  of,  in 
iliatrnoKis,  117. 

Hui'iiins  jrius  (H.  a^rn^joncs  ciiiisnlatiis'.  in  jicri- 
tonitis.  I'.ili;  in  iniciMMo-inriciirirmni,  O'Jii. 

15acillus,  jriistrii'iis,  ;!77 ;  of  trliiMilcrs,  'jsn;  of 
sinc;.'nia,  Ifit;  in  w)ioo|iiMt,'-coiiirli,  ss  ;  ma- 
laria', li<7;  if  Icin'osy,  27'.';  ol'  ^y|iiiilis,  ls4; 
of  tetanus,  Isl  ;  jiyoeyanfU.s,  l-js;  stivjito-, 
in  ty|iliiis  fiivcr,  41. 

Hafiilii>.  Klil).--LoclH(T,  lO.'i ;  toxinc  of,  lor,. 

IJacilius  iincmnonia',  t^u^i. 

Viii'iliiis  tulicrclllosis,  'jot;  tliajrnostif  valuL'  of, 
'J.")0;  (li.striljution  of,  L'o.') ;  in  simtuin,  240; 
ini'tlioils  ot' tlotccfion,  '_'tl  ;  mitsido  tlic  body, 
'Jii,", ,  jiroduct.s  of  irrowtli  of,  \>i>'). 

Haciiliis  siiiciriiiii,  1H4. 

Bacillus  tyiilii  abdominalis,  ;J,  liJil. 

Bueillus  jirotfus  fluort>si!oii8,  286. 

BuctL'riii,  ]>rotcus  irvoiip  in  diarrlioen,  418;  rela- 
tion to  diarrlio-a,  417. 

Baclcrium,  coli  coumiunc  (sec  Hacillis  Com 
CoMMixis) ;  lactis  acrogcncs,  418. 

Balanitis  in  diabi'tc'.'*,  325. 

Balantidiuin  coli,  1082. 

''  Balloon-niiin,"'  tlic.  4.")4. 

Bull-tlironibus  in  left  auricle,  051. 

/?(//(//»(/ '.V  method  ill  obesity,  1077. 

"Barben  eliolcfa,"  1071. 

Barkint;  cough  of  puberty,  1020. 

Jiar/nw'x  disease,  ;!41. 

Barrel-shaped  chest  in  cinphy?cina,  580,  582; 
ill  enlarged  tonsils,  aUO. 

Basedow''s  disease,  751. 

Basilar  artery,  embolism  and  thronihonis  of, 
952. 

Baths,  cold,  in  typhoid  fever,  3S ;  in  hyperi\v- 
rexia  of  rhcumati.sin,  2',i(» ;  in  scarlet  fever,  «0. 

Beaded  ribs  iu  rickets,  334. 

Bed-bug,  1109. 

Bed-sores,  acute,  890  ;  in  paraplegia,  891. 

Beilnav's  aphtlue,  .^53. 

Beer-drinkers,  heart  disease  in,  G74. 

BeWs  (Luther)  mania,  980. 

Beirs  palsy,  855. 

Beri-beri,  838  ;  in  Great  Britain,  838 ;  in  Ja- 
pan, 838  ;  in  the  United  States,  838. 

Besoili  de  respirer,  281). 

Biernacik''!:  symptom,  909. 

"  Big-jaw  "  in  cattle,  282. 

Bile  coloring  matter,  tests  for,  458. 

Bile-ducts,  ascarides  in,  471 ;  cancer  of,  471, 
487  ;  stenosis  of,  471. 

Bilo-pussages,  diseases  of,  403. 

Bilharzia  hu-matobia,  1083. 

Bilious  remittent  fever,  167. 


Biliary  cirrhosis  of  liver,  475. 

Biliary  colic,  400. 

Iiiliary  listiilie.  470. 

Kiitli  jialsics,  '.nil. 

r.liK'k  death,  144. 

Black  sjiit  of  miners,  589. 

Black  vomit,  llo. 

Bladder,  paralysis  of,  in  locomotor  ata.via,  907  ; 
care  of,  ill  iiiyc'litis,  Mi.'i ;  hypcrlri'pliy  of.  in 
diabetes  insipidus,  331  ;  tuberculosis  ol',  'Ji'..".. 

•'  Bleeders,"  VA^. 

lilccding,  ill  arterio-sclcrosis,  7O0  ;  in  cenbr.il 
hii'iMorrhagc,  9.')3  ;  in  emphysciiui,  5s;i ;  in 
heart-disease,  059;  ill  ]illciimoliia.  504;  in 
sunstroke,  I077  ;  in  yellow  fever,  143. 

lilcpluii'iispasm,  s.J8. 

Blindness  (sec  A.MAIKosis). 

Blood  and  ductless  glands,  diHciuses  of,  720, 

Blood-<'iists  (see  Casts). 

Blood,  characters  ot',  in  aiuemiii.  720  ;  in  ciincir 
of  the  stoiiiiich.  .107;  in  chlorosis,  72!!;  in 
cholera.  135;  in  diabetes,  322;  in  gout.  312: 
in  Im'mophilia,  349;  in  leuka'mia,  7.">7 :  in 
pernicious  ameiiiia,  7'.'9 ;  in  pseiido-leuka'- 
niia,  llodgkiii's  iliscasc,  744;  in  pui|inra. 
310;  in  secoinhiry  aniemia,  720. 

Blood  serum  tlieraiiy  in  diphtheria,  121  ;  in 
l>iieumoiiia,  51«;  in  tetatius,  183;  in  typhniil 
fever,  41. 

Blood-vessels  of  liver,  affections  of,  401. 

"  liluc  disease,"  097. 

B'.ue  line  on  gums  in  lead  poisoning,  1064. 

Boils,  ill  diabetes,  325  ;  after  small-pox,  59. 

Bones,  lesions  ot',  in  acromegalia,  1045  ;  in  con- 
genital syphilis,  190;  in  leukiemia,  740;  in 
rickets,  333  ;  in  typhoid  fever,  29. 

Borborygmi,  388,  116. 

Bothriocephalus  latus,  1097;  anoomia,  1097. 

Botulism,  1009. 

Botyroid  liver  in  syphilis,  196. 

Bovine  tuberculosis,  203. 

Bowel,  affections  of  (see  Intestines)  ;  acute 
obstruction  of,  446  ;  infarction  of,  455. 

Brachial  plexus,  affections  of,  873. 

Braehycardia  (Bradycardia),  088;  in  tvphoid 
fever,  18. 

Brain,  diseases  of,  924  ;  abscess  of,  974 ;  abscess 
of,  in  conirenital  heart  disease,  098;  anieiniii 
of,  93ri  ;  atrophy  and  sclerosis  of,  959  ;  con- 
gestion of,  937  ;  cortical  centres  of,  821 ;  cysts 
in,  971;  echinococcus  of,  1105;  in  syphilis. 
191;  glioma  of  970;  liypcrwinia  of,  937:  in- 
fiainmation  of,  974;  a'denia  of,  939:  ponn- 
cephalus  of,  959. 

Brain,  sclerosis  of,  903;  diffuse,  904;  iiisuhir, 
905  ;  miliary,  904  ;  tuberous,  905. 

Brain-murmur  in  rickets,  335. 

Brain,  softeuiiig  of,  red,  yellow,  and  white, 
949,  950. 


INDEX. 


1115 


Brnin,  tubercle  of,  2fi«,  070. 

Hruiii,  tiirnnrs  (if,  UTO  ;  iiicdi<'iil  treiitiiieiit,  ot', 

ItT-l;  Miri;ieal  ticiitiiient  of,  UVl ;  syiiiiituius, 

tfi'iienil  mill  liM'iiliziiif.',  '.'71. 
lirtiiiil^n  iiietliocl  ill  ty|iliiiid  fever,  .'iS. 
nieakli(iiie  fever  (see  Denuie;,  Di. 
Hreiisl-i)iiiij,',  tJ'JO. 
lireatli,  odor  of,  in  diabetic  coimi,  .'J^t! ;  foul,  in 

Hcurv.y,  \VV.\  \  fiutid,  in  ciilarjjed  tonsil.-i,  ;ji;7. 
Hreutliili),'  /see  Uhsi'IUation  )  ;  nioutli,  \'A\. 
15iiek-iiuilccr"s  aiiieiiiia,  loilO, 
Urii;lit's  disea>e,  acute,  7^-  ;  diai;iiosiH  >>\\  1>\\  ; 

etiology  of,  7s'^ ;  I'l'oifnosis  in,  7t<i;;symii- 

toliis  of,  7^:i  ;  treatiiielit  of,  7«"). 
Hri>,'lit's  disease,  elironic,  71^7  ;  interstitial  f  miii 

of,    7'.io  ;     causes    of,    7'.'0  ;     cai'dio-vaseular 

eliaiiij;es  in,  7'.'l  ;    hereditary   iiilhieiices  in. 

70O ;  syiiiiitoms  of,  7'J3  ;  treatiueiit  of,  7'Jii ; 

piireneliyiiiatous  form  of,  7^^*^. 
Brisbane  liusjiital,  statistics  of  Brand's  method 

ut,  ;i'j. 

"  Broken-winded,"  071. 

Broinisni,  lOlO. 

Bronebi,  easts  of,  53ii ;  diseases  of,  5'24. 

Broiicliial  asthma,  ri.'il. 

Brnncbial  catarrh  f  Bronchiti.s),  o'Jl. 

Bronchial  jrlaiids,  tuberculosis  of,  •IW).  212,  218, 
227  ;  enlaiyenient  in  wliooj)inj;-cou)ih,  iio, 
Oil;  suin>uration  in,  Oil;  perforation  of,  into 
a'sophajius,  iU2. 

Bronchiectasis,  r)21i ;  absec.ss  of  brain  in,  .")31  ; 
congenital,  02'.!;  cylindrical,  i52l» ;  etiology 
of,  521);  rheumatoid  allectifms  in,  531;  sac- 
cular, 529 ;  si>utuiii  in,  nao  ;  universalis,  52'J. 

Bronchiolitis  exudativa,  5;U. 

Bronchitis,  524;  acute,  524;  etiology  of,  524; 
symptoms  of,  524 ;  treatment  of,  525  ;  capil- 
lary, 570. 

Bronchitis,  chronic,  52(!  ;  etiology  of,  520 ; 
symptoms  of,  527  ;  treatment  of,  528. 

Bronchitis,  librinous,  535. 

Bronchitis,  in  measles,  S3 ;  in  sinull-po.\,  59 ; 
in  typhoid  fe%er,  25  ;  putrid,  528. 

BronchoctOc  (see  Goitke),  750. 

Bronchophony,  554. 

Bronclio-pneumonia,  acute,  570  ;  chronic,  507  ; 
acute  tuberculous,  231. 

Broncliorrhagia,  540. 

BronchorrlK.ea,  527  ;  serous,  528. 

Bronze-skin,  in  phthiriasis,  1108  ;  in  Addison's 
disease,  748  ;  in  Basedow's  disease,  753. 

Brown  atrophy  of  heart,  078. 

Brown  induration  of  lung,  538. 

Broivn-SeqtMrd''s  paralysis,  880. 

Bruit,  d'airain,  610;  de  cuir  ncuf,  018;  de 
diablc,  720;  dc  pot  fele  (see  Cuacked-i'ot 
Sound),  247;  de  souffle,  029;  eesopliageal, 
371. 

Bubo,  parotid  (see  also  1'auotitis),  357. 


Bubonic  plague,  144;  bacillus  of,  144. 

liuecal  psoriasis,  350' 

IIuIU'k  disea.se,  347. 

BuUiur    iniralysis,    922;    acute,   922;  chronic, 

923;  in  progressive  muscular  atrophy,  922. 
Bulimia,  325, 

Cachexi      ill   cancer  of  the  stomach,  404,409; 

malarial,  101,  ITO;  periosteal,  341  ;  saturnine, 

loot;  stnmiipriva,  755;  syi>hilitie,  187. 
(.'aissuii  disease,  sss. 
Cali'an-nus  concretions,  in  phthisis,  23ij ;  in  the 

t'lii^ils,  307. 
Calcareous  degeneration,  of  arteries,  099;   of 

lieart,  07^;  of  muscle  libres,  lu50. 
I'alcilicatioii,  aumilar,  of  arteries,  099. 
('alciticatioii  in  tuliercU',  215. 
Calculi,  biliary,  405;  '•  coral,"  SOO  ;  pancreatic, 

497;  reiial,  800;  tonsillar,  307  ;  urinary,  forms 

of,  SOO. 

Calculous  pyelitis,  7'.e,i. 

Calm,  stage  of,  in  ydlow  fever,  141. 

Cancer,  of  bile  jiiissages,  471,  487 ;  of  bowel, 
415;  of  brain,  971;  of  gall-bladder,  487; 
of  kitliicy,  ^11;  nf  liver,  4S5;  of  Ipiig,  590; 
of  ccsci[)hagus,  372  ;  of  pancreas,  490  ;  of  pcri- 
toiiieum,  miliary,  500;  oi  pleura  and  lung, 
590;  of  stomach,  402;  acute,  404. 

Caiicrum  oris,  354;  in  measles,  s3. 

('alifornia,  southern,  climate  of,  for  tubercu- 
losis, 273. 

Canities,  the  result  of  neuralgia,  1014. 

Canned  goods,  iioisoning  by,  1071. 

Capillary  pulse,  in  aortic  insutlieiency,  641  ; 
in  neurasthenia,  1U34;  in  ijhthisis,  248. 

Capsule,  internal,  lesions  of,  925. 

(.'aput  Medusie,  476,  508. 

Caput  quadratum,  in  rickets,  335. 

Carboluria,  777. 

Carbuncle  in  diabetes,  325. 

Cardiac,  compensation,  rupture  of,  669  ;  disease 
(see  Disease  of  Heaut). 

Cardiac  murmurs,  hitmic,  in  chlorosis.  725 ;  in 
chorea,  990;  in  idiopathio  aniemia,  730. 

Cardiac  murmurs,  organic,  in  aortic  insutfi- 
ciency,  040 ;  in  aortic  stenosis,  044  ;  in  eon- 
genital  heart  alfections,  (!98;  in  mitral  in- 
competency, 648 ;  in  mitral  stenosis,  651 ;  ia 
tricuspid  valve  disease,  654. 

Cardiac  nerves,  neuralgia  of,  690. 

Cardiac  overstrain,  071. 

(,'ardiae  septa,  anomalies  of,  695. 

Curdialgia  (see  Gastuai.gia). 

Cardinal's  case  (hydrocephalus),  978. 

Cardiiicelltesls.  083. 

Cardio-rcspiratory  murmur,  247. 

Cardio-sclerosis,  t)7S. 

Cartlio-vascular  ehanues  in  renal  disease,  794. 

Caries  of  cervical  vertebnc,  914. 


:  !       .  i:  ; 


\m 


1116 


INDEX. 


Curies  of  Hpinc^,  014. 

Curitmtcil  lilicldincli,  2'J3. 

C'arotiil  iirtiT,v,  liiriiiurt;  and  comprussion  ol', 
in  curcbriil  liu'iuoriliiife'o,  'J.j3. 

<.'iir|ilioloi{iu,  ^7. 

('iir|M'-]]('(liil  .sjiiism,  l(fJO. 

Ciiinaii,  '.!ii(i. 

C'liHcatioii,  2 IS. 

CastH,  lilooil,  of  bronc'hiul  tubes  in  hmmopty- 
nis,  .142;  in  flbrinous  liiMnt'iiitirt,  530;  of  pel- 
vis of  kiiliii'v  anil  Mrt:lcr,  .sll. 

CiiHts  of  urinary  tulmlcs,  "x'l;  uiiitlii'lial,  7^3, 
7Hi");  iaay,7nO;  (irainiiar,  7'^'.",  7'J4. 

CastH,  tulic,  in  aeiitu  llri^fhi's  iHhousc,  783 ;  in 
uhronii'  Hri^'ht'w  diseusf,  7'JO,  7114. 

Cutulfpsy  in  liysluria,  lOiJ'J. 

Cataract,  diabttii',  ;l'J7  ;  after  typlioid  fever,  2H. 

Cuturrli,  acute  giwtric,  374;  autumnal,  ul.'i; 
broneliiul,  524;  chronic  gn.stric,  377;  dry, 
52H ;  nuHal,  513  ;  simple  clironie  (nasal),  513  ; 
sullbeative,  .')74, 

Catarrbal  inllammution,  intlucnco  in  tubercu- 
losis, 212. 

Catai  rhe  sec,  528. 

Catarrhus  U'stivus,  515. 

Cats,  diplitlieria  in,  104. 

Cauda  e((uina,  lesions  of,  910. 

Cavernous  breutliing,  247. 

Cavities,  pubnoiniry,  physical  Bigus  of,  247 ; 
quiescent,  237. 

Cayor  fly,  1110. 

Celluliti.     "•'     neck,  861. 

Centrum  .esions  of,  925. 

Ceplialii  .  ..       3  Heauacue). 

Cephalic  tetanus,  182. 

Cephulodynia,  304. 

Ccrcomonos  intcstinalis,  147, 1082 ;  C.  hotninis, 
1082. 

Cerebellar,  ataxia,  912, 926 ;  lieredo-ataxia,  912 ; 
vertigo,  926. 

Cerobellum,  tumora  of,  926 ;  affections  of,  926. 

Cerebral  arteries,  aneurism  of,  955 ;  arterio- 
sclerosis of,  956 ;  endarteritis  of,  956  ;  syphi- 
litic endarteritis  of,  191,  956. 

Cerebral  hiemorrhage,  940 ;  aneurisms,  miliary, 
in,  941;  convulsions  in,  948;  dia!,'nosis  of, 
948 ;  etiology  of,  940 ;  forms  of,  941 ;  morbid 
anatomy  of,  941 ;  prognosis  in,  949 ;  symp- 
toms of,  942 ;  treatment  of,  953. 

Cerebral  localization,  821. 

"  Cerebral  i)neumoiiia,"  556. 

"Cerebral  rheumatism,"  296. 

Cerebral  sinuses,  thrombosis  of,  956. 

Cerebral  softening,  949. 

Cerebritia  (see  Enceimialitis),  974. 

Cerebro-spinal  meningitis,  epidemic,  96  ;  anom- 
alous forms  of,  100;  complications  of,  100; 
malignant  form,  98  ;  ordinary  form,  98. 

Cerebro-spinal  motor  segment,  lesions  of,  831. 


Cervical  pachymeningitis,  882. 

Cervieal  vertebric,  caries  of,  914. 

CervicD-brui'liial  neuralgia,  l(il4. 

Cervico-oecipital  neuralgia,  liil4. 

Cestodes,  disease  duo  to,  1096;  visceral,  1099. 

Cluilieosis,  5157. 

Cliancr',  1S5. 

Cliarlion,  174. 

Chnnvt-Lii/(hn^a  cry atali^,  416,  534,  735 ;  joints, 
907. 

Chattering  teeth,  H54. 

Cheek,  gangrene  of,  354. 

Cheese,  poisoning  by,  1071. 

Cheesy  pneumonia,  217. 

Chest  expansion,  diminution  of,  in  Ciraves's 
disease,  7.">3. 

Ch' yiii-Stiihs  breathing,  Cheyne's  original 
description  of,  679;  in  apoph^xy,  943;  in 
fatty  heart,  679 ;  in  sunstroke,  lo76;  in  tuber- 
culous meningi.is,  219;  in  uriemia,  780. 

Chiasma  and  tract,  atlections  ol,  845. 

Chicken-lireast,  335,  366. 

Chicken-pox,  69. 

Child-crowing,  520. 

Children,  constij)ation  in,  452;  diabetes  in,  325; 
tuliereulous  broncho-pneumonia  in,  232; 
pneumonia  in,  559;  tuberculosis  of  mesen- 
teric glands  in,  22H  ;  mortality  from  small- 
pox in,  60;  rheumatism  in,  292;  typhoid 
fever  in,  32. 

Chills  (see  Rioous),  in  typhoid  fever,  15. 

Chloasma  phthisicorum,  250. 

Chloro-anieniitt  in  phthisis,  248. 

Chloroma,  741. 

Chlorosis,  723  ;  and  anscmia,  sinus  thronibosis 
in,  957  ;  diagnosisof,  726  ;  dilatation  of  stoni- 
aeh  in,  725;  Egyptian,  1090;  etiology  of,  723; 
fever  in,  726  ;  heart  symptoms  in,  725 ;  men 
strual  disturbance  in,  726 ;  morbid  anatomy 
of,  723;  symptoms  of,  723;  thrombosis  in, 
726,  956. 

Choked  disk,  844. 

Cholwmiu,  458.  • 

CholangitiB,  catarrhal,  468;  suppurative,  460, 
481. 

Cholecystectomy,  473. 

Cholecystitis  acuta,  466. 

Cliolecystitis,  suppurative,  468;  plilegmonous, 
468. 

Cholecystotomy,  indications  for,  473. 

Cholelithiasis,  40.5. 

Cholera,  asiatica,  132 ;  bacillus  of,  133 ;  epi- 
demics of,  132;  infantum,  419;  nostras,  137; 
sicca,  136;  typhoid,  136. 

Cholerine,  136. 

Cholestersemia,  458. 

Cholcsterin  in  biliary  calculi,  466. 

Choluria,  778. 

Chondrodystropliia  foetalis,  333. 


INDEX. 


1117 


Clioren,  aeiito,  9«5;  otioloffy  of,  (iSS;  lieiirt 
HymiitoiiiM  of,  »S7,  (IIM) ;  itil'cctiiiUM  nrit'in  of, 
Oh«  ;  111  prix'tiiiiicy,  WH;  jmnily.sis  in,  i'lm; 
rlR'Uiiiutiniii  anil,  !tH5;  Hchool-iiunli.',  Its"; 
NeiiMDiial  riliitions  (if,  wr>. 

Cliona.  cHniiiu,  'JSC,,  .litfl ;  chronic,  Ofls,  osr.. 

t'iiurcu,  lialiil  or  HpiuHiii,  'JDO. 

C'liorua,  //iihIiihji/dii'k  or  licrcilitary,  '."'.H. 

Cliorc'u,  innnniunrt,  y«'J,  U'.il  ;  limp  or  imiiilytic 
form  of,  9!iO;  ni^jor,  "Jlti!;  imiidutniL',  O'.iO; 
post-lioniiplci,'!!',  OfiO;  iircln'iiiiplt'irif,  013; 
rliytlmru^  or  liyKtericai,  '.''.•!*;  sciiilu,  iW\ 
Hpa.Htica,  Itil'.',  '.Wi ;  Sydenharn's,  886. 

Cliup'U.-*,  puiiiful,  UDl. 

Choroid  ph.'Xiwcs,  solurosls  of,  978. 

Choroid,  tulifri'lur*  in,  224. 

<'horoiditi.s  in  r-ypliilis,  187. 

V/iorixtil-'n  syiiiiitoni  in  tetany,  1020. 

Cliylangioiiiuta,  ■l.">ii. 

Cliylo  vi'hsoIh,  tli»ordor«  of,  4.')0. 

Chylo-pcrioiirdiuin,  ii'_'(j. 

Ohyluriu,  noii-para.siti(',  7V2;  parasitic,  1093. 

Cicatrii'os  flstiilc^ust's,  271. 

Cicatricial  wtt'iiosi.-*  of  bowul,  445. 

Ciliary  inusule,  parulysiH  of,  850. 

Ciliata,  parasitic,  1082. 

Cinicx  Icotularius,  lin!>. 

Circulatory  system,  diseases  of,  filfl, 

Cireuiiieision,  inoculation  of  tuberculosis  by, 
208;  in  liinniopliilia,  349. 

CircuiiiHex  nerve,  aflectiona  of,  874. 

Cirriiosis,  of  kidney,  790 ;  of  liver,  474 ;  of 
luiijr,  .'iOii;  of  pancreas,  495  ;  vcntriculi,  37S. 

Cliidothrix,  282. 

Clapotenient,  3<.'2. 

Clarke's  vesicular  column,  825,  904. 

Claudication,  intcrniitteiit,  091. 

Cluviceps  purpurea,  poisoning  by,  1072. 

Clavus  liystericus,  1025. 

Claw-hand  (main  en  griftel,  921. 

Climate,  influence  of,  in  asthma,  535;  in 
chronic  Bright'.s  disease,  790 ;  in  tubercu- 
losis, 272. 

Cloisters,  tuberculosis  in,  209. 

Clonus  (see  .\nki.e  Clonts)  ;  jaw,  921. 

Clownism  in  hysteria,  1023. 

Cnethoeampa,  1110. 

Cobalt  miners,  cancer  of  lung  in,  590. 

Coecidiuin  oviforme,  1080. 

Coccydynia,  1015. 

Coehin-China  diarrhoea,  1095. 

Cieliae  affection  in  children,  420. 

Coflce-ground  vomit,  405. 

Cog-wheel  respiration,  246. 

Coin-sound,  610. 

Cold  pack,  method  of  giving,  80. 

Colic,  biliary,  466;  in  appendicitis,  431,  435; 
in  angio-neurotic  oedema,  1043 ;  in  purpura, 
345;  lead,  ?.065;  mucous,  422 ;  renal,  808. 


Colica  Piotonum,  106!^. 

Colitis,  iiHicoiis,  42'.";  simjile  ulcerative,  42.3; 
croupous,  .l.'p'*. 

Collapse  stage,  in  cholera,  135;  in  peritonitis, 
500. 

Collateral  o'llcma  of  liiiitr,  5rti>. 

Collective  Invcstigatii'ii  l!cport>i  of  the  British 
Mcdicul  Assoi'iatioti,  'Jlo,  iilfj,  9X6. 

<'i>lln<'n  law,  ISo. 

Colloid  cancer,  of  lunu',  51");  of  perilona'uni, 
507;  of  stomai'h,  M'". 

Colon,  cani'cr  of,  445;  dilatation  of,  454. 

Comii,  diabetic.  32i'j ;  epileptic,  liMi,'', ;  from  heat- 
stroke, 1071;  from  muscular  exertion,  7^1; 
in  abscess  of  brain,  936;  in  aeule  yellow 
atrophy,  4t'i0;  in  alcoholic  j)oisoning.  10,")7  ; 
in  ajioplcxy,  94-",,  94>*;  in  een^bral  syphilis, 
192;  ill  general  paresis,  IHi"';  in  miilti|ilo 
sclerosis,  iiilt) ;  in  jicrnii'ious  malaria,  Iii9;  in 
thrombosis  of  cerebral  sinuses,  957 ;  in 
typhoid  fever,  27  ;  uneiiiie,  779. 

Coma  vigil.  27. 

Comatose  form  of  malaria,  169. 

Coma-vigil,  in  typhoid  fever,  27;  in  typhus 
fever,  4.'".. 

Comma  bacillus.  133. 

Common  bile-duct,  obstruction  of,  468. 

Compensation  in  vaivi;  lesions,  636;  periods 
in,  669  ;  rujiture  of,  111)9. 

Comj.osite  portraiture  in  tuberculosis,  211. 

Compression  and  contraction  of  the  bowel,  445. 

Comjiression  paraplegia,  914. 

<'oneretions  i  see  C.M.cAUKor.s). 

('oiu'iission  of  spinal  cord,  1037. 

Confusional  insanity,  2». 

(.'ongenital  heart  atfe  tioiis,  695. 

Congenital  stricture  of  the  bowel,  445. 

Congenital  syphilis,  18S. 

Conjugate  deviation,  in  brain  tumor,  973;  in 
hemiplegia,  944  ;  in  meningitis,  224. 

Conjunctiva,  diphtheria  of,  114. 

Consecutive  nephritis,  799. 

Coii'^tipation,  451 ;  in  adults,  451 ;  in  infants, 
452  ;  spa.-'inodic,  451 ;  treatment  of,  452. 

Constitutional  disea.sos,  292. 

Consumption  (sec  TunKitcuLosis),  228. 

Contracted  kidneys,  790. 

Contracture,  liysterieal,  1023 ;  in  hemiplegia, 
947;  of  nurses,  1019. 

Contusion  pneumonia,  546. 

Conus  arteriosus,  stenosis  of,  697. 

Conns  medullaris,  lesions  of,  916. 

Convalescence,  fever  of,  15 ;  from  typhoid 
fever,  management  of,  42. 

Convulsions,  epileptic,  1005;  hysterical,  1008, 
102*^  in  acute  yellow  atrophy,  460  ;  in  alco- 
holism, 1057 ;  in  a.spiration  of  pleural  effu- 
sion, 605  ;  in  cerebral  hicmorrhage,  943  ;  in 
cerebral  syphilis,  192,  1008 ;  in  cerebral  tu- 


1118 


IN'DKX. 


MiDrs,    '.171 
7M!t. 


•Iirciiiii'     nr'iu'lit'M    iliscuHc, 


('onviilMiciiis,  inriiiililc, '.I'.i'.i ;  iliuj.'tiiisi->  cii',  liml  ; 

otiolojfy    (pf,    unit;    rcllltirill    t>>    rifkitH,   ;'.;!i) ; 

nyiii|itiiiii!< 'if,  liii'd;  tnuliiniit  of.  liiol. 
("oiiviilniiiiis.  in  L'l'iicnil  pnnily.-is,  nils;  in  li,.- 

|>iiti<' iMilic,  'li;;  ;  in  int'unlilo  lKtni|iliL.'iii, '.i">l» ; 

in  lrii(l-|ic)iMininu',  li'ilil;  in  nirninLtili-  '.'."f! ; 

in  MMn-Nipikc,  lnVil;  in  iimiuiii,  TT'.i;  .liuk- 

HDniiin,  U»>7. 
ConviilHivc  tic,  <.m,  007. 
<'()-nriiiiiiiti'in,  iiir<turl)iinoo  of.  in  tiiboH,  'Mil], 
(!o|iiiiliu  cruiition,  Ml. 
f'oppLT  test  f<>r  HU^ur,  324. 
('opni'niiii,  t.')!,  7'J3. 
('(ppnilaliii,  'JUT. 
Cor  iiiii|pnsiini,  (ITS. 
Cor  liiiin'iiiiirc,  iin.'). 
(,'i>r  hovinuin,  ti09. 
Cor  villosuni,  fil7. 

Ciirncii,  iilccnition  of,  in  ninall-po.x,  fiO. 
Coroiuu'v  Mrtci'iis,  in  iiiif,'inii  iicctiiri.s,  ilitl  ;  oli- 

iitcnition  ot',  dvi;. 
Corporn  <iuii(lritrL'rninii,  tutnorn  in,  ii73. 
Corpiilciicf,  1077. 
('(in'ii/it/i\i  ilist'iiKc,  ()37. 
(.'orri(/iiii''ti  [lulsc,  tin. 
Curyzii,  acutf,  i'>\'2;  fu'tiito,  r>14  ;  froin  the  io- 

cliilc'H,  202. 
Costivcncss.  irA. 
Coujrli,  l.arkini,',  of  pulp'.Tty,  102i! ;  liystericiil, 

lO'Jti ;  in  acute   livonciiitis,   r)25 ;  in  clironic 

broncliitis,  r>\i~  ;  in  I'lTtiissis,  (s!t ;  in  plulii.sls, 

240 ;  during  a!«])irntion  of  pleural  clFusion, 

604 ;    in   pnciinioniii,    f^M ;    paroxysmal,    in 

Vjroncliicctasis,  AiiO ;  paroxysmal,  in  libroid 

phthisis,  2ri2  ;  stoniuch,  380. 
Country  fever,  1070. 
Coup  lie  soleil,  1073. 
Cow-pox,  04,  72. 
Crocked-pot  sound,  247. 
Crnnip,  writer's,  1017. 
Cronip.s,    in    cholera,    135;  in    gout,    316;  in 

chronic  Brifjht'.s  disease,  795. 
Cranio-selerosis,  3.'!5. 
Cranio-tahes,  relation  to  congenital  syphilis, 

335  ;  in  rickets,  335. 
Cruw-eraw,  1092. 
Creophila,  1109. 
Crepitus,  frnll-stone,  468. 
Crcsconta  in  blood  in  malaria,  160. 
Cretinism,  sporadic,  754. 
Cretinoid  change,  754. 
Crises,    gastro-intestinal,     in     angio-ncurotic 

oedema,  1044 ;  in  locomotor  ataxia,  400,  907  ; 

in  purpura,  345. 
Crisis,  in  pneumonia,  551 ;  in  relapsing  fever  ; 

49  ;  in  typhus  fever,  46. 
Crossed  or  alternating  paralysis,  925,  946. 


t'riisscd  seuHory  pnrnlyHld,  925. 

Croup,  nicnibninoiis,  imi;  spasinodle,  521. 

Croupous  enteritis,  421. 

('roupous  pneumonia,  545. 

Crura  cirdiri.  lesions  of,  925,  946. 

'  'nUi'li  paral\sis.  S74. 

Criiii  i//iii r'K  palsy,  '.119. 

Cry,  epileplie,   loo,",;  liyclrociplialic,  222  ;  li_\  ■ 

terical,  102tl ;  in  coiiifcnital  syphilid,  189. 
('rypti';.'inelic  septieii'inia,  12M. 
OysiaU.  I.n/il, ii's,  r:.\\,  5:17. 
('iirsrliinttiiii^  spirals,  .'i.".-!.  5.'17. 
Cyannsis,  in  ai'Ute  tulierculosis,  'j|(t ;  in  eon;,'(M 

ital  heart-disease,  097  ;  in  omphyHcmo,  5m1. 
c:yclopli'L'ia,  s,'0. 
Cynani'lie  tiialiirtui,  I03, 
Cynoliex  lleliclica,  lo;i(i. 
Cystic  ili>ease,  of  kiilru'y,  Ml;! ;  of  liver,  ^14. 
Cystic  iluct.  obstruction  of,  407. 
Cystieercns  cellulosa^  10'.'9;  ocular,  lldO;  siib- 

cutaneous,    lo'.ilt;  syinpfoiiis  of  invasion   ni, 

lo',ni;  irciicral,  lo',i9;  eerebro-spinal,  ll'io. 
Cystine  calculi,  774,807. 
Cystinuria,  774. 
Cystitis,  in  locomotor  ataxia,  9<i7  ;  in  transvi •r.-.> 

iiiyclitis,  s'.e_' ;  tuberculous,  205. 
Cytozou.  loso, 
Cysts,  chylous,  of  niesciitcry,  450  ;  in  kidni'V.-, 

Hi.'! ;  ot' brain,  apoplectic,  942;  porencephalii'. 

i»59;  of  lirain,  thrombotic,  951;  pancreatic,  l',i."i. 

Daiicinc'  mania,  996. 

Dandy  tcver  (dcngU'.')i  !'4. 

Davuinca  .Madagascariensis,  1097. 

l)ay-bliiuliiess,  843  ;  in  scurvy,  340. 

Ueaf-niutism  after  eerebro-spinal  fever,  l<n. 

Deifness,  in  cerelirat  tumor,  973  ;  in  cerebro- 
spinal meningitis,  101  ;  in  hysteria,  1020;  in 
.l/t/(i(';'c'«  <lisease,  801;  in  scarlet  fever,  77: 
in  tnbes  dorsalis,  907  ;  nervous,  800. 

Death,  modes  of,  in  tuberculosis,  255  ;  sudden, 
in  typlioid  fever,  35;  in  iileurul  ert'usion,597. 

Deliility,  nervous  (see  NKiitASTUENiA),  1032. 

Di'bove's  forced  feeding,  274,  1032. 

Decubitus,  acute,  944;  (bed-sores)  in  trans- 
verse myelitis,  890. 

Defensive  alkaloids,  1009. 

Degeneration,  reoetion  of,  829,  838,  8,57. 

Degeneration,  systemic,  of  spinal  cord,  881. 

Deijlutition.  ditlicult  (see  Dysi-iiaoia). 

Deirlutition  i>neunionia,  571. 

Delayed  resolution  in  pneumonia,  561, 

Delayed  sensation  in  tabes,  906. 

Delirium,  acute,  980;  acute,  in  Icad-poisoniuL'. 
1000  ;  cordis,  35,  684,  686  ;  expansive,  9tlh ; 
ill  acute  rheumatism,  296 ;  in  pneumonia, 
555  ;  in  typhoid  fever,  26 ;  in  typhus  fever, 
45;  tremens,  1059. 

Deltoid,  paralysis  of,  874. 


rt 


INPKX. 


Ill)) 


I)i'luf>iciiiiil  iiixiiiiity  iil'lcr  trvcrH,  '.''*,  ."'.i,  ".'i(i. 

|)cliij.i.iim  (if  (rruiiilt'tir,  '.'Hs, 

|)(!iui.'ntiu  [iiinilvtii'ii, '.It'll! ;   iiU'oIihI  u.h  u  I'^u'tor 

in,  lo.'iK;  i«jiiliili«  itiiil,  lf»!s,  ii»L',  m;;. 
Di'iiinclcx  liillicnlnruiii,  Ho" 

l)l'llll|ll|l.-',   Nlli. 

UiiiLfuc,  '14. 

l)uiiliti(ili,  ill  t'dii^fi'iiitiil  .■*yiiliilis,  I'.io;  ill  iiier- 

I'liriiil  Htonmtitii*,  .'i.'iii;  in  ricixutH,  !)iJ5. 
Dirimirciitnr  iiiiu'iiiiimit,  lln". 
|)rriiiiilili>,  r\l'iiliiiiivf  I'dirii,  77. 
Dcriimtnliiii,  11  111. 
lUrinutosc  iiiini-itiiin',  ln'.i'J. 
Dt'sli'oiitioii  in  siimll-iiiix,  r)i'i. 
l)('S((iiniMiitiiin,  in  niriislfs.  '<-2:  in  rulicliu,  8r> ; 

in  siiii'ift   I'cvcr,  71;   in  i^inull-iJo.s,   50;   in 

tyiilmiil  I'rvcr,  li'i. 

|)i'viiitinii,  sci'iindnry,  Ho\. 

DfViin^liiri'  t'lilic,  10t(3. 

l)('XtnH'iivilia.  I'i'.t.'i. 

Diiilicti'.s  in-ipiiliis,  ."i.'JO;  licRMlity  in,  ."i;;*) ;  in 
iiliiliiMiiniil  Uiiiinr,  '■','■)]  ;  in  tuliiTculmiH  in'ri- 
tunitis,  .".:'.l. 

UiiilH'ti'mncliituH,  lijo;  iiciite  fnrni,  3'23;  chronic 
loriii,  ")'J.J ;  cnnm  in,  iJ'Jii ;  diet  in,  ."'28;  tlic- 
trtic  t'orni.i'rj.'i ;  LTiuifrrcnc  in,;!'2.'>;  liircditary 
intlm'iii'fs  in,  JiL'ii;  in  nlicsity,  ;i'_'ii;  in  diil- 
(Ircn,  y2.") ;  lipoirunic  liirni,  ,'?'J.'i;  neurotic 
form,  .•W.'J;  piiii  r  as  in,  ;j'2l,3'2'2;  pancreatic 
form,  ;120;  paraiilciria  in,  3'27 ;  tiicurics  of, 
3-2'  :  treatment  of,  .'.-JT  ;  urine  in,  o2.'i. 

Dialicfes,  l>lios]iliatic,  T7'i. 

l-)ial)etic,  centre  in  meilulla,;!20  ;  eirrliosin,  S'2"2  ; 
comu,  3'2ti ;  iilithi.sis.  .'i-2'2;  tubes,  S'20. 

Diacetic  acid,  777. 

I)iii).'nosis,  topical,  cerebral,  i'2t;  spinal,  870. 

Diaplira^rin,  paralysis  of,  h72  ;  defj'enerution  of 
muscle  of,  ^72. 

Uiurrluca,  414;  acute  dyspeptic,  418 ;  nll)a,42n; 
bacteria  in,  417;  chronic,  treatnient  nf,  4211 ; 
chylosrt,  420 ;  endemic,  of  hot  couthries,  lOii.') ; 
from  ancliylo.stomiasis,  lo'.to ;  hill,  421;  in 
cliildren,  treatment  of,  4211;  in  cholera,  1.3."); 
in  dysentery,  140,  150,  151 ;  in  iiysteria, 
10'27;  in  plitliisis,  24fl ;  in  typhoid  fever,  21 ; 
in  ura'tnia,  7>'^0;  nervous,  415;  of  Coehin- 
Chiiia,  lo'J5;  tuliular,  422  ;  lienteric,  410. 

Diathesis,  ffouty,  310,  815;  Incmorrluyic,  .'!43  ; 
lithwinie,  773;  tuberculous  or  scrofulous,  211. 

Diuzo-reaction  in  typhoid  fever,  28. 

Dicrotism  of  pulse  in  typlioid  fever,  11, 18. 

Diet,  in  chronic  dyspepsia,  381 ;  in  constipation, 
453;  in  convalescence  from  typlioid  fever, 
42;  in  diabetes,  328;  in  gout,  317;  in  inuin- 
tile  diarrliani,  427 ;  in  leprosy,  278 ;  in  obe- 
sity, 1078;  in  scurvy,  340;  in  tuberculosis, 
273 ;  in  typhoid  fever,  37. 
DietPs  crises,  700. 

Digestive  system,  diseases  of,  351. 


Dilatation  of  bronchi,  .'2!i ;  of  col.m,  l.vi;  nf 
heart,  ''170;  of  stomach,  ;!'.io. 

Dioctophyme  ni;;as,  lo'.'.i, 

Diplillii'ria,  lo;);  at\  pieal  forins  of,  111;  nC  au- 
ditory meatus,  115;  of coniiiurtiva.  111:  and 
croup,  lii'.i;  bacillus  of,  lo.'i ;  contii;.'inii>lie>» 
of,  I113;  dlau'iio^is  ot',  117;  immunity  from, 
loi'i;  in  animals,  lot;  laryngeal,  113;  latent, 
112;  morbid  anatomy  of,  los;  nephritis  in, 
115;  neuritis  in,  117  ;  nasal.  113;  pliaryniftal, 
111;  <if  skin,  115;  symptoms  of,  HI;  sys- 
temic inl'eiiion,  112;  tiiatment  of,  l'.!o;  anti- 
toxine  tnatimnt  of,  121  ;  <if  bounds,  115. 

Diphtheritic,  colitis,  421  ;  iiniobrane,  liistolo(ry 

of,    110;    processes   ill   pliellllionia,   5.')0 ;    pro- 
cesses in  typhoid  I'l'ver,  '■'". 

DipbtlurilU,  loi'i. 

Diphtheroid  inllammations,  loi;. 

Diplegia,  facial,  850 ;  in  children,  !t58,  (toi. 

Diplococciis  pneiimoniie  1  inieroeoceiis  lancco- 
latlis,  piieiiMiiirocells  1,  510  ;  ill  eiripN  eiiia.  5',is  ; 
in  eiidoi'arditis,  iWJl  •  oi  peritonitis,  l'.''.'. 

Di|i|opia  (see  Doiiii.K  V  isi-  vi,  S52. 

Dipsomania  (see  (.'iiuonk;  ,\  i.iiuioi.is.m  i,  1057. 

Dipyli<lium  caninuin,  '  >'.i7. 

Discrete  form  of  si.ndl-pox,  '•!>. 

Disinfection  ill  111  litlieria,  \Vi:  in  typhoid 
fever,  30. 

Dissectiii);  iineurisiii,  700. 

Distomiasis,  los-i. 

Distomum  lanceoliitiim.  los-j;  D.  Iiiiski,  los-j; 
D.  elideinicum,  los-J  ;  D.  pcrniciosiim.  1oh>J; 
D.  Sineiise,  1082;  I),  felincuni,  1082;  D. 
Westcrinunni,  541,  1083. 

Dit/rii'h'n  plucs,  528. 

Diuresis,  330. 

Diver's  paralysis,  8'" 3. 

Diverticula  of  (esoplia),'Us,  373. 

Doclimius  duodcnalis,  lO'JO. 

Dolor  pectoris,  092. 

Dorsodynia,  304. 

Dotliieiienteritc,  1. 

Double  heart,  0'.i5. 

Double  vision,  852;  in  ataxia,  905. 

Dracontiasis,  1093. 

Dracunculus  niedincnsis,  1093. 

l)rainaj,'c,  and  diphtheria,  103;  and  .scarlet 
fever,  72 ;  and  toiisilliti.s,  301  ;  and  typhoid 
fever,  4. 

Dreamy  state  in  epilepsy,  1004. 

Drcpanidiuni  runarum,  158. 

Dropsy,  cardiac,  treatment  of,  OCl ;  in  nnic- 
niia  ((cdeina),  729  ;  in  acute  liritrht's  disease, 
783;  in  aortic  insiillieicncy,  042;  in  aortic 
stenosis,  044 ;  in  cancer  of  stoinacli,  407  ;  in 
clironic  Briglit's  disease,  795;  in  mitral  in- 
suHiciency,  047 ;  in  mitral  stenosis,  653 ;  in 
phthisis,  250;  in  scarlet  fever,  76. 

Drug-ruslies,  78,  343. 


■I     ^f 


I      n! 


■hi 


1120 


INDEX. 


Drunkoimoss,  diagnosin  from  apoplexy,  940, 

1057. 
Dry-iiioutli,  zr>7. 
Duchiiine'K  parnlysis,  932. 
Dulnoss,  movable,  in  ^aurnl  cfruslon,  590 ;  in 

pniiuniotiiornx,  010. 

Duini)  uijruc,  ny. 

Uuoilenul  ulcer,  304;  diiignasis  of,  from  gastric, 
400. 

Duodenum,  defect  of,  445 ;  ulcer  of,  304. 

Dura  muter,  diseases  of,  881,  932 ;  hiemutotim 
of,  032. 

Duraiide^  mixture,  472. 

Dvrozies'n  murmur,  041. 

Dust,  diseases  due  to,  508, 587 ',  tubercle  bacilli 
in,  200. 

Dysacusis,  800. 

Dysentery,  145;  abscess  of  liver  in,  14!<,  152; 
acute  catarrhal,  140 ;  aniueba  coli  in,  147 ; 
chronic,  151;  diphtheritic,  149;  treatment 
of,  153  ;  tropical  or  amoebic,  147. 

Dyspepsia,  acute,  374  ;  clironie,  377  ;  nervous, 
380;  treatment  of  chronic,  381. 

Dysphagia,  hysterical,  370,  1027;  in  cancer  of 
the  oesophagus,  372  ;  in  hydropiiobia,  171 ; 
in  ajsophagismus,  370 ;  in  a'sophagitis,  309  ; 
in  pericardial  effusion.  020;  in  thoracic  an- 
eurism, 712;  in  tuberculous  laryngitis,  522. 

Dyspud-a,  cardiac,  treatment  of,  001  ;  from 
aneurism,  711;  hysterical,  1020,  1030;  in 
acute  tuberculosis,  220 ;  in  aortic  insuffi- 
ciency, 042 ;  in  bilateral  paralysis  of  ab- 
ductors, 804;  in  cardiac  dilatation,  073;  in 
chlorosis,  725 ;  in  diabetic  coma,  320 ;  in 
mitral  insutlicieney,  047  ;  in  mitral  stenosis, 
652;  in  pneumonia,  551 ;  in  phthisis,  242;  in 
oedema  of  tlie  glottis,  510;  in  spasmotlic 
laryngitis,  520 ;  uricmic,  780. 

Dy.xtropliics,  muscular,  1051 ;  etiology  of,  1051 ; 
symptoms  of,  1051;  clinical  forms  of,  1052; 
morbid  anatomy  of,  1053 ;  diagnosis  of,  1053. 

Ear,  complications  of  scarlet  fever,  77 ;  affec- 
tions of,  in  syphilis,  187,  190;  symptoms 
simulating  meningitis.  077. 

Ears,  care  of,  in  scarlet  fever,  80. 

Ebstei)i''s  method  in  obesity,  1078. 

Eburnation  of  cartilages,  300. 

Eehinococous  cyst,  fluid  of,  1102,  1104. 

Eehinococcus  disease,  1100;  distribution  of, 
1102;  symptoms  of,  1103;  of  liver,  1103;  of 
respiratory  system,  1104;  of  kidneys,  1105; 
of  nervous  system,  1105. 

Eehinococcus,  endogenous,  1101;  exogenous, 
1101 ;  multilocular,  1001,  1105. 

Eehinorliynchus  gigaa;  E.  moniliformis,  1095. 

Echokincsis,  997. 

Echolalia,  997. 

Eclampsia,  999. 


Ectopia  cordis,  095. 

Eczema,  of  the  tongue,  356;  in  diabetes,  325; 
in  gout,  315. 

Khrlicli'ii  reaction  in  typlioid  fever,  28. 

Fllastic  tissue  in  sputum,  241. 

Electrical  reactions,  in  exophthalmic  goitre, 
753;  in  facial  palsy,  857;  in  Z'(«(/;v/V  paraly- 
sis, 807  ;  in  multiple  neuritis,  838  ;  in  period- 
ical paralysis,  1040 ;  in  poliomyelitis  anterior, 
804 ;  ill  yV/ow.scwV  disease,  1055. 

Electrolysis  in  aneurism,  715. 

Klephantia.sis,  1003. 

Kliminutive  treatment  in  typhoid  fever,  40. 

Knuiciation,  in  anorexia  nervosa,  1027;  in  gas- 
tric cancer,  404;  in  a-.sophageal  cancer,  372; 
in  phthisis,  245. 

Embolic  abscesses,  130. 

Embolism,  and  aneurism,  707  ;  in  chorea,  0R7 ; 
in  typhoid  fever,  21 ;  of  cerebral  arteries,  040; 
of  cerebral  arteries,  diognosis  of,  951. 

Embryocardia,  554,  080. 

Emphysema,  578;  atrophic,  583;  compensa- 
tory, 578;  hypertrophic,  579;  liypertro|iliio, 
cyanosis  in,  581 ;  hypertrophic,  hereditary 
character  of,  679 ;  intei-stitial,  578 ;  vesicular, 
578. 

Emphy.scma,  subcutaneous,  after  tracheotomy, 
015;  in  gastric  ulcer,  395;  in  phtliisis,  2.")ii; 
of  the  mediastinum,  015. 

Emprosthotonos  in  tetanus,  182. 

Empyema,  507  ;  bacteriology  of,  598 ;  necessi- 
tatis, 284,  500,  713;  perforation  of  lung  in, 
500  ;  terminations  of,  500;  treatment  of,  ilot. 

Encephalitis,  mcningo-,  chronic  diffuse,  OHO ; 
nieningo-,  foetal,  001 ;  polio-,  of  Strinnpdl, 
950;  suppurative,  074;  syphilitic,  191. 

Encephalopathy,  lead,  1000. 

Enchondronui  of  lung,  500. 

Endocarditis,  acute,  027 ;  chronic,  634;  chronic 
vegetative,  032;  diphtheritic,  03O ;  etiology 
of,  030;  in  chorea,  030,  980;  infectious,  0:30; 
in  the  fietus,  630,  000 ;  in  gonorrha'a,  030 ;  in 
pneumonia,  030;  in  puerperal  fever,  030;  in 
rheunuitism,  205,  030  ;  in  septicicmia,  030 ;  in 
typhoid  fever,  10;  in  tuberculosis,  238,03(1; 
malignant,  620;  meningitis  in,  030;  luiiro- 
organisms  in,  031 ;  mural,  031 ;  recurring, 
629  ;  sclerotic,  030 ;  simple  or  verrueose,  027 ; 
syphilitic,  197;  ulcerative,  630. 

Endoplilebitis,  704. 

Enteric  fever  (see  TviMioin  FeveuI,  1. 

Enteritis,  catarrhal,  414;  croupous,  421 ;  diph- 
theritic, 421 ;  in  children,  417  ;  phlegmonous, 
422  ;  membranous  or  tubular,  422 ;  ulcerative, 
423. 

Entero-eolitis,  acute,  420,  501. 

Enterodysis  in  cholera,  138. 

Enteroliths,  430,  446  ;  as  n  cause  of  appendici- 
tis, 430 ;  in  sacculi  of  colon,  452. 


INDEX. 


1121 


Entcroptosis,  759, 700, 1034. 

Entozoa  (see  Animai,  I'arasites^,  IOSO. 

Phiviroiiiuent,  ill  tubcrouloais,  ;i7:i;  cxjiL'riinent, 
of'Trudcuu,  \i1'i. 

Eo!<iiiop)iiIeH  in  Iculocinin,  7'38. 

Epfiulyinitis,  purulent,  935,  979 ;  granular,  in 
goni'nil  paresis,  9i)7. 

Ephoniural  fcvor,  'J85. 

Kpidcmio  luvmoijtloljinuria,  347,  70G. 

Epidemic  roseola,  85. 

Epidemic  stoiruititis,  'J'tO. 

j;pididymiti8  (sec  OitcniTis),  198,  266, 

Epilepsia,  larvata,  1007  ;  nutans,  870. 

Epilepsy,  lW-2  ;  and  aleoliolism,  1003 ;  and 
syphilis,  1003,  1008  ;  diagnosiis  of,  1007  ;  eti- 
olofjjy  of,  100:' ;  heredity  in,  1003  ;  in  chronic 
ergotism,  1072;  in  general  paresis,  908;  in 
lead-poisoning,  10G6 ;  in  Iiaynaud''8  disease, 
1043;  Jachonian,  832,  1007;  masked,  1007; 
symptonis  of,  1004;  post-epileptic  symptoms 
of,  1000  ;  proeui-sivc,  1005 ;  reflex,  1004 ;  ro- 
tatory, 1005  ;  spinal,  899  ;  surgical  treatment 
of,  1010  ;  treatment  of,  1009. 

Epileptic  llt.s,  stages  of,  1005. 

Epistaxis,  510;  in  hremopliilia,  349  ;  in  scurvy, 
339;  in  typhoid  fever,  25;  "renul,"7C4;  vi- 
carious, 517. 

Epithelioid  cells  in  tu'^  "rele,  215. 

pj-gotism,  1072 ;  convulsive,  1072 ;  gangrenous, 
1072. 

Erkhgeii's  disease  (railway  spine),  1035. 

Erosion  ot  teeth,  350. 

Erroneous  projection  from  strabismus,  852. 

Eructations,  379. 

Eruptions  (sec  Hashes). 

Erysipelas,  123;  abscess  in,  125;  after  vaccina- 
tion, 65  ;  complications  of,  125  ;  diagnosis  of, 
125;  facial,  124;  in  typhoid  fever,  30;  mi- 
grans, 125 ;  puerperal,  123. 

Erythenui,  exudativum,  344 ;  in  pellagra, 
1073;  in  typhoid  fever,  10;  in  tonsillitis, 
303 

Erythromclalgia,  1010. 

Eschar,  sloughing,  in  hemiplegia,  944. 

Eustrongylus  gigas,  1095. 

Exaltation  of  ideas  in  general  paresis,  968. 

Exanthematic  typhus,  43. 

Exfoliative  dermatitit,  'TT. 

Exophthalmic  goitre,  751 ;  acute  form,  752 ; 
diminution  of  ele-'trica!  resistuuee  in,  753  ; 
pigmentutioi  in,  ',"53;  tremor  in,  753 ;  urti- 
caria in,  753. 

Experts,  medical,  function  of,  in  railway  cases, 
1038. 

Eye,  motor  nerves  of,  paralysis  of,  851. 

Kyc-strain  in  migraine,  1011. 

Eyes,  conjugate  deviution  of,  in  brain  tumor, 
973 ;  in  hemiplegia,  944 ;  in  meningitis, 
224. 

71 


Faciei,  asymmetry,  ftOS,  1014 ;  diplegia,  856; 
heiniatriii>hy,  1044;  nerve,  paralysis  of,  s.")5  ; 
paralysis  from  cold,  856 ;  paralysis  from 
lesion  of  trunk  of  nerve,  850  ;  paralyses 
from  lesion  of  cortex,  855  ;  paralysis,  symp- 
toms of,  856. 

Facial  spasm,  858. 

Facies,  llijipocrntie,  500;  loontlna,  in  lepro- 
sy, 279;  in  mouth-l)rcathers,  365;  Parkh,- 
soiiian,  98i' ;  sypiiilitic,  190;  in  typhoid 
fever,  13. 

Fiecal,  accumulation,  440,  451  ;  concretions, 
430,  452  ;  vomiting,  449. 

Frt'ccs,  bacteria  in,  417  ;  in  jaundice,  458. 

Falkenstein  Sanitarium,  27".. 

Fallopian  tubes,  tuberculosis  of,  206. 

Famine  fever  (>ce  Kklapsino  Fkveu),  47. 

Farcy,  acute,  281 ;  chronic,  281. 

Farcy-buds,  281. 

fhrre^K  tubercles,  486, 

Fasciola  liepatico,  1082. 

Fat  embolism  in  diabetes,  326. 

Fat  necrosis,  494  ;  of  pancreas,  in  diabctc.'i,  323. 

Fatty  degeneration,  in  ansemia,  728 ;  of  ar- 
teries, ()99  ;  of  heart,  677  ;  of  kidneys,  788  ; 
of  liver,  489;  of  the  new-born  {liuhVs  dis- 
ease), .^47. 

F'ltty  stools,  497. 

Febricula,  285. 

Febris,  carnis,  43  ;  recurrons,  47. 

Fi'hUnifn  test  for  sugar,  324. 

Fermentation,  test  for  sugar,  324. 

Fetid  stomatitis,  352. 

Fever,  in  cholcrii,  136  ;  gastric,  374  ;  hysterical, 
1029;  pernicious  malarial,  161, 109  ;  in  jineu- 
monia,  551 ;  in  acute  pneumonic  jihthisis, 
2oO,  231  ;  in  acute  miliary  tuberculosis,  219  ; 
in  i>rimary  multiple  ncuriti.s,  835  ;  in  menin- 
gitic  tuberculosis,  222  ;  in  pulmonary  tuber- 
culosis, 242;  in  pyiemia,  130;  in  pylephle- 
bitis, suppurative,  484  ;  in  intermittent  fever, 
106 ;  in  relapsing  fever,  49 ;  in  remittent 
fever,  168;  in  scarlet  fever,  74;  in  septiciu- 
mia,  127  ;  in  sniall-pox,  54 ;  in  suti-stroko, 
1076;  in  ai)pe  "'  'tis,  436;  in  secondary 
sypliilis,  18ti;  in  typhoid  fever,  13  ;  in  yellow 
fever,  141;  lung,  545;  Malta,  287  ;  Mediter- 
ranean, 287  ;  mountain,  288  ;  Neapolitan, 
2S7  ;  putrid  malignant,  1 ;  rehipsing,  47 ; 
ship,  43;  slow  nervous,  1;  s])lenie,  174; 
spotted,  43;  typhoid,  1;  typho-nialariul,  34, 
169;  typhus,  43;  yellow,  139. 

Fever,  idiopathic  intermittent,  129, 

Fever,  intermittent,  in  abscess  of  liver,  482; 
in  ague.  160  ;  in  chronic  obstruction  of  bile- 
passages,  469  ;  l)y  gall-stones,  4t')9  ;  in  gastric 
cancer,  407  ;  in  IhilifkhCs  disease,  745 ;  in 
pyiemia,  130;  in  pyelitis,  801  ;  in  secondary 
syphilis,  180  ;  in  tuberculosis,  239,  243. 


I  ; 


i 


i     U 

itff 


M 


1122 


INDEX. 


Fibrillntioii,  021. 

FibrinouH,  bronchitis,  .5.'?5  ;  pneumonia,  r)45. 

Fibro-cuseous  cliansri^  in  tubcrelu.s,  21(). 

Fibroid  disease  of  lioiirt,  tJT'J. 

Fibrosis,  arterio-capiiiary,  TOO. 

Fiuvrc,  inllaiiniiatoire,  loTO  ;  t.vp'ioido  a  forme 

renale,  29. 
Fiftli  nerve,  paralysis  of,  Si'i^ ;  (fustatory  l)rancli, 

854;  symptoms  of,  S.'iy ;  tropliie  clianges  in 

paralysis  of,  854. 
Filaria    hominis    sanguinis,   F.   Banerofti,   F. 

diurna,  F.   perstans,   101»1 ;   F.   medinensis, 

1011.3. 
Filaria  Loa,  F.  lentis,  F.  labialia,  F.  hominis 

oris,  F.  broncliialis,  F.  imitis,  10'.)4. 
Filariasis.  10!tl. 
First  sound  of  lieart,  obliteration  of,  in  typhoid 

fever,  19. 
Fish,  poisoning  by,  1071. 
Fisher's  brain  murmur,  33.5. 
Fistula  in  ano  in  tuberculosis,  253.  2G2. 
Fistula,  oesopliago-pleuro-eutaneous,  373. 
Flagellated  organisms  in  blood  in  malaria,  IfiO. 
Flatulence,  in  hysteria,  1027 ;  in  nervous  dys- 
pepsia, 390  ;  treatment  of,  384. 
Flea,  bite  of,  1 109. 

FlinVs  munnur  in  lieart-disease,  640,  G51. 
Floating  kidney,  758. 
Florida  fever,  1070. 
Fluke,    bronchial,    1083;  blood,    1083;  liver, 

1082. 
Fluke.s,  diseases  caused  by,  1082. 
Fnetal  heart-rhythm,  680. 
Foetus,  endocarditis  in,  696  ;  syphilis  in,  188  ; 

tuberculosis  in,   200 ;  white  pneumonia  of, 

194. 
Folic  Brightique,  779. 
Follicular  colitis,  420. 
Follicular  tonsillitis,  361. 
Food  (see  Diet). 
Foot  and  mouth  disease,  290. 
Foot-drop,  835,  836. 
Foreign  bodies  in  intestines,  446. 
Fourth  nerve,  S.'iO  ;  paralysis  of,  851. 
FVactures  in  rickets,  336. 
Fremitus,  yocal,  245,  5.54  ;  liy.lntid,  110.3. 
Fresh-air  treatment  in  tuberculosis,  272. 
Frictior     pericardial,    018;    jieritoneal,    .506; 

pleural,  247,  590  ;  pleuro-pericardial,  247. 
FriedreivK's  ataxia,  911. 

F'riedreick'a  sign  in  adherent  pericardium,  025. 
Frontal  convolutions,  lesions  of,  972. 
Frontal  sinuses,  pentustomes  in,  1106. 
Fungi  in  pulmomiry  cavities,  242. 
Funnel  breast,  245,  366. 

Gait,  ataxic,  906 ;  in  paralysis  agitans,  983 ; 
in  pseudo-hypertrophic  nniseular  paralysis, 
1052 ;   in  spastic  paraplegia,  bU9 ;   pseudo- 


tabetic,  008  ;  steppage,  in  peripheral  neurit!. 
837  ;  in  diabetic  tabes,  320. 

(iiill-bladder,  atrophy  of,  40S ;  calcitication  i, 
408;  dilatation  of,  407;  empyema  of,  .i<;- ; 
forming  abdominal  tumor,  407  ;  phlegmoiiii  h 
intiammaticm  of,  408. 

(Jallop-rhythin,  080. 

(lalloping  consumption,  232. 

Gall-stone  crepitus,  408. 

Gall-stones,  405. 

Galvano-puncturo  in  aneurism,  715. 

(iame-birds,  poisoning  by,  1071. 

(janglia,  basul,  tumors  of,  972. 

Gangrene,  in  diabetes,  325 ;  in  ergotism,  luT-'; 
in  pneumonia,  501  ;  in  typhoid  fever,  2'  ;  in 
typhus,  40;  local  or  symmetrical,  1042  ;  mul- 
tiple, 1042  ;  of  lung,  584  ;  of  mouth,  3.54. 

(iangrcnous  stomatitis,  .354. 

GarroWs  thread  test  for  uric  acid,  312. 

Gas-bacillus  (sec  Bacillus  ^rooenes  capsi;- 

LATCS). 

(iustralgia,  385. 

Gnstrectasis,  390. 

(iastric  catarrh,  acute,  374. 

(Jastric,  crises,  375,  400,  907  ;  fever,  374. 

Ga.stric  juice,  hyperacidity  of,  387,  40ij ;  suh- 
acidity  of,  387. 

Gastric  ulcer,  394 ;  clinical  forms  of,  398. 

Gastriti.s,  acute,  374 ;  acute  suppurative,  .".7 
chronic,    377;    dii)litheritic,  3''7 ;    meniKra- 
nous,    377 ;    mycotic,    377 ;    parasitic,    ",'', 
phlegmonous,  87'i ;  polyposa,  37J- ;  selemtii 
378  ;  simple,  374  ;  simple  chronic,  378  ;  lu\i 
370. 

Gastrodynia,  3S5. 

(iastro-enterostomy,  statistics  of,  893. 

Gastrorrhagitt,  41 1. 

Gastrotoiny,  373. 

Gastroxynsis,  387. 

General  paralysis  of  the  insane  (general  ]n 
rcsis),  906;  diagnosis  of  from  syphilis.  I',': 
969;  influence  of  syphilis  in,  188,  192,  w:. 

Genito-uriiuiry  system,  tuberculosis  of,  204. 

Gentles,  1110. 

Geogrophieal  tongue,  356. 

Geophagism,  389. 

(iei'lier's  disease,  802. 

German  measles,  85. 

Giant  cells,  21.5. 

Giant  growth,  1047. 

Giants,  relation  to  acromegaly,  1046. 

Gigantism  and  acrotnegaly,  1046. 

Gigantoblasts,  729. 

Gigantorhynchus  gigas,  1095. 

Oi//),Tt\3  sirup,  201. 

(lilies  lie  la  Toiirettc^s  disease,  997. 

Gin-drinker's  liver  (see  Cnmnosis  ok  I.imi; 
474. 

Girdlc-foeling  in  tranaverso  myelitis,  891. 


INDEX. 


1123 


Glnndcrs,  280 ;  acute,  281  ;  ehronie,  281  ;  (liiijr- 
nosis  iVoiii  small-pox,  (J;i. 

Glioinu  of  bruin,  U70. 

(Miosis,  913. 

(flisfoiiiaii  cirrhosis,  475. 

Glohulin  in  urine,  770. 

Globus  hystericus,  1023. 

Glonicrulo-ncphritis,  783. 

(;i()sso-lubio-liirynj,'C'al  paralysis,  022. 

Glosso-pharynfjeul  nerve,  81)3. 

(ilossy  skin  in  arthritis  deformans,  307. 

(tlottis,  uedema  of,  519  ;  in  Hrif.'lit's  disease,  519, 
78-4 ;  in  sniull-po.x,  59 ;  in  typhoitl  fever, 
10. 

Gluteal  nerve,  870. 

(ilycogen,  formation  of,  321. 

Glycogenic  function  of  liver,  321. 

tilycosuria,  321,  778  ;  gouty,  317. 

Gineliit''8  test,  458. 

Goitre,  750 ;  exophthalmic,  751 ;  sudden  death 
in,  750  ;  symptoms  of,  750. 

Gonorrhoial  arthritis,  301  ;  anatomical  changes 
in,  301 ;  endocarditis  in,  302. 

Gout,  309  ;  acute,  313  ;  chronic,  314  ;  Ebsteiii's 
theory  of,  312;  etiology  of,  309;  hereditary 
influence  in,  309 ;  influence  of  alcohol  in, 
3ii9;  influence  of  food  in,  309 ;  influence  of 
lead  in,  310  ;  irregular,  315  ;  morbid  anatomy 
of,  312;  nervous  theory  of,  312;  retrocedent 
or  suppressed,  314  ;  synjptonis  of,  313  ;  treat- 
ment of,  317. 

(touty  kidney,  790. 

von.  Graefe^s  sign,  752. 

drain,  poisoning  by,  1072. 

(Jrnmleur,  delusions  of,  968. 

(irand  nial,  1004. 

(irunular  kidney,  790. 

(travel,  renal,  80i). 

liraves^s  disease,  751. 

(ireen  cancer,  741. 

(ireen-sickness  (see  Chlorosis),  723. 

(Ireen-stiok  fracture  in  rickets,  330. 

(iregarinid*,  p.irasitic,  1080. 

(irinder's  rot,  587. 

Grippe,  la,  92. 
ilruebler's  tumor,  1005. 

Uuaiacum  test  for  blood,  76.5. 

(iuineu-worm  disease,  1093. 

(lummata,  185;  in  acquired  syphilis,  138;  in 
congenital  sypliilis,  191 ;  of  brain  and  spiiuil 
cord,  191 ;  of  heart,  197  ;  of  kidneys,  198  ;  of 
liver,  195;  of  lungs,  194;  of  rectum,  197;  of 
testis,  198;  structure  of,  1S5. 
(lummatous  periarteritis,  198. 
(iums,  black    line  on,  in  miners,  1065 ;  blue 
hnc  on,  in  lead-poisoning,  1O04;  in  scurvy, 
339;  in  stonuititis,  352;  red  line  on,  in  pul- 
monary tuberculosis,  248. 
Gustatory  paralysis,  854 


Habit  spasm,  090;  in  mouth-hreatliers,  307. 

Habitus,  apoplectic,  940;  phtliisicus,  211. 

Hicmatcmesis,  411;  causes  ot',  411;  in  cirrho- 
sis "f  liver,  477  ;  diagnosis  from  hiemoptysis, 
413;  in  enlarged  spleen,  171,  411 ;  in  scurvy, 
339. 

Hicmato-chyluria,  non-parasitio,  772;  para- 
sitic, 1092. 

HaMuatogenous  jaundice,  457. 

HiPtmitotiia  of  dura,  of  bruin,  932 ;  ol  cord,  883 ; 
of  mesentery,  454. 

Hiematomyeliu,  887. 

Ihemutorrhaohis,  88."). 

Hipmatozoa  of  malaria,  155,  158. 

Hicmaturia,  704;  endemic,  of  Egypt,  1083;  in 
acute  nepiiritis,  783 ;  in  chronic  phthisis, 
250;  in  p.sorospermiasis,  lOSl ;  in  renal  cal- 
culus, 809  ;  in  renal  cancer,  81 1 ;  in  tubercu- 
losis of  kidney,  205;  malarial,  170. 

Htcmoglobin,  reduction  of,  in  chlorosis,  724. 

Ikemoglobinicmia,  707. 

Hiemoglobinuria,  705 ;  epidemic,  in  infants, 
190,  347,  700;  in  J{(iyiiaud''8  disea.se,  1042; 
paroxysnud,  70t) ;  toxic,  700. 

Hicmolysis,  457 ;  in  pernicious  anicmia,  727 ;  in 
toxic  ha>mogloLinuna,  707. 

Hiemo-pericardium,  020. 

Hsemophilia,  3'^:3,  348. 

liiemoptysis,  causes  of,  540;  hysterical,  1026; 
at  onset  of  phthisis,  239 ;  in  acute  broncho- 
pneumonic  phthisis,  233;  in  acute  tubercu- 
losis, 220  ;  in  aneurism,  541,  711  ;  in  aortic  in- 
Butticiency,  042 ;  in  arthritic  subjects,  541 ;  in 
broneliiectasis,  531 ;  in  cirrhosis  of  lung,  509 ; 
in  empliysema,  583 ;  in  miliary  tuberculosis, 
220;  in  mitral  insurticionc}',  047;  in  mitral 
stenosis,  653 ;  in  pneumonia,  553 :  in  pul- 
monary gangrene,  585 ;  in  scurvy,  339 ; 
symptoms  of,  541  ;  treatment  of,  543 ;  in  ty- 
phoid fever,  20 ;  relation  to  tubercuU>sis,  541 ; 
])arasitic,  1083 ;  periodic,  541 ;  vicarious,  541. 

Ha'morrhage,  brrncho-pulmonary,  540;  cere- 
bral, 940;  frrm  mesentery,  454;  from  the 
stonuich,  411 ;  in  acute  yellow  atropiiy,  40O; 
in  antcmia,  731 ;  in  cirrhosis  of  tlie  liver,  477  ; 
in  contractetl  kidney,  794;  in  gastric  cancer, 
405 ;  in  gastric  ulcer,  397  ;  in  hiemophilia,  349 ; 
in  hysteria,  1020,  1028;  in  intussusception, 
449;  in  leukiemia,  730;  in  nudaria,  170,  171 ; 
in  nephrolithiasis,  809  ;  in  the  new-born,  347  ; 
in  purpura  hiemorrhagicu,  340 ;  in  scarlet 
fever,  75;  in  scurvy,  339;  in  small-pox,  56; 
in  splenic  enlargement,  171,  411;  into  pan- 
creas, 492 ;  into  spinal  cord,  8«7  ;  into  spinal 
membranes,  885 ;  in  tuberculous  pyelitis,  265 ; 
in  tuberculosis  of  bowels,  202 ;  into  ventri- 
cles of  brain,  942;  in  typhoid  fever,  9,  23; 
in  yellow  fever,  141 ;  pulmonary,  242,  640. 

Hicmorrhagic  diathesis,  343,  348. 


ii 


1124 


INDEX. 


llasniorrhftfrio  diHcoses  of  the  ncw-l)orn,  0-17. 

lliciiiiithoriix,  liOO. 

Hair  tuiiiiirs  in  stomnoli,  41'i. 

lliiir,  the,  in  tyjilmid  fever,  17. 

Hallucinations  in  lijHteriii,  10-_'9. 

llundwritinji^  in  f;enerul  piire.sis,  008. 

Ilarrisoii's  trroovc  in  ricivets,  '■Vih ;  in  enlarged 
tonsils,  SiiO. 

Ilarvest-liii;,',  1107. 

Iluy-iLsthtim  I  hay-fever),  .11.'). 

llaygartfi's  nodosities,  SOU. 

Headache,  from  eerel)ral  tumor,  071 ;  in  cere- 
bral sypliilis,  102;  in  inr>utii-brcathers,  .'!i)7  ; 
in  typhoid  fever,  11,  12,  20;  in  uraemia,  7«0 ; 
sick,  1011. 

Head-elicesp,  poisoning  by,  lOtlO. 

Heart,  diseases  of,  G27;  disea.sea  of,  OertcVs 
treatment  of,  fisl ;  amyloid  degeneration  of, 
()7H ;  aneurism  of,  G81 ;  athlete's,  037  ;  brown 
atrophy  of,  078 ;  calcareous  degeneration  of, 
078  ;  congenital  att'cctions  of,  005  ;  dilatation 
of,  070;  displacement  in  pleuritic  effusion, 
504;  displacement  in  pneumothorax,  000; 
fatty  disease  of,  077 ;  fragmentation  of  fibres 
of,  077 ;  liydatids  of,  083 ;  hypertrophy  of, 
003;  liypertrophy  of,  in  Bright's  disease, 
704;  in  exophthalmic  goitre,  7r)2;  irritable, 
674,  084 ;  new  growths  in,  082 ;  neuroses  of, 
084;  palpitation  of,  684;  parcncliymatous 
degeneration  of,  077 ;  rupture  of,  082 ;  scle- 
rosis of,  070  ;  valvular  diseases  of,  037. 

Heart-failure  in  diphtheria,  116. 

Heart-muscle  in  fevers,  077. 

Heart- valves,  congenital  anomalies  and  lesions 
of,  000 ;  rupture  of,  038. 

Heart-  weakness,  treatment  of,  in  typhoid  fever, 
38. 

Heat,  exliaustion,  1073;  stroke,  1073. 

//(.'ic/v/fwV  nodes,  306. 

Hi  brews,  prevalence  of  diabetes  among,  320. 

liectic  fever,  243,  244. 

Heel,  painful,  1015. 

lleller'a  test,  709. 

Hclniinthiasis  (see  Animal  Parasites),  1080. 

llemeralopia,  843  ;  in  scurvy,  340. 

Hemialbumose,  770. 

Ilemianu'sthesia,  in  cerebral  lin>morrhngc,  940; 
in  liystcria,  1025 ;  in  lesions  of  internal  cap- 
sule, 925  ;  in  unilateral  cord  lesions,  880. 

Hemianopia,  heteronymous,  845;  1  omonymous, 
845;  in  migraine,  1011;  lateral,  845;  nasal, 
845 ;  significance  of,  848 ;  temporal,  845. 

Hetnicrania,  1011. 

Hemi-  mc  pupillary  inaction,  847. 

Hem      cgia,  944;  crossed,  025,  046. 

Hemiplegia,  infantile,  058 ;  apliasia  in,  900 ; 
epilepsy  in,  900 ;  in  liystcria,  1023 ;  mental 
defeeis  in,  OfO;  post-hemiplegic  moveuients 
\u,  900 ;  spant  ca  ecrebralis,  960. 


Ilemiplegie  flasque,  947. 

Ihnoc}C»  purpura,  345. 

Hepatic,  abscess,  480;  artery,  enlarcremcdt  nf, 
403;  colic,  460;  intermittent  t'ever,  400;  Niiu, 
affections  of,  403. 

Hej)atitis,  diffuse  syphilitic,  195;  inteiMiii^il 
(see  Ciititnosis),  474;  suppurative,  4S0. 

nciiatization,of  lung, 548;  white,  of  fa'tus,  ivt. 

Hepatogenous  jaundice,  457. 

Hereditary  form  of  (edema,  1044. 

Heredity,  in  Bright's  di«ease,  70o;  indial.drs 
insipidus,  3.'50;  in  Friedrtivli's  ataxia,  Oil; 
in  gout,  300;  in  hiemophilia,  348;  in  pani- 
niyoclonus  multiplex,  1050 ;  in  spastic  jiara- 
plegia,  900;  in  syphilis,  184;  in  tuberculosis, 
200  ;  in  tuberculosis,  chart  of,  207. 

Herpes,  in  trifacial  neuralgia,  1014;  in  cerebro- 
spinal meningitis,  09 ;  in  febricula,  28il :  in 
malaria,  100 ;  in  pneumonia,  555 ;  zo.-tir, 
1015. 

Hiccough,  872 ;  hysterical,  1026. 

Hiccough,  causes  of,  872  ;  treatment  of,  873. 

High-tension  pulse,  characlers  of,  704,  704. 

Hill  diarrha-a,  421. 

Hippocratic,  facies,  500  ;  fingers,  250  ;  succiis- 
sion,  010. 

Hippus,  1012. 

//oi/;/kiii's  disease,  742 ;  intermittent  fevir  in, 
745 ;  morbid  anatomy  of,  742 ;  symptoms  ol', 
743. 

Horn-pox,  58. 

Hot  Springs,  of  Arkansas,  301 ;  of  Banff,  SOI ; 
of  Virginia,  301. 

Iluiitinijdon's  cliorea,  998. 

Husband  and  wife,  diabetes  in,  320 ;  tubercu- 
losis in,  210. 

Ilutcldagoii's  teeth,  190. 

Hyaline  casts  in  urine,  783,  789,  794. 

Hybrid  measles,  85. 

Hydatid  disease  (see  Eciiinoooccus),  lO'.'O, 
1100;  prevalence  of,  in  America,  1102. 

H.vdatid  thrill  or  fremitus,  1103. 

Hydrarthrosis,  chronic,  302;  intennittent,  \i'-l^. 

"  Hy drencephaloid  condition,"  410,  030. 

Hydriatic  treatment  (see  Hydrotiiekai'V). 

Hydrocephalus,  acquired,  078  ;  acute,  221,  '.CS; 
chronic,  977  ;  chronic,  after  cerebro-s|iiiuil 
meningitis,  101;  congenital,  977 ;  spurious, 
419. 

Hyilromyelus,  882,  912. 

Hydronephrosis,  803 ;  congenital,  803;  inter- 
mittent, 701,  804. 

Ilydropericardium,  626. 

HydroperitoniBuni,  507. 

Hydrophobia,  177. 

Hydro-pneumothorax,  608. 

Hydrops  vesicas  felleie,  407. 

Hydrotherapy,  intyplioid  fever,  88i 

Hydrothorax,  008. 


INDEX. 


1125 


Ilymcnolcpsis  diininutn ;  II.  nnna,  1O07. 

IIy|)L'nu'usis,  SiiO. 

llypcni'stlu'Miu,  in  ntnxiii,  '.'Oit ;  in  liystcria,  lOi,") ; 
in  ricliot.s,  ;vi4  ;  in  uniluturul  cord  leMions,  fSMO. 

Ilyperosinia,  841. 

HyinTpyrexia,  hystoricnl,  lii;!(t;  in  rliounintio 
feviT ;  2',tr) ;  in  .scuriut  I'uvcr,  75  ;  iu  .sun-slrokc, 
lOTti ;  in  ti'tanns,  IWJ. 

llypertiiyrcu,  T">1. 

Hypt'rtliyri)iili.'<in,  7">1. 

Ilypertropliio  cirrlio.si.s  of  livor,  475. 

Ilypnoti.sin  in  hysteria,  lo.'iii. 

Hypochondriasis  and  nourusthonia,  lO.lS. 

llypodiTinic  syringe  in  diagnosis  of  [)l(!ural 
cttusion,  002. 

lIy;.oglossal  nerve,  diseases  of,  870  ;  paralysis 
of,  870;  spasm  of,  871. 

Ilypopiiysis,  enlargement  of,  1046. 

Hypoplasia  of  aorta,  7-'-'i. 

ny()ostatio  congestion,  of  lungs,  539;  in  ty- 
phoid fever,  '2ii. 

Hysteria,  1021 ;  and  disseminated  sclerosis,  006 ; 
conUaetures  and  spasms  in,  1023;  eonvulsive 
forms  of,  1022;  cries  in,  1020;  diagnosis  of, 
1030 ;  disorders  of  sensation  in,  1025 ;  etiology 
of,  1021 ;  forms  of  fever  in,  1029;  hiemopty- 
sis  in,  1O20 ;  insanity  in,  102'J ;  joint  allec- 
tions  in,  1028;  mental  .symptoms  of,  lO'js; 
metabolism  in,  1021* ;  metallotlierapy  in,l02."); 
non-convulsive  forms  of,  1023  ;  paralysis  in, 
1023;  special  senses  in,  1020;  stigmata  in, 
344,  1028;  traumatic,  1035;  treatment  of,' 
1030 ;  visceral  manifestations  of,  1020. 

Hysterical  angina  pectoris,  093. 

Ilystero-ei)iiepsy,  1007,  1022. 

Hysterogenic  points,  1025. 

Ice-cream,  poisoning  by,  1071. 

Ice,  typhoid  bacillus  in,  4. 

Ichthyosis  lingualiu,  350. 

Iclithysmus,  1071 ;  paralyticus,  1072. 

Icterus  (sec  Jaundice),  457  ;  acute  febrile,  280 ; 
gravis,  459  ;  neonatorum,  459. 

Idiocy  in  infantile  hcmi]ilcgia,  9ip0. 

Idiopathic  anavnia  of  At/difon,  720. 

Idiopathic  intermittent  fever,  129. 

lleo-eipcnl  region,  in  typhoid  fever,  24;  in  ap- 
pend.jk..,  430;  in  primary  tuberculosis  of 
bowel,  202. 

Ileus  (see  Sthangii.ation  of  Bowel),  443. 

Iiril)ecility  in  infantile  hemiplegia,  900. 

Imitation  in  chorea,  987. 

Impetigo,  contagious,  and  vaccination,  05. 

Impetigo,  contagious,  and  ulcerative  stonuititis, 
352. 

Impotence,  in  diabetes,  327 ;  in  locomotor  ataxia, 
907. 

IncarceratiiMi  of  bowel,  443, 

lucoOrdiuution,  of  arms,  900;  of  legs,  900. 


Indians,  .\mericnn,  chnren  in,  0!^5 ;  consump 
tion  in,  204;  snuill-pox  among,  'A. 

Imlicanuria,  770. 

Infantile,  convulsions,  999;  par.ilysis,  892; 
scurvy,  ,341. 

Infantilism,  190. 

Infarcts,  hieniorrhagic,  in  typiioid  fever,  21  ; 
pyiemie,  130. 

Infection,  definition,  120. 

Infectious  discuses,  1 ;  multiple  neuritis  in, 
837. 

Inflation  of  bowel  for  intussusception,  4.'iO. 

Influenza,  92  ;  diagni>sis  of,  93  ;  etiolngy  of,  93; 
symptoms  of,  92  ;  treatment  of,  94 ;  complica- 
tions of,  92. 

Infusoria,  parasitic,  1082. 

Inhalation  pneumonia  (see  .Vspiisatmn  I'nki'- 
monia),  571. 

Injection,  intravenous,  of   milk,    1:!n:    intra 
venous,  of  salines  in  diabetes,  330 ;  subcu- 
taneous, of  salines  in  cholera,  138. 

Inoculation,  against  small-pox,  5o,  58  ;  pro- 
tective, in  cholera,  138  ;  preventive,  in  hydro- 
phobia, 179;  preventive,  in  pneumonia,  r)47  ; 
preventive,  in  yellow  fever,  143;  tuberculosis 
transmitted  by,  208. 

Insanity,  post-febrile,  28  ;  in  small-pox,  59. 

Insanity,  relation  of  drink  to,  lo.'iS;  relations 
of  chronic  phthisis  to,  250  ;  relation  of  lieart- 
disease  to,  042. 

Insects,  parasitic,  1108. 

Insolation,  1073. 

Insular  sclerosis,  005. 

Intention  tremor  (see  Volitionai.  Tiikmor). 

Intermittent  claudication,  091. 

Intermittent  fever,  103  ;  forms  of  (se,   i  kvki(). 

Intermittent  hepatic  fever,  4<'i9. 

Intermittent  hydrarthrosis,  1028. 

Internal  eapstde,  lesions  of,  925. 

Internal  carotid  artery,  blocking  of,  952. 

Intestiiiid  casts,  422. 

Intestinal  coils,  tumor  formed  by,  259. 

Intestinal  obstruction,  443. 

iTitestines,  diseases  of,  414 ;  actinomycosis  of, 
283  ;  dilatation  of,  454. 

Intestines,  hiemorrhage  from,  in  typhoid  fever, 
9.  23  ;  in  dysentery,  140,  l.")0  ;  in  ttibercidosis 
of  bowel,  202;  in  intu.ssusception  ot',  449  ;  in 
ulceration  of,  424. 

Intestines,  infarction  of,  45r) ;  intussusception 
of,  444,  449;  invagination  of,  444;  miscel- 
laneous atleetions  of,  454 ;  new  growths  in, 
445. 

Intestines,  obstruction  of,  443,  .V>1  ;  acute,  440  ; 
by  enteroliths,  440;  by  foreign  bodies,  440; 
by  gall-stones,  440. 

Intestines,  perforation  of,  in  typhoid  fever.  8. 

Intestines,  primary  tuberculosis  of,  201  ;  stran- 
gulation of,  443,  449  ;  strictures  and  tumors 


M 


111 
f'l 


1126 


INDEX. 


of,  445;  twists  and  knots  in,  445;  ulcers  of, 

423. 
Inloxieution,  ilcfinition  of,  127. 
Intuxicutioiis,  lu.")". 
lntussU8fci>tioii,  444, 441>. 
Invuj^inntion,  444  ;  post-inortom,  444. 
Invorse  type  of  terniieruture,  in  tuberculous 

meningitis,  ai'j  ;  in  typhoid  fever,  15. 
Iodide  eruptions,  L'OJ. 
Iridoplegiii,  850  ;  acconiniodutivc,  850  ;  reflex, 

850. 
Iritis,  syphilitic,  187,  190. 
Itch,  1107. 
Itching,  of  feet  in  pout,  316;  of  eyeballs  in 

gout,  31ti;  of  si? in  in  Bright's  disease,  795; 

of  skin  in  jaundice,  457. 
Itch  insects,  1107. 
Ixodes  ricinus,  1107. 

Jueksonian  epilepsy,  832,  1007. 

Japan,  Ueri-bcri  iu,  838;  endemic  fluke  dis- 
ease in,  1082. 

Jaundice,  black,  4.')7  ;  catarrhal,  413 ;  clioluria 
in,  458  ;  from  cirrhosis  of  liver,  477,  478;  epi- 
demic form  of,  4(!4  ;  febrile,  280  ;  from  acute 
yellow  atrophy,  450;  from  cancer  of  liver, 
488 ;  from  gall-stones,  467,  469 ;  hn!matoge- 
nous,  457 ;  hepatogenous,  457  ;  in  pneumonia, 
558;  purpura  in,  343,  458;  in  WcWs  disease, 
286  ;  malignant,  459  ;  of  the  new-born,  459  ; 
non-obstructive,  458  ;  obstructive,  457  ;  xan- 
thelasma in,  457  ;  in  yellow  fever,  141. 

Jav  clonus,  921. 

Jigger,  1109. 

Jolins  Hopkins  Hospital,  statistics  of  tubercu- 
losis at,  204,  207. 

Joints  (see  Akthuitis). 

Jumpers,  097. 

"June  cold,"  515. 

Keloid  of  AddUnn,  1048. 

Keratitis,  in  small-pox,  GO;  interstitial,  of  in- 
herited syphilis,  190. 

Keratosis  foUicularis,  1081. 

Keratosis  mueosic  oris,  356. 

Kidney,  diseases  of,  758 ;  amyloid  or  larda- 
ceous  disease  of,  798 ;  anomalies  in  form  and 
position  of,  758  ;  cancel-  of,  811  ;  cardiac, 
763 ;  cin.'ulatory  disturbance  in,  762 ;  cir- 
rhosis of,  700;  congenital  cystic,  813;  con- 
gestion of,  762;  contracted,  790;  cyanotic 
induration  of,  763;  cystic  disease  of,  813; 
echinococcus  of,  1105;  fused,  758;  gouty, 
700  ;  granular,  790  ;  horseslioe,  758  ;  large 
white,  787,  788  ;  movable,  758. 

Kidney,  removal  of.  for  cancer,  812  ;  for  mov- 
able kidney,  761. 

Kidney,  rhabdo-myoma  of,  811  ;  sarcoma  of, 
811;  scrofulous,  265,  800;  small  white  kid- 


ney, 788  ;  surgical  kidney,  800  ;  syphili-i  of, 

198;  tuberculosis  of,  264;  tumors  of,  811  • 

unsymmetrical,  758. 
A'lebn-Loefller  bacillus,  105. 
Knee-jerk,  loss  of,  in  ataxia,  905  ;  in  diphthci  i.i, 

116. 
h'oc/i  treatment  of  tuberculosis,  264. 
Kopftetanus  of  A'wsc,  182. 

Labyrinthine  disease,  860,  861. 

"  Lacing"  liver,  401. 

Lacunar  tonsillitis,  361. 

"  Ladder  pattern,"  448. 

Lu  grippe,  92. 

Lamblia  intestinalis,  10S2. 

Landry^H  paralysis,  806. 

Lardaceous  degeneration  (see  Amvi.oid). 

Larvte  of  flics,  diseases  caused  by  (lIlyia^iv), 
1109. 

Laryngeal  crises,  907. 

Laryngismus  stridulus,  520. 

Laryngitis,  acute  catarrhal,  518  ;  chronic,  ."10  ; 
axlenuitous,  519;  spasmodic,  520;  sypliilitii', 
523 ;  tuberculous,  521. 

Larynx,  diseases  of,  518,  864  ;  adductor  paral- 
ysis of,  865  ;  anie.sthcsiu  of,  866  ;  hy|itiii>tli(- 
sia  of,  866;  paralysis  of  abducti>rs  of,  m;4; 
spasm  of  the  mu.scles  of,  866 ;  unilateral  ab- 
ductor, paralysis  of,  805. 

Latah,  997. 

Lateral  .sclerosis,  primary,  898 ;  amyotropliio, 
919. 

Latcritious  depo.sit,  773. 

Lathyrism,  1072. 

Lavage,  383  ;  in  dilatation  of  stomach,  30;! ;  in 
gastric  ulcer,  401. 

Lead,  colic,  1065 ;  in  the  urine,  1064. 

Lead-palsy.  1065 ;  localized  forms  of,  1O05. 

Lead-pipe  contraction,  900. 

Lead-poisoning,  lo63;  acute,  1064;  artcrid 
sclerosis  in,  1066 ;  cerebral  symptoms  in. 
1060;  chronic,  1064;  convulsions  from,  li";ii; 
gouty  deposits  in,  1066;  treatment  of,  luiiii. 

Leatl-workcrs,  prevalence  of  gout  in,  310. 

Leichen-tub(Tcle,  208. 

Leontiasis  ossea,  1047. 

Lepra  alba,  279. 

Lepra  mutilans,  279. 

Leprosy,  277;  ana'stlietic,  279;  bacillus  Vyxiv 
in,  279;  contagiousness  of,  278;  diiiirnn^i^  <a\ 
280;  etiology  of,  277;  macular  form  nt'.  -'7:'; 
morbid  anatomy  of,  279 ;  treatment  of,  l"-"  : 
tubercular,  279. 

Leptomeningitis,  acute,  883,  933  ;  chroiiii-.  -^1, 
937  ;  in  Bright's  disea.se,  934 ;  infuutuiu,  'j;i4, 
935 ;  in  pneumonia,  934. 

Leptothrix  in  mouth,  284. 

Leptus  autumnalis,  1107. 

Leuciu,  461. 


INDEX. 


1127 


ai'ti'i'ii" 
MIS    ill. 

111.;.;. 
111. 


^  1. 

|.r;i- 

lo>' 

-  "f, 

of. 

■'so  ■_ 

nil' 

--t, 

uia 

%\, 

l.iMU'ocyti's,  varioties  of,  737 ;  rclntion  to  uric 
iioiil,  31 -J. 

LcuoofytosKs,  in  aniPiniii,  722,  7;!";  ohlorosi.s, 
720 ;  c'LTi-'bro-spiiiul  iiidiin^itiw,  'Mi ;  <lij>li- 
tliiTia,  ll.'i;  I'lnpycniu,  ,V.i.H;  ciysiiiclas,  1-jr.; 
llotlgkiii''s  (lisuasc,  744;  luukiLMiiia,  "Ji^ ;  iim- 
laria,  171;  inuasles,  84;  pyirmi'i,  Uil  ;  jiir'H- 
luoiiiu,  554,  500;  pleurisy,  5il6 ;  .  Iiouiiiutif 
J'uviT,  294 ;  warlct  fiivor,  7H ;  stoinacii<;aiu'cr, 
407;  tuberciilowis  (acute),  220;  tuljcrculosis 
(elironic  puliiioiiary),  248;  typhoid  fever, 
18,  34. 

Leucoilerina,  753, 1048. 

Leueoiii..iiic'S,  lOO'J. 

Leucuinata,  187. 

LeuliiPiiiiu,  733 ;  lyniplintic,  740  ;  blood  in,  737  ; 
c'oiij,'enital,  734 ;  definition  of,  733  ;  diagnosis 
of,  740;  etiology  of,  734;  heredity  in,  734;  in 
animals,  734;  in  pregnancy,  734;  morbid 
anatomy  of,  734;  myelogenous,  735;  prog- 
nosis of,  741 ;  spleno-meduUary,  730;  symp- 
toms of,  73ti ;  treatment  of,  741. 

Leukoplakia  buecalis,  350. 

Leydtti's  crystals,  534,  537. 

Lkhtheiiii's  schenui,  927. 

Lienteric  diarrluea,  410. 

Life  assurance,  and  albuminuria,  770;  and 
sypliilis,  202. 

Lightning  pains  in  ata.\ia,  905. 

Linew  atrophictc,  17.      , 

Lingual  corns,  350. 

Lipaciduria,  777. 

Lipiemia,  322,  326. 

Lipothyniia,  500. 

Lipuria,  777. 

Lips,  tuberculosis  of,  200 ;  cl'ancre  of,  184. 

Lhsauer's  zone,  904. 

Lithiemia,  772,  773. 

Lithicjuic  stale,  315. 

Litbiusis,  773. 

Lithic-aeid  diathesi.s,  772. 

Lithuria,  772. 

Liver,  al)sces8  of,  480;  actinomycosis  of,  283  ; 
acute  yellow  atrophy  of,  459  ;  amyloid,  490; 
unieiniu  of,  401 ;  angioma  of,  487 ;  cardiac, 
402;  anomalies  in  form  and  position  of,  491. 

Liver,  cirrhosis  of,  474 ;  ascites  in,  477 ;  atro- 
phic, 475  ;  fatty,  475  ;  GUssoninn,  475 ;  liiem- 
orrhago  from  stomach  in,  477  ;  hypertrophic, 
475,  478;  in  tuberculosis,  203;  in  children, 
474;  jaundice  in,  477;  toxic  symptoms  in, 
477  ;  with  cancer,  480. 

Liver,  cysts  of,  4s7  ;  fatty,  489 ;  gummata  of. 
195;  hepato-phlcbotomy  incongestion  of, 402  ; 
hydatid.*  of,  1103 ;  hypcricmia  of,  4t>l ;  itifarc- 
tion  of,  403;  inelano-sarcoma  of,  4s7 ;  new 
growths  in,  485 ;  nutmeg,  402 ;  passive  con- 
gestion of,  401 ;  periodical  enlargement  of, 
461 ;  primary  cancer  oi',  480  ;  psorospcrmiasis 


of,  1080;  pulsation  of,  402;  sarcoma  of,  4h7  ; 
secondary  cancer  of,  480;  sjphilisof,  195; 
tuberculosis  of,  203;  in  typhoid  fever,  9,  25. 

Liver,  diseases  of,  457. 

Liver  dulness,  obliteration  of,  in  perforative 
peritonitis,  24,  5oo. 

Liver,  movable,  491. 

Liver,  new  growths  in,  485. 

J/iving  skeletons,  921. 

Lol)ar  pneumonia,  .'>45. 

L(ihstiiii\  cancer,  8i-j. 

Localization,  cerebral,  821 ;  spinal,  819, 

Localized  peritonitis,  433,  5o2. 

Lock-jaw,  180. 

Lock-spasm,  1018. 

Locomotor  ataxia,  902  ;  diagnosis  of,  908  ;  eti- 
ology of,  902 ;  gastric  crises  in,  90";  hemi- 
plegia in,  90S ;  morl)id  anatomy  of,  903 ; 
paresis  in,  908  ;  prognosis  of,  909  ;  rectal  crises 
in,  907  ;  relation  of  syphilis  to,  903  ;  reputed 
cures  of,  909 ;  symptoms  of,  905 ;  treatment 
of,  909. 

Long  thoracic  nerve,  att'ections  of,  874. 

Loose  shoulders,  1052. 

Lort:ta\i  operation,  715. 

Loitix'  law,  212. 

Lucilia  nuiccllaria,  1109. 

LuJifu/s  angina.  Sill. 

Lues  venerea  (syphilis),  184. 

Lumbago,  303. 

Lumbar  plexus,  lesions  of,  870. 

Lumbar  puncture  of  Qiiinclr,  937,  979. 

Lung,  aljsce.ss  of,  580;  causes  of,  580;  embolic, 
580  ;  etiology  of,  580  ;  symptoms  of,  580. 

Lung,  actinomycosis  of,  283  ;  albinism  of,  5S0  ; 
brown  induration  of,  538 ;  cancer  of,  acute, 
591 ;  carnifieation  of,  572;  cirrhosis  of,  500. 

Lung,  di.seases  of,  537  ;  stones,  230. 

Lung  fever,  545. 

Lungs,  congestion  of,  .'>37 ;  active,  537;  acute 
luemorrhagic,  538;  hypostatic,  539;  meuhan- 
ical,  538;  passive,  538. 

Lungs,  echinococcus  of,  1105. 

Lungs,  gangrene  of,  584 ;  abscess  of  brain  in, 
585,  975  ;  causes  of,  584  ;etiology  of,  584 ;  mor- 
bid anatomy  of,  584;  symptoms  and  course 
of,  585;  treatment  of,  5S5. 

Lungs,  new  growths  in,  590;  in  cobalt-miners, 
590  ;  ]ihysical  signs  of,  591 ;  diagnosis  of,  591. 

Lungs,  hiemorrbagic  infarction  of,  .542;  o>dema 
of,  539;  splenizatioii  of.  539,572;  syphilis  of, 
193;  tuberculosis  of,  ^28. 

Lupinosis,  1072. 

Lymphadenitis,  general  tuberculous,  226 ;  local 
tuberculous,  220;  simple,  Oil;  suppurative, 

on. 

Lymphadenoma.  general,  742. 
Lympii-scrotum,  1093. 
Lymph,  vaccine,  07. 


.   1 


1128 


INDEX. 


T,yrii|ili  vpssi'ls,  dilatution  of,  1003. 
LysHii,  IV". 
Ly«siop)ioliia,  ISO. 

Macular  riypliil'ules,  187. 

Main  iMi  ^jritlc  ^s•J,  ii-Jl. 

Mui/.o,  jxiisoniiij,'  I'y  (ix'llnsrrn'),  1073. 

Mulnrinl  ('ever,  !">.");  afcidt'iital  and  lato  loslons 
of,  ItJ^i;  ii'stivo-autuiunal,  I*!"  ;  al^id  form  of, 
170;  ooinutiiHo  form  of,  1U!I;  coiitinued  and 
ruiiiitti'iit  form  of,  1(17;  desorijitioi>  of  tliu 
)iaroxysm  in,  li!;i;  dia)j;nosi.s  of,  171 ;  ctiolofxy 
of,  Im\  f;('Ofi;nij>iru'al  distribution  of,  l.')"); 
liii'morrliau'io  form  ot',  170;  inturniittcnt,  lti3  ; 
malarial  (Mulipxin,  1(51,  170;  ini'tforologifal 
conditions  intiucnoiiij;,  1")7  ;  niorliid  anatomy 
of,  Itll ;  pernicious,  liil,  Kilt;  pneumonia  in, 
1)1.'! ;  quartan,  107  ;  quotidian,  1(17  ;  season  in, 
l.jil ;  sjiecittofxcrni  of,  ir)7  ;  telluric  conditions 
in11uencinj5,  150;  turtiuu,  107;  treatment  of, 
172. 

Malifjrnant  .jaundice,  4.'J0. 

Malifjiuint  (Edema,  \~r)\  jmstulc,  175. 

Maliftnant  purpuric  fever,  'J(5. 

Mallein,  2H2. 

Malta  fever,  '287. 

AUunmary  glands,  liypertrnphy  in  tuberculosis, 
2')0  ;  in  hysteria,  \»2l[  tuberculosis  of,  2(17. 

Mammitis,  clirunic  interstitial,  iu  tuberculosis, 
250,  207. 

Mania  a  potu,  1059. 

Mania,  />V//\  liSO. 

Marantic  tlirmubi,  !150. 

Marine  Hospital  Service,  statistics  of  nuilaria 
in,  155. 

Marriasre,  question  of,  in  lupniopliilia,  350;  in 
sypliilis,  2('2  ;  in  tabes  dorsalis,  t)10;  in  tu- 
berculosis, 208. 

Marrow  of  bones,  in  smnll-pox,  53  ;  in  leukiu- 
mia,  735 ;  in  pernicious  untcmia,  728. 

Masque  des  fenuues  enceinte,  741). 

Mastication,  spasm  of  the  muscles  of,  854. 

McIiitnuifK  tender  point,  430. 

Measles,  81 ;  complications  and  sequela?  of,  83  ; 
contagiousness  of,  81 ;  de.squanuition  in,  82  ; 
diagnosis  of,  84;  eruption  in,  ,h2  ;  etiology 
of,  81 ;  (icrnuin,  S5;  morbid  amitomy  of,  si ; 
period  of  incubation  in,  81  ;  prognosis  of,  84  ; 
symptoms  of,  si  ;  treatment  ot',  84. 

Measly  meat,  examination  of,  10118. 

Meat,  poisoning  by,  lOOlt ;  tuberculous  infection 
by,  211  ;  inspection  of,  for  trichina',  1080. 

Mt'vkifs  diverticulum,  443. 

Median  nerve,  atfcetions  of,  875. 

Mcdiastino-pericnrditis,  indurative,  014. 

Mcdia.stinum,  att'ections  of,  Gil  ;  abscess  of, 
613  ;  t umors  of,  01 2 ;  cancer  of,  012  ;  diagnosis 
of,  013;  empliyscma  of,  015;  pleural  effusion 
iu,  613;  sarcoma  of,  012;  symptoms  of,  61'2. 


Medlterrnnoon  fever,  287. 

Medulla  oblongata,  tumors  of,  973. 

Megalo-ccplialie,  1047. 

.Megalocytes,  729. 

.Megastrie,  390. 

Meiiunu,  in  duodenal  ulccir,  400;  in  ty[ihoi'l 
fever,  23;  in  tuberculosis  of  bowels,  202; 
neonatorum,  348. 

Melano-.sarcoma  of  liver,  487. 

.Melanuria,  770. 

Melasma  suprarenale,  749. 

MiHure^s  disease,  sOl, 

•Meningcul  htcmorrhagc,  941 ;  in  birth  palsies, 
901. 

Meninges,  affections  of,  881,  032. 

Meningitis,  acute,  spimd,  8S3 ;  in  erysipelas, 
124,  1'25;  in  gout,  31<1;  in  tyj'hoid  fever, 
10,20;  occlusive,  934  ;  posterior,  979;  serosa, 
078;  syphilitic,  191  (see  also  Lei'tome.\in- 
QiTis,  883) ;  tuberculous,  221. 

Meningo-eneephalitis,  chronic  diffuse,  900  ;  tu- 
berculous. 22'2. 

Mercurial,  tremor,  984;  stomatitis,  355. 

Merycismus,  388. 

Mesenteric  artery,  aneurism  of,  455  ;  enibolisni 
of,  455. 

Mesenteric  glands,  tuberculosis  of,  228  ;  tuber- 
culous tumors  of,  200 ;  in  typhoid  fever,  9. 

Mesenteric  veins,  diseases  of,  455. 

.Mesentery,  chylous  cysts  of,  450  ;  affections  ol', 
454. 

Metallic,  echo,  010  ;  tinkling,  247,  610. 

Metallotherapy,  1025. 

Metastasis  in  mumps,  87. 

Metastatic  abscesses,  130. 

Metatarsalgia,  1016. 

Meteorism  in  typhoid  fever,  23;  treatment  of, 
41. 

Micrococci,  in  dengue,  94  ;  in  Malta  fever,  288 ; 
in  vaccine  virus,  64. 

Micrococcus  lanceolatus,  545,  540,  573,  031. 

Micrococcus  melitensis,  288. 

Microcytes,  729. 

Micromelia,  333. 

Middle  cerebral  artery,  embolism  and  throm- 
bosis of,  952. 

Migraine,  1011 ;  treatment  of,  1012. 

Mihary  abscesses  in  typhoid  fever,  9. 

Miliary  aneurism,  941. 

.Miliary  fever,  289;  epidemics  of,  289. 

.Miliary  tubercle,  214;  tuberculosis,  acute,  217: 
tuberculosis,  chronic,  235. 

.Milk,  and  scarlet  fever,  71 ;  and  typhoid  fever, 
5 ;  products,  poisoning  by,  1071 ;  sickness, 
287  ;  tuberculous  infection  by,  210. 

Mind-blindness,  928. 

Mind-deafness,  929. 

Miner's,  aniemia  or  cachexia,  1090;  lung,  587; 
nystagmus,  850;  sarcoma  of  lung,  590. 


INDEX. 


1129 


Mitchell,  W<ii\  trcatiiiont  in  liystor'm,  1031. 

.Mitrul  iru'oniiu'tciicy,  'U');  diii'riiiisi.s  of,  »14fi ; 
I'ti'iliiiiv  of,  i\iU\  iiiorlikl  iiiiiitiiiny  nt',  t!4."); 
l>liy.sk'iil  siL'iis  iif,  t'lls;  syiiii)tiiiu!(  ol',  iltt. 

Milrul  stenosis,  lil'.t;  eiiorcii  uiul,  1)411;  (■tiolo;.'y 
of,  04'J ;  morbid  nniitoriiy  of,  650 ;  pliysii'ul 
siifiis  of,  ti')l ;  i»r(.'syst<ilio  iniirimir  in,  t>")i ; 
rlu'uumtisni  luul,  (i4'.';  symptoms  of,  li'il. 

Moist  souiiils,  'Jill. 

MoilusL'um  ooiitajfiosum,  pariisitos  in,  losl. 

MoMoiilt'jjriH,  hiil,  1)24;  fufiul,  Vi'>.i\  in  liyHterin, 
10-':!;  in  truimuitic  nuurosus,  1037. 

.\f(iiil<iii/iii  on  I'cniii  I'olii',  sos. 

Montival  (i<'m'ral  llosi>ital.  autopsies  in  dipli- 
tlioria,  lo'.i ;  in  typlioid  fever,  0;  ileatli-ratc 
from  typlioid  fever  nt,  3").  Statistios,  of  apex 
lesions  in  l.ooo  autopsies,  271  ;  of  dysentery, 
14.') ;  of  liiemorrluiirie  sniall-pox,  T)!! ;  of  pnen- 
nionia,  Ml  ;  of  rheumatic  fever,  21)2;  of  ty- 
phoid fever,  •'!. 

.Montreal  small-pox  epidemic  1885-'8(5,  CO,  09. 

Morl)illi  liaMiiorrhajjiei,  ^3. 

Morbus  eu'ruleus,  (H17. 

Morbus,  eoxiu  senilis,  300,  308  ;  errorum,  lli'S  ; 
niaoulosits,  343. 

Morluis  maeulosus  neonatorum,  347. 

Morphia  habit,  10)11  ;  treatment  of,  1002. 

Morphinism,  I'd'iI. 

Morphioiimnia,  loOl. 

Rrorphiva,  1048. 

.Mortality,  in  cerebro-.«pinal  nicningitis,  102; 
in  pneumonia,  ."))il  ;  in  typhoid  fever,  3") ;  in 
whoopinir-eoujjrh,  'Jl  ;  in  yellow  fuvcr,  142. 

Morton's  painful  foot,  101)i. 

Morcaii'n  disease,  '.)13. 

Mosquitoes,  relation  of,  to  filaria  disease,  10i)2. 

Motor,  nuclei,  ehronie  detrenei'ation  of,  019, 

Mountain,  aiuemia,  lO'JO;  fever,  2s8  ;  sickness, 
288. 

Mouth-brcathinfr,  "04. 

Mouth,  diseases  of,  3,")1  ;  dry.  357;  putrid  sore, 
.352. 

Movable  kidn<_,, ,  758  ;  dilatation  of  stomach  in, 
700;  symptoms  of,  700;  treatment  of,  701. 

Movable  liver,  491. 

Mucous  colitis,  422. 

Mucous  patches,  187. 

Muftuct,  353. 

"  Mulberry  "caleidi,  800. 

Multiple  ttanf,'i'ene,  1042. 

Multiple  sclerosis,  905, 

.Mumps,  8I),  3.")7. 

Munich  Patholoirical  Institute,  statistics  of  au- 
topsies in  typhoitl  fever  at,  0  ;  of  tuberculosis 
in  children  at,  254. 

Munich,  reduction  of  typhoid  mortality  in,  35. 

Murmur,  in  aneurism,  7I<1;  brain,  335  ;  cardio- 
respiratory, 247  ;  in  couirenital  heart-disease, 
698 ;  Flint^s,  040 ;  luemic,  725 ;  in  endocar- 


ditis, 020  ;  in  lunjr  cavity,  247 ;  In  (>ubcluvian 

artery  in  phthisis,  247  ;  in   valvular  disea.-c, 

1I40,  )!44,  );4s,  )151,  054. 
Must'a  domeslica,  1  llo  ;  .M.  vomitoria,  1  \W. 
Muscle  callus  in  sterno-nuistoid  in  infants,  sOS. 
.Muscles,  diseases  of,  1050;  deu'eneration  of,  in 

typhoid  fever,  11,  :''». 
.Muscular  atrophy,  t'onns  of,  lo51  ;  hereility  in, 

li'51  ;  atrophic  and   hypertrophic   variities, 

1052;   infantile   form,   lo52;  juvenile   type, 

1053;  projjtre.ssive   neural    form,  lo54  ;  pei'o- 

ncal  type,  li)54. 
Muscular  atrophy,  proirressive  s]>inal,  919;  eti- 

oloiry  of,  920;  luMcditary  intlueuce  in,  920; 

morbid  anatomy  of,  920 ;  syiii]itoms  of,  921. 
Muscular  contractures  in  hysteria,  1023. 
Muscular  exertion,  coma  after,  7f^l. 
Muscular  exertion  in  heart -disease,  037,  674. 
Muscular  rheumatism,  3))3. 
Museulo-sjiiral  paralysis,  s74. 
Musical  faculty,  loss  of,  in  aphasia,  929. 
Musical  murmurs,  )144,  098. 
.Mussel  poisoning,  lo71. 
Myalgia,  303. 
Mycosis  intestinalis,  170. 
Mycotic  gitstritis,  377. 
.Myelin  defrcneration  of  alveolar  cells,  525. 
Myelitis,  acute,  8S9  ;  acute  central,  890  ;  acute 

ti'ansvcrse,  i^Ol ;  compression.  914  ;  in  measles, 

84  ;  of  anterior  horns,  892  ;  retlexes  in,  891  ; 

transverse,  of  cervical  region,  892  ;  syphilitic, 

191,  193. 
Myelocytes,  738. 
.Myelojrenous  leukiemia.  735. 
Myiasis,  1109;  of  nostrils  and  of  oars,  1109;  ot 

vajfina,  1109;  cutaticous,  1109. 
Myocarditis,  070  ;  acute  interstitial,  070  ;  llbrous, 

070  :  in  rheunuitism.  290;  proirnosis  ot',  080; 

scirnu'iitinir,    20,    077  ;    symptoms    of,    ))78  ; 

in  syphilis,  197  ;  in  typhoid  fever,  19;  treat- 
ment of,  080. 
.Myocardium,  diseases  of,  075 ;  lesions  of,  due 

to  disease  of  coronary  arteries,  075. 
Myoclonia,  1055. 
.Myoclonies,  lo5i!. 
Myopathies,  the  primary,  li>51 ;  diagnosis  of, 

11)53. 
Myositis,  10.50  ;  ossificans  progressiva,  1050. 
.Myotonia  congenita,  l)i54. 
Myotonic  reaction  of  i,'rb,  li>55. 
.Myriachit,  997. 
.Mytilotoxln,  IO71. 
Myx(edema.  754 ;  acute,  755  ;  congenital  form, 

754  ;  operative,  755. 

Xails,  in  typhoid  fever,  17  ;  in  jihthisis,  250.. 
Nasal  diphthci'ia,  113. 
Naso-pharyngeal  obstruction,  304. 
Neapolitan  fever,  287. 


1130 


IN' DFX 


Neck,  (•(•llulitis  of,  nr.i. 

NucnmiH,  wutf,  III'  lioiic,  2!C  ;  in  fyiiho'ul  t'cvor, 
'M. 

NciTONiH,  ntiU'riiic,  l^ri. 

Nccros'm  it)  tiihcri'lf,  'Jir). 

N('iiiat(nl('s,  (lisciiHcs  omiscil  liy,  los.T. 

Nciniitdiil  wiiriiiH  ill  tlic  cuimiiuli  iliict,  t"!. 

Ni'iiliriilj,'iu,  loll). 

No[)liritis,  782;  noute,  7ft2;  afttr  (liplitlicrin, 
lir);  fliroiiic,  7«7 ;  elirDtiic  liu'iiiorrliaj^io, 
7Mt. 

Nc'iilirilis,  cliroiiic  intirstitiiil,  7'.iO  ;  diiiixri'isis 
of,  7'.i'"> ;  itioldny  of,  7l">;  Ini'innrrliii^ri's  in, 
1\)!i',  incri'H(*i'il  tunnion  in,  7!i4  ;  nioiiiid  iiniit- 
otny  of,  7'Jl  ;  proiriiosin  of,  7!Mi ;  ri-iatioii  of 
licart  liyiH-'rlrojiliy  to,  7!'^  ;  Hyiii])foni»  of, 
"'.•■'! ;  tnatnii'Ut  of, "!••) ;  urim;  in, 7'.iy  ;  vomit- 
ing,' in,  7'.'''. 

Kopliritis,  c'lironio  parfncliyiiiatoUH,  788;  con- 
Kcciitivc,  7!'U  ;  in  urysipulas,  125;  in  i-lirfniiu 
suppuration,  78S ;  in  inaluriu,  1(!;!,  7^8;  in 
Moarict  fever,  '!!'> ;  in  typtioiil  fever,  'J'J. 

Nephritis,  lyniplioniatouH,  2',i ;  KU])purativc,  800. 

Is'eplirolitliiusis,  80() ;  nyniptoni.s  of,  H(I7. 

Kepliro-plitiiisis  (sec   Kidney,  Tubeiici'i-osis 

ot ). 

Nepliroptosis,  7.')8. 

Neplirorrliapliy,  701. 

Nejilirotoniy,  hOJS. 

Nepliro-typhus,  29. 

Nerve-ttlircs,  intlaniniation  of,  833. 

Kerve-root  symptoms,  1)14. 

"Nerve-storms,"  1012. 

Nerves,  diseaaos  of,  833;  diseases  of  cranial, 
840;  diseased  of  spinal,  871, 

Nerves,  lesions  of,  874;  anterior  erural,  87(i ; 
cireumile.v,  874;  external  popliteal,  877  ;  ii\u- 
teiil,  87(i ;  internal  popliteal,  877  ;  lon^r  tlui- 
raeic,  874;  median,  87") ;  niuseulo-spiral,  874; 
obturator,  87ti :  sciatie,  870 ;  small  seiatie, 
870 ;  ulnar,  875. 

Nervous  diarrliujn,  415,  1027. 

Nervous  dyspepsia,  380. 

Nervous  system,  diseases  of,  810. 

Nettle  rash  (see  Uktkahia). 

Neuralfjia,  1013;  causes  of,  1013;  cervieo-bra- 
ehial,  1014;  cervieo-oeeipital,  871,  1014;  in- 
fluence of  nuilariu  in,  1013  ;  intercostal,  1015  ; 
lumbar,  1015;  of  nerves  of  feet,  1015  ;  phrenic, 
1015 ;  plantar,  1015 :  reflex  irritation  in,  1013  ; 
treatment  of,  1010;  trifacial,  1014;  visceral, 
1010. 

Neurasthenia,  1032;  etioloj^y  of,  1032:  symp- 
toms of,  1033 ;  traumatic,  1035 ;  treatment  of, 
1039. 

Neuritis,  833 ;  arsenical,  837 ;  fascians.  834 ;  in- 
terstitial, 833;  lipomatous,  834;  localized, 
833,834;  parenchymatous,  834 ;  multiple,  833, 
835  ;  alcoholic,  830 ;  diagnosis  of,  838 ;  en- 


demic, srsH  ;   in  diphthorio,  110;  in  elironii' 

jihtliisis.  2111 ;  in  tiie  infectious  dis«'uses,  h:!7  ; 

in  typhoid  fever,  2";  recurrinjf,  h3ti;  suiur 

nine,  H37  ;  traumatic,  835  ;  treatmunt  of,  839  ; 

optic,  844. 
Neuro>{lioma,  970. 
NeuroMui,  iilexiform,  840. 
Neuromata,  839. 
Neurons,  810. 

Neuroses,  occupation,  1017. 
Ncutrophiles,  7;iH. 

New-born,  liu'iriorrha;rlc  diseases  of,  347. 
New  j;rowtlis  in  the  bowel,  445. 
Nijfht-blindness,  843;  in  scurvy,  340. 
Nijrht-sweuts  in  ])lithisis,  245;   treatment  of, 

270, 
Niffht-tcrrors,  3ti(), 
Nipple,  Ptt<iKVii  disciwe  of,  1081. 
Nitric-acid  test  for  albumin,  709. 
Nits,  1108. 

Noddiiiff  spasm,  870, 
Nodes,  IMnrden^s,  ".or,. 

Nodes,  symmetriciil,  in  conjfcnital  syphilis,  190. 
Nodules,  rheumatic,  297. 
Noma,  3,54;   in  scarlet  fever,  77;   in  typlioM 

fever,  30,  32, 
Normoblasts,  729, 

Nose,  bleedinj;  from  (see  Epista.ms),  510. 
Nose,  diseases  of,  512. 
Nose-bleedinjjf  in  typhoid  fever,  11. 
Nucleo-albumin,  7t'i9. 
Nunnnular  sputa  i;;  phthisis,  240. 
Nurse's  contracture  of  Trousseau,  1019. 
Nutinc),'  liver,  402. 
Nyctalopia,  843 ;  in  scurvy,  340. 
Nystajrmus,  8.50  ;  in /><V(/c/'/<'AV  ataxia,  912;  in 

insular  sclerosis,  900  ;  of  miners,  650. 

Obesity,  1077. 

Obsession,  997. 

Obstruction  of  bowels,  443  ;  acute,  44ri ;  chronic, 

447. 
Obturator  nerve,  870. 
Occipital  lobes,  tumors  of,  972. 
Occupation  neuroses,  1017. 
Ocular  palsies,  treatment  of,  853. 
Oculo-motor  paralysis,  recurrinj,',  849. 
Odor,  in  smuU-pox,  03;  in  typhoiil  fever,  17. 
(.PaIcuui,   nnjrio-neurotic,    1043 ;  collateral,  in 

lunjj;s,  ,540;  febrile  purpuric,  345;  liereditaiy, 

1044;    of    luni,'s,   ,539;    maligmuit,   175;   of 

brain  in  uraemia,  779,  940. 
(Kdematous  laryngitis,  519. 
(h'rUVs  method  in  obesity,  081,  1078. 
(Rsophageal  bruit,  371. 
(Esophago-pleuro-cutuneous  ttstula,  873. 
(Ksophagismus,  370. 
(Esophagitis,  acute,  369  ;  chronic,  370. 
CEsopliagus,  diseases  of,  309;  cancer  of,  ;)72; 


INDKX. 


1I3I 


diliitntinns  of,  .17.1;  ilivortiiMilii  of,  37-1;   i>n 
ralysis  nt',   .'t"<>;   poHt-iiiortiiii   diffcsfioii  ni', 
37.'!;  rii|iturc  nf,  ;i7;!;  h|iii.siii  of,  370;  Htric- 
tiiru  of,;i71 ;  fypliilin  of,  r.C;  tulfcrculowisof, 

Oiiliuiii  iitliicims.  3.'.1. 
OUiK'tory  nci-vc,  hJo. 
Oiiu'iituiii,  tiilKTi'ulourt  tumor  ol,  25!);  tumor 

of,  m  ciiiK'i'r,  r>07. 
Oiiioclyiiiii,  304. 
<  >iiomutoiuuniu,  007. 
Oiiycliiu,  in  iirthriti.s  tlcformans,  .^07  ;  in  loco- 

motonitiixia,  007  ;  sypliilitic,  1M7,  IHO. 
OptTiitioiiyicr  w,  utfi'i'ts  of,  in  epilepsy,  1011, 
Opcrution,  tuhoroiilosis  ultcr,  L'Ut. 
Ophthulniiit,  ifonorrlicul,  with  iirtliritis,  '2'.>><. 
Opiithulmoiilegiii,  8.52;  cxternii,  H.')2 ;  intcrmi. 

8.'):?. 
Opistliotono.s,    ctTvicul,    in    infunt.-i,   0.11;    in 

tctunus,  182. 
Opium,  poi.-ioning,  (liasjnosis  from  uni'mia,  71I  ; 

lial)it,  lotJl  ;  smokili!.'.  etl'ci'ts  of,  1im;i. 
Optio  norvi!  atrophy,  Hit ;  iicreditary,  844;  in 

utu.xia,  00.') ;  primary,  844;  .Ht'oomliiry,  844. 
Optic  nerve  and  tract,  diseusea  of,  841,  844. 
Optio  neuritis,  844;  in  ahscews  of  lirain,  07."> ; 

in  brain-tumor,  071 ;  in  tuberculous  menin- 

>;iti»,  224. 
Orcliitis,  in  malaria,  171;  in  nmmps,  87;  inter- 
stitial, in  syphilis,  198  ;  in  typiioid  fever,  20  ; 

in   variola,  53 ;  parotidua,  87 ;  tuberculous, 

2()6;  value  of,  in  diagnosis,  200. 
Oriental  plague,  144. 
Orthotonos,  in  tetanus,  182. 
Osteitis  deformans,  1047. 
Osteo-arthropathy,   hypertrophic    pulmonary, 

1047. 
Osteo-myelitis  simulating  acute  rheumatism, 

207. 
Otitis  media,  in  typhoid  fever,  28 ;  in  scarlet 

fever,  77. 
Ovaries,  tuberculosis  of,  200. 
Over-c.\ertion,  heart  affections  duo  to,  674. 
Oysters  at^d  typiioid  fever,  5. 
0.\alat.e-of-lime  calculus,  800. 
Oxaluria,  774. 
Oxygen,    inhalations    of,    in    diabetic    coma, 

330. 
Oxyuris  vcrmicularis,  1084. 
Oysters,    poisoning    by,    1071 ;    and    typhoid 

fever,  5. 
Ozwna,  514. 

Pachymeningitis,  932. 

Pachymeningitis  cervicalis  hyperirophien,  882. 

Pachymeningitis    hroniorrhagioa,    of   cerebral 

dura,  932;  of  spinal  dura,  881. 
IhgeVs  disease  of  the  nipple,  losl. 
Palate,  paralysis  of,  in  diphtheria,  110;  in  fa- 


cial i)aralysin,  S.'7;  perforation  of,  in  scarlet 

fever,  77. 
Palate,  tlllii>rculosis  of,  201. 
Palpable  kidney,  7."i8. 
Palpitation  of  heart,  084. 
Palsies,  cerebral,  of  children  ("see  IlKMiPi.Enu 

liK  ('llll.miKN),  0.58. 

Palsy,  lead,  loO,".. 

Paludistn  (see  .Mai.akiai.  Kkvkui,  1.1.'). 

Pancreas,  diseases  ot",  402. 

Pancreas,  cancer  of,  400;  lesions  of,  in  dial)e- 
tcs,  322;  cysts  of.  40."i ;  ha-morrluige  into, 
402  ;  influence  of,  in  diabetes,  321. 

Pancreatic  diabetes,  323  ;  calculi,  4'.'7. 

I'ancreatitis,  acuti^  hii>mr)rrhagic,  403  ;  chronic, 
40."> ;  fat  necrosis  in,  404;  gangrenous,  40."i ; 
suppurative,  404. 

Papillitis,  844. 

Pariesthesia  (numbness  and  tingling),  in  neu- 
ritis, 830 ;  in  locomotor  ataxia,  OOO ;  in  tumor 
of  brain,  072;  in  primory  cotnbined  sclerosis, 
002. 

Parageusis,  80.3. 

I'aralysis,  acute  ascending,  8O1'  ;  acute  spiiuil, 
of  adults,  80(! ;  acute,  of  infants,  802;  agitans, 
082;  alcoholic,  836;  JwU'n,  8.'>.'i ;  l)ull)ar, 
acute,  922  ;  chronic  j)rogressive,  923  ;  of  lilad- 
der,  in  myelitis,  890;  of  brachiid  plexus, 
873 ;  in  chorea,  900 ;  of  circumflex  nerve, 
874;  crossed  or  alternate,  925,  940  ;  "crutch," 
874;  Criu'(il/iier''>i,  010;  diver';s,  8ss ;  of 
diaphragm,  872;  after  diphtheria,  110;  />«- 
c/uiiiie^ii,  922;  following  e|)ilepsy,  IdOO;  of 
facial  nerve,  8.")5 ,  of  fifth  nerve,  8.">3;  of 
fourth  nerve,  850 ;  general,  of  the  insane, 
000;  of  hypoglo.ssal  nerve,  870;  hysterical, 
1023  ;  infantile,  802  ;  labio-glosso-laryngeal, 
922;  Z««(//'y«,  89i') ;  of  laryngeal  abductors, 
804;  of  adductors,  805;  in  lateral  sclerosis, 
808 ;  from  lead,  1065 ;  in  locomotor  ataxia, 
008;  of  long  thoracic  nerve,  874;  in  menin- 
gitis, 223,  930;  of  median  nerve,  875;  of 
musculo-spiral  nerve,  874;  of  oculo-iiiotor 
nerves,  840;  of  olfactory  nerve,  841  ;  period- 
ical, 1II39;  in  progressive  muscular  atrojihy, 
021  ;  radial,  874;  of  rectum,  in  myelitis.  800; 
of  recurrent  laryngeal  nerve,  8ri4  ;  secomlary 
to  visceral  disease,  835  ;  of  sixth  lu^rve,  851  ; 
of  third  nerve,  849  ;  of  ulnar  nerve,  875 ;  of 
vocal  cords,  804. 

Paramyoclonus  multiplex,  lo.')5. 

Paraphasia,  030. 

Paraplegia,  from  alcohol,  830;  from  an«?min  of 
spinal  cord,  880;  from  compression  of  cord, 
914;  dolorosa,  OKi;  from  luemorrliage  into 
cord,  887 ;  from  ergotism,  1072 ;  hereditary 
form  of,  000;  hysterical,  1023 ;  in  lathyrism, 
1072;  from  myelitLs,  890 ;  in  pellagra,  1073; 
spastic,  898,  002 ;  spastica  cerebrulis,  OUO ; 


I  i 


ir 


1132 


INDEX. 


from  Mpinnl  phpIoh,  01  i ;  Hyjihilitic.  siis  ;  from 
liiiiinr  (iftlic  I'onl,  IMm  ;  ill  tiilicn,  IMiH. 

riirii|ili  jfir  tlatiiiif,  H'.is. 

I'aru.-<iti's.  ilixi'itst'N  (liic  to  iinliiiul,  10*^0, 

I'liniMitic  (.'uxtrit'w,  .'!77. 

I'liriiHitic  stiiirmtitiH,  ;)."i.'t. 

I'lirusypliilitic  iiUfcticinn,  !'*><,  !' '.y. 

"  rarcliiiunt  (•riicklirn; '"  iu  lii'iln,  3!W. 

pHrciu'liyiiiatipiiH  iif|p|irili>.  7'^h. 

l'uiii'tc>-(ii'i'i|iital  riiriiiii,  l>raiii  tiiiinprs  in,  ii7'j. 

"  I'ar'iH  ifrccii,"  iHiihuniiiif  liy,  I01.7. 

/'iiri'iiinDii'H  ilisciiso,  [<•*•!, 

I'niiPMiriiu,  Mlo. 

I'ariiticl  li\il">,  .">.'i7. 

I'arDtitiH,  I'liidcrn'u',  Si!  ;  (U'afiu'sx  in.  s7;  dclir- 
iiiiii  ill,  h7  ;  clironii',  35s  ;  oroliilis  in,  S7  ;  hjic- 
ciHc.  K<\ 

ranititis,  nymptoinatic,  ^'>7  \  after  iiliiliiininiil 
Buction,  !1')S  ;  in  ]in('iiiuiinia.  .'i.^s  ;  in  tyiiiioid 
fi'ViT,  'Jl  ;  in  tjiilius  t'l'Vcr,  -li'.. 

PuroxyHnial  liuMn();,'l()binuria,  7il'i. 

/'iirriit'n  ulcors,  !!.Vi. 

I*ati'llar-tfncl(>n  ri'lU'X  (see  Knke-.(erk). 

I'fi'tiiril(»iiiy,  '_'47. 

I't'ilieuli,  llus;  relations  of,  to  taelie  Meuutre, 
16,  1108. 

I'l'ilieulosiH,  nOS. 

I'l'dieiilus  eapitis  ;  I',  corporis,  11(I8. 

I'l'iioiiiata,  li>. 

I'l'lioMis  riiiMiiiiatica,  .'Ut ;  in  eiiorea,  Wii, 

IVllavTrt,  W">. 

I'd  vis  of  tcidney,  atl'i'i'tions  of  (see  I'vki.iti.-), 

l'unij)hij;oid  purpura,  .'il-t. 

I'l'tnphifiiis  neonatorum,  IS',). 

IVnnsylvania  lIosi)ital,  107;!,  1070. 

I'eniisyivanin  Institution  for  Feeble-minded 
CliiUlren,  iir)8,  IdO'J. 

rentastomes,  Hot). 

I'l'ptie  uleer,  .'?lt-t ;  dyspepsia  in.  .'?07 ;  hipmor- 
rluijfe  in,  3'J7 ;  pain  in,  ;!!i7 ;  tentlerness  on 
pressure  in,  3H7. 

Peptones  in  the  urine,  tests  for,  770. 

I'eptonuria,  7T0. 

Perforating  uleer  of  foot,  !"I7. 

Perforation  of  bowel  in  dysentery,  loS;  in  ty- 
phoid fever,  8,  2i. 

Periarteritis,  nunumitous,  198;  nodosa,  719. 

Pericardial  frietion,  CIS. 

Periearditis,  (51i>;  aeute  plastie,  617;  acute 
tuberculous,  206;  aphonia  in,  'J'20 ;  chronic 
ndhesive,  6^4;  chronic  tuberculous,  iir)7  ;  dc- 
lirlumin,  Oa.l ;  diairnosis  of,  (iltl,  622  ;  dyspha- 
(fia  in.  620;  epidemics  of,  617;  epilepsy  in. 
621;  from  extension  of  disease,  617;  from 
foreign  body,  616  ;  in  chorea,  tt'Jl ;  in  fa'tus, 
617 ;  in  gout,  316 ;  in  rheuniutism,  2i(.5 ;  hiern- 
orrhagic,  257, 1120  ;  hyperpyrexia  in,  618,  621  ; 
physical  signs  of,  61S,  (i21  ;  primary,  616; 
prognosis  uf,  622 ;  pulsus  paradoxus  in,  620  ; 


Bccondnry,  616;  oymptoinHof,  618,  620;  treat- 
ment of,  tl23  ;  with  etfnsion,  tillt. 

Perieardiuiii,  ailhereiit,  621;  f'riiilr<ii/i'n  sign 
in,  625. 

Pericardium,  iliseases  of,  >\\i<;  tiiberciilosis  ut', 
256  ;  air  in,  6'_'i;. 

I'erieboiidritis,  hiryiiL'eal,  in  tyjilioid  l"ever,  25; 
in  tulurculnsis,  5'.".', 

Perihepatitis,  475,  .505. 

I'erinephric  abscess,  sl4. 

I'eriodical  |iHralysis,  I031), 

I'eriosteal  ciichexia,  o41. 

Peripheral  miiritis,  >>;'. I. 

Peristaltic  unrest.  JiN-^,  1027. 

I'eritonieiim,  diseases  of,  41i8. 

Peritonieum.  tliiiil  in,  .507,  511 ;  cancer  of,  606  ; 
new  u'rowilis  in,  5oi!. 

Peritonieum.  tuberculosis  of,  25s  ;  aente  iiiil- 
iary,  25s;  chronic,  25s ;  chronic  tlbroid,  25s. 

PeritoniLMiiii,  tumor  formations  in  tuberculosis 
of,  2511. 

Peritonitis,  acute  u'cnenil,  43.1,  438,  4!is,  MKi; 
appendicular,  4;'.s,  ,"iIp4;  chronic,  5o.'),  511; 
chroiiie  hu'iiiorrhagie,  506  ;  ditl'use  adhesive, 
505 ;  livstcrical,  .501  ;  idiopathic,  4li8 ;  in  in- 
fants, 502;  in  tyjihoid  fever,  24;  leukiemie, 
7;i7  ;  local  adhesive,  .505  ;  localized,  4;!3,  502  ; 
pelvic,  504;  pirforative,  4',is  ;  primary,  4'.is ; 
proliterativc,  ,"io5  ;  pya'iiiic,  4!'8  ;  rheiimnlic, 
4!is  ;  secondary,  498  ;  septic, 498;  subphrenic, 
.502  ;  tuberculous,  268,  5o6. 

Peritonitis,  tuberculous,  etiects  of  operation  on, 
511. 

Perityphlitis.  429. 

"Perles"  of /.((,/,«,'<■.  533. 

Pernicious  aiuLMiiiu,  726. 

Pernicious  malaria.  161.  169. 

I'croneal  type  of  inu.scular  atrc  phy,  1054. 

Pertussis  (see  WnooiM.Nu-Coioii  1,  88. 

Pesta  magna,  .50. 

Petectiin;  in  epilepsy,  1006;  in  relapsing  fever, 
48 ;  in  scurvy,  339 ;  in  small-pox,  57  ;  in 
typhus  fever,  45. 

Petechial  fever,  911. 

Petit  nial,  loo2,  1006  ;  in  general  paresis,  96S. 

Pei/er''s  patches  in  typlioid  fever,  6  ;  in  meiisUs, 
81  ;  in  tuberculosis,  262. 

Phairocyt 'sis  in  erysipelas,  124;  in  innlarin, 
liil ;  ill  tuberculosis,  21.5. 

Pharyngitis,  359  ;  acute,  359 ;  chronic,  359  ; 
retrfi-pharyngeal  abscess  of,  361 ;  sicca,  360. 

Pliarynx,  acute   infectious  phlegmon  of,  360; 

hiemorrliage  into,  358;  liyiicriemia  of,  35s ; 

ledcma  of,  359;  paralysis  of,  864 ;  spasm  "f. 

1;  tuberculosis  of,  261  ;  ulceration  of,  3ilii. 

Pharynx,  diseases  of,  358. 

Philiidelphiu  Hospital,  relapsing  fever  at,  IS  1 1. 
48;  typhoid  and  typhus  fever  a*,  2;  tyi'liu- 
cpideniic  in  1883,  44;  statistics  of  cerebi'o- 


IK  HEX. 


ii:i;j 


H|iiiml   fever,   'M>\    '■(  tleliriuiu    tremrnn  in, 

lOlill, 

riiiliiilel|iliiii  Innnimry  fur  NervcuiK  Disn-iuie'', 
ftnliitii'i  of  elmreu, '.i'<r> ;  of  heliilpUviu  itiul 
<li|i|eL'iu  ill  illfllllts,  '.i."i^  ;  of  e|iile|wv,  loo-.', 

I'llilililelplliii,  luKerelllosis  ill  eilv  wiinlit,  ^10 ; 
Jellow-fever  epiileliiie  ill,  17'.'''1,  iJi'.l. 

I'hleliilis  of  [lortiil  vein,  inO. 

I'llli'lio-nelero.tin,  7l''!. 

I'lioHpliiiteM,  iilkarnu'.  TT'' ;  e  irtliy,  '''i. 

I'lio^pliatie  eilli'llli,  Mill. 

I'lin,i|ilmturiii,  77i"i 

riio!*])|iorus  iMpi.Hoiiinir,  Nliiiiliirity  of  ueute  yel- 
low utri)i>liy  to,  401. 

riireiiie  nerve,  iiU'eetioiis  of,  «71. 

I'litliiriiisi.H,  lio.H. 

I'litliiriii^  puliis,  llOH. 

I*lithi«ieiil  friime,  llipiKuratiii'a  deseription  of, 
211. 

J'litliiuls,  228;  elironie  iileerutivo,  2.".l ;  iieiite 
j>neuiiii>iiie,  2211;  urterio-Hcieronis  in,  2.'i:! ; 
l)u.sie  form  of,  2;!.''i ;  HriKlitV  (liseii.se  in,  2.'iii; 
of  coiil-iniiiers,  2l;i,  .")S7  ;  elironie  arthritis  in, 
2.'J3  ;  couxh  in,  2  JO  ;  eiiiloeiinlitiH  in,  2;t8, 24M  ; 
iliii^fnosis  of,  2.')0  ;  (listriiiiitioii  of  lesions  in, 
2i'.4  ;  erysijieliis  ill. 'J.">2  ;  fatal  lia'inorrliinre  in, 
2.")r> ;  fever  in,  242  ;  forms  of  eavities  in,  2;i(p ; 
pLstrie  syiiiptoins  of,  248 ;  hieinoiitysis  in, 
242  ;  modes  of  death  in,  255  ;  inodeH  of  onset 
in,  238;  pliysieul  »»i).'lis  of,  245;  pneumonia 
in,  253;  relation  of  tistula  in  aiio  to,  2ii2 ; 
Hputuin  in,  240;  summary  of  lesions  in,  2:t.'. ; 
syiiiptoins  of,  2;il» ;  typhoid  fever  in,  2."i;i ; 
vomitinif  in,  249. 

riithisis,  tigroid,  251,5liii;  florida,  231  ;  reiiiim, 
21)4:  syphilitie,  1!I4;  of  stoiie-eutters,  213, 
5H7  ;  unity  of.  21ti ;  vdiitrioiili,  378. 

Physii>lo;;ieal  alliumimiria,  707. 

I'iii  mater,  disea-ses  of,  883,  1)33. 

J'iea,  38U. 

I'ierio-ttoid  test  for  altiuinin,  7'10. 

l'if,'eon-t)reast,  in  rickets,  335  ;  in  niouth- 
breuthers,  3(iti. 

I'ijfiiientation  of  skin,  from  arsenic,  1008;  in 
Jia»tiiuic''s  disease,  753  ;  from  ]ihtliiriiisis, 
1108;  in  Addixoii's  disease,  748;  in  chronic 
pulmonary  tuberculosis,  250;  in  mel:'.liosis, 
74',» ;  in  peritoneal  tuberculosis,  25il. 

I'iffinentatioii  of  viscera  in  pellajfra,  lo73. 

Pi;^s,  tuberculosis  in,  203. 

Pin-worms,  1084. 

Pitch,  in  cavities,  cliansrn  of.  247. 

Pitting  in  small-pox,  55;  metisures  to  prevent, 
02. 

Pituitary  body  in  ucroinei,'alin,  1040  ;  in  gigan- 
tism, 1040. 

Pityriasis  versicolor,  2.')0. 

Plaques  a  surface  rcticulee,  7. 

Plaques  juuncs,  950. 


I'liistic  bronchitis,  5.10, 

I'leura,  disiiises  of,  5',i2. 

Pleura,  eeliilioi'oceUH  of,  UoJ;  tllliercillosis  of, 
25il, 

Pblinil  eirusion,  /liiii,  l/i'n  hit'll  ill,  5'.i0,  5'.i><  ; 
compression  of  luiuf  in,  .M'.l ;  dia;;iiosis  of. 
Ool  ;  hiemorrbiiu'ic,  lioo  ;  in  marlet  fever,  7<''; 
position  of  heart  in,  o'.i  I ;  pseudo-cavernous 
HiiriiK  in,  51*0;  purulent,  5',i7  ;  iteri>UH  elfu-^ioii, 
eolistitliellts  of,  .'I'.l'l ;  sudden  dealii  ill,  5'.i7. 

Pleural  meliibranes,  eabilieutiiin  of,  I'liM'i, 

Ph'iirisy,  acute,  5'.i2  ;  diaphniifinatic,  lioo  ;  en- 
cysted, Onl  ;  etiolojfy  of,  •lie.',  ,-,^7  ;  tlbriiious, 
5ii2;  interlobular,  Ool  ;  in  typhoid  fi'Vcr,  20; 
pain  in  side  ill,  51H;  plastic,  51'2 ;  pleural 
friction  in,  5'.Mi;  pulsatiiii.',  5!i'.i,  71;!;  scim- 
tlbrinous,  5!i2 ;  treatment  of,  >;>>:;;  tulnr.u- 
loiis,  250,  5113,  Ooo. 

Pleurisy,  chronic,  005;  dry.iio:. ;  primitive  dry, 
000;  vaso-motor  plieiiomeim  in,  Oo7 ;  with 
etliisioli,  Oo.'), 

Pleurodynia,  'M>i. 

Pleuro-pcritoiieal  luberi'ulo>is,  255, 

Plcurosthotoiios  ill  tetanus,  ls2. 

Plexiform  iii'iiroiiia,  s4o. 

Plica  poloniea,  llos. 

Plumbism,  1O03;  and  gout,  310;  as  n  causes  of 
renal  cirrhosis,  7in  ;  paralysis  in,  I0);,"i. 

Plymouth,  epidemic  ot' typhoid  fever  ut,  5. 

Pncumaturia,  324. 

I'neumogastric  aiine,  lo(i4. 

Piictimogastric  nerve,  all'eetions  of,  sri3  ;  cardiac 
branches  of,  800;  j;astrie  mid  (csoplmgcal 
branches  of,  807  ;  laryngeal  liranclies  of,  804; 
jiharyngeal  branches  of,  804 ;  pulmonary 
branches  of.  sr.o. 

Pneumonia,  acute  eroii[M)iis,  545;  abscess  in, 
501;  acute  delirium  in,  555;  bleeding  in, 
504 ;  clinical  varieties  of,  558;  eoliti.s,  croupous, 
in,  5.50 ;  eom])licatioiis  of,  551! ;  crisis  in,  551 ; 
delayed  resolution  in.  5t!l  ;  dia^iiiosis  of,  502; 
dia;;nosis  from  acute  jineumonie  phthisis, 
2.11;  dii)lococeus  piicumoniii',  545,  540;  en- 
docarditis in,  550;  eniforgemetit  of  lung  in, 
548;  epidemics  of,  540,  551) ;  etiolo;;y  of,  .545; 
fever  of,  551 ;  fibroid  indurution  in,  501  ; 
gangrene  in,  501  ;  gray  he|iati/utioii  in,  5r.l; 
herpes  ill,  555;  immunity  from,  547  ;  in  dia- 
betes, 55ii;  in  infant.s,  55'.t;  in  intlueii^.a,  55'J; 
ill  old  age,  55!) ;  iiieniiiiritis  in,  5.50;  morbid 
anatoiny  of,  .548;  mortality  of,  501  ;  pericar- 
ditis in,  5.50;  physical  signs  of,  553;  prog- 
nosis in,  50O  ;  pseudo-crisis  in,  551 ;  purulent 
infiltration  in,  54U ;  recurrence  of,  558 ;  red 
hepatization  in,  54M ;  rela|ise  in,  558;  resolu- 
tion of,  50O;  serum-thcrupy  in,  548;  symp- 
toms of,  551  ;  terminations  of,  500  ;  treatment 
of,  503. 

Pneumonia,  ocute  syphilitic,  103 ;  apex  pneu- 


1134 


INDEX. 


innnia,  ri.Mt ;  iispirafum  or  (loiflutitioii,  .">71  ; 
"  i'i'rL'l>riil,"  i>M;  I'lironic  iiiterstitiiil,  r)ilii, 
SliH;  chronic  ])li-uroj,'i'ii()u»,  tiOT  ;  ooiaunioii, 
54t!;  double,  f).')'.! ;  tihriiious,  Mri ;  liyiio.stiitic, 
.l;!!*;  in  maliirlii,  l'i.'5;  iniLTstitiiil.  of  tlic  root, 
in  wvpliilis,  I'.it;  in  tvplioiil  tVviT,  St;  lar- 
viil,  iVi'.i ;  loliur,  r>4.'i;  niiissivo.  r)."plt ;  niitrra- 
tory,  'iW  ;  plc'rotft'iious  interstitial,  TitiT  ;  ty- 
phoid )>nt'uinoniu,  Ti.")!! ;  white,  of  tla-  fo-tiis, 
1'.I4. 

PlU'Uiiioiiitis,  rit"). 

I'nciiiMoiiokuninsis,  TiiiS,  nst. 

rni'iunu -ptrioanliiiin,  CrMi. 

I'nt'innorrha^ia,  M". 

I'nciunotliorax,  tins ;  after  tracheotomy,  ril.'>; 
causes  ot',  ilUS  ;  ehronit'.  ill  1  ;  Ilippoernlie  sue- 
cussiou  in,  tllo  ;  inorliid  anatomy  of,  (io'.i  ;  in 
jilithisis,  ;i;!H ;  from  inuseulur  ellort,  rto'.t ; 
Skoiid'n  rcHonaliec  in,  fdiil ;  gy  rnptonis  of,  ilOit ; 
treatment  of,  illl. 

Pnennioto.vin,  .Vts. 

I'neunio- typhus,  •J.'i. 

J'oila),tru,  ."O'J. 

I'ododyniu,  1015. 

]'oikil(ieyto»i«,  72!*. 

J'oisoiiiiijf,  by  li'Ui'omaines,  IdilO  ;  by  leail,  lO'l:! ; 
hy  nicMt,  loi'i'.t;  Ipy  ptomaines,  10i;',i  ;  Uy  sewer- 

(jas,  'Js"). 
Polioniyelitis,  acute   and  suhucute.  in   adults, 

S'.Hl. 

Poliomyelitis  anterior,  acute.  S'.i-J  :  epidemics 
of,  S'.t-J  ;  etioloifv  ot".  S!i2  ;  morbid  ariati'iiiy  of, 
H'.ti! ;  proiTliosis  of,  S'M  ;  symptoms  ot',  3U3. 

Poliomyelitis  anterior  chroiiicu,  'Jl'.i. 

I'olyadi'tioiiiata,  41o. 

Piilyu'mia.  7">'). 

polyneuritis,  acute  febrile,  835  ;  reeurrens, 
8;tt!. 

Polyphagia,  ■T25. 

Polysareia,  I077. 

Polyuria  iscc  Di.miktks  Insiimims).  .'tllo. 

Polyuria,  in  abdominal  tum>>rs,  .'mU  ;  in  hys- 
teria, a.'l-J,  loj-J. 

pons,  lesions  of,  '.•2'> ;  tumors  ot',  ','7'!. 

Poor-man's  s:out,  "di>. 

Popliti'al  nerve,  external,  S77  ;  internal,  >77. 

I'orenci'phaliis,  '.t'l'.'. 

pork  in  relation  to  trichinosis,  I0S7, 

Portal  vein.  4<('i  ;  throndiosis  of,  4''c,i ;  suppurn- 
tion  in,  4*i. 

F'ost-cpilcjitic  coiiditiniis,  loor,. 

Post-hcmiplei;ic  clion^a,  '."lo ;  epilepsy,  '.li'.O, 
I11114  ;  movement.s,  "Jilil. 

post-mortem  movement)*  in  ehidera  bmlies,  \:Vt. 

Post-pharynjfcal  abscess,  ;!iil. 

i'ost  typhoiil,  anaMiiiu,  18;  uluvutiuiu  of  toiii- 
perature,  l,'). 

J^'tf'i  disease,  !I14. 

Pounion,  ulcL^ren  du,  509,  539. 


Pre^naney,  and  acute  yellow  atropliy,  4'>'.> ;  an. I 

chorea,  ',»ii> ;  and  phthisis,  'jr,',i ;  and  typhr>ld 

fever,  3J, 
Presystolic  niunnur,  C51. 
Priapism  in  leukuMina,  7<'!7. 
Prickly  heat  (see  riiTiOAlti.v ). 
I'roeession  catiTpiUjir,  etleets  of,  1110. 
Professiomd  >i  ;ij<nis,  loi7. 
Projfloitis  of  ta-nia,  I'iih;. 
l'r<n;ressjve  muscular  atropliy,  01(>. 
Proj^'rossive  pernicious  ameniia,  7;;''' ;  bloo<l  in, 

7'Js  ;  diagnosis  of,  731  ;  etiolojry  ot',  7'Ji) ;  iiior 

bid  anatomy  of,  7'.i8 ;  proirnosis  of,  731  ;  symp 

tomsof,  7"J>< ;  treatment  of,  733. 
Propepton,  770. 
I'rippbylaxis,    a^fainst    cholera,     137  ;    airainsl 

scurvy,    310;     atruiiist     tuliereulosis,     ^iHi ; 

iVainst  ta'iiia,  loim  ;  airainst  trichina,  losji ; 

airainst  typhoid   t'vwr,   3.J ;    iijj;ainst   yellow 

fever,  14-'. 
Prosopaltria.  lol  1, 
I'rostate,  tul)ereulosis  of,  2»ifi. 
Protozoa,  diseases  caused   by,  lOso  ;  parasitic, 

1080. 
Prune-juice  expectoration,  .M>1. 
I'ruriiro,  in  ll'uhikiu'x  disea.se,  74."). 
Pruritus  in  diabeti's,  ;',-J."i ;  in  ura'mia,  7'-ii;  in 

obstructive  jaundice,  4.''i7  ;  in  ({out,  31ti. 
Pseudo-aiiirina  pectoris,  tJH3,  lo-.'H. 
Pseudo-apoplectic  seizures  in  fatty  heart,  tl7''. 
I'seudo-biliary  colic,  4ii7. 
Pseudo-bulbar  paralysis,  '.cj3. 
Pseudo-cavernous  sinns,  l'4S,  M6,  (J02. 
Pseudo-eyesis,  10'J4. 
Psendo-di])htherilic  linx'esscs,  106. 
Pseudo-hyilrophobia,  1m). 
P.seudo-liuka'inia,  74'J. 
I'seudo- ptosis,  s4;). 
Pseudo-rheumatie  atVeetiona,  301. 
!*seud')-s<'lerose  en  plaipies,  'Jili!. 
Psilosis.  4'Jl. 
P.soriasis,  buccal.  "M. 

Psorospcrmiitsis,   loso;    eutuneous,    losl  ;    in- 
ternal, liixo. 
Ptomaine  poisuniiiir,  lO'IO. 
Ptosis,  forms  of,  sl'.i ;  hysterical,  S4'J  ;  ia  ala.xia, 

'."O.'i;  pselldo-,  s4;). 
Ptyalism,  3.")."i,  ;!,')7. 
Puberty,  barkin);  coui^li  of.  102«. 
Pubx.  irritaiis,  llO'.i;  penetrans,  1109. 
Pulnional-cerebral  abscesses,  U75. 
Pulmonary  f  see  I.rNcjsi. 
Pulmonary  ap"ple\y,  .'il'J. 
I'ulmonary  artery,  sclerosis  of",  70:1 ;  pirforati"n 

of,  71 'J. 
I'ulmonary    Inemorrhai^e.    540  ;    treatment    "!', 

:.i:t. 
Pulmonary  oriflec,  ennifcnitiil  lesions  of,  O'.C  : 

valves,  lesioim  uf,  U55. 


INDEX. 


1 135 


Piiltnonory    ustco-iirtliropatliy,    liyportropliic, 

I'ltr. 
I'ulsaiiriv'  I'lfurisy.  '>'.i',i,  71;). 
I'lilsation,  (lyiiiiiulo,  (it'uortii,  713. 
I'ulsi',   iiltcniati',   "l^il ;    anaftoiiiMtii'.    V'^t;    <li- 

•  Totic,   !•<;    UlllllT   illtilll'lU'l.-    nf  (liuMtallr*.    I'llid  ; 

int»Tiiiittt'iit,  <lN,"i ;  irri'ifulur,  ij>i; ;  liitri'iii'mal, 
tisd,  (Js"  ;  rri'urri'iit,  T'll. 

l'iili<i',  oapillury  i  scu  r.vi'ii.i.Aiiv  i ;  C'lrriij'in's, 
lUl  ;  vvatcr-liaimruT,  tlU. 

I'uisc,  s\i<\\\  in  tiiluTciiloiis  nu'iiitiiritis.  •-'•Jo;  in 
jamnlii'i'.  4i'4  i  »cf  liitAi  itv<'.\iti>iA,  •(>•?). 

I'lilstw  parailiixus.  liiio,  I'l-J.'i.  lis.'i. 

I'llpil,  Ar(j!/U- h'lihi  Hkoii,  s.IO. 

I'lipillary  iiuu'tion,  liciiiiKpic.  >»t7. 

I'lipil.s.  uncinial,  >."iii;  in  L'tiuTal  paresis.  '.I'W. 

I'lirpiira,  ".t't;  artliritii'.  ".tl;  caclicctic,  .'li:!: 
diau'iiosis  (if,  . 'fill;  t'ulniinans.  .'Hii ;  //<  iidcIi'm, 
34'> ;  int'eetii)iis,  ;t4.'{ ;  nu-oliunical,  ;U4  ;  neu- 
rotic, .'U4;  peliosis  rlieuHiatieain.  :!H  :  liaiii- 
orrluijxiea,  ;!t'i;  simplex,  .">U;  syinptnnialie, 
y4-'! ;  toxie,  ;!i;i ;  tri'atiiient  of,  ;U7  ;  urticans, 
344;  variolosa,  ">ti,  ."i7. 

I'lirpuric  ii>(lcnia.  :!4."i. 

I'ustiilc.  niarnriiant,  174,  17'). 

I'utriil  son-  inoiitli,  :Vt± 

I'yieiiiiu,  l-Jii;  arterial. '1:11 ;  iiliopntliic,  I'JU. 

I'ya'inic  alisi'css  of  liver,  |sl,  iXA, 

Tyclitis,  7'.i'.t :  iliaijMosis  o|',  so-j;  jnterniiltent 
fever  in,siil  ;  nioiUid  anatomy  ol'.  son  ;  prns;- 
nosis  ot",  H(»;t ;  pyuria  iTi,  sol  ;  symptoms  of, 
Mol  ;  treatment  of,  so.! ;  m  typlmitl  tcver,  S.i. 

ryelonepliritis,  ~m. 

I'yieplileldtis  u<lliesiva,  4iVJ. 

I'yieplileliitis.  iit  ilyseiitery,  1.")'.';  in  pyivtiiia, 
l;iii;  sujipurativc   4''i-'l,  »s|. 

I'yIortH'tomy,  statistics  of.  ;i',t.'i. 

I'yloroplasty.  statistict"  of,  ;j'.i;), 

l'yonepliro«i.s,  7'.'9. 

l'yo-piieuiiiotliora\,  :.!.".'!.  iM>'*. 

l'yo-pneiiiiiotliora\  siiopliriiiicus.  .T.i.'i.  .")(i;),  tUo. 

I'yuria.  771  ;  in  ty\ilioiil  I'ever.  '.'.  •_".'. 

(Quarantine  a'^ainst  vcllo'v  I'ever,  14-;  U{;aiilst 

cholera.  1">7. 
(Quartan  airue.  li;7. 
l^ucliec,  elioU  ra  at.  in  isi'cj,  \:\>. 
<Jiiiifir'n  lumliar  puncture,  '.••17,  97!>. 
<juin:ne  ra-'i.  7'.i.  7*. 
(Quinsy  (see  ToNsii, LITIS.  :m  I'i'i  iiativk;. 
(juotiiliuii  Ufiw,  \<H, 

Kaliies.  177;  etiology  of.  17.  ;  morliii!  anatomy 
of.  17'.*  ;  preventive  inoculation  in.  17'.'; 
Hyniptoins  (if,  17^;  treatment  of.  17'.'. 

Ivacliitic  liones,  ;i:'in. 

Kacliitis  (see   UicKKTsi,  ."J.TJ. 

Uaijial  paralysis,  '^'i. 

Uau'-picker's  disease,  176. 

Uuilwuy  bruin,  1035. 


Railway  spine.  10".">. 

/t'llhiii/'K  tlllies.  los'l. 

Kapiil  lieart,  <i">7. 

Hashes,  from  dniirs.  7"^.  34^  ;  in  srlaMilers.  '.'Sl  ; 
in  measles,  s-J ;  in  rclapsiii<.'  fever,  4s;  in 
rulielhi,  s."i ;  in  scarlet  fever,  73;  in  sniall- 
pox ;  .V) ;  in  syphilis,  ls7;  in  typhoid  fever, 
I'l;  in  typhus  I'ever.  4.">;  in  pya'iiiia,  13o;  in 
vaccination,  t'o  ;  in  varicella.  7". 

liasplierry  tnnirue  in  si'iirlet  fever.  73. 

Ka> -l'uni.'u>  I  actinomyces  I.  -Jsj. 

/I'li/iniio/'s  disease,  lo41  ;  aphasia  in,  lop',  ;  and 
sclepHlernia,  lo4',' ;  epilepsy  in,  I04;;;  lu'.-iiio- 
t'loliinuria  in.  lo4i; :  patholot'y  ot",  1"43. 

Reaction  of  de;;eneratioii.  s-.",i.  s:;s.  s,-,7. 

Kccrudescence  of  t'cvcr  in  typhoid  fever,  l.'i. 

Kcctal  crises  ill  tahes,  '.Mi7. 

Kcctiim.  irritalile.  loj7  ;  stricture  ot".  I',i7  ;  syph- 
ilis ot'.  I',t7;  tulierciilo.-.is  ot'. 'Jil'J. 

Uci-urrciit  laryiiiTcal  lurve.  paral\  sis  ot',  sr)4. 

IJecurrellt  pulse.  7ol. 

Keciirriiii.'  multiple  neuritis,  s3ii. 

Red  sot'teiiili!.'  of  liraill.  '.'."lO. 

Re(lu|ilieution  of  heurt-souuils,  0«rt. 

Re(lux  crepitus.  .".■>4. 

RcHex  epilepsy,  loo4. 

Ucltexes  in  asccndiiiiT  paraly>i~,  s;»7 ;  in  (>prp- 
iiral  liiemorriiai.'e.  '.'17;  in  locomotor  ataxia, 
!iM."i;  in  p(jrK)-myelitis  acuta.  s<.i4;  in  spastic 
paraplciria.  K'M>:  in  hysterical  parapleiria.  !'Ol. 
10'.'3;  in  proirressive  muscular  atrophy.  '.'Jl. 

RcL.'iiri.'itation.  tricuspid.  •i,'')3. 

lifiihmnHii's  disease.  3s7. 

Rohipse  in  typhoid  fever.  32. 

Relapsiiii.'  fever.  47;  spirillum  of.  48. 

l{emitteiil  fever.  li'C 

Reiial  calculus,  sm;. 

Renal,  eolic,  sus;  .sand,  sor,;  sypliilis,  i;i'»; 
sclerosis,  7W. 

A'.  ((.///'»  type  of  tremor.  U'l'S. 

Ren  niohilis.  7"''<. 

Resoliitiiin  in  pneumonia.  .'>>'>o. 

Resonance,  umphoric,  J47,  'lo'.' ;  tympanitic.  •J47, 
.I'.i.'i,  iKtit. 

Respiratory  system,  diseases  of.  ."il'.'. 

Rest  treatment.  lo"d  ;  in  aneiiri;iii,  714. 

Rcliiia.  legions  of.  sil. 

Retinal  hypeni'sthesia.  s4:i. 

Retinitis,  ulhuniinuric.  *>■_':  it;  anii'miu.  '*4'i; 
ill  malaria.  M'i;  leiika'iiiic.  ^\1:  piirmeiitosn, 
s»j;  ssphilitic.  Is7.  s4-.'. 

Retraction  of  head  in  nieiiin;.'itis.  ^-^3,  '.t3il. 

liclro-iiillic  spasm,  s.'.'.t. 

Retroperitoneal  uliseess.  434.    , 

RetiopcritoniiMim.  lueniorrhaire  into,  M, 

Retro  pharwiL'cal  al>»eess,  3i'd. 

Ikctropulsion  in  paralysii*  ajfituns,  t>83. 

Revaecination,  'i.'i. 

UlinbaitiH  Niully,  1002. 


'i^l 


1136 


INDEX. 


Hliiitpilii-Miyonin  of  kiclncy,  811. 

Hliuliiloiicinii  ilitestiiinlc,  \'>'.>'>. 

Hlmtriuli'.s,  isii. 

KliuuiiiatiL-  fever,  2'.)iJ ;  h}.'o  in,  202 ;  oprcbnil 
foniiilii'Htioll.s  of,  •i'.ii) ;  diiijriio.sis  of,  2!»7  ;  ftl- 
dociirilitis  ill,  'J'.i."> ;  etioloifv  of,  2!''J ;  HhrouH 
iioiliili's  ill,  :.".i7  :  fTfrrii  theory  of,  'J'.i.! ;  iierol- 
ity  ill,  2',i:!;  iiyiii'r|iyri-.\iii  in,  211;") ;  iiictiiliolic 
theory  of,  2',i.'!;  iiiorltid  iiiiiitoiiiy  of,  21t.'! ; 
nervouH  theory  of,  '2Wi  ;  iierieunlitis  in,  2!i.") ; 
purpura  in,  2'."!;  sex  in,  •J'.i2;  Kyniptonis  of, 
2!i4  ;  treatment  of,  2'.ts. 

Rlieuniatie  jjout  isee  Aktiikitis  Defoumans). 

Khcuiniitio  noiluies,  2!C 

lilieuiiiatisni,  elironie,  300;  etiolojjy  of,  300; 
niorliiii  uniitoniy  of,  .'ioo;  pr(i;.'niisi.s  ot",  300; 
syiii|)toins  of,  30(1 ;  treatment  of,  300. 

Kheuiiialisiii,  musouhir,  ."ios. 

Hheuniatisin,  suhiieute,  2'.ir). 

liheuiiuitoid  urthritls  (nue  Authritis  Defok- 

MA.NS). 

Kliinitis  atropliica,  .MS;  flbrinosa,  113 ;  hyper- 

tropliiea,  513;  ^iilnpl»•x,  .')13;  sypiiilitie,  1811. 
Kii>»,  reseetion  of,  in  eiiipyeiiia,  (lOi"). 
Kiee-water  Htooin,  130. 
Kieket.H,  332;  aeute,  33ii,  311  ;  etioloiry  of,  332  ; 

fiL'tai,  332;  morbid  anatomy  of,  333;  projrno- 

sis  of,  33ij ;  Kyinptoms  of,  334;  treutiuent  of, 

337. 
AVj/fj'n  discuHO,  S.'ia. 
Rijfidity,  early,  in  heniiple^ria,  013. 
Kiu'idity,  late,  in  heiiiipleifia.  017. 
Kitjors,  in  absee.ss  of  brain,  1'7") ;  in  abHopss  of  | 

liver,  4^?2  ;  in  a^'iie,  I'i;!;  in  pneuiiKHiia,  r>.")l  ; 

in  pyaMiiiu,  130;  in  jiyelitis,  hoi  ;  iu  tuber- 

eiilosis,  230  ;  in  typhoid  fever,  15. 
Kisus  !*ardoiiiciis,  l^l. 
Kivernide    Hospital,    New    Vork,   typhus   epi- 

deiiiie,  IM'^I.  44. 
KocU-fuver,  2.S7. 
Hontlirrij'ii  symptom,  oot). 
Uoot-iierve    .syniptoiii.s    in   eoinprcssioli    para- 

pli'iiia,  014. 
Kosary.  riekety.  3;!4. 
Roseola  isee  RosB  R.v.sii  oF  TviMloiK),  10;  epi- 

demie,  «.'». 
"  Rose  eold,"  51,"). 
Rose  rasli  ill  typlioid  fever,  10. 
Itotatioii  in  epilepsy,  1<mi,"i, 
Rotatory  spawn  in  liyHteriii.  lO'i.*). 
Rr.theln.  k5. 

"  Roiiu'li-on-rats."  poisoninii.'  by,  1007. 
Round-worms,  lo,s3. 
Rub  I  see  FmeruiN;. 
Rubella,  K.'i. 
liubeola  nothn.  Si's, 
Runiiiiation,  3ss. 

Runnintr  pulse  in  typhoid  fever,  19. 
Rutisiun  fvvcT,  02, 


Saceliaromyeos  albicans,  35.1. 

Sacral  plexus,  lesions  of,  ^~>'<. 

St.  V'ilus's  dance.  '.•>^5. 

Salaam  convulsions,  '.lOO,  lo-J4. 

Saline    injections,    intravenous,    in    diiibeti'' 

coma,  3.'!(i;  siilicutaiicous,  in  cholera,  13.s, 
Saliva,  arrest  of,  ;)57  ;  hypcrsccrctinii  (if,  ;\:,-, 
Salivary  glands,  di.seases  of,  357  ;  intlumiiuiti"ii 

of,  357. 
Salivation  (see  Ptvamsm).  355,  ;!57 ;  in  sniiiU- 

pox,  50;  ill  bulbar  ]ianil.\sis.  '.(•J2. 
Salpiiiiritis,  tuherculous,  20o,  2il7. 
Saltatorie  s]iasiii,  007. 
Sand-tlea,  1100. 
Sanitaria  for  tuborculosi.s,  273. 
Saimemia,  127. 
Saraiiac  Sanitarium,  273. 
Sarciiia  veutriculi,  3!il  ;  in  liiiiir  cavities.  242. 
Sarcocy.-ititt  Micscheri,  lOMi ;  sarcocysti.s  lioini- 

nis,  1080. 
Sarcoma,  of  lir.iiii,   071;   of  kidney.   ^11;  xi 

liver,  4><7;   of  luiii.',  50o  ;  mediaslinal,  01;i; 

melanotic,  4^7. 
Sarcoptes  scabei,  1107. 
Saturnine  ncuriti.s,  837. 
Saturnism,  loo;!. 
Sausairc  poisoniiiir,  looo. 
Scajiulodynia,  .".o4. 
Scarlatina,  niiliaris,  73. 
Scarlatina  sine  eriiptione,  75. 
Scarlatinal  nephritis.  75. 
Scarlet  fever,  71;    anginose   form,  75;   atactic 

form,  75;   complications    and   seiiuehi',   7'; 

contagiousness  of,  71;  <lesi|uamation  in,  71: 

diagnosiH  of,  77  ;  eruption  in,  73;  etioloiry  oi, 

71;   hieiuorrhagic  form,  75;   incubation  of. 

73;  invasion  in,  73;  malignant,  75;  iimrliid 

anatomy  of,  72  ;  proiriiosis  of,  70  ;  puerperal. 

72;  surgical,  72;  treatment  of,  70. 
Schistosoma  litematobiiim,  1083. 
•Sr/i,"niliiii'ti  disease.  344. 
Schodl-made  chorea,  0^7. 
Sciatica.  ^77. 
Sciatic  nerve.  s70. 
Scirrhous  cancer     ''stomach,  4o3  ;  of  pancrca.-. 

400. 
Sclerema  in  cholera  infantum.  410. 
Sclerema  neonatorum,  IoJh. 
Sc^lcrodactylie,  I040. 
SdenKlerina,  104H. 
Sclerose  ell  plmiues,  !i05. 
Sclerosis,   ccrcl)ro-s|iiiial,   003,   005 ;  degeneni 

tive,  003;   developmental,   0<!4  :    inHamiiiii 

tory,  004  ;  of  scurvy,  33it ;  syphilis  nn  a  cai>' 

of.  18H. 
Scleroses,  lateral,  HOS  ;  insular.  005  ;  nuiltipU  . 

005. 
Sclerosis.    po>terior    spinal     (see    LoroMoTod 

Ataxia),  002;  in  clironic  urgotimn,  1072. 


INDEX. 


1137 


Sclerosis,  primary  combined,  901. 

Sclerosis  in  tulnTclcs,  21.j. 

Sclerosis,  ri'iiiil,  T'JO. 

Sclcriwtoiiiiiiii  tluoduuale,  1090;  S.  equiniliii, 
lO'.iO. 

Sclerotic  (gastritis,  378. 

Scdlices  of  ediiiiococous,  1102. 

Scorbutus,  .3;?7. 

Scrivener's  palsy,  1017. 

Scrofula,  M-J-l ;  alle^^ed  protective  inoculation 
by,  ii:iC. 

Scrofulous  piiiumoiiia,  :il7.  ii-iO. 

Scurvy,  337 ;  diii<,'nosis  of,  340;  ctiolofry  of, 
337  ;  infantile,  3il  ;  morbid  anatomy  of,  339; 
prognosis  of.  310  ;  prophylaxis  of,  340  ;  i-clc- 
rosis,  339  ;  symptoms  of,  339  ;  treatment  of, 
340. 

Scybala,  45:^. 

Scii.sonal  relations,  of  chorea,  9.Hr) ;  of  malaria, 
15G;  of  pneumonia,  r>45  ;  of  rheunuitism,  U9J. 

Secondary  contracture  in  hemiplcffia,  947. 

Secondary  deviation,  .h,"i1. 

Secondary  fever  of  snuill-pox,  So. 

Sclf-liiuitation  in  tuberculosis,  •i<\H. 

Semilunar  space  of  Trnuhe^  iV,n\. 

Setiiilumir  valves,  aortic,  incompetency  of,  637. 

Senile  enij)hysenia,  Tis;!. 

Sensation,  painful,  loss  of,  in  syringomyelia, 
913. 

Sensation,  retardation  of,  in  ataxia,  906. 

Septicicmla,  \M\  cryptogenetic,  128 ;  general, 
I'j,');  progressive,  lii:);  tyjihoid,  11. 

Septico-pyninia,  129. 

S'    iiittis  palsy,  874. 

'Sevcn-iluy  fever,  47. 

Sewer-gas  and  tonsillitis,  3r>l. 

Sewer-gas  poisoniii:^,  cllei'ts  of,  285. 

Sex,  intluclii'i'  ot',  in  heart-disease,  Otlti. 

Sexes,  proportion  of,  atl'eeletl  with  acute  yel- 
low atrophy,  459  ;  in  chlorosis,  723  ;  in  cho- 
rea, 9s,") :  in  exo|ihthaIiuie  goitre,  7."d  ;  in 
general  paresis,  9iitl ;  in  lueiiiophilia,  34'J. 

Shaking  piilsv,  '.is2. 

Shi'U-lisii,  poisoning  by,  1071. 

Ship-lever,  43. 

Shock  as  a  cause  of  traumatic  neuroses,  lO.'i.'i. 

Slioi'U.  death  from,  in  acute  obstruction,  447. 

Si<-k  headache,  loll. 

!^iekness,  sleipiug,  1092. 

Siilerosis,  i187,  0^9. 

Sit'iuil  symptom  (ineortieid  lesiims),  924. '.172. 

Sin'.'ultus  (si'c  Ilic'coroM  I. 

Sinus  thrombosis,  9.")t! ;  in  chlorosis,  72t'i,  '.t.'iii ; 
and  pyii'inia,  9.">7  ;  secondary,  in  eur-disea.se, 
9."iii. 

Sixth  nerve,  paralysis  of,  H,')l. 

Skin,  itching  c)f,  in  unemia,  7H0. 

Skoda's  resonance  in  pleural  ctfuaion,  595  ;  in 
pnuumuuiu,  onS. 

7a 


Skull,  of  congenital  syphilis,  190;  of  hydro- 
cephalus, 978  ;  of  rickeUs,  330  ;  pereussiou  of, 
977. 

Skeiiing-sickne.ss,  1092. 

Slow-heart,  (is^. 

Small  sciatic  nerve,  876. 

Small-pox,  .jo  ;  complications  of,  59;  confluent 
form,  5.');  contagiousness  of,  5o ;  diagnosis 
of,  60;  discrete  form,  55;  eruption  in,  55; 
etiology  of,  50 ;  ha-morrhugic,  56  ;  inocula- 
tion in,  50  ;  morbid  anatotny  of,  52  ;  progno- 
sis of,  1)0;  symptoms  ot',  53;  treatment  of, 
62  ;  vaccination  in,  50. 

Smell,  atl'ectionrt  of  scuse  of  (,seo  Oi-FAcToBir 
Nkiivk),  840. 

Snake- virus,  purpura  caused  by,  343. 
]  Snuffles,  189. 
I  Softening  of  brain,  949. 

:  Soil,  intlueiKc  of,  in  cholera,  134;  in  tubercu- 
losis, 212;  in  tvplioid  fever,  5. 

Solvi'iit  treatment  of  renal  calculi,  '^10. 

Soor,  3,53. 

Sordes,  21. 

Sore  throat,  359. 

Suya  bread,  329. 

Spasms,  in  ergotism,  1072 ;  in  hydrophobia, 
178;  in  hystina,  lo23 ;  of  face,  8.')H ;  o/ 
nmscles,  after  facial  paralysis,  H5« ;  prol'es- 
siojud,  10l7  ;  saltatoric,  997. 

Spasm,  lock,  in  writer's  cramp,  1018. 

Spasmodic  wryneck,  868. 

Spastic  paraplegia,  ^98;  family  form  of,  900; 
/;>//■>■  syphilitic,  ^9S  ;  i:i  children,  900. 

SpiiMtic  infectious  di>eases,  1. 

Specillc  treatment  of  typhoid  fever,  41. 

Sjiectra,  fortilicalion,  lol2. 

Spccill  (see  .\lMI.\si,\ '.  927. 

S|icech,  in  adenoid  vegetations,  367;  in  bulbar 
paralysis,  923  ;  in  insula"'  sclerosis,  9i'i6 ;  in 
general  paralysis,  96.S ;  in  hereditary  ataxia, 
912;  in  paralysis  airitans,  9s;i. 

Speech.  scamii>i,r,  in  insular  sclerosis,  966. 

Spes  phthisicu.  21'.i. 

Spina  bifida,  involvement  of  cauda  e(|uina  in, 
917. 

Spinal  accessory  nerve,  paralysis  of,  867. 
I  Spinal  apopli  \y,  >iS7. 
j  Spinal  eoMclissioll,  ellccts  of,  lo36. 

Spinal  conl,  diseases  of,  h7'.». 
I  Spinal  I'ord,  abscess  of,  919;  acute  affections 
of.  s-9 ;  ana'iuia  of.  ss6  ;  clironic   affections 
'      ol',  s'.is  ;  chronic  h  ptomeningitis  of,  Kh4  ;  com- 
pression of,  ',il4;  comrestion  of,  HH6;  embo- 
lism and  throridiosis  of  vessiMs  of,  J5S6  ;  cn- 
I  ' 

dnrtcritis  of  vessels  of,  886  ;  fissures  in,  >(»N; 

hietnorrhage   into.   8S7  ;   leptomeniliifitis   of, 

8.'S3  ;  localization  of  fimctions  of,  sr.i ;  pachy- 

1       meniiiiritis  of',  s>i  ;  sclerosis,  primary  com- 

j      bined,  of,  901 ;  syphilis  of,  191  ;  tuborculuois 


h\ 


1138 


INDEX. 


of,  264;  tumors  of,  917 ;  unilateral  losiona  of, 
880. 

Spinal  epilepsy,  8i)9. 

Spiiiul  irritation,  1033. 

Spinal  nionibranos,  lia>niorrhagc'  into,  88r). 

S[)inal  iiiuningitiH,  acutf,  883. 

IS[)inal  iicrvus,  diHoasus  of,  S71. 

Spinal  nmirastluiiia  l(i33. 

Spinal  paralysis,  atropine,  89'i. 

Spine-chair  off/.  K.  MitcliifU,  OlO. 

Spino  -  niuseular  sejtment  (of  motor  path), 
lesions  of,  820. 

Sjiirals,  f'Kruchinivui^H,  .^34.  r)37. 

Spirilhiru  of  relaiwiiiif  fever,  4S. 

Spirnehiete  Obeniieieri,  48. 

SplaneliMoptosis,  TlJO. 

Spleen,  apiyioid  de^'cnerati'm  of,  in  syphili>, 
VM\\  in  tul)ereulo.>is,  J38. 

Sjileen,  in  airue,  102,  170;  in  antlniix,  17ii ;  in 
cirrhosis  of  liver,  477  ;  in  //(/i/;/X'//r,s' clisfa>e, 
743 ;  hvilaticl  of,  1103 ;  in  leukieniiu,  73.j,  730 ; 
in  rieiiets,  333,  330 ;  in  acute  tiiliereulosis,  -JiiO  ; 
in  typhoid  fever,  '.\  24;  in  tyiiliiis,  44. 

Spleen,  enlarirenient  of,  in  eontjenital  syphili'^, 
185),  1"J1 ;  in  malaria,  101,  170. 

Spleen,  excision  of,  in  hypertrophy,  741  :  in 
lonkieiiiia,  741. 

Sjileen.  tloatint;,  excision  of  741. 

Spleen,  puncture  of,  3.'). 

Spleen,  rupture  of,  in  malaria,  101  ;  in  typhoid 
fever,  9,  25. 

Siileneetoiny,  .stutisties  of.  741. 

Splenic  fever,  174. 

Spleiii/.ation  of  lunf.',  232,  572. 

Spondylitis  dcfoiujans,  30!<. 

S]iorozoa,  lOyO:  parasitic,  lOtsO. 

Spotted  fi^ver,  *i. 

Sprue.  421. 

Sputa,  all>umini'iid.  after  ns|iiriition  of  chest. 
t)04;  iilveolur  cells  in,  .52.">.  ."^'is ;  amieha  eoli 
in,  103;  in  cancer  of  Iuul'.  .'i'.'!  :  hicmatoidin 
crystals  in,  4s3 ;  in  anthracosis,  .")8li ;  in 
asthma,  533;  in  hrorichicctasis,  .  .".o ;  in 
acute  hronehitis,  r>2.'>;  in  chronic  hn  iichitis. 
.'527;  in  putrid  hmni-hitis,  Wl^;  in  _'aii.rrcne 
of  lunsf,  ."i«.'>. 

Sputa,  in  phthisis.  2lo  ;  iti  pneiinioniii.  .'i."i3  ;  in 
acute  ]iuluionary  tulieri'ulosis.  22o  ;  prunc- 
juicc,  fiyi ;  uric-aeiil  crystals  in,  313. 

Staphylocoi'ci,  in  iliphtheria.  loii;  in  endocar- 
ditis, 031;  in  ]iiiir. mills,  4'.i',i;  in  i)neuinonia, 
.549;  in  pyiemia.  129;  in  scptlcicniia,  128. 

Staphylococcus  citrcils  in  rlicuinatic  fever, 
293. 

Status,  epilcpticus,  100r> ;  liystericus,  1029. 

Stcarrhu'a.  490. 

t^tilliviufs  siirn.  7.'>2, 

Stenocardia,  090. 

btonosis,  of  aortic  oritlcc,  043 ;  of  mitral  orittce. 


049;  of  ]i\)linonary  oriflco,  655,  697;  of  tricus- 
pid orifice,  0.'j4. 

Stcppai.'c  ^'iiit,  837. 

Stercofacccnis  voniitintf,  440. 

Stercoral  ulcers  in  colitis,  423. 

Stcrtf>r,  in  apoplexy,  943, 

.■^titrncck,  303. 

Stitriiiata,  in  hysteria,  1028;  in  purpura,  344. 

Stitch  in  side  in  pneumonia,  S.'il,  .")li4. 

Stolidity  of  face  in  >:cneral  paresis,  9ii8. 

Stomach,  acute  cancer  of,  404. 

Stomach,  atrophy  of,  37S ;  cancer  of,  402;  iih- 
seiicc  of  ficc  llCl  in,  4o,"> ;  dia.u'nosis  tVom 
;fustric  ulcer  and  ehronii'  trastritis,  40S ;  cij. 
olo^ry  of,  4o'j;  liaMuorrhaire  in,  405;  morhid 
anatomy  ot',  \'<1\  vmuilinir  in,  fo.'i. 

Stoiiiarh,  dilatation  of,  ;;',iij ;  tetany  in,  391. 

Stomach,  iliseascs  of,  374. 

Siipmaili.  clinmic  catarrh  of,  377;  foreicrn  1">.1 
ies  in,  410;  Inemorrhajte  from,  397,  411 ;  linir 
tumors  in,  410;  neunwes  of,  38,5;  non-cancer- 
ous timiors  in,  410;  ojierations  on,  statistics 
of,  .",',•:!;  tulierculosis  of,  -ji'il ;  ulcer  of',  394; 
w  :i>lii!iLr  out  of  ( lavairel,  383. 

>^loi>i;ititl--.  ".-'it;  acute,  3.'d  ;  a|ihthous,  S'll  ;  cpi- 
d<M]ii'.  •_'!"!;  fetid.  3.''i2;  follicular.  ;!51  ;!ranL'rc-- 
nous,  r,."ii ;  mcrc\irial,  ".")•'> ;  neurotica  chronica, 
3.")3  :  parasitic,  3r)3  ;  ulcerative,  3,"i2  ;  vesicu- 
lar, 3rd. 

Stone-cutter's  phthisis,  213,  ,').-^7. 

Stool.s,  of  acute  \cllo\v  atrophy,  40O;  of  chnlern, 
130:  of  dy.scntery,  110,  ll'.i.  l.")l ;  of  typlioiii 
fever,  2-;;  in  luemateiuesis,  413;  ofolislrucl- 
ivi'  jaundice,  4.''>8. 

St.  IVtersl'iii-y:  Foundliii;,'  Asylum,  statistics  ul' 
tulieiTulosi.-  at,  2r>4. 

St.  T!i'.)iiia--V  iii'>pitid,  >tiilisti<'s  of  i)neumon'a 
at.  "i02  :  of  aiipendicitis,  441. 

Stridiismu>,  s.M  ;  as  an  early  symptom  of  tubes, 
91 1."). 

Strani:ulation  of  liowel.  44-".,  449. 

•' Strawiierry '"  tonL''ue  in  scarlet  lever,  73,  7."'. 

Streptococci  in  diiihtlieiia,  loO;  in  cmpyenia. 
"I'.is  ;  in  eiidi>carditis,  031 ;  in  pneumonia,  .MH: 
in  iniitoiiitis,  499;  in  [lyaMuia,  13o;  in  smr- 
ht  lever,  72;  in  septiciumiu,  128;  in  tonsilli- 
tis, M-^. 

.Slrcptocoi'cus  iliphtheritis,  100. 

Strcptococi'Us  erysipelatos,  123. 

StrcpliM'occus  pyocrcnes  in  erysipelas,  123. 

Strictures  and  tumors  of  the  bowel,  44."). 

Strictm-e  of  bill-duct,  471. 

Sirietnrc  of' colon.  I'aiiceroiis,  445. 

Stricture  of  iiitcstim'.  445  ;  after  dysentery,  152, 
445;  after  tuberculous  ulcer,  202. 

Stricture  of  (I'sophajrus,  371. 

Stricture  ot' pylorus.  .'I'.iO, 

Stroiuryloiilcs  intcslimilis,  1096. 

Strongylus,  1090. 


INDEX. 


1139 


StriiiiiitiH,  7i")l. 

Stu|>i's,  turpo'Utino,  mctliod  of  application,  41. 

Stutti'iiiii;  in  iiiDutli-liri'iitlicrs,  ;iii7. 

Stvriiiti  iiciiMiiils,  iii-sfn'u'ul  lial>it  in,  loiiS. 

.Siilicliiviiin  aitiiv,  luuiiiiiir  in  and  throl)binif 
(if,  in  plilliisis,  -.'IT. 

Sul)p)irenio  peritonitis,  ,'0:.'. 

!jul)sultus  ti'iuliniiiii  in  tvplioitl  fuvur,  27. 

!^ll^'l•u>si()n,  HippiK-ratii',  liln. 

SiUH'M>siiin  splasli  in  (liliitcd  stomach,  •'!li:J. 

Sucklinjrs,  lulicivulosis  in,  l'ot. 

Suilaniinu  in  typlioid  fuvi-r,  H!. 

Smldi-n  dcatli,  in  aortic  iiisMlUi'icin'y,  lUJ ;  in 
ooronary  artery  disease,  07 'i ;  in  pleural  etlu- 
nion,  r)',i7  ;  in  typlmid  fever,  .'i5. 

Sudoral  furui  of  typlioid  lever,  17. 

Sii;;ar  in  the  urine,  ;!'j:i. 

Sulplioeyanides  in  excess  in  saliva  in  rlieuiiia- 
tisiii.  -j'.iri. 

Sun>tioU(',  10.",7,  107;!:  after-ellects  of,  loTH; 
treatment  o|',  loVi'.. 

Suppression  of  urine,  7'1'i;  treatment  of,  71JI. 

Suppurative  lU'phritis,  ^oo. 

Suppurative  pyK'plileliitis.  -lO.!. 

Supimiative  ton>iUitis,  ;;i'i;!. 

Suiuical  kidney,  soo. 

Suspension  in  compression  parnplcL'ia,  Ol'i. 

Sweatin;;  in  acute  rlieumatisiii,  'J'J4;  in  aLrnc. 
K)!!;  in  dialictes,  :VJ.') ;  in  plilliisis,  '21^1 ;  in 
pya'iiiia,  I'.o;  in  tyi'hoid  fever,  17  ;  in  ulcera- 
tive eiiiloc:irditis.  ii  IJ ;  profuse,  in  rickets, 
n.'M;  unilateral,  in  ccrvicul  caries,  iU.");  uni- 
lateral, in  aneui'isiii.  71-. 

Sweatiii;.'  sickni'ss,  i;--'.'. 

Si/'hii/t(ti/i/<  chorea,  '.'^'>. 

Symmetrical  j,'an;rrciic,  lotJ. 

Syuiiiathetic  jjrani^lia.  in  .li/.//.w)//'.'(  disease,  71". 

Sympatlu'tic  nerve  fibres  (sec.  V.vso-.motoii  1. 

Syiiiptoiiiiitic  parotitis,  :i."p7. 

Syncopal  airue,  \~0. 

Syncope,  I'atal,  in  diphtlieria,  110;  in  cardiac 
disease,  M\i,  ('i,')7,  (J7y;  in  phthisis,  -J.")."!:  in 
pleural  elfusion,  ."i'J7. 

Syncope,  local,  loH. 

Synovial  rlu'umatism  isee  (ioxoifitniK.M.  IJuei- 
.M.MisM  I.  ;!i)l. 

Synovitis,  u'oiiorilueid,  Wi. 

Synovitis,  symmi  trical,  in  cotiiri'nital  syphilis, 
"1110. 

Syphilides.  macular,  l.'<7;  papular,  ls7;  pustu- 
lar, l''7;  squamous,  ls7;  tli,.  lute.  I'^s. 

Syphilis,  ls4:  accidental  inleetion  i;i.  \>i: 
Hci|uireil,  Isil;  amyloid  dcireiicration  in,  Iss; 
eon;;enital,  !>'' ;  diagnosis  of,  I'.im  ;  curly  mrve 
lesions  in,  I'.i'J;  cliolo^ry  of,  [-n  ;  i;miimala  in, 
IK");  hereditary  transmission  of.  l^t;  modes 
of  infection  in.  1st;  morhid  aiuitomy  ol'.  is,"); 
of  hrain  and  cord.  I'.il  ;  of  circulatory  system, 
11)7;  of  digestive  tract,  11)7;  of  liver,  lit.);  of 


lunjx,  10;i;  orchitis  in,  IDS;  primary  sta;:e  ot", 
Ibti;  prophylaxis  of,  l',);i;  renal,  I'.is;  sce- 
ondary  sta^re  of,  isi;;  symptoiiis  ot',  Isi;,  iss; 
I  tertiary  sta„'e  of,  Iss;  treatment  of,  200;  vis- 
ceral, I'.n. 

Svphilis  luemorrhaj,'iea  neonatorum.  Is'.',  ".17. 

Syphilis  hercilitaria  tarda,  •.'07. 

Syphilis  and  dementia  paralytica,  Iss,  I'.iJ,  ui;7. 

Syphilis  and  locomotor  ata.\ia,  ls>i,  DUO. 

Syphilitic  urtclltis,  I'.U. 

S_\  philitie  t'ever,  Im'p. 

Syphilitic  phthisis,  I'.i:!. 

Syrin:;o-niyclia,  '.dJ;  with  hiumorrliai,'e,  S.s7. 

Tabes,  diabetic,  Siil. 

Tabes  dorsalis  (see  LocoMoroit  .\r.\.\i.v  1, '.m)J; 
in  idiroiiic  cri,'otisiii,  io7-. 

'fai'cs  dorsalis  spasmodi(pu>,  S'JS, 

Tabes  mesenteriea,  'JliS. 

Tache  cirebralc,  17,  ".i-j:!. 

Taclics  bleuatres,  li'i,  llos;  relation  to  pcdiciili, 
10,  llos. 

Tachycardia.  1^7,  7.">1 ;  paroxysmal,  i'>--7. 

Tactile  fiemilis,  in  em|physciiia,  .'.sj  ;  in  pneu- 
monia, ,'i.Vi ;  in  pleural  ell  iisioii,  .'c,!.");  in  piu-u- 
motliorax,  Ooii;  in  pulmonary  tuberculosis, 
•Jb'. ;  at  ri.Liht  apc.\,  'Jl."). 

Ta'iiia  echinococciis,  lo'.il),  I  loO. 

Tania  elliptiea,  T.  ein-utncrina,  T.  llavopiuic- 
tata,  T.  nana,  T'.  Madau'asi  arien-is.  loii7. 

Taiiia  sau'inata  or  medioeaiU'llata,  lo'.iO. 

Taenia  solium,  loiMj. 

Tape-Worms,  lo'.n'i;  treatment  of,  iniis. 

Taste,  disturbaiu'cs  of,  bO;! ;  tests  for  sense  .if. 
.si;;j. 

Techomy/a  fuscn,  1  llo. 

Teeih,  actiiiomyecs  in,  '2S.1 ;  Inoseiics.^  of.  in 
sciu'vy,  .'!:'.!• ;  elf.'cts  of  stomatitis  on,  •'.."i."i ;  ero- 
sion of,  ."..TO;  }liilihiiiiiou\i,  I'.iO,  .'J.JO ;  of  in- 
fantile stomatitis.  :!,"0, 

T'eichopsia,  lol-.'. 

Tele;,'rapher's  cramp,  I0I7, 

Temperature  sense,  loss  of,  in  syriniro-my'lia, 
'.lb!;  in  .l/My(''(;/".v  di.seasc,  i)b(. 

Temperature,  subnormal,  in  acute  alcoholism, 
10."i7  ;  in  acute  tiibcri'ulosis,  'Jl'.i ;  in  apoplixy, 
'.'|:f;  in  heat  cvliaustion.  lo7(;  in  malaria, 
li'iii,  170;  in  piilmonMry  tuberi'ulosis.  ^jl  I ;  in 
tuberculous  meniii:.'ilis.  '-'•-'■-';  in  tinemia,  77'.'. 

Temporal  lobe,  I'cntn;  for  hciiriii:,;'  in,  ^."I'.i ; 
timiors  of,  !C-.>, 

Tender  [loints  in  iieurali.'ia,  lolt;  in  livsteria, 

lOl'."), 

Tender  toes,  in  typhoid  fever,  '^7. 
Tclldon-rctlexes  (see  IvKKl.K.XKS^. 

Terminal  iiifeciions,  l;!:J. 
Tertian  U'/uc.  Iii7, 

Testes,  tuberculosis  of,  '_'00 ;  syjiliilis  ot",  l'.)S 
(^suc  ul.so  OiieiiiTis), 


i 


1140 


INDEX. 


Tutiinus,  180;  bacillus  of,  IHl;  (rmi.'iio.His  (if, 
IM'J;  ctidlofiy  <>f,  1«0;  iifoiiatoniiii,  1«0 ; 
proirno.His  of,  182;  Hjiiiptoiiis  of,  1.H1 ;  lox- 
ulliumiii  of,  IHl ;  trcutiiieiit  of,  18;j. 

Totmius,  (■(■iilinrK',  IK'J. 

Tetany,  in  Hi ;  nftfi-  thyroidcetoniy,  1010  ;  diiig- 
iiosiM  of,  Iml'O;  cpidfinid  or  rheuiniitic,  lOl'J; 
ill  dllutatinii  of  tliu  Mtoiuaoli,  'itil,  loi'J;  in 
niyxo'dfiiia,  1019;  iu  typhoid  fever,  Ml  \ 
rarity  of  in  Amerieu,  1019;  syinptoins  of, 
1020;  treatment  of,  1020;  varieties  of,  1019; 
Use  of  thyroid  extraet  in,  1021. 

Totrodon,  jioiHonirij^  by,  lo72. 

Theruiicutie  test  in  Hvphilis,  199. 

Therinie  fever,  107.'!;  continued,  lOTH. 

Thei;;;ic  sense,  loss  of,  in  .syringo-inyelia,  913. 

Third  nerve,  diseases  of,  818. 

Third  nerve,  reeurriiijf  paralysis  of,  849;  signs 
of  paralysis  of,  849. 

Third  ventricle,  tumors  in,  972, 

Thirst  in  diabetes,  n24. 

TliomiK  ii's  disease,  10r)4. 

Thoracic  duct,  tuberculosis  of,  218. 

Thorax,  deformity  of,  in  luoutli-breatliers,  3G0; 
in  rickets,  KH. 

Thorax  in  eniphjsenia,  .')82;  in  phthisis,  211, 
245. 

Thorn-licadcd  worms,  lOH.'). 

ThoniivahWK  disease,  3(i8. 

Threud-woru),  1084. 

Throlibiii^r  a,)rta,  717,  10;U. 

Tlirondii  in  heart,  (ii'iO ;  in  dipJithcria,  111 ;  in 
I>iu'uinonia,  "iriO. 

Thrombi  in  veins  in  typhoid  fever,  20. 

Thrombi,  marantic,  9.')i>. 

Thrombosis  of  eerebral  arteries,  OoO ;  of  cere- 
bral sinuses,  9.')() ;  of  eerebral  veins,  95U ;  of 
portal  vein,  402. 

Thrush,  .-..-in. 

Thynac  asthma,  .'520,  014. 

Thymus  jrland,  in  acromcfralia,  104fi;  cnlargfc- 
mcnt  of,  til4;  sudden  death  in,  t!14. 

Thyroid  abscess,  7r>l. 

Thyroiil  extract,  administration  of,  7''')i>,  1021. 

Thyroid  trlaixl,  disea.'«cs  of,  7i")0. 

Thyrnjd  L'land,  al)crrant  or  ai'cessory  tumors 
of,  7^">1 :  Jibscess  ot',  7.')1  ;  absence  of.  in  cretins, 
7r)4;  adenomata  of,  7.">0;  cancer  of,  1U(\\  in 
exophthalmic  froitre,  7f>l ;  in  >roitre,  7nO  ;  in 
niyx«denia,7."i4;  sareoniaof,  014, 751;  tuniore 
of,  750. 

Tllyroidi^m,  750. 

Tic  convulsif,  8.58,  997. 

Tic  douloureux,  1014, 

Ticks,  1107. 

Tiiniitus  auriinn,  860, 

Tintement  nu'talliiiuc,  007. 

Tobacco,  influence  of,  ou  tlio  heart,  604,  609, 
684. 


]  Ton;,'iie,  atrophy  of,  870;  eczema  of,  356  ;  gco- 
(.'rapliical,  350 :  in  bulbar  paralysis,  li2.". ; 
spiLsm  of,  871 ;  tuliercidosis  of,  201. 

Ton;fue,  tremor  of,  in  (general  paresis,  ims 
ulcer  of  fricnum  in  whoo|)lii;;-eout;li,  89. 

Tonsillitis,  301  ;  acute,  3t;i  ;  albuminuria  in, 
303;  endocarditis  in,  31)3;  in  tlie  newly  mar- 
ried, 302. 

Tonsillitis,  chronic,  304;  follicidar,  301;  lacii 
niir,  3i;i ;  suppurative,  303;  and  rheumatism, 
301. 

Tnnsils,  diseases  of,  301. 

Tonsils,  abscess  of,  303  ;  calculi  of,  307  ;  (diecsy 
nuisses  in,  307 ;  enlar),'ed,  304 ;  tuberculosis 
of,  201. 

Toi>hi,  314. 

Topical  diafrnosis,  sjiinal,  879;  cerebral,  924. 

Toronto  General  Hospital,  statistics  of  typhoid 
fever  at,  3. 

Torticollis,  ."03,  808;  conrrenital,  808;  facial 
asymmetry  in,  808;  spasmodic,  808;  treat- 
ment of,  869. 

Toxu-  gastritis,  370, 

Toxines,  1009;  in  scpticoBinia,  127. 

Tracheal  tujririnjr,  710. 

Traction  aneurism,  707. 

Trance  in  hysteria,  1023,  1029. 

Trdiihi'')!  semilunar  sjiacc,  590. 

Trauma  as  a  factor,  in  delirium  tremens,  1059  ; 
in  neurasthenia,  1035;  in  pneumonia,  540; 
in  tid)(  I'culosis,  213. 

Trematodcs,  diseases  caused  by,  1082, 

Trend)les  in  cattle,  287. 

Tremor,  aleoliolic,  984,  1058 ;  licreditary,  9S  i ; 
liystcrical.  984,  1025;  in  exophthalmic  goitre, 
753;  lead,  lOi'iO;  in  jiaralysis  agitans.  iis2; 
I^iiiiti(''n  type  of,  1025;  senile,  9s4  ;  simple, 
984:  toxic,  984;  volitioiud,  in  insular  scle- 
rosis, 905. 

Trichiiui  spiralis,  1085;  distribution  of,  lO'^ii; 
statistics  of,  in  American  hogs,  1087;  in  (icr- 
nuiny,  lOSO;  modes  of  infection,  1087. 

Tricliiniasis,  1085;  diagnosis  of,  1089;  epidem- 
ics of,  10.S7  ;  propliylaxis  of,  1089;  symptoms 
of,  1087  ;  treatment  of.  1089. 

Trichocephalus  dispar,  lo94. 

Trichomonas  vatrinalis.  1082;  T.  Iiominis,  1082. 

Triehtcr-brust,  245,  300. 

Tricuspid  orifice,  stenosis  of,  054. 

Tricuspid  valve,  insutlieiency  of,  053. 

Trigeminus  (see  Fifth  Nkiive), 

Trismus  neonatorum,  ISO  ;  hysterical,  1024. 

Trommer's  test,  324, 

Trojildc  disorders,  1041. 

Tro])ieal  dysentery,  147. 

Troiimi'iiu''s  symptom,  in  tetany,  1020. 

Tubal  pregnancy,  ruptured,  simulating  perito- 
nitis, 501, 

Tubercle  bacilli,  204,  240. 


INDEX. 


lUl 


Tubercle,  diffuse  inflltratcil,  21(5,  2ar, ;  miliary, 
214;  I'hungcK  in,  215;  struoturc  of,  21.">; 
noiluliir,  214. 

TubtTcleK,  iniliury,  in  oiironie  jilitliisis,  20.'). 

TuIrtcuIu  iloluriisii,  840. 

TuixTculiii,  205;  ti'st,  203,  273. 

TulH'ivuloMiH,  ucuto,  217;  freiuTul  or  tv[ilini(l 
form,  218;  mt'iiiiijLfi-iil  form,  221  ;  iiulmoiiiiry 
form,  220. 

Tuberculosis,  bacillus  of,  204,  240 ;  clianfrus 
produced  i)y  l>ucillus,  214;  cliroiiie  miliary, 
235;  eonditiourt  iiittucncinf,' infection,  211; 
confjcnitul,  201!;  dietetic  treatment  of,  273; 
distril>ution  of  the  tubercles  in,  214 ;  duration 
of  pulmonary  I'oriu  of,  2(i8;  etiolojry  of, 
203;  freneral  measures  in  treatment  of,  272  ; 
hereditary  transmission  of,  20i'>;  individual 
propliylnxis  in,  2(l!i;  infection  by  niout,  211  ; 
infection  by  milk,  210;  infection  by  inha- 
lation, 20'J;  inoculation  of,  208;  in  infants, 
254;  in  old  age,  254;  nietlieinal  treatment  of, 
274 ;  modes  of  death  in  pulmonary,255;  modes 
of  infection  in,  20(5 ;  natural  or  spontaneous, 
cure  of,  270 ;  of  alimentary  canal,  200 ;  of 
arteries,  207  ;  of  brain  and  cord,  203  ;  of  Fal- 
lopian tubes,  200 ;  of  genito-uriiuiry  system, 
204;  of  kidneys,  204;  of  liver,  203;  of  lymph 
glands,  224 ;  of  nuimmary  gland,  2G7 ;  of 
ovaries,  200 ;  of  pericardium,  250 ;  of  peri- 
tonicum,  25s  ;  of  pleura,  250 ;  of  prostate, 
200  ;  of  serous  membranes,  255  ;  of  testes, 
200;  of  ureters  and  bladder,  205;  of  uterus, 
200;  of  vesiculte  seminalea,  200;  pregnancy, 
inttuence  of,  in,  20'J  ;  prognosis  of,  207  ;  pro- 
phyla.\i8  in,  209  ;  pulmonary,  228  ;  specitlc 
treatment  of,  273 ;  treatment  of,  270,  275 ; 
and  typhoid  fever,  30  ;  and  valvular  disease 
of  lieart,  253. 

Tn/neirn  treatment  of  aneurism,  714. 

Tumors  of  brain,  U70. 

Tunnel  anieniia,  lOOO. 

Twists  and  knots  in  the  bowel,  445. 

Tympanites,  in  intestinal  obstruction,  447 ;  in 
peritonitis,  409;  in  tuberculous  peritonitis, 
259 ;  in  typhoid  fever,  24 ;  as  a  cause  of  sud- 
den heart-failure,  454 ;  in  the  constipation 
of  infants,  452. 

Typlditis,  429. 

Typhoid  fever,  1 ;  abortive  form,  81 ;  afebrile, 
15,  32  ;  ambulatory  form,  13,  31  ;  antrmia  in, 
''18  ;  antl  tuberculosis,  43  ;  bacillus  of,  3 ; 
chills  in,  15;  circulatory  system  in,  18;  dia- 
betes in,  30 ;  diagnosis  of,  33 ;  diarrhopa  in, 
21 ;  digestive  system  in,  21 ;  Efirltc/i^s  reac- 
tion in,  28  ;  erysipelas  in,  30 ;  etiology  of.  2  ; 
grave  form  of,  31  ;  haemorrhage  in,  9;  huMU- 
orrhagie,  31  ;  historical  note  on,  1 ;  in  the 
aged,  32 ;  in  children,  32 ;  in  pregiiuncy. 
32 ;  liver  in,  9,  25 ;  meteorism  in,  23 ;  mild 


form,  31;  (nodes  of  conveyance  of.  4  ;  morliid 
anatomy  of,  0;  nervous  system  in,  10,  20; 
nonui  in,  30,  V,'l\  osseous  system  in,  29;  oys- 
ters and,  5 ;  parotitis  in,  V.l  ;  perforation  of 
bowel  in,  8;  peritonitis  in,  24,  42;  ]iost-ty- 
]ihoid  elevations  of  temperature  in.  15  ;  ]inig- 
iiosis  of,  35;  jirophylaxis  of,  35;  pyuria  in, 
9,  29;  relapses  in,  32;  renal  system  in,  28; 
resjiirutory  system  in,  25;  serum  therapy 
in,  41;  skin  raslies  in,  l(i  ;  sjileen  in,  24  i 
.symptoms  of,  11  ;  tender  toes  in.  l;7  ;  tetany 
in,  27  ;  treatment  of,  37  ;  varieties  of,  30. 

Typhoid-malarial  ferer,  so  cidleil,  34,  109. 

Typhoid  sejitieaMnia,  11. 

Typhoid  sjiine,  30. 

Typhoid  state,  458,  400. 

Typhr>toxin,  0. 

Typhus  fever,  43;  complications  and  se<;uelic 
of,  40 ;  contagiousness  of,  44 ;  diagnosis  of, 
40;  etiology  of,  43  ;  morbid  anatomy  of.  44  ; 
Jieriod  of  incubation  of,  44;  ))rogii(>sis  of,  40; 
stage  of  erupti'.n  in,  45;  symjptoms  of,  44; 
treatment  of,  47. 

Typhus  sideraus,  40. 

Tyrosin,  4iil. 

Tyroto.\icon,  1071. 

I'lecr,  cancerous,  of  intestine,  424 ;  gastric, 
394  ;  of  duodenum,  394  ;  of  bowel  in  dys- 
entery, 147,  150  ;  in  typhoid  fever.  S. 

L'leer  o*'  mouth,  352  ;  in  the  new-born,  .'1.'.'! ;  in 
niu'sing  women,  353  ;  of  palate  in  infants, 
353. 

L'leer,  peptic,  394;  perforating,  of  foot,  907; 
vaccimition,  00. 

Ulcerative  endocarditis,  030. 

IMeers,  Parrot^  353. 

Ulmir  nerve,  affections  of,  875. 

Uncimiria  duodenalis,  1090. 

Unconsciousness  (see  ComaI. 

Ura>min,  778  ;  cerebral  manifestations  of,  779, 
781  ;  conui  in,  779  ;  convulsions  in,  779  ;  diag- 
nosis from  apoplexy,  948  ;  dyspno-a  in.  780  ; 
headache  in,  780  ;  in  Bright's  disease.  798  ; 
local  palsies  in,  780  ;  u>dema  of  brain  in,  940  ; 
stomatitis  in,  780  ;  symptoms  of,  779  ;  theory 
of.  778. 

Urate  dithate)  of  soda  in  gout,  311. 

Urates  in  the  urine,  773.  , 

Urates  (lithates),  amorphous,  773. 

Ureter,  blocking  of,  703  ;  mucous  cyst.s  of, 
1081 ;  obstructed  by  calculi,  808  ;  psorosper- 
miasis  of,  1081  ;  tuberculosis  of,  205 

Urethritis,  gouty,  317. 

Uric  acid,  calculus,  806 ;  deposition  of,  773 ; 
in  gout,  311;  in  urine,  773  ;  "showers,"  810. 

Uric-acid  diathesis  (.see  Litii.gmia),  773, 

Uric-acid  headache,  310. 

Uric-acid  theory  of  gout,  311. 


1142 


INDEX. 


Uriiiiiry  calculi,  S06. 

K'riiic,  iiri'iiiialics  of  the  Hcontinn  rif,  71'''. 

Urine,  (k'iir«ity  of,  in  uciitc  I!iii.'lit"H  ilisciiso, 
T83;  ill  chmniL'  JJi'ijrlit's  discaso,  Tl'"> ;  in 
(lial)ctcn,  .'ii:;; ;  in  diulu'tcM  insii>iilus,  ;!;!!, 

Urine,  liii']nn;.'l()l)ln  in,  TO.") :  in  aoiilc  yellow 
utrojiliy  1)1'  liver,  UK) ;  in  ^rrave  anawnia,  T''!l ; 
ill  clidlera,  '[M;  in  dialietcs  iiiMiiiiilu.i,  3.'U  ; 
in  diabetes  iiieHitus,  ;!•_'.') ;  in  (lijilitlierirt,  llo; 
in  el\>>iiielas.  l:i,');  in  jrout,  ■"l.'?,  :;i(>;  in 
jaiin.licc,  'l.">s  ;  in  nielaiidtie  sarcoma,  VT'l ;  in 
imeuiMonia,  ."),"i.") ;  in  acute  i>uliM(>nary  tuber- 
eulosis,  -J.")!) ;  in  typlioid  lever,  iiK ;  oxalates 
in,  774:  jius  in,  771. 

Urine,  (luantity  of,  in  elironie  UriLrlit's  di.sease. 
V'.''"';  in  diabetes  insipidus,  a.'il  ;  in  diaht'tes 
mellitus,  :!l';!;  in  intestinal  obstruction,  417. 

Urine,  retention  of,  in  typhoid  fever,  28. 

Urine,  suppression  of,  7ii;> ;  treatment  of,  704  ; 
in  cholera,  \'M;  in  acute  lu'iihritis,  7S3  ;  in 
scarlet  fever,  7"! ;  in  acute  intestinal  obstruc- 
tion, 447  ;  obstructive  sup|)ressioii,  SOS. 

Urine,  lists  for  albumin  in,  7'!1" ;  biliary  jii^r- 
inent  in,  4.">8;  blood  in,  705;  nlbunioses  in, 
770  ;  peptones  in,  770. 

Urobilin,  increase  of,   in  pernicious  anicnuu, 

7;u. 

Uro-genital  tuberculosis,  204. 

Urticaria,  after  tapping  of  liydatid  cysts,  llO."  ; 
ejiidemica,  1110;  t;iant  form  (see  Xkiuotio 
(KiiKMA't,  1044;  with  purpura,  ;)44  ;  in  sinuU- 
pox,  r)4  ;  in  typhoid  fever,  17. 

Uterus,  tuberculosis  of,  2iU!, 

Uvula,  tt'demu  of,  .I.j'J  ;  infarction  of,  345,859. 

Vuceinotion.  .W,  (14;  mark,  04;  operation  of, 
08;  phenomena  of,  04;  rashes,  07;  ulcci-s, 
00  ;  value  of,  08. 

Vaeeinc  lymjili,  choice  of,  07 ;  from  the  calf, 
08;  liumanized,  07. 

Vaccinia,  04 ;  jreneralizod,  05. 

Vueeino-syphilis,  00;  diagnosis  from  vaccina- 
tion ulcers,  (iO. 

Vagabond's  discoloration,  749,  1108. 

Vatrinitis,  gonorrlueal,  of  the  new-born,  208. 

Valvular  disea.se  of  lieart,  0;i7 ;  prognosis  in, 
(!;■)(; ;  treatment  of,  O.'iS;  and  tuberculosis,  253. 

Varicella,  09  ;  lucmorrhagie,  70. 

Va^'icolla  bullosa,  70;  cscliarotiea,  70. 

Varices,  (esophageal,  in  eirrho.sis  of  liver,  370. 

Variola,  .IO;  ha'inorrhagiea,  5.3,  50,  58  ;  vera,  53. 

Variola  hieinorrhagiea  pustulosa,  50,  58. 

Variola  sine  eruptione,  58. 

Varioloid,  53,  68. 

Vaso-motor  disorders,  1041. 

Vaso-inotor  disturbances  in  caries,  915;  in 
chronic  pleurisy,  007 ;  in  exophthalmic  goi- 
tre, 753;  in  hemicrania,  1012;  in  myelitis, 
890;  in  neuralgia,  1014. 


Veins,  cerebral,  tlirombosis  in,  950;  diastnlic 
collapse  of,  r,'j,') ;  pulsation  in,  '.'is,  I'lio^  Urn. 

Vena  cava,  ii.fcrior,  twist  in,  5!(4. 

Vena  cava,  superior,  perforation  of,  by  aneu- 
rism, 70S,  ~l^. 

Venereal  disease,  184. 

Vene>ectioti  (see  Bi.oodi.ettino). 

Venous  pulse.  218,  SC.K),  10;54. 

Ventricles  of  brain,  ililatation  of  (liydrocepha- 
lus),  97'.i ;  puncture  of,  979. 

Ventricular  hiemorrhage,  942. 

Verruca  iiecrogenica,  2o8. 

\'ertebra\  caries  of,  914  ;  cervical,  caries  of,  915. 

Vertebral  artery,  obstruction  of,  li52. 

Vertigo,  auditory,  SCl  ;  cerebelhir,  920;  in  ar- 
terio-sclerosis,  7"5  ;  in  brain  tumor,  971  ;  gas- 
tric, ;ib0 ;  labyrinthine,  801  ;  paralyziii;,', 
802. 

Vesiculie  seminalci,  tuberculosis  of,  200. 

Vicarious,  epistaxis,  517;  luemoptysis,  541. 

Vitiligoidca,  457. 

Vocal  fremitus,  55."),  505;  resonance,  554,  590. 

Voice  (see  Si-Kicoii). 

Voice,  alteration  of,  in  niouth-brcathcrs,  307. 

Volitional  tremor,  905. 

Volvulus,  445,  449. 

Vomica,  signs  of,  in  phthisis.  236. 

Vomit,  black,  141  ;  eoll'ee-ground,  405. 

Vomiting,  in  .J(/f//.vo/i,V  disease,  748;  in  Briyht'n 
disease,  7!I5 ;  in  cerebral  ab.scess,  970;  in 
cerebral  tumor,  971  ;  in  chronic  ob.structiuii 
of  intestines,  447 ;  in  chronic  ulcerative 
plithisis,  249;  gall-stone  colic,  400:  in  gius- 
tric  cancer,  405;  in  gastric  ulcer,  897;  in 
acute  obstruction  of  intestines.  440  ;  in  tuber- 
culous meningitis,  222  ;  in  migraine,  1012;  in 
peritonitis,  499 ;  in  small-pox,  53 ;  nervous, 
387;  primary  periodic,  383;  stercoraceous, 
440 ;  uricmic,  780. 

Wall-paper,  poisoning  by  arsenic  in,  1007. 

War  of  rebellion,  statistics  of  dysentery  in,  145. 

War  of  rebellion,  malignant  measles  in,  83. 

Wart-po.\,  58. 

Warts,  po.st-mortein,  208. 

Washing  out  stomach,  383,  393. 

Water-hammer  pulse,  041. 

Water,   infection   by,  in  diphtheria,  103;    in 

cholera,  134;  in  typhoid  fever,  5. 
"  Water  on  the  brain,"  221. 
Weher,  syndrome  of,  224,  940,  973. 
Weifn  disease,  280. 
Werlhqfs  disease,  345. 
Wernick(''ii  lieniiopic  pupillary  inaction,  847. 
Wet-pack,  80. 
VVhip-worni,  1094. 
White  flux  of  India,  421. 
White  softening  of  brain,  950. 
White  thrombi  in  heart,  050. 


INDEX. 

WhooplnK-cnujrli,  8S;   conipHcatioiw  iiiul    sc-  '  \Vr\  n.vk, '-r,-* ;  spnMiKulio,  Kiifl. 

(liulii-  of,  W);   (rmi.'iio>i.s  of,  OO;  ftiol.wy  of,  WriVzlmriJ  Suivicii 

•HM;   iiMiihid    uniiloiiiy    of,  H',) ;  proiriiosis   of,  ;  culosis  at,  u'll. 

'.•1  ;  s.viMptoiii.s  of.  S'J  ;  tiviitiiimit  of,  itl.  ! 

Winrkel'ti  di,->C'ii.so    (sire    Kimdk.mic    H.k.mooi.o-  '  X"iitliclasiiin.  4'i7. 

ni.vuKiA  OK  TiiK  Niiw-iioKN  I,  IIH),  ,'1(7,  7(;ij.        '  Xaiitliiiic,  S07, 

"  Wind  "  ill  the  profc.-is  of  tmiiiiiif,',  (ITD.  .V'linilioinata,  .".•.''>,  45",  467. 

"  Wiiiifod  .scapula',"  245.                                           I  .Xaiitliojisia,  1084. 

n7////'/.7/V  Hi;;ii,  247.                                              I  XiTnstoiiiia,  357. 


1143 


mil',  statistics  of  tuber- 


M'oi/Uz,  inulititte  (If,  r^'it. 

Wool-soitir's  disoaso,  176. 

NVord-iiliiidiicss,  ll-JS. 

Word-dcafru'ss.  Has. 

Woriiiiiiii  l)oiit's  in  liydroccpliulus,  y78. 

Worms  (soo  Pakasites). 

Woutids  of  tlio  licart,  683. 

Wrist-drop,  s;.') ;  in  lead-poisoning,  1065. 

Writur'.s  crump,  1017. 


Yellow  fovor,  mi);  diagnosis  of.  14'J;  .'pidi'mics 
of,  l.'iii;  L'tioloiry  of,  i;!ii;  niorl>i.l  anatomy  <,t'. 
140;  jiro^nosi.s  of,  142;  imipliylnxis  of,  "14-^; 
symptoms  of.  Ml  ;  trcutmcni  of,  143. 

Yellow  softening  of  hruin,  li.jij. 

Yellow  vision,  1084. 

JV'<',«  dietary  in  obesity,  1078. 

Zona,  1015. 


THE     END. 


\ 


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Bv    ROIIKRTS    r.AIITIIoLOW,    M.  A.,  M.  D,  M..  I)., 

Late  Profes.sor  of  Miitcriii  Mi'ilica  uinl  (ii'ij'Tiil  'riicniiiciititH  in  tlio  .TclTi'isdn  Mnliciil  Col- 

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in  preparation  another  woik  on  the  '  I'rinciples  of  Jlcdicinc,'  which,  together  with  the 
one  under  review,  and  his  '  Materia  Medica  and  Therapeutics,'  shall  constitute  a  trio  of  vol- 
unn'S  each  containing  matter  complementary  to  the  others.  Certainly  three  such  vohmicH 
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Medical  Press  of  Western  New  York. 


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A  TREATISE 

ON   DISEASES   OF  Till- 

R1^]('TUM,  AXrs,  aM> 

SIGMOID  Fl.EXrRE 


P.v  JOSKPH    M.  MATIIKWS.  M.l)., 

or  i.<iri>vii.i  K.  K\  ., 

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Sniooi.  OK  Mkdicixh,  uti-. 

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SOLD  os'LY  nv  sriisciurrios. 


'•  Till'  uiitlior  \\\<  pliu'cil  lii('..ri-  tlio  profosHifin  tlio  friiit<  of  flftc'ii  M'liro'  <•>]  •rit'ncf  ii!<  u 

r<'>'t.il  -I'l- ■i;ili'>t \  ciirt'liil  ihtiimI  oI   M»tlnW'<"s  work  (■••in  not   liiil  to  [iwi-  tlir  |iiiirti- 

tioilcriill  till"  klio«  lid^'r  liiiit  i>  ilc;<iiiil>li'  t  '  MH'iT>.-liill_v  iliairiicwMc'iti- iilul  tli-iit  alix  i'jim- ol 
n''t:il  (li>iii.->i-  that  lli.iv  i"IIU'  lul'oi-c  liiiii,  it'  Iii.  |hiksi>m'^  a  iii'ulriilii  ••!  liic  i|i'.\trrit_>  lliat  an 
onliiiarv  Kiiriffoii  >lioiili|  luivr.  .  .  .  'I'li.'  U.ok  i-  rirli  in  lini.jil  inatriial.  ati.l.  in  tin-  »ril«r'» 
o|iiiiioii,  i.s  till'  Ih'«I  work  on  tlii-*  ^iM-rialtv  xct  |'iil>li!4|»M|.  'I'lir  |>iil>li>li(TK  liavi- ilom-  i[nir 
Work  will,  till'  >i.\  .iirmiolitliontaiili:*  Ix'iii;;  Mtiflii-."  —  t'/iioujo  .\l<Ui>ttl  A'rcon/o-. 

"...  Tin-  Work  i-  a  most  prai-tii'al  aiiil  cla-'xical  jTrTii'iition  of  tlic  va.nt  ainl  variril 
cxiK-rifiu'i'  of  11  |iiiiii-lakiiiL'  oii«<rviT  aiul  Wiirkir.  I'ln-  i«i>iMiuli,>i  will  Iniv  it  ninl  niul  it. 
«>tliir»i-'i-  iifttoiil.l  not  Im-  |iro.'r.  R>i\c.  'I'lit- t:«'ninil  |iiuctilioiui>.  ul.ovr  all.  ?>li"iilil  |iro.Mir«' 
lili<l  H'a'l  this  iHH.k.  f  >r  I'll'  ti'U'on  tlial  it  will  at  Ka-t  as-i  t  tluni  in  inakitit;  a  i-ornrt 
di.iijiiosi)! ;  anil,  it  tiny  larc  t"  treat  tli<M  iUm'sl'-i-.  it  >;ivi'»  tliciii  all  lliul  i-  mwi-l  an.l 
Ik'oI  "  — J/t!./i  ■;/  M.rnr. 

''Tlii*  Inxik  wi'  think  i«  iln'i.lcilly  ori/inal  in  inonv  of  it*  li.itun-.  Tln'  author  Im-  not 
tnkt'ii  otlKT  ini'ii'ii  o|iinion«  n-.  hii  i;u'i|i',  fof  ilic  ml-oii  that  in  lii-  llt>«-<ii  viar"'  ixpirirni'T' 
■k  a  r<  I'tai  i<|>"i'ialist  lir  lia"  Irariircl  'that  iiiai.v  tliiiiL''-  that  ai'<'  tail'.'lit  alv  not  tiiK-,  iiii'l  tfiit 
niaiiv  true  tliiiii'-  liavr  not  Ixcii  taiiu'lit.'    Ili'  lui*  tlurrlon  ac-ii't-  •!  un  Inilli-  ciiily  tliow  tliiiiif!* 

%vliii'li  iiiiilil  111'  »iili-tantialc  ii  In  fa, 'Ik,  an  1  lias  hrif  l^ rih'il  tlniii.     Si-v«nil  rliai'lcr*  iit-w 

tn  I)  ,^>k'«  nil  tills  siiliji-.'t  have  U'lii  intr-xlili'i-.l  liv  iiiiii,  alijon.'  w  iiii'li  will  Iw  touii  I  t'lf  foil  .»- 
Inif :  IK-iiiM'in  till' Si^ftnoid  Kn-Min',  tin-  lU^ti-rii-al  or  Ni  rvtiiis  Uii'inm.  Anat'Hiiy  "t  iIm' 
lU'  tiiin  in  Kila'i  >ii  to  Ki.|irM"<,  \llliM-ii|io»  in  Itri'lal  Snri,"  t'x  .  an  I  a  N<  »  '  'J"  r..lioh  lor  Ki'-tiilu 
ill  .\  no,  .  .  .  Illii-tnitiil  w  itii  si\  >Ar«l!i'iit  i'.ilori-il  ilati  •>  anil  nulla  p. Ill*  I'lit- ;  i-lrarlv  ['riiili-.l 
with  lar^t!  fviH-,  aii>l  nii-ily  Uiuti<i,  it  iirtTW-ntx  ii  ino«i  iitinuti.i'  n|<|H'amnt-<'.  Wr  i|o  n<l 
kfioK  o|  any  Work  on  i|ic  xuliji-i't  ttliii'li  inon-  tlioMU|{lily  iiuftd  our  ii|i|in»val." — Mtmj-ki* 
J/rJti'iil  Monthli/. 

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lit  u!"  n 
(iiii -ti- 

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AMKI5I(AN  fJYN.KCOl.OCICAl.  ANI»  OMSTF.TIIICAI,  .HXUNAI.. 
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COjlV,   .'}.*)  Cl-IltS, 

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lUll.  .110  Hospital.  A  Coiirso  of  l.j-ctuiis  valiiiiMu  nlikf  to  t(n-  Stiuivnt  ami 
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Klehlh  rdllUa.  i^'viM'(l.  t'nlar).'('tl.  and  a(la|>ti(l  to  "The  Ni.-w  IMiarhiucii|)'i 

Hvo.       Clolh,    <!."». HO;    »lii-«'|i,   ^'i.dO. 


ni. 


»AUTIlOl.(>W  (ItonKinS  .  A  Tn-atiM'  ..n  tin-  I'nwtico  of  MtHli.ine,  lor  tlic 
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KVO.       Cloth,   ^ri. HO;    sli,,|(,  IJK'i.OO. 

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Iwi'i-n  Kt-niodii's  and  !>iM'a«is.  {{I'in:;  tiie  ("arfwri^ht  I.wtureH  lor  the  Vtiir 
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BASTIAN  (II.  CI!  MM.TON).  l'aral\-.«:  (Vrtd.ral,  Hulhur.  and  Si.ini.l.  A 
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tinn>.     Small  >*\».  tiTl  [(a^'i*.     Cloth,  ifsi.."!'!. 

UASTIAN  (II.  CIIAKI.TO.N).  Paralvsir.  from  IJrain  hisoBM'  in  its  Comni.  ii 
Forms.     With  llhi»tralion-.     Ii'mo,  :Hu  |,am-s.     Cloth.  ij!l.7.">. 

BILMN(fS  (F.  S.).  Tlio  Kcdationot  Anim.il  I'.-Hjnuc!*  to  the  i'uldic  liiallli,  ami 
tht'ir  I'rfVfHtion.     8vo.     Clolh.  $».••(•. 

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edition,  hv  speiial  |iermis<!ion  of  the  author.  \>\  Charles  K.  Iltu-kley,  M.  I>. 
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BOYCF  (KIUKKT).  A  iext-liook  of  Morhid  Ili-tolo^y.  For  Students  and 
I'raetilioners.     W  iih  l:i(i  Cidored  lllisiratioiif*.     (.  loth,  ♦7..'i<". 

mtAMWKI.I-  (MYKOM).  Hi-eases  ..f  the  Heart  and  Thorncic  Aort.-i.  Ilhi- 
trnted  with  "J'-'ti  \\  oi.d-F.nL'ra\inL'>  and  <»•«  l.ithoifraph  l'l»te«— showing  l»l 
Figures — in  all  ;tl7  Illustrations.     8vo.     Cloth.  jtS.'Mi:  sheep,  l|i'.».(K). 

BRYANT  (JOSEIMI  l>.).  A  Manual  of  Operadve  Surfrorr.  Vw  HIIIm.  rvTlw4 
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t'AMPUKM,  (F.  K.).  Tlie  I.anj.Mmgt' of  Medicine.  A  Manual  t'lving  the  Origin, 
Ktvriiolofry,  I'rotiuiic'iatioii,  and  Mianin^r  <>f  the  Tt'clmical  Terms  found  in 
Medical  Literature.     Hvo.     Cloth,  !f;{.(i<i. 

CAIIMICIIAKL  (.lA.MK.S).  Disease  in  ('hildren.  A  Manual  for  Students  and 
I'ractitioners.      Illustrated    with    Thirtv-tme   (harts.      I'iiiio.    5111     pages. 

(.'^Tl  DKNTs'  .SkIMK?..)       (loth,  ^H.OO. 

CASTIJO  (l)'(»l.l\KIHA).  Eleiiients  ot  Therapeutics  nnd  Practice  accordinp 
to  the  Kosiinetriu  Svsteni.     Hvo.     Cloth,  !j(4. 00. 

CIIAl'VK.M'  (.\.).  The  Comparative  Anatoniv  of  the  Domesticated  .\nimaU. 
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J.vons  N'eterinnry  .'School.  .*>econd  l'ji),'li>h  »'<lition.  Translated  and  edite<l 
l>.v('eorge  Flemini:,  C.  M..  1.!..!)..  F.  U.C.  V.S.,  late  TriiKipal  Veterinary 
Surjieon  of  the  iJritish  Army;  Foreijrn  Correspontlin>;  Memher  of  the 
Societe  lloyaK-  de  Medecine.  and  of  the  ."^ociete  lioyale  de  .Medecine  I'lil- 
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COKNIN(i  (.].  I,.i.     IJrain  Kxhaustion,  with  Honne  Preliminary  Considerations 

on  Cerehral  l>ynnmics.     Crown  Mvo.     (^loth,  ijl'2.<i0. 
COU.SINd  (.1.  I,.).     Local  .Ana'sthesia  in  (ieneral  Medicine  and  Sinyery.     Heint 

the  Practical  .\pplication  of  the  .Author's  liecent  l»iscovcries.     With   Illus- 
trations,    .^mail   Hvo.     Cloth,  !J!l.'i.">. 
DAVIDSON    (.\NDI;KW).      (ieonraphical  I'jilholo^'y  ;    An   hupiiry  into  tht 

(ieo-rraphical    Di.-trihution  of  Infecliv*'    and     Climnlic     Diseases.     'J    .    'x. 

8vo.     Cloth,  !j;7.(l0. 
DKNCII  (F.   M.i.      Discuses  of  the  Far.      A    Tcxt-Mook  for  Practitioner,^  m  .i 

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text.     «vo.      Cloth,  ^.">. oil;   sheep,  ^ti.oo. 

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EVANS  ((iFdUtJF  .\  ).  Ilaiid-Mook  of  Historical  an<l  Cieoiirajdiical  Plithisi- 
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Inited  States.     Hvo.     Cloth,  |'2.(t0. 

KWAI.D  (C.  .v.).  Lectures  on  the  Diseases  of  the  Stomnch.  By  Dr.  C.  A. 
Ewald,  Professor  of  Patholo;:y  and  Therapeutics  in  the  Iniveisity  of  Merli-i, 
etc.  rran>lated  fniiii  tiie  (ieriiian  hy  special  |iermi!<sioii  of  the  auth<ir,  hy 
.Morris  Miiiilms,  A.  M.,  M.  D.     Cloth,  f'..ou;  sheep.  !J;'i.Oo. 

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of  Dr.  Flint.     l-_'mo.     Cloth,  |(I.O(i. 

FLINT  (Al'STIN,  Ju.).  Te-tt-Mook  of  Human  Physiidogy;  designe.l  for  tin' 
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FLINT  (AUSTIN,  .Ik.).  The  Source  of  Muscular  Power.  Arfruiiieuts  ftiid  (\)ii- 
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of  Iie»t  anil  of  .Muscular  E.\ercise.     I'Jnio.     Olotli,  |l.iiO. 

KLINT  (Al'STIN,  .Ik.).  Pliysioloj.'v  of  Man.  Designed  to  represent  tiie  K.xist 
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KLINT  (.VrSTIN,  .lit.).  Manual  of  Clieiniorl  Kxaininalions  of  the  I'rine  in 
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Varieties  of  Trinary  Calculi.     Itevised  edition.     12nio.     (loth,  ijil.oo. 

KOSTKIt  (FRANK  P.).  Illustrated  Kncydopa'dic  Medical  Dictionary  :  Mein« 
a  Dictionary  of  the  Technical  Terms  u>ed  hy  Writers  on  .Meilicine  and  the 
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FRP:Y  (IIFINPvlCIl).  The  llistolo-y  and  Ilis|u<heiiii!.try  of  Man.  A  Treatise 
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lateil  from  the  fourth  (iernian  edition  hy  .Arthur  K.  .1.  Marker,  .Si.  D.,  and 
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GiHSON-RrssKLL. 
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CoULKY  (.IDIIN  W. 
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GRUMKR  (.lOSKFi.     A   Text-Hook   ot    the  Diseases  of   the  Kar.     Translated 
from  the  seccuid  (ierman  edition  hy  sjiecial  jiermi^sion  ol  the  author,  and 
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HAMMOND  (W.  A.).  Clinical  Lectures  on  l>i>ea.ses  of  the  Nervous  System. 
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HARVEY  (A.).      First  Lines  of  Therapeutics.     12mo,     Cloth.  $1.50. 

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5 


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l.FAiit  (J.  \VICKH.\M).  On  the  Mile,  Jaiindiie,  iintl  Bilious  Diseases.  With 
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LITTI.K  (W.  J.).  Modieal  and  Siirtrical  .\speet9  of  In-Knee  ((ienii-Vai>riiiii): 
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!-ORIN(i  (KDWAIJD  G.).     A  Text-Hook  of  Ophfhalm<.seopy. 

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Media.  With  J;U  Illustrations,  and  i  Chrotnolithograplis.  8vo.  Muck- 
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8 


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